Court Opinion

ID: 9756478
Source: CourtListenerOpinion
Date Created: 2023-08-28 21:30:24.627817+00
Date Added: 2024-06-11T07:28:23.485593
License: Public Domain

POLLOCK, J.,
dissenting.
The majority holds that a physician who fails to warn a pregnant woman of a potential adverse effect of a prescribed drug virtually insures that her child will be born without birth defects from any cause. I respectfully dissent.
Under the majority opinion, the parents of a child born with congenital defects may maintain a wrongful birth action against physicians who failed to warn the mother of the potential adverse effects of a drug that did not cause the defects. The import of the holding is that the parents need not prove that the drug was the proximate cause of the birth defects that give rise to the action. All the mother need prove is that she would have aborted the fetus if apprised of potential risks, even if the risks never materialized. Both the reasoning and the result of the majority opinion are flawed.
*521I.
Because this appeal arises from the grant of summary judgment for defendants, plaintiffs’ version of the facts and all favorable inferences that may be drawn therefrom are assumed to be true. See Brill v. Guardian Life Ins. Co., 142 N.J. 520, 523, 666 A.2d 146 (1995); Pierce v. Ortho Pharm. Corp., 84 N.J. 58, 65, 417 A.2d 505 (1980). So viewed, the facts support the following summary.
In June 1991, Melissa Canesi (Canesi) was twenty-nine years old, married, and the mother of one child. When she missed her menstrual period that month, she feared that she might be pregnant.
A home pregnancy test indicated that Canesi wás not pregnant. She nonetheless consulted defendant, Dr. James Wilson, on July 1, 1991. For the purpose of this appeal, Canesi concedes that she did not become pregnant until shortly after that date.
Dr. Wilson administered a urinalysis pregnancy test, which indicated that Canesi was not pregnant. To restart her menstrual cycle, Dr. Wilson prescribed ten Provera tablets, to be taken one per day. After taking eight of the tablets without success, Canesi again consulted Dr. Wilson.
On July 15, Dr. Wilson administered a blood serum test, which indicated that Canesi was pregnant; in fact she was carrying twins. Although Canesi expressed to Dr. Wilson a concern about the use of drugs during her pregnancy, he told her not to worry. On two prior occasions, Canesi had aborted pregnancies, once because of a concern about the side effects of painkillers and x-rays administered in connection with a broken leg.
Because Dr. Wilson was not a participating physician in Canesi’s health plan, she next consulted Dr. Ronald Loewe. On July 25, Canesi told Dr. Loewe that she was pregnant and that she had taken Provera. Like Dr. Wilson, Dr. Loewe told Canesi that she need not be concerned about the drug. For reasons unrelated to the ingestion of Provera, Canesi experienced spotting and mild polyhydramnios (the presence of excessive amniotic fluid) during *522her pregnancy. One of the two fetuses that she was carrying died and was spontaneously aborted.
When Canesi consulted the two doctors in 1991, the medical profession was divided over the effects of Provera during pregnancy. In that year, the drug manufacturer, Upjohn, included in the Physicians’ Desk Reference (PDR) 2251 (45th ed. 1991), a warning that the use of Provera was “not recommended” during the first four months of pregnancy. The warning stated that if a pregnant woman took Provera during that time, she should be told of the risk to her fetus of congenital anomalies, including possible “limb reduction defects,” and the risk of delay in the spontaneous abortion of defective fertilized ova. Ibid. For the purpose of this appeal, both doctors concede that they had a duty to warn Canesi of those risks. They further concede that they did not warn her.
Subsequent scientific research revealed that Provera neither causes nor increases the risk of limb reduction defects. Consequently, in 1993, Upjohn deleted its warning about those defects from the PDR.
Consistent with the elimination of the warning, defendants’ expert, Dr. A.F. Haney, Professor of Obstetrics and Gynecology at Duke University Medical Center, found “no scientific basis for limb reduction with exposure to progestins,” such as Provera. Dr. Haney explained that early reports of an “association” between Provera and limb reduction defects were based on “very bad epidemiology.” He concluded:
When careful analysis was performed, it became very obvious there was no scientific information whatsoever to support any association of limb reduction with progestins of any kind.... As a consequence, this patient and her family have been [misled] into thinking there is some potential association. It’s certainly understandable for them [to] try and find a cause for their child’s anomaly. The one thing that can clearly be said is that this is not related to the 10 days of Provera she took during [the] luteal phase of her eonceptive cycle.
Plaintiffs’ experts, Dr. William Vilensky and Dr. Deborah P. Consoli, likewise declined to attest to any connection between Provera and limb reduction defects. Specifically, Dr. Vilensky testified that he could not render any opinion about a causal *523relationship. Dr. Consoli, after conceding that current medical knowledge does not support a causal connection, stated that she no longer warned her own patients that Provera potentially could cause limb reduction. She testified that the warning was unnecessary
[b]ecause I think overall, I think medieal-legally, you know, the warning has been taken out of the PDR and just in general the literature doesn’t support that anymore, and I would tell them, because I’m conservative, I would tell them that years ago we used to warn people and at this point most doctors generally feel there is no support for that but I would warn them about cardiovascular [problems], that that still is a possibility.
