Case: 13-51008Document: 00512592062Page: 1Date Filed: 04/10/2014No. 13-51008IN THE UNITED STATES COURT OF APPEALSFOR THE FIFTH CIRCUITPLANNED PARENTHOOD OF GREATER TEXAS SURGICAL HEALTHSERVICES; PLANNED PARENTHOOD CENTER FOR CHOICE; PLANNEDPARENTHOOD SEXUAL HEALTHCARE SERVICES; WHOLE WOMAN’ SHEALTH; AUSTIN WOMEN’ S HEALTH CENTER; KILLEEN WOMEN’ SHEALTH CENTER; SOUTHWESTERN WOMEN’ S SURGERY CENTER;WEST SIDE CLINIC, INCORPORATED; ROUTH STREET WOMEN’ SCLINIC; HOUSTON WOMEN’ S CLINIC, each on behalf of itself, its patientsand physicians; ALAN BRAID, M.D.; LAMAR ROBINSON, M.D.; PAMELAJ. RICHTER, D.O., each on behalf of themselves and their patients; PLANNEDPARENTHOOD WOMEN’ S HEALTH CENTER,Plaintiffs-Appellees,v.ATTORNEY GENERAL GREGORY ABBOTT; DAVID LAKEY, M.D.;MARI ROBINSON, Executive Director of the Texas Medical Board,Defendants-Appellants.On Appeal from the United States District Court for theWestern District of Texas, Austin DivisionCase No. 1:13-cv-00862-LYPETITION FOR REHEARING EN BANCR. James George, Jr.Elizabeth von KreislerGeorge Brothers Kincaid & HortonLLP1100 Norwood Tower114 West 7th StreetAustin, TX 78701April 10, 2014Janet CreppsEsha BhandariJennifer SokolerCenter for Reproductive Rights120 Wall Street, 14th FloorNew York, NY 10005Attorneys for Plaintiffs-Appellees(complete list of counsel follows)Case: 13-51008Document: 00512592062Page: 2Date Filed: 04/10/2014R. James George, Jr.Janet CreppsElizabeth von KreislerEsha BhandariGeorge Brothers Kincaid & Horton Jennifer SokolerLLPCenter for Reproductive Rights1100 Norwood Tower120 Wall Street, 14th Floor114 West 7th StreetNew York, NY 10005Austin, TX 78701(864) 962-8519 (Crepps)(512) 495-1400(917) 637-3600 (Bhandari & Sokoler)(512) 499-0094jcrepps@reprorights.orgjgeorge@gbkh.comebhandari@reprorights.orgevonkreisler@gbkh.comjsokoler@reprorights.orgAttorneys for all Plaintiffs-AppelleesAttorneys for Plaintiffs-Appellees WholeWoman’ s Health, Austin Women’ sBrigitte AmiriHealth Center, Killeen Women’ s HealthRenée ParadisCenter, Southwestern Women’ s SurgeryAmerican Civil Liberties Union Center, West Side Clinic, Inc., AlanFoundationBraid, M.D., Lamar Robinson, M.D.,Reproductive Freedom Projectand Pamela J. Richter, D.O.125 Broad Street, 18th FloorNew York, NY 10004Helene T. Krasnoff(212) 519-7897Alice Clapmanbamiri@aclu.orgPlanned Parenthood Federation ofrparadis@aclu.orgAmerica1110 Vermont Ave., N.W., Suite 300Rebecca L. RobertsonWashington, D.C. 20005American Civil Liberties Union of (202) 973-4800Texashelene.krasnoff@ppfa.org1500 McGowen Street, Suite 250alice.clapman@ppfa.orgHouston, TX 77004(713) 942-8146Attorneys for Planned Parenthoodrrobertson@aclutx.orgPlaintiffs-AppelleesAttorneys for Plaintiffs-AppelleesRouth Street Women’ s Clinic,Houston Women’ s Clinic, andSouthwestern Women’ s SurgeryCenterCase: 13-51008Document: 00512592062Page: 3Date Filed: 04/10/2014CERTIFICATE OF INTERESTED PERSONSPlanned Parenthood, et al. v. Abbott, et al., No. 13-51008The undersigned counsel of record certifies that the following listed personsand entities, as described in the fourth sentence of Rule 28.2.1, have an interest inthe outcome of this case. These representations are made in order that the judges ofthis Court may evaluate possible disqualification or recusal.Plaintiffs-AppelleesPlaintiffs-Appellees’ CounselHelene T. KrasnoffAlice ClapmanPlanned Parenthood Federation ofAmericaPlanned Parenthood of Greater TexasSurgical Health ServicesPlanned Parenthood Center forChoicePlanned Parenthood SexualHealthcare ServicesPlanned Parenthood Women’ sHealth CenterWhole Woman’ s HealthAustin Women’ s Health CenterKilleen Women’ s Health CenterSouthwestern Women’ s SurgeryCenterWest Side Clinic, Inc.Alan Braid, M.D.Lamar Robinson, M.D.Pamela J. Richter, D.O.Routh Street Women’ s ClinicHouston Women’ s ClinicSouthwestern Women’ s SurgeryCenterJanet CreppsEsha BhandariJennifer SokolerCenter for Reproductive RightsBrigitte AmiriRenée ParadisAmerican Civil Liberties UnionFoundation, Reproductive FreedomProjectRebecca L. RobertsonAmerican Civil Liberties Union of TXiCase: 13-51008Document: 00512592062Page: 4Date Filed: 04/10/2014All PlaintiffsR. James George, Jr.Elizabeth von KreislerRico ReyesGeorge Brothers Kincaid & Horton,LLPDefendants-AppellantsGreg AbbottDavid Lakey, M.D.Mari RobinsonDefendants-Appellants’ CounselJonathan F. MitchellJohn B. ScottAdam W. AstonAndrew S. OldhamArthur C. D’ AndreaBeth KlusmannPhilip A. LionbergerMichael P. MurphyGunnar P. SeaquistOffice of the Attorney GeneralDefendants in the District Courtdismissed from this action upon thestipulation of the partiesDavid EscamillaCraig WatkinsDevon AndersonMatthew PowellJames E. NicholsJoe Shannon, Jr.Rene GuerraSusan D. ReedAbelino ReynaJaime EsparzaDismissed Defendants’ CounselElaine A. CasasDismissed prior to appearance ofcounselAmici CuriaeAmerican Association of Pro-LifeObstetricians & GynecologistsChristian Medical AssociationCatholic Medical AssociationPhysicians for LifeAmici Cur iae’ s CounselMailee Rebecca SmithAmericans United for LifeiiCase: 13-51008Document: 00512592062National Association of Pro-LifeNursesNational Catholic Bioethics CenterNational Association of CatholicNursesTexas Alliance for Life Trust FundTexas Center for Defense of LifeDavid DewhurstAssociation of American Physicians& SurgeonsTexas Eagle ForumTexas Right to LifeEagle Forum Education & LegalDefense FundTexas State Representatives:o Charles Andersono Cecil Bell, Jr.o Dwayne Bohaco Dennis Bonneno Greg Bonnen, M.D.o Cindy Burketto Bill Callegario