The PDR still warns against taking Provera during the first four months of pregnancy. See PDR 2110-11 (49th ed. 1995). According to the PDR, if a pregnant woman is exposed to Provera, she should be apprised of two potential risks: possible genital abnormalities in the fetus and possible delay in spontaneous abortion of defective fertilized ova. Ibid. Neither of those two potential risks eventuated in this case. On March 18,1992, Canesi gave birth to plaintiff Brandon Canesi, who was bom with bilateral limb reduction of the hands.
Canesi and her husband (jointly described as “the Canesis”), filed a wrongful birth action in which they claimed that Drs. Wilson and Loewe, by failing to warn of the risks that Provera posed to a fetus, had deprived them of the right to abort Brandon. The Canesis claimed that Provera had caused Brandon’s limb reduction and that the two doctors had been negligent in failing to warn them of the limb reduction risk. In a separate count, which is not before us, the Canesis asserted a claim on Brandon’s behalf for his “wrongful life.”
The Law Division granted the doctors’ motion for summary judgment, reasoning that the Canesis had failed to establish that Provera had caused Brandon’s limb reduction or that the ingestion of Provera was related in any way to the defect. The trial judge also observed that expert testimony was required to support a claim that Canesi’s fertilized ova were defective or that Provera caused a delay in her spontaneous abortion of one of them. In the *524absence of any supporting expert testimony, the trial court correctly discounted those claims.
The Appellate Division likewise found that the record contained no evidence that Provera had caused or increased the risk of limb reduction. 295 N.J.Super. 354, 359-60, 685 A.2d 49 (App.Div.1996). The court stated: “[I]t is clear in this case that if the fetus had been aborted because of the concerns expressed in the PDR, it would have been based on a medical premise now found to be fallacious.” Id. at 362, 685 A.2d 49.
II.
A.
The majority acknowledges that proximate cause is an essential element of an action based on a physician’s failure to obtain a patient’s informed consent. Ante at 504-05, 730 A.2d at 812-13. It also acknowledges the strong similarities between an action based on lack of informed consent and a wrongful birth action based on a physician’s failure to warn. Id. at 506, 730 A.2d at 813. Specifically, the majority recognizes that wrongful birth claims, as well as those based on lack of informed consent, stem from a patient’s right of self-determination. Id. at 503-04, 730 A.2d at 812. With both claims, a cause of action accrues when a physician denies a patient information necessary to make an informed decision.
As the majority notes, a wrongful birth action does not require proof that the physician’s negligence caused the birth defect. Id. at 506, 730 A.2d at 813. Physicians may be liable for the failure to detect a birth defect simply because the failure deprives the mother of her right to choose to abort. Similarly, they may be liable for the failure to warn about a birth defect related to the mother’s age or genetic makeup rather than to any aspect of her medical care.
*525Contrary to the majority opinion, nothing in this dissent requires proof that the doctor’s failure caused the child’s defect. Id. at 514-15, 730 A.2d at 817-18; see also id. at 502-03, 730 A.2d at 811. The dissent recognizes that a wrongful birth action based on the doctor’s failure to warn requires only the occurrence of the unwarned risk. In this case, the unwarned risk was that Provera might cause birth defects. Provera, however, was not the cause of Brandon Canesi’s limb reduction, the only defect that materialized. In fact, Provera did not cause any birth defects.
The majority opinion identifies different elements of proof of proximate cause for informed consent and wrongful birth actions. Id. at 504-06, 730 A.2d at 812-13. In an informed consent action, a plaintiff must “meet a two-pronged test of proximate causation: she must prove that the undisclosed risk actually materialized and that it was medically caused by the treatment.” Id. at 506, 730 A.2d at 813. In a wrongful birth action, in contrast,
a plaintiff need not prove that the doctor’s negligence was the medical cause of her child’s birth defect. Rather, the test of proximate causation is satisfied by showing that an undisclosed fetal risk was material to a woman in her position; the risk materialized, was reasonably foreseeable and not remote in relation to the doctor’s negligence; and, had plaintiff known of that risk, she would have terminated her pregnancy.
[Id. at 506, 730 A.2d at 813.]
According to the majority, “medical causation” is not an element of proximate cause in a wrongful birth action. Id. at 514-17, 730 A.2d at 817-19. Thus, the majority finds irrelevant the fact that . Provera did not cause Brandon’s limb reduction. See id. at 507-08, 730 A.2d at 814. For the majority, it suffices that the doctors failed to warn of the risk of birth defects that Provera did not cause or of other risks that did not result in defects.
Loss of choice is also an essential element of an informed consent action. The physician’s failure to explain the risk of a course of treatment, like the failure to disclose the risk of a potential birth defect, deprives the patient of the right to make a *526choice that is informed. Thus, in both informed consent and ■wrongful birth actions, the injury is the patients’ loss of the opportunity “to determine for [themselves] the direction in which [their] interests seem to lie.” Canterbury v. Spence, 464 F.2d 772, 781 (D.C.Cir.1972).
B.
The majority opinion acknowledges that “[l]egal or proximate cause is clearly an essential element of a wrongful birth cause of action.” Ante at 514, 730 A.2d at 817. It redefines “proximate cause,” however, to permit parents to recover for a child’s wrongful birth even if the alleged negligence of the physicians is unrelated to the child’s defects. The opinion’s rhetoric is seductive and its reasoning subtle; its result is extraordinary. Depending on one’s interpretation, the majority either eliminates proximate cause, a result that the opinion disavows, id. at 514, 730 A.2d at 817, or redefines it beyond recognition. Either alternative, in my opinion, is wrong.
Because the difference between the majority and dissenting opinions turns on so elemental a point, a brief review of fundamental principles might illuminate our differences. At the risk of stating the familiar, basic negligence law requires “not only that the actor’s conduct be negligent toward the other, but also that the negligence of the actor be a legal cause of the other’s harm.” Restatement (Second) of Torts § 431 (1965); Prosser & Keeton on Torts, § 41 & n. 14 (5th ed.1984). Causation often is described as consisting of “cause in fact” or “but for” causation, and “legal cause” or “proximate cause.” Id. § 41.
Cause-in-fact or but-for causation encompasses every occurrence related to an event such that, but for the occurrence, the event would not have happened. See, e.g., ibid. By itself, but-for causation generally is an inefficient and unfair means of allocating liability. As one leading text states:
It should be quite obvious that, once events are set in motion, there is, in terms of causation alone, no place to stop. The event -without millions of causes is simply *527inconceivable; and the mere fact of causation ... can provide no clue of any land to singling out those which are to be held legally responsible.

[Ibid.]

Proximate cause, on the other hand, confines responsibility to acts that are so closely related to a result as to justify the imposition of liability. Ultimately, a finding of proximate cause depends on considerations of fairness, justice, and public policy. Williamson v. Waldman, 150 N.J. 232, 245-46, 696 A.2d 14 (1997); Cowan v. Doering, 111 N.J. 451, 466, 545 A.2d 159 (1988); Brown v. United States Stove Co., 98 N.J. 155, 173, 484 A.2d 1234 (1984); Johnson v. University Hosps., 44 Ohio St.3d 49, 540 N.E.2d 1370, 1377 (1989).
The differing views of causation represented by the majority and dissenting opinions reflect deeper differences about the imposition of liability for the legal consequences of a physician’s conduct. Here, the doctors’ alleged failure to warn about the risks posed by Provera is a but-for, but not a proximate cause of Canesi’s lost opportunity to elect to abort. Their failure is a but-for cause of Brandon’s birth in that but for their impairment of Canesi’s lack of choice, Brandon would not have been born. It is also a but-for cause of Brandon’s defects because but for his birth, Brandon would not have been born with birth defects. For the failure to warn to constitute a proximate cause, however, more is required. Restatement (Second) of Torts, supra, § 431 comment a.
Before today, this Court has limited the right to recover in wrongful birth actions to claims that a doctor’s failure to detect or to warn of a birth defect resulted in the birth of a child with that specific defect. See Procanik v. Cilio, 97 N.J. 339, 478 A.2d 755 (1984) (doctor failed to diagnose mother’s rubella; child born with congenital rubella syndrome); Schroeder v. Perkel, 87 N.J. 53, 432 A.2d 834 (1981) (doctor failed to diagnose genetic defect resulting in cystic fibrosis in older child; second child born with cystic fibrosis); Berman v. Allan, 80 N.J. 421, 404 A.2d 8 (1979) (doctor failed to warn 38-year-old woman of increased risk, due to her age, that her child would be born with Down’s Syndrome; child *528born with Down’s Syndrome). Implicit in that limitation is the recognition that a failure to diagnose or to warn does not cause the birth defect. The doctor’s failure, however, can deprive the mother of her ability to choose not to give birth to a child with the very defect about which the doctor should have warned her. In such wrongful birth actions, the Court therefore has found that the doctor’s malpractice was the proximate cause of the parents’ injury. See, e.g., Schroeder, supra, 87 N.J. at 53, 432 A.2d 834. Satisfaction of the requirement of proximate cause confines the liability of physicians to consequences that are sufficiently related to their failure to justify imposing on them the costs of the breach.
It is one thing to impose liability for a child’s congenital rubella syndrome on a doctor who failed to diagnose rubella in the child’s mother, Procanik; for a child’s cystic fibrosis on a doctor who failed to test a symptomatic sibling for that genetic disease, Sckroeder; or for a child’s Down’s Syndrome on a doctor who failed to warn a pregnant woman that her age put her at increased risk of delivering a child with that condition, Berman. It is quite another to impose liability for prescribing a drug that had no connection with a birth defect. In one ease, the condition is the foreseeable result of the doctor’s omission; in the other, it is not.