Giovanni Capriglioneo Tony Daleo John E. Daviso Gary Elkinso Pat Fallono Allen Fletchero Dan Flynno James Franko Craig Goldmano Linda Harper-Browno Bryan Hugheso Jason Isaaco Philip Kingo Stephanie Klicko Matt Krauseo Jodie Laubenbergo George LavenderPage: 5Date Filed: 04/10/2014Stephen Daniel CaseyCasey Law Office, P.C.Lawrence John JosephiiiCase: 13-51008Document: 00512592062o Jeff Leacho Rick Millero Jim Murphyo John Ottoo Chris Paddieo Tan Parkero Charles Perryo Larry Philipso Jim Pittso Scott Sanfordo Matt Schaefero Ron Simmonso David Simpsono John T. Smitheeo Drew Springero Jonathan Sticklando Van Tayloro Ed Thompsono Steve Totho Scott Turnero James Whiteo Paul Workmano Bill ZedlerTexas State Senatorso Brian Birdwello Donna Campbello John Caronao Bob Deuello Craig Esteso Tony Frasero Kelly Hancocko Glenn Hegar, Jr.o Eddie Lucioo Jane Nelsono Robert Nicholso Dan Patricko Ken Paxtono Larry TaylorTexas State Representative DanielHugh BranchPage: 6Date Filed: 04/10/2014Daniel Hugh BranchWinstead, P.C.ivCase: 13-51008Document: 00512592062Page: 7Date Filed: 04/10/2014Catherine Glenn FosterAlliance Defending FreedomAlliance Defending FreedomBioethics Defense FundFamily Research CouncilAmerican College of Obstetriciansand GynecologistsAmerican Medical AssociationKimberly A. ParkerSkye Lynn PerrymanWilmer, Cutler, Pickering, Hale & Dorr,L.L.P/s/ Janet CreppsJanet CreppsAttorney for Plaintiffs-AppelleesvCase: 13-51008Document: 00512592062Page: 8Date Filed: 04/10/2014STATEMENT OF COUNSELOn March 27, 2014, a three-judge panel of this Court reversed a districtcourt judgment declaring unconstitutional two provisions of a Texas lawrestricting the provision of abortion. Specifically, the Panel opinion reversed thedistrict court’ s judgment: (1) facially invaliding a requirement that everyphysician performing an abortion in Texas have active admitting privileges at ahospital within 30 miles of where the abortion is performed, and (2) enjoining aban on the provision of medication abortion after 49 days of pregnancy only asapplied to those women for whom a physician, in his or her reasonable medicaljudgment, determines that a medication abortion is significantly safer than asurgical procedure.Counsel represents that en banc reconsideration by this Court is necessarybecause the Panel opinion conflicts with decades of precedent from the UnitedStates Supreme Court in two ways:First, the Panel decision conflicts with the decisions of the Supreme Courtin Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833(1992); City of Akron v. Akron Center for Reproductive Health, 462 U.S. 416(1983), overruled on other grounds, Casey, 505 U.S. 833; and PlannedParenthood of Central Missouri v. Danforth, 428 U.S. 52 (1976), in which theCourt applied heightened scrutiny to assess restrictions on abortion asserted toviCase: 13-51008Document: 00512592062Page: 9Date Filed: 04/10/2014further the State’ s interest in women’ s health. In particular, in those cases, theCourt considered evidence presented by the parties, including the standards ofleading medical groups, to determine whether an abortion restriction that the stateclaims advances women’ s health actually does so. Contrary to these decisions,the Panel opinion applied only rational basis review, and held that not only doesthe State bear no evidentiary burden to justify such a requirement, but there needonly be a “conceivable rationale . . . for [its] enactment.” Planned Parenthood ofGreater Tex. Surgical Health Servs. v. Abbott, No. 13-51008, 2014 WL 1257695,at *7 (5th Cir. Mar. 27, 2014). This is a question of exceptional importance notonly to women’ s constitutional rights, but because this Court’ s docket, as well asthose in other courts of appeals, include similar challenges to abortion restrictionsthat the state seeks to justify as advancing women’ s health.Second, the Panel decision conflicts with the Supreme Court’ s decisions inCasey, 505 U.S. 833; Ayotte v. Planned Parenthood of Northern New England,546 U.S. 320 (2006); and Gonzales v. Carhart, 550 U.S. 124 (2007), because itupholds a statute that exposes women to significant health risks. Following theinstruction of these cases, Plaintiffs-Appellees (“Appellees” ) brought a preenforcement, as applied challenge to the medication abortion restrictions, seekingto have those provisions declared unconstitutional and enjoined only as applied towomen past 49 days in pregnancy for whom surgical abortion presentsviiCase: 13-51008Document: 00512592062Page: 10Date Filed: 04/10/2014significantly greater health risks. The Panel, contrary to the holding in Gonzales,incorrectly held that such a challenge was a “facial challenge.” This is a questionof exceptional importance not only because the Panel’ s decision would precludevirtually all, if not all, pre-enforcement as-applied challenges, but because itexposes Texas women to significant health risks.viiiCase: 13-51008Document: 00512592062Page: 11Date Filed: 04/10/2014TABLE OF CONTENTSPageCERTIFICATE OF INTERESTED PERSONS .........................................................iSTATEMENT OF COUNSEL .................................................................................viTABLE OF CONTENTS ..........................................................................................ixTABLE OF AUTHORITIES ..................................................................................... xSTATEMENT OF THE ISSUES............................................................................... 