The majority’s result is unprecedented in any jurisdiction. In every previous failure-to-warn case, the harm about which the doctors failed to warn was the harm that in fact occurred. See, e.g., Estate of Doe v. Vanderbilt Univ., 824 F.Supp. 746 (M.D.Tenn.1993) (holding medical providers who failed to warn mother about danger of exposure to HIV liable when baby born with HIV); Phillips v. United States, 575 F.Supp. 1309 (D.S.C.1983) (finding parents entitled to damages where doctor failed to advise and counsel them of risk of Down’s syndrome, and child born with Down’s syndrome); Siemieniec v. Lutheran Gen. Hosp., 117 Ill.2d 230, 111 Ill.Dec. 302, 512 N.E.2d 691 (1987) (allowing wrongful birth claim when child born with hemophilia where doctor failed to warn accurately of genetic probabilities of hemophilia); Proffitt v. Bartolo, 162 Mich.App. 35, 412 N.W.2d 232 *529(1987), appeal denied, 430 Mich. 860 (1988) (allowing wrongful birth claim when physician failed to diagnose mother’s rubella and warn her of dangers; child born with congenital rubella syndrome); Smith v. Cote, 128 N.H. 231, 513 A.2d 341 (1986) (same).
Throughout our wrongful birth and wrongful life decisions, the Court has stretched the bonds of logic to achieve fair and reasonable results. See Procanik, supra, 97 N.J. at 351-52, 478 A.2d 755. In Berman, while denying recovery to parents for “the medical and other expenses” incidental to raising a child born with Down’s syndrome, Berman, supra, 80 N.J. at 432, 404 A.2d 8, the Court allowed recovery for their “mental and emotional anguish upon their realization that they had given birth to a child afflicted with” the condition, id. at 433, 404 A.2d 8. Two years later in Schroeder, we “advance[d] the frontier a little farther” by permitting the parents of a child born with cystic fibrosis to recover the extraordinary medical expenses attributable to that disease. Schroeder, supra, 87 N.J. at 70-71, 432 A.2d 834. Critical to SchroedeP s extension of damages was the fact that the omitted diagnostic test would have revealed the risk of the disease that caused the medical expenses. The omitted information, although not the cause of the infant’s cystic fibrosis, proximately caused the mother to give birth to a child with the disease that engendered the extraordinary expenses. Withholding accurate and useful information, which was directly related to the resulting condition, justified a finding of proximate cause. In the present case, by contrast, the failure to warn concerned a risk, limb reduction, that Provera does not cause. The failure also concerned other risks, such as the retention of a defective ovum, genital abnormalities, and generic other risks. None of those risks materialized.
Here, as in Berman, Schroeder, and Procanik, the parents’ lack of choice is but a link in the chain of events that led to the birth of a child with defects. In contrast to those cases, however, the present case involves a risk that did not materialize and an undisclosed warning based on information now known to be inaccurate.
*530The majority opinion in effect eliminates the requirement of proximate cause. As the majority explains, a causal connection between the doctors’ breach and the plaintiffs’ injury is not essential. Instead, “in establishing proximate cause for wrongful birth, plaintiffs must show that the resulting birth defect was reasonably foreseeable, that is, not too remote in relation to defendants’ negligence, and that had defendants not been negligent, the pregnancy would have been terminated.” Ante at 515, 730 A.2d at 818. The majority, however, claims that it has retained proximate cause as an element. It justifies the imposition of liability in the absence of a causal connection by asserting that “medical causation” is not an element of a wrongful birth action. Id. at 514, 730 A.2d at 817. According to the majority, the term “medical causation” means either “a causal connection between the undisclosed risk and the injury ultimately sustained,” id. at 505, 730 A.2d at 812 (quoting Grasser v. Kitzis, 230 N.J.Super. 216, 221-22, 553 A.2d 346 (App.Div.1988)), or “that the drug was the medical cause of the child’s congenital impairment,” id. at 499, 730 A.2d at 809. “Medical causation,” as used in our prior opinions is an ambiguous term. It may mean either cause-in-faet, Fiore v. Consolidated Freightways, 140 N.J. 452, 464, 659 A.2d 436 (1995), or proximate cause, James v. Bessemer Processing Co., 155 N.J. 279, 299, 714 A.2d 898 (1998). No matter what “medical causation” means, it cannot be eliminated in this case without also eliminating proximate cause.
Initially, the majority acknowledges the absence of any causal connection between Provera and Brandon’s birth defect. Ante at 507-08, 730 A.2d at 814. Later, however, the majority relies on the “factual similarity or parallel between the unwarned or detected risk and the birth defect that eventuated.” Id. at 517, 730 A.2d at 819. The majority concludes, “This record clearly demonstrates a sufficient connection or parallel between the various allegations of physician negligence and the resulting harm to the infant, and warrants submission of plaintiffs wrongful birth claim *531to a jury.” Id. at 516-17 n. 10, 730 A.2d at 819 n. 10. In effect, the majority has substituted parallelism for proximate cause.
For the majority, proximate cause is satisfied in a wrongful birth action because the PDR once included an inaccurate warning of a correlation between Provera and limb reduction defects. Rejected by the majority in its causation analysis is the fact that medical science now accepts that the drug does not cause the defect. That rejection also informs the majority’s conclusion that “the risk materialized.” For the purposes of determining causation, however, the risk did not “materialize.” The unwarned risk was that Provera would cause limb reduction. Nothing in the record establishes that Provera caused Brandon’s limb reduction. It follows that the risk did not materialize. The majority is left, as it expressly acknowledges, with a risk that parallels, but is not the proximate cause of Brandon’s birth defect.
To support its finding of proximate cause, the majority states that the birth defect was “reasonably foreseeable, ... not too remote ... and that had defendants not been negligent, the pregnancy would have been terminated.” Id. at 515, 730 A.2d at 818. In so defining “proximate cause,” the majority confuses the role of foreseeability when determining proximate cause with its role when determining the existence of a duty.
The concept of foreseeability relates to both proximate cause and duty. In negligence cases, including those asserting wrongful birth claims, the time for determining foreseeability differs, depending on whether the determination concerns the scope of the physician’s duty to warn or the consequences proximately caused by a breach of that duty. See Kuzmicz v. Ivy Hill Park Apartments, Inc., 147 N.J. 510, 532-33, 688 A.2d 1018 (1997) (Stein, J., dissenting); Hill v. Yaskin, 75 N.J. 139, 143, 380 A.2d 1107 (1977). Compare Restatement (Second) of Torts, supra, § 289 (requiring actor to recognize risk of conduct based on knowledge then possessed or imputed to be possessed), with id. § 435 (actor’s conduct not legal cause of harm if, in hindsight, it appears “highly *532extraordinary” that the conduct should have brought about the harm). When considering the scope of a duty, the focus is on the level of knowledge existing at the time of treatment. See id. § 289. If, for example, medical knowledge at the time of treatment indicates that a warning is appropriate, the doctor is bound to give the warning. “Foresight, not hindsight, is the standard by which one’s duty of care is to be judged.” 57A Am.Jur.2d Negligence § 136 (1989); see also Lewis v. American Cyanamid Co., 155 N.J. 544, 565-66, 572-75, 715 A.2d 967 (1998) (stating that duty of manufacturer to use fire-retardant propellant, later banned for causing ozone depletion, is to be determined considering what was known at time of manufacture).
The role of foreseeability in the analysis of proximate cause, however, is determined by looking back, with full knowledge of all that has transpired since the breach of duty. Thus, an actor’s conduct is not the proximate cause of harm “where after the event and looking back from the harm to the actor’s negligent conduct, it appears ... highly extraordinary that it should have brought about the harm.” Restatement (Second) of Torts, supra, § 435; see also Basten v. United States, 848 F.Supp. 962 (N.D.Ala.1994) (finding no proximate cause in failure to warn when warning subsequently omitted from PDR).
The medical profession knows now, as distinguished from what some believed in 1991, that Provera does not cause limb reduction defects. Furthermore, the PDR ho longer warns that Provera may cause those defects. Indeed, the Canesis’ own experts no longer warn their patients about limb reduction defects. As a matter of law, the defects cannot be considered the foreseeable result of the doctors’ failure to warn. The doctors should not be held liable for medical expenses arising from those defects. By conflating the role of foreseeability in determining the physician’s duty to warn with its role in determining causation, the majority imposes liability for an injury unrelated to the breach of the doctor’s duty to the patient.
According to the majority,
*533The appropriate proximate cause question ... is not whether the doctor’s negligence caused the fetal defect; the congenital harm suffered by the child is expressly not compensable. Rather, the determination to be made is whether the doctors’ inadequate disclosure deprived the parents of their deeply personal right to decide for themselves whether to give birth to a child who could possibly be afflicted with a physical abnormality.
[Ante at 515, 730 A.2d at 818.]
That conclusion redefines the risk posed by a physician’s duty so that the physician is subject to liability not only for defects related to the physician’s failure to warn, but for all defects, whether related or not.
Until now, the absence of a causal connection between a prescribed drug and subsequent injury would preclude a claim against the physician in both informed consent and wrongful birth actions. “An unrevealed risk that should have been made known must materialize, for otherwise the omission, however unpardonable, is legally without consequence.... Negligence unrelated to injury is nonactionable.” Canterbury, supra, 464 F.2d at 790. By creating a cause of action for defects unrelated to the doctor’s omission, the majority eliminates the requirement that the resulting injury be precisely the one about which the physician failed to warn.
The result is that the majority has constituted physicians virtual insurers of the health of every baby born to women whom they fail to warn of all relevant risks. Miss any warning and the physician runs the risk of liability for any defect, even if unconnected with the omitted warning. Everything that follows from the child’s birth is “caused by” the doctor’s negligence. Despite its protestation to the contrary, ante at 514, 730 A.2d at 817, the majority has eliminated proximate cause and reconstituted but-for cause as the basis for the imputation of liability. By imposing liability in the absence of proximate cause, the majority strays beyond the limits established in this or any other jurisdiction.
Justice O’Hern’s concurring opinion makes explicit the flaws that in the majority opinion are implicit. Both opinions conflate *534the effect of a failure to warn in determining a breach of duty of care with its effect in determining causation. Proximate cause, according to the concurrence, is established not because Provera caused limb reduction defects, but because the risk and the defects were “parallel.” Only by eliminating proximate cause can the concurrence sustain its position that “[t]his case is about the occurrence of one of the very risks about which there was a legal duty to warn.” Ante at 520, 730 A.2d at 821 (O’Hern, J., concurring). The risk about which the doctors had a duty to warn was limb reduction defects caused by Provera, not limb reduction defects from unknown causes. The defect that occurred was not caused by Provera. The risk of that defect, therefore, was not “one of the very risks about which there was a legal duty to warn.” Ibid. The risk that “eventuated” was a birth defect caused not by Provera, but by something else, unrelated to the doctors’ breach of duty. Until today, a wrongful birth action required proof of more than a breach of duty and a birth defect. The additional element was proximate cause.