1STATEMENT OF THE COURSE OF PROCEEDINGS ANDDISPOSITION OF THE CASE ...................................................................... 1ARGUMENT AND AUTHORITIES ........................................................................ 6I.The Panel’ s Opinion Applying Rational Basis to the PrivilegesRequirement Conflicts With Supreme Court Precedent.................................. 6II.The Panel’ s Ruling With Respect to Appellees’ Pre-Enforcement AsApplied Challenge to the Medication Abortion Restrictions IsContrary to Supreme Court Precedent and Could Eliminate SuchChallenges...................................................................................................... 10CONCLUSION ........................................................................................................ 14CERTIFICATE OF SERVICE ................................................................................ 15ixCase: 13-51008Document: 00512592062Page: 12Date Filed: 04/10/2014TABLE OF AUTHORITIESCasesPageAyotte v. Planned Parenthood of Northern New England,546 U.S. 320 (2006) ...................................................................................... passimCity of Akron v. Akron Center for Reproductive Health, 462 U.S. 416(1983), overruled on other grounds, Planned Parenthood ofSoutheastern Pennsylvania v. Casey, 505 U.S. 833 (1992) ......................... vi, 1, 7Gonzales v. Carhart, 550 U.S. 124 (2007) ...................................................... passimJackson Women’ s Health Organization v. Currier, No. 13-60599 (5th Cir.) ...........8Lawrence v. Texas, 539 U.S. 558 (2003) ...................................................................6Planned Parenthood of Central Missouri v. Danforth,428 U.S. 52 (1976) .................................................................................... vi, 1, 7, 8Planned Parenthood of Greater Texas Surgical Health Services v. Abbott,134 S. Ct. 506 (2013) ..............................................................................................5Planned Parenthood of Greater Texas Surgical Health Services v. Abbott,734 F.3d 406 (5th Cir. 2013) ..................................................................................5Planned Parenthood of Greater Texas Surgical Health Services v. Abbott,No. 13-51008, 2014 WL 1257695 (5th Cir. Mar. 27, 2014) ........................ passimPlanned Parenthood of Southeastern Pennsylvania v. Casey,505 U.S. 833 (1992) ...................................................................................... passimPlanned Parenthood of Wisconsin v. Van Hollen, 738 F.3d 786 (7th Cir. 2013) .....9Planned Parenthood Southeast, Inc. v. Strange, No. 2:13cv405-MHT(M.D. Ala. Mar. 31, 2014) ......................................................................................9Roe v. Wade, 410 U.S. 113 (1973) ...........................................................................10Whole Women’ s Health v. Lakey, No. 14 CV-00284-LY(W.D. Tex. filed April 2, 2014) ..............................................................................8xCase: 13-51008Document: 00512592062Page: 13Date Filed: 04/10/2014STATEMENT OF ISSUES1)Does the Panel opinion, applying rational basis scrutiny to the issueof whether the admitting privileges requirement is justified by the state’ s assertedinterest in women’ s health, conflict with the decisions of the United StatesSupreme Court in Planned Parenthood of Southeastern Pennsylvania v. Casey,505 U.S. 833 (1992); City of Akron v. Akron Center for Reproductive Health, 462U.S. 416 (1983), overruled on other grounds, Casey, 505 U.S. 833; and PlannedParenthood of Central Missouri v. Danforth, 428 U.S. 52 (1976), in which theCourt applied heightened scrutiny in assessing restrictions on abortion asserted tofurther the State’ s interest in women’ s health?2)Does the Panel opinion’ s rejection of Appellees’ as-applied pre-enforcement claim – that the medication abortion restrictions pose an undueburden on women past 49 days in pregnancy for whom surgical abortion presentssignificantly greater health risks – as a “facial challenge,” conflict with Casey,505 U.S. 833; Ayotte v. Planned Parenthood of Northern New England, 546 U.S.320 (2006); and Gonzales v. Carhart, 550 U.S. 124 (2007), and operate topreclude virtually all, if not all, pre-enforcement as-applied challenges?STATEMENT OF THE COURSE OF PROCEEDINGSAND DISPOSITION OF THE CASEAppellees respectfully seek rehearing en banc of the Panel’ s March 27decision overturning the district court’ s ruling that two provisions of Texas House1Case: 13-51008Document: 00512592062Page: 14Date Filed: 04/10/2014Bill 2 (“the Act” ) violate the substantive due process rights of women seekingabortions. The first requires that physicians who perform abortions have admittingprivileges at a hospital that provides obstetrical or gynecological services within 30miles of the location of the abortion (the “admitting privileges requirement”). Thesecond limits the provision of medication abortion, a safe and effective way to end anearly pregnancy (the “medication abortion restrictions” ).1The Act was enacted during a July 2013 special legislative session to beeffective October 29, 2013. Appellees, licensed abortion providers and physicians,filed suit on behalf of themselves and their patients. On October 28, 2013, the districtcourt, following a trial, issued an opinion, ROA.1532-57, and final judgment,ROA.1558-60, permanently enjoining the admitting privileges requirement and1A medication abortion involves taking the prescription