The concurrence’s confusion of duty and causation is made manifest by its emphasis that although
[i]t may be that science is unable to establish to a reasonable degree of medical certainty that Provera was the cause in fact of Brandon’s condition^ t]hat does not detract from the reality that the risk was one about which the patient should have been warned and was the risk that eventuated.
[Id. at 519, 730 A.2d at 820.]
Assuming that the doctors’ failure to warn that Provera could cause limb reduction defects constituted a breach of their duty of care, the point remains that to establish a cause of action, plaintiffs must prove that Provera caused the defect.
The concurrence acknowledges that “[w]e would not sustain a cause of action, for example, if Brandon had been born with a hereditary hip dislocation, a condition totally unrelated to the unwarned risk.” Id. at 518-19, 730 A.2d at 820. The reason that the concurrence would not impose liability is that Provera does not cause hip dislocations. Medical science, including plaintiffs’ experts, now accepts that Provera does not cause limb reduction *535defects. The PDR’s former warning of the risk of such defects, even if relevant on the issue of the doctors’ duty to warn, should not suffice, in light of current medical knowledge, to establish causation. If proximate cause is to remain an element of the cause of action, the failure to warn should not lead to the imposition of liability for limb reduction defects any more than it should for the hypothetical hip dislocation.
Apparently, the concurrence also would shift the burden of proof on causation from plaintiffs to the doctors. The concurrence states, “This case is about the occurrence of one of the very risks about which there was a legal duty to warn. It is not as though the record established that there was some other cause, genetic or environmental, that caused the defect.” Id. at 520, 730 A.2d at 821. Implicit in the comment that the record does not establish another cause for the birth defect is the premise that the doctors were obligated to establish such a cause. The logic of the concurrence is that absent proof of another cause, the doctors are liable for the cause asserted by plaintiffs. Thus, the concurrence would shift the burden of proof on causation from plaintiffs to defendants.
The determination of proximate cause necessarily involves public policy considerations. Prosser & Keeton on Torts, supra, § 42. As Justice Handler has stated:
In considering the standards that govern an appropriate duty of care and limitations of liability in [the context of health care], we must be especially mindful of the principles of sound public policy that are informed by perceptions of fairness and balance. We therefore insist that an immediate, close and clear involvement or connection be present between a person suffering emotional distress [the claimed injury] and the conduct of the professional health care providers whose fault has contributed to [the event that precipitated the emotional distress].
[Gendek v. Poblete, 139 N.J. 291, 302, 654 A.2d 970 (1995).]
Identifying relevant public policy considerations is crucial when considering such sensitive claims as those for wrongful birth or wrongful life. Those claims implicate understandable compassion both for the child and for the child’s parents. Accompanying that compassion is concern for the financial costs that the parents and child must bear because of the child’s birth defects. Another *536consideration is the woman’s constitutional right to choose whether to abort a fetus or to carry it to term. A countervailing consideration is the fairness of imposing liability on a physician for a result unrelated to the physician’s act. Childbearing and childbirth, moreover, pose inherent risks for both mother and child. Finally, if physicians are to ensure the birth of perfect babies, the cost of that insurance will be spread among all pregnant women. Thus, the majority opinion also implicates concerns about the undue escalation of the cost of health care. Until today, courts have struck the balance in failure-to-warn wrongful birth actions by requiring the unwarned risk to be the one that eventuates. From my perspective, that conclusion still represents the appropriate balance.
C.
The majority suggests that both the Law Division and the Appellate Division may have failed to consider all of plaintiffs’ claims. According to the majority, those courts overlooked plaintiffs’ wrongful birth claim, which sought to recover only the parents’ own damages, as distinct from the informed consent claim in which they sought to recover damages on Brandon’s behalf for his impaired condition. Ante at 507-09, 730 A.2d at 814. Additionally, the majority contends that the lower courts may not have permitted plaintiffs to argue on grounds “not dependent on medical causation between the prescribed drug and the resulting birth defect.” Id. at 508, 730 A.2d at 814.
These “ ‘other independent grounds of liability’ ” include “defendants’ negligent failure to ‘inform and warn’ plaintiffs ‘that the drug manufacturers issued clear warnings that Provera should not be taken during the first four months of pregnancy’ and that the PDR required warnings of general ‘congenital anomalies,’ and that this negligence, together with other negligent acts, deprived them of the opportunity to terminate the pregnancy:” Id. at 508, 730 A.2d at 814. Additionally, the majority states that plaintiffs’ *537attorney “expressly argued” that by neglecting to warn Melissa Canesi, the doctors “ ‘didn’t give her a chance’ ” to evaluate all the possible detrimental effects that could result from taking Provera. Ibid. The majority’s concerns reflect a tortured reading of the record.