medications mifepristone(also known by its brand name Mifeprex) and misoprostol. Research and years ofpractical experience has shown that the medication abortion protocol used byAppellees before the Act took effect, which differs from the one on the Mifeprexlabel, is effective through at least 63 days after the first day of the woman’ s lastmenstrual period (“ LMP” ). As the district court found, “ when performed inaccordance with the off-label protocol, medication abortion is a safe and effectiveprocedure,” Record on Appeal (“ROA” ) 1552, through 63 days LMP, which is “thede facto standard of care in Texas.” ROA.1547. A regimen that extends to 63 daysLMP is also recognized as superior by both the American Medical Association andthe American Congress of Obstetricians and Gynecologists. Brief of Amici CuriaeAmerican College of Obstetricians and Gynecologists and the American MedicalAssociation in Support of Plaintiffs-Appellees and in Support of Affirmance at 17.The Act nonetheless limits medication abortion in Texas, inter alia, to 49 daysLMP..2Case: 13-51008Document: 00512592062Page: 15Date Filed: 04/10/2014enjoining the medication abortion restrictions as applied to those procedures “wherea physician determines in appropriate medical judgment, such a procedure isnecessary for the preservation of the life or health of the mother.” ROA.1559.The district court held the admitting privileges requirement unconstitutionalbecause it does not advance the state’s interest in women’s health.2 After reviewingthe evidence presented by the parties, it correctly found that “whether an abortionprovider has admitting privileges does nothing to further the interest of patient care”with respect to communication, timeliness or quality of emergency room and hospitalcare, patient abandonment, or provider accountability. ROA.1541-42. Indeed, it heldthat “admitting privileges have no rational relationship to improved patient care,” andthat a “lack of admitting privileges on the part of an abortion provider is of noconsequence when a patient presents at a hospital emergency room.” Id.In support of this conclusion, the district court found that: “emergency-roomphysicians treat patients of physicians with admitting privileges no differently thanpatients of physicians without admitting privileges” ; there is “no evidence ofcorrelation between admitting privileges and improved communication with2The district court also concluded that the admitting privileges requirement“places an ‘ undue burden’ on a woman seeking abortions services in Texas” bycreating “a ‘ substantial obstacle’ to access.” ROA.1542. Specifically, the courtfound that, as a result of the requirement, “there will be abortion clinics that willclose,” and in particular noted that “the Rio Grande Valley would be left with noabortion provider.” Id.3Case: 13-51008Document: 00512592062Page: 16Date Filed: 04/10/2014patient handoff or that a communication problem actually exists between abortionproviders and emergency-room physicians” ; “[a]dmitting privileges make nodifference in the quality of care received by an abortion patient in an emergencyroom” ; and admitting privileges do not “impact the timeliness of care in theemergency room, where the nature of the practice is to treat patients with allpossible haste.” ROA.1541.The district court also enjoined the medication abortion restrictions as appliedonly to those procedures “where a physician determines in appropriate medicaljudgment, such a procedure is necessary for the preservation of the life or health ofthe mother.” ROA.1559. The district court explained that it had been presented with“uncontroverted evidence” that:some women have medical conditions that can make first-trimestersurgical abortion extremely difficult or impossible. Such cases mayinclude women who are extremely obese, have uterine fibroidsdistorting normal anatomy, have a uterus that is very flexed, or havecertain uterine anomalies. For these women, surgical abortion posesmuch higher risks of failed abortion, as well as complications such asperforation of the uterus. Another circumstance where surgicalabortion may be higher risk is when a woman has a condition knownas stenotic cervix – a cervix with an abnormally small opening, oftencaused by scarring from prior surgeries. It may also happen when awoman has undergone female genital mutilation. Requiring a womanwith these conditions to have surgical rather than medication abortionmay put them at significantly higher risk for damage to the cervix orother complications, including uterine perforation.ROA.1551 n.18.The district court concluded that the medication abortion restrictions are an4Case: 13-51008Document: 00512592062Page: 17Date Filed: 04/10/2014“undue burden on those women for whom surgical abortion is, in the soundmedical opinion of their treating physician, a significant health risk during theperiod of pregnancy falling 50 to 63 days LMP.” ROA.1556. It therefore enjoinedDefendants-Appellants (“Appellants” ) from enforcing the medication abortionrestrictions “to the extent those provisions prohibit a medication abortion where aphysician determines in appropriate medical judgment, such procedure is necessaryfor the preservation of the life or health of the mother.” ROA.1559.Appellants moved this Court for an emergency stay of the district court’ sinjunction. On October 31, 2013, a three-judge panel granted that motion in largepart, staying the district court’ s injunction against the admitting privilegesrequirement and narrowing the injunction against the medication abortionrestrictions. Planned Parenthood of Greater Tex. Surgical Health Servs. v. Abbott,734 F.3d 406 (5th Cir. 2013). Appellees filed an application with Justice Scaliaasking the Supreme Court to vacate this Court’ s stay, and on November 19, 2013,in a 5-4 decision, the Supreme Court denied that application. Planned Parenthoodof Greater Tex. Surgical Health Servs. v. Abbott, 134 S. Ct. 506 (2013).On March 27, 2014, a three-judge panel of this Court reversed both thedistrict court’ s holding that the admitting privileges requirement is faciallyunconstitutional and its limited injunction against the medication abortionrestrictions. As relevant to this petition, the Panel held that the district court erred5Case: 13-51008Document: 00512592062Page: 18Date Filed: 04/10/2014by “second guess[ing] legislative factfinding,” and should have only asked“ whether any conceivable rational exists” for the admitting privileges requirement,rather than consider evidence or data. Abbott, 2014 WL 1257965, at *7. Withrespect to the medication abortion restrictions, the Panel held that they “ do notfacially require[] a court-imposed exception for life and health of the woman,” anda subsequent as-applied challenge is “the proper means of challenging the lack ofan exception to the regulations at issue.” Id. at*16.ARGUMENT AND AUTHORITIESI.The Panel’ s Opinion Applying Rational Basis to the PrivilegesRequirement Conflicts With Supreme Court Precedent.The Supreme Court has consistently applied heightened scrutiny to reviewabortion restrictions that purportedly further the state’ s interest in women’ s health.The Panel, however, applied the rational basis test, which is wholly inconsistentwith the fundamental nature of a woman’ s right to decide whether to continue apregnancy. See Casey, 505 U.S. at 834, 851 (the “decision whether to bear or begeta child” is one of those “fundamental[]” choices that is “central to the libertyprotected by the Fourteenth Amendment” ); see also Lawrence v. Texas, 539 U.S.558, 565 (2003) (the right to abortion has “real and substantial protection as anexercise of [a woman’ s] liberty under the Due Process Clause” ).Indeed, the Supreme Court has repeatedly rejected rational basis review asthe standard for evaluating restrictions on abortion. Casey, 505 U.S. at 845-466Case: 13-51008Document: 00512592062Page: 19Date Filed: 04/10/2014(refusing to overturn Roe and adopt a rational relationship test); Akron, 462 U.S. at420 n.1 (rejecting rational basis review).Therefore, when confronted with a regulation purporting to advancewomen’ s health, the Supreme Court carefully examines the extent to which therestriction is actually (as opposed to hypothetically) tailored to advance thepurported state interest and whether it is consistent with accepted medical practice.See, e.g., Akron, 462 U.S. at 431 (“If a State . . . undertakes to regulate theperformance of abortions . . . the health standards adopted must be legitimatelyrelated to the objective the State seeks to accomplish.” (quotation marks omitted));Akron, 462 U.S. at 430 (“the decisive factor” in upholding recordkeepingregulations in Danforth, 428 U.S. 52, was that “the State met its burden ofdemonstrating that these regulations furthered important health-related Stateconcerns” ).Contrary to the Panel decision’ s holding, Abbott, 2014 WL 1257965, at *3,Casey did not overrule Akron and Danforth as those cases relate to the standard forevaluating abortion restrictions purportedly designed to promote women’ s health.3The Casey Court considered only one regulation designed to advance women’ s3The Casey Court was clear that it overruled Akron and Danforth only “to theextent that we permit a State to further its legitimate goal of protecting the life ofthe unborn by enacting legislation aimed at ensuring a decision that is mature andinformed.” 505 U.S. at 883.7Case: 13-51008Document: 00512592062Page: 20Date Filed: 04/10/2014health – the recordkeeping and reporting requirements – and it conducted the sameanalysis as in Akron and Danforth. It upheld those requirements as “a vital elementof medical research” that were “reasonably directed to the preservation of maternalhealth.” 505 U.S. at 900-01 (citing and quoting Danforth, 428 U.S. at 80).Moreover, the Panel’ s reliance on a single sentence in Gonzales to supportits use of the rational basis test, 2014 WL 1257965, at *10 (quoting 550 U.S. at158), is misplaced. The Gonzales Court did not consider an abortion restriction thatwas justified as advancing women’ s health. See 550 U.S. at 158 (holding that banon method of second trimester abortion furthered the state’ s interest in respectingfetal life). More importantly, the Gonzales Court was reiterating the standards setforth in Casey – not sub silentio effectuating a significant change from heightenedscrutiny to rational basis review on an issue not before the Court.This question – whether the Panel applied the proper standard of review forabortion restrictions that purportedly further women’ s health – is an exceptionallyimportant one because it is likely to affect future cases. Other abortion restrictionsare being challenged in the district courts in this Circuit, and this Court will hearargument in a similar abortion challenge on April 28, 2014. Jackson Women’ sHealth Org. v. Currier, No. 13-60599 (5th Cir.); Whole Women’ s Health v. Lakey,No. 14 CV-00284-LY (W.D. Tex. filed April 2, 2014).This exceptionally important question of the proper standard to review an8Case: 13-51008Document: 00512592062Page: 21Date Filed: 04/10/2014abortion restriction justified in the name of women’ s health is before other federalcourts as well. For example, in Planned Parenthood of Wisconsin v. Van Hollen,738 F.3d 786 (7th Cir. 2013), the Seventh Circuit upheld a preliminary injunctionin a challenge to a law – like the one at issue here – requiring physicians whoperform abortions to have admitting privileges at a local hospital. In its analysis,the court explained that “cases that deal with abortion-related statues sought to bejustified on medical grounds require . . . evidence . . . that the medical grounds arelegitimate.” Id. at 798. In reaching this conclusion, the Seventh Circuitacknowledged that this standard is what Casey demands. Id. (citing, inter alia,Casey, 505 U.S. at 900-01 (upholding the challenged recordkeeping requirementafter analyzing whether the requirement was “reasonably directed to thepreservation of maternal health” )); see also Planned Parenthood Se., Inc. v.Strange, No. 2:13cv405-MHT, slip op. at 53-55 (M.D. Ala. Mar. 31, 2014)(holding, in challenge to admitting privilege requirement for abortion providers,that it is “not enough” for the State to invoke a legitimate interest but rather thatunder Supreme Court precedent the court should, inter alia, consider “ whether theanticipated or hoped-for benefits of the regulation are quite likely to actuallyoccur” ).As these cases and this Court’ s docket demonstrate, this is an exceptionallyimportant question that is likely to come before this Court again. Because the Panel9Case: 13-51008Document: 00512592062Page: 22Date Filed: 04/10/2014answered that question incorrectly – in conflict with U.S. Supreme Court precedent– en banc review is warranted.II.The Panel’ s Ruling With Respect to Appellees’ Pre-Enforcement AsApplied Challenge to the Medication Abortion Restrictions IsContrary to Supreme Court Precedent and Could Eliminate SuchChallenges.For more than 40 years, the Supreme Court has never wavered from itsholding that a state may not restrict access to abortions that are “necessary, inappropriate medical judgment, for the preservation of the life or health of themother.” Roe v. Wade, 410 U.S. 113, 165 (1973); see also Ayotte, 546 U.S. at 32728; Casey, 505 U.S. at 879. Specifically, the Court has held that an abortionrestriction may not expose women to significant health risks. See, e.g., Casey, 505U.S. at 880 (upholding Pennsylvania law only because it had been interpreted suchthat it “would not in any way pose a significant threat to the life or health of awoman” ) (emphasis added).In Gonzales and Ayotte, the Court hewed to this holding, reaffirming that alaw that exposes some women to significant health risks is unconstitutional, butinstructing that the appropriate remedy may not be facial invalidation. SeeGonzales, 550 U.S. at 161 (reaffirming that abortion restrictions that subjectwomen to significant health risks are unconstitutional); Ayotte, 546 U.S. at 327329 (holding that states may not restrict access to abortions that are necessary toprotect women’ s health, but that when confronted with a constitutional flaw, courts10Case: 13-51008Document: 00512592062Page: 23Date Filed: 04/10/2014should endeavor to “enjoin only the unconstitutional applications of a statute whileleaving other applications in force” ). The Gonzales Court explicitly noted that“preenforcement, as-applied challenges” are “the proper manner to protect thehealth of the woman if it can be shown that in discrete and well-defined instances aparticular condition has or is likely to occur in which the procedure prohibited bythe Act must be used.” 550 U.S. at 167.Appellees followed the instructions from these cases to a tee. They broughtboth a facial and an as-applied pre-enforcement challenge to the medicationabortion restrictions. They sought to have the medication abortion restrictionsinvalidated in their entirety because they do not advance the state’ s interest inwomen’ s health, and they increase the burdens and costs associated with theprocedure. See, e.g., ROA.201-04 (seeking to preliminarily enjoin the medicationabortion restrictions as a whole). But they also, alternatively, sought to have thoseprovisions enjoined as applied to those women for whom medication abortion issignificantly safer. See, e.g., ROA.48 (complaint alleges that “ [f]or some womenwith certain medical conditions, the Act’ s denial of access to medication abortionwill significantly threaten their health” ); id. at 200, 205 (seeking to preliminarilyenjoin the medication abortion restrictions “as applied to women with gestationalages greater than 49 days LMP for whom a medication abortion is necessary, intheir doctor’ s appropriate medical judgment, to protect their lives or health” ).11Case: 13-51008Document: 00512592062Page: 24Date Filed: 04/10/2014The district court rejected Appellees’ facial challenge to the medicationabortion restrictions and granted relief only on the as-applied claim, notingspecifically that the restriction was an “undue burden on those women for whomsurgical abortion is, in the sound medical opinion of their treating physician, asignificant health risk during the period of pregnancy falling 50-63 days LMP.”ROA.1556 (emphasis added); see also id. at 1554-55 (finding that the medicationabortion restriction was not facially unconstitutional but holding that “ there arecertain situations where medication abortion is the only safe and medically soundoption for women with particular physical abnormalities or preexisting conditions”(emphasis added)).Appellees did not appeal the district court’ s ruling on their facial challenge.Therefore, only the pre-enforcement as-applied challenge to the medicationabortion restrictions was before the Panel on appeal. That is precisely the type ofchallenge envisioned by the Gonzales Court where an abortion restriction violatesthe Constitution by subjecting women to significant health risks. Indeed, thedistrict court made findings of fact, based on “uncontroverted evidence,” that somewomen have “ medical conditions that can make first-trimester surgical abortionextremely difficult or impossible.” ROA.1551 n.18.The Panel claims that these conditions were not “clearly defined.” Abbott,2014 WL 1257695, at *16. But the district court specifically delineated these12Case: 13-51008Document: 00512592062Page: 25Date Filed: 04/10/2014medical conditions, which include obesity, uterine fibroids, flexed uterus, or otheruterine anomalies. ROA.1551 n.18. These are precisely the type of “discrete andwell-defined instances” the Gonzales Court contemplated in sanctioning preenforcement as-applied challenges. See Gonzales, 550 U.S. at 167. And the limitedrelief the district court awarded is consistent with the Court’ s holding in Ayotte,namely that courts should endeavor to “enjoin only the unconstitutionalapplications of a statute while leaving other applications in force.” 546 U.S. at 329.Importantly, the Panel improperly characterized the medication abortionclaim before it as a “facial challenge.” This was in error.4 If Appellees’ challenge isnot the “pre-enforcement, as applied challenge” that the Supreme Courtenvisioned, then no avenue remains for women to challenge abortion restrictionsthat threaten their health. The Panel seemed to suggest that these women could filepost-enforcement challenges, but such challenges would never provide meaningfulrelief. For example, it is not uncommon for women to discover that they arepregnant after 49 days LMP. ROA.1553 n.20. At that same time, a woman mightlearn that she has large uterine fibroids blocking the pregnancy or a stenotic cervix.If she decides to have an abortion, a medication abortion is significantly safer. Tobe able to get that medication abortion, she would have less than two weeks (since4The Panel’ s decision can be viewed as either conflicting with Supreme Courtprecedent or misapplying Supreme Court precedent. As a result, this issue isappropriate either for a request for panel rehearing or rehearing en banc.13Case: 13-51008Document: 00512592062Page: 26Date Filed: 04/10/2014medication abortion would be available through 63 days LMP but for the Act) toget to court and obtain an injunction that allows her physician to provide her with amedication abortion. Her only other alternative is a surgical abortion, which wouldexpose her to significant health risks.This is the result rendered by the Panel opinion, and it is both contrary toSupreme Court jurisprudence and raises an issue of exceptional importance. Enbanc review is essential to protect women’ s health.CONCLUSIONFor all of the foregoing reasons, Appellees respectfully urge this Court togrant their petition for rehearing en banc.Dated: April 10, 2014Respectfully submitted,/s/ Janet CreppsJanet CreppsCenter for Reproductive Rights120 Wall Street, 14th FloorNew York, NY 10005(864) 962-8519jcrepps@reprorights.orgAttorney for Plaintiffs-Appellees14Case: 13-51008Document: 00512592062Page: 27Date Filed: 04/10/2014CERTIFICATE OF SERVICEI hereby certify that on the 10th day of April, 2014 I electronically filed theforegoing Petition for Rehear ing En Banc with the Clerk of the court by usingthe CM/ECF system, which will send a notice of electronic filing to counsel forDefendants-Appellants and Amici Curiae./s/ Janet CreppsJanet Crepps15Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:281DateDateFiled:Filed:03/27/201404/10/2014I N T H E U N I T E D S T AT E S C O U R T O F AP P E AL SUnited States Court of AppealsF OR TH E F IF TH CIR CUITFifth CircuitFILEDMarch 27, 2014No. 13-51008Lyle W. CayceClerkP LANN E D P ARE N TH OOD OF GRE ATE R TE XAS SU RGICAL H E ALTHSE RVICE S; P LAN NE D P ARE NTH OOD CE NTE R F OR CH OICE ;P LANN E D P ARE N TH OOD SE XU AL H E ALTH CARE SE RVICE S; WH OLEWOMAN'S H E ALTH ; AUSTIN WOME N'S H E ALTH CE N TE R; KILLE E NWOME N'S H E ALTH CE NTE R; SOUTH WE STE RN WOME N'S SURGE RYCE NTE R; WE ST SIDE CLINIC, INCORP ORATE D; ROUTH STRE E TWOME N'S CLINIC; H OUSTON WOME N'S CLINIC, ea ch on beh a lf of it self,it s pa t ien t s a n d ph ysicia n s; ALAN BRAID, M.D.; LAMAR ROBINSON, M.D.;P AME LA J . RICH TE R, D.o., ea ch on beh a lf of t h em selves a n d t h eir pa t ien t s;P LANN E D P ARE N TH OOD WOME N'S H E ALTH CE N TE R,P la in t iffs - Appelleesv.ATTORNE Y GE NE RAL GRE GORY ABBOTT; DAVID LAKE Y, M.D.;MARI ROBINSON, E xecu t ive Dir ect or of t h e Texa s Medica l Boa r d,Defen da n t s - Appella n t sAppea l fr om t h e Un it ed St a t es Dist r ict Cou r tfor t h e West er n Dist r ict of Texa sBefor e J ONE S, E LROD, a n d H AYNE S, Cir cu it J u dges.E DITH H . J ONE S, Cir cu it J u dge:P la n n ed P a r en t h ood of Gr ea t er Texa s Su r gica l H ea lt h Ser vices a n dot h era bor t ionfa cilit iesandt h r eeph ysicia n s(collect ively“P la n n edP a r en t h ood”) su ed t h e At t or n ey Gen er a l of Texa s a n d ot h er in dividu a ls(collect ively “t h e St a t e”), seekin g t o en for ce t h eir r igh t s a n d t h ose of pa t ien t sfor decla r a t or y ju dgm en t a n d t o en join t wo pr ovision s of 2013 Texa s H ou se BillCase:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:292DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008No. 2 (“H .B. 2”) per t a in in g t o t h e r egu la t ion of su r gica l a bor t ion s a n d a bor t ion –in du cin g dr u gs. 1 Th e dist r ict cou r t h eld t h a t pa r t s of bot h pr ovision s wer eu n con st it u t ion a l a n d gr a n t ed, in su bst a n t ia l pa r t , t h e r equ est ed in ju n ct iver elief. A m ot ion s pa n el of t h is cou r t gr a n t ed a st a y pen din g a ppea l, a n d t h eSu pr em e Cou r t u ph eld t h e st a y. We con clu de t h a t bot h of t h e ch a llen gedpr ovision s a r e con st it u t ion a l a n d t h er efor e r ever se a n d r en der ju dgm en t , wit hon e except ion , for t h e St a t e.I.Ba ck gr ou n dP a ssed on J u ly 12, 2013, H .B. 2 con t a in s t wo pr ovision s t h a t P la n n edP a r en t h ood con t en ds a r e u n con st it u t ion a l. Th e fir st r equ ir es t h a t a ph ysicia nper for m in g or in du cin g a n a bor t ion h a ve a dm it t in g pr ivileges on t h e da t e oft h e a bor t ion a t a h ospit a l n o m or e t h a n t h ir t y m iles fr om t h e loca t ion wh er et h e a bor t ion is pr ovided. 2 Th e secon d m a n da t es t h a t t h e a dm in ist r a t ion ofa bor t ion –in du cin g dr u gs com ply wit h t h e pr ot ocol a u t h or ized by t h e F ood a n dDr u g Adm in ist r a t ion (F DA), wit h lim it ed except ion s. 3 We follow t h e pa r t ies inr efer r in g t o dr u g–in du ced a bor t ion s, a s dist in gu ish ed fr om su r gica l a bor t ion s,a s “m edica t ion a bor t ion s.”4Act of J u ly 12, 2013, 83r d Leg., 2d C.S., ch . 1, §§ 1-12, 2013 Tex. Sess. La w Ser v.4795-802 (West ) (codified at T E X. H E ALTH & S AFE TY C ODE §§ 171.0031, 171.041-048, 171.061064, & a m en din g § 245.010.011; T E X. O CC . C ODE a m en din g §§ 164.052 & 164.055).2 T E X. H E ALTH & S AF E TY C ODE § 171.0031(a)(1). Sect ion 171.0031(b) cr im in alizes aph ysicia n’s fa ilur e t o com ply wit h Sect ion 171.0031(a )(1).3 Id . § 171.063(a); P la nn ed P a r en th ood of Gr ea ter Tex. S u r gica l H ea lth S er vs. v.Abbott, 951 F . Su pp. 2d 891, 905 (W.D. Tex. 2013).4 Alon g wit h Texas, five ot h er st a t es h a ve r ecent ly passed laws su bst a nt ia lly sim ila rt o t h e pr ovisions at issue h er e, wh ich h a ve a lso been ch a llen ged in feder a l cour t s. In ea ch oft h ese cases, t h e dist r ict cour t en join ed a ll or pa r t of t h e la w pending t r ia l on t h e m er it s.J a ckson Wom en' s H ea lth Or g. v. Cu r r ier , 940 F . Su pp. 2d 416 (S.D. Miss. 2013) (a dm it t in gpr ivileges); Pla n n ed Pa r en th ood S e., In c. v. Ben tley, 951 F.Su pp.2d 1280 (M.D. Ala . 2013)(a dm it t in g pr ivileges); MBK Mgm t. Cor p. v. Bu r d ick, 954 F . Su pp. 2d 900 (D. N.D. 2013)(a dm it t in g pr ivileges); P la n n ed P a r en th ood of Wis., In c. v. Va n H ollen , No. 13–CV–465–WMC, 2013 WL 3989238 (W.D. Wis. Au g. 2, 2013) (a dm it t in g pr ivileges); P la n nedP a r en th ood Sw. Oh io Region v. DeWine, No. 1:04-CV-493; 2011 WL 9158009 (S.D. Oh io Ma y23, 2011) (m edica t ion a bor t ion). F ou r of t h ese cases—Ben tley, Bu r dick, Va n H ollen, a nd12Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:303DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008P la n n ed P a r en t h ood pr esen t ed fou r gr ou n ds t o t h e dist r ict cou r t forin va lida t in g t h e h ospit a l a dm it t in g pr ivileges r equ ir em en t : viola t ion ofpa t ien t s’ su bst a n t ive du e pr ocess r igh t s, viola t ion of ph ysicia n s’ pr ocedu r a l du epr ocess r igh t s, u n la wfu l delega t ion of a u t h or it y t o h ospit a ls, a n d va gu en ess.As t o t h e m edica t ion a bor t ion r egu la t ion , P la n n ed P a r en t h ood a r gu ed t h a t ita lsoviola t edpa t ien t s’su bst a n t ivedu epr ocessr igh t sandwa su n con st it u t ion a lly va gu e. F a ced wit h a plea din g filed on ly da ys befor e H .B. 2wa s t o becom e effect ive, t h e dist r ict cou r t con solida t ed t h e pr elim in a r yin ju n ct ion a n d m er it s h ea r in gs. Wa ivin g a ju r y t r ia l, t h e pa r t ies con sen t ed t oa ben ch pr oceedin g in wh ich P la n n ed P a r en t h ood pr esen t ed a few wit n essesa n d bot h sides offer ed n u m er ou s a ffida vit s. On Oct ober 28, 2013, five da ysa ft er t h e con clu sion of t h e t r ia l, t h e dist r ict cou r t issu ed a n opin ion t h a t wou ldper m a n en t ly en join t h e a dm it t in g–pr ivileges pr ovision a n d pa r t ia lly en join t h em edica t ion a bor t ion r egu la t ion .Th e St a t e n ot ed it s a ppea l a n d m oved for a n em er gen cy st a y of t h edist r ict cou r t ’s or der .Wit h in for t y-eigh t h ou r s, on Oct ober 31, t h is cou r tr espon ded t o t h e pa r t ies’ br iefin g a n d h eld t h a t t h e St a t e m a de a su bst a n t ia lsh owin g of it s likelih ood of su ccess on t h e m er it s of t h e a dm it t in g pr ivilegesr equ ir em en t , a n d t h a t it dem on st r a t ed likely su ccess a s t o pa r t of t h e dist r ictcou r t ’s h a n d–cr a ft ed “h ea lt h of t h e m ot h er ” except ion t o t h e m edica t ionDeWin e—ar e pen din g befor e t h e dist r ict cour t . Th e Sevent h Cir cu it issu ed a n ext en siveopin ion a ffir m in g t h e pr elim in a r y in ju n ct ion in Va n H ollen. Pa r en th ood of Wiscon sin , In c. v.Va n H ollen, 738