Plaintiffs’ attorney acknowledged to the trial court that he had “ ‘some big problems on the causation’ issue,” but claimed that a causative link between Provera and Brandon’s birth defect was unnecessary to plaintiffs’ wrongful birth claim. Id. at 508-09, 730 A.2d at 814. The attorney contended that plaintiffs’ wrongful birth claim was “ ‘not the more typical case of a failure to obtain informed consent.’ ” Id. at 508, 730 A.2d at 814. Despite this argument, the majority insists that “the trial court did not determine whether plaintiffs’ contentions based on a wrongful birth claim fell beyond the scope of defendants’ motion for summary judgment and whether the evidence was sufficient to support a wrongful birth claim.” Id. at 509, 730 A.2d at 814. Having made these observations, the majority determines that the case merits a fresh analysis by this Court of plaintiffs’ evidence. Id. at 508-09, 730 A.2d at 814.
A close reading of the record reveals, however, that the lower courts considered all of plaintiffs’ claims. In the Law Division, plaintiffs’ attorney argued and the court considered each of the arguments propounded by the majority. Although plaintiffs’ attorney initially labeled plaintiffs’ wrongful birth claim as one for “informed consent,” plaintiffs’ attorney and the court understood the claim as one for wrongful birth.
To illustrate, the briefs and oral argument in the Law Division centered on the two leading wrongful birth opinions, Berman and Procanik. Additionally, plaintiffs’ attorney relentlessly asserted what he described as the “lost-opportunity-to-eleet-to-abort” claim. He differentiated that claim from a “typical” informed consent claim and argued that the differences, including the different damages sought, justified dispensing with proof that Provera *538caused Brandon’s defect. To support plaintiffs’ wrongful birth claim, their attorney pointed to three potential effects of Provera: limb reduction, retention of a defective ovum, and “other abnormalities.”
In dismissing the complaint, the trial court summarized plaintiffs’ argument:
The issue in this case ... is a unique issue and a very interesting issue____ [T]he arguments really have honed down to what can be read into the second basis. Mr. Valore had argued that by virtue of the contents of the 1991 PDR black box regarding Provera that ... that’s sufficient to go to the jury with respect to proximate cause between the failure to warn and the birth of a child with limb reduction deficit____
Absent any supporting expert testimony, the trial court correctly found that the physicians’ breach of their duty of care was not causally related to the birth defect:
It was argued that [the case] goes to a jury because the prescribing of Provera to a pregnant woman increased the risk that if she was carrying an abnormal fetus, that such fetus would be retained rather than spontaneously aborted [defective ovum argument]____ There is no testimony to that in the case____ And that brings us to the issue, which is really the heart of the argument. Number 2, that the failure to inform and warn Mrs. Canesi once they knew she was pregnant, that the taking of Provera during the early stages of her pregnancy posed potential risk to the fetus[,] thus depriving her of the opportunity to make a reasoned determination as to whether the pregnancy should be terminated or not____ That is the real issue in this case and that’s the issue that gave me a lot of concern____ I view that as an argument that' would extend the parameters of current and existing law or would fly in the face of current existing law. The cases that I’ve read cited by both parties with respect to failure to warn [including Berman and Procanik] all, without exception, involve failure to warn of risks which ultimately involve the patient suffering from one of the veiy risks that she was not warned about. There hasn’t been one ease in the reported decisions that has deviated from that concept. This would be that case.
In plaintiffs’ motion for reconsideration, their attorney again differentiated wrongful birth and informed consent claims. Their attorney repeated that the omitted warnings should have included not only the possibility of limb reduction defects, but of “fetal abnormalities” in general.
Plaintiffs raised the same arguments in the Appellate Division, contending that they need not prove that Provera caused Canesi’s ovum to be defective. They did not address the need to show that *539an ovum was defective or that Provera caused Canesi to retain it. In this Court, plaintiffs likewise have failed to claim that Canesi’s fertilized ova were defective or that Provera delayed her spontaneous abortion of one of them.
Like the trial court, the Appellate Division rejected plaintiffs’ wrongful birth claim for lack of proof of proximate cause:
[W]e are convinced that plaintiffs’ cause of action cannot exist unless it is demonstrated that the undisclosed harm or risk actually occurred and that defendant’s negligence was a proximate cause of the condition complained of. We do not believe that legal acceptance of plaintiffs’ theory of causation is appropriate or desirable. Plaintiffs’ theory would impose liability for a failure to warn or to obtain informed consent without regal’d to whether the ultimate consequence in fact related to the condition of which the doctor failed to warn or inform the patient.
[295 N.J.Super. at 362, 685 A.2d 49 (emphasis added).]
The Appellate Division concluded:
Because Brandon’s deformity is not related to the drug to which the warning pertained, we hold, as a matter of law, that legal or proximate causation between the consequences of the birth and the failure to warn, resulting in a lost opportunity to abort, may not be found. To hold otherwise would lead to a multitude of tort claims based on “chance occurrences,” rather than legally definable causal relationships.
[Id. at 362-63, 685 A.2d 49.]
Contrary to the majority’s assertion, the lower courts considered and determined all of plaintiffs’ claims. Both the Law Division and the Appellate Division dismissed Canesi’s wrongful birth claim because she was unable to establish that Provera had caused Brandon’s birth defect.
The majority also seeks to bolster Canesi’s failure-to-warn claim with other claims based on the doctors’ failure to detect or diagnose Brandon’s defect. That effort leads the majority to reach for evidence of “maternal indicators”: spotting, the death of a fetal twin, and excessive amniotic fluid. According to the majority, those indicators suggest that defendant doctors are liable for a failure to diagnose Brandon Canesi’s birth defect. Ante at 511 n. 5, 513 nn. 6 & 7, 730 A.2d at 816 n. 5, 817 nn. 6 & 7.
*540Plaintiffs’ experts did not address the claimed “maternal indicators” in their reports. Neither did plaintiffs’ attorney brief the issue in the Law Division. Plaintiffs also omitted any reference to “maternal indicators” from their brief in the Appellate Division and their petition for certification to this Court. In sum, the only argument about “maternal indicators” was a fleeting reference in the heat of oral argument in the Law Division. Until introduced by the majority, the issue was not a part of this appeal.
Reliance on the doctors’ failure to detect Brandon’s defects is the majority’s unique contribution to plaintiffs’ claim. The sole mention of plaintiffs’ failure-to-detect claim, like the reference to “maternal indicators,” was at oral argument in the Law Division. Plaintiffs understandably did not base their wrongful birth claim on the doctors’ failure to diagnose. They could not because no expert identified a test capable of detecting Brandon Canesi’s defect. As is the case with “maternal indicators,” plaintiffs’ petition for certification to this Court does not even mention “failure to diagnose” as a basis for liability. Instead, plaintiffs have concentrated exclusively on the doctors’ failure to warn of the adverse effects of ingesting Provera.
As we have said before, “[ojrdinarily courts do not raise issues that the parties have not raised.” Office of Employee Relations v. Communications Workers, 154 N.J. 98, 108, 711 A.2d 300 (1998) (criticizing Appellate Division’s introduction of arbitrability issue on its own motion and without notice to parties). If the interests of justice demand that an omitted issue be raised, “the better practice is to permit the parties to address it.” Ibid.; cf. R. Wilson Plumbing & Heating v. Wademan, 246 N.J.Super. 615, 617, 588 A.2d 444 (App.Div.1991) (reversing trial court’s award of treble damages based on statutory violation never alleged by plaintiff). The majority should not introduce at this juncture claims that plaintiffs do not assert, the record does not support, and the lower courts never considered.
A failure-to-detect case differs fundamentally from one based on failure to warn, particularly with respect to proximate cause. The *541majority nevertheless relies on a failure-to-deteet case, Keel v. Banach, 624 So.2d 1022 (Ala.1993), to support its elimination of the “medical causation” aspect of proximate cause. Ante at 502-03, 730 A.2d at 811. Keel involved a doctor’s failure to detect or diagnose genetic abnormalities. The plaintiffs’ child was bom with handicaps that the omitted tests would have revealed. The parents claimed that the doctor’s failure to diagnose the child’s defects had deprived them of the right to choose to terminate the pregnancy. The majority quotes Keel for the proposition:
The nature of the tort of wrongful birth has nothing to do with whether a defendant caused the injury or harm to the child, but, rather, with whether the defendant’s negligence was the proximate cause of the parents’ being deprived of the option of ... making an informed and meaningful decision either to terminate the pregnancy or to give birth to a potentially defective child.
[Ibid, (quoting Keel, supra, 624 So.2d at 1029).]
Missing from the majority’s quotation, however, is the remainder of the paragraph:
Like most of the other courts that have considered this cause of action, we hold that the parents of a genetically or congenitally defective child may maintain an action for its wrongful birth if the birth was the result of the negligent failure of the attending prenatal physician to discover and inform them of the existence of fetal defects.
[Keel, supra, 624 So.2d at 1029.]
A fair reading of Keel, therefore, reveals that it does not eliminate the requirement of proximate cause. Instead, it applies the concept to the circumstances of a failure-to-detect action.
The flaws in plaintiffs’ claim become apparent on viewing the claim as they view it, as one for failure to warn. Ultimately, the claim’s expansion on the basis , of “other independent grounds of liability,” ante at 508, 730 A.2d at 814, must relate to plaintiffs’ assertion that Provera was detrimental to Canesi’s fetus or to her pregnancy. See id. at 506-08 & n. 4, 730 A.2d at 813-14 & n. 4. Brandon’s only birth defect was limb reduction, which the majority concedes Provera did not cause. Plaintiffs have not demonstrated the essential relationship between Provera and the birth defect. *542Consequently, the physicians’ failure to warn should not expose them to liability.
The cause of action created.by the majority subjects physicians to liability for failing to warn about the adverse effects of a drug that are not causally linked to the claimed birth defect. By breaking that link, the majority has unleashed a cause of action that knows no bounds.
I would affirm the judgment dismissing the wrongful birth claim.
GARIBALDI, J., joins in this dissent.
For affirmance .in part; reversal in part; remandment — Chief Justice PORITZ and Justices HANDLER, O’HERN, STEIN, and COLEMAN — 5.
Concurring in result — Justice O’HERN — 1.
For affirmance — Justices POLLOCK and GARIBALDI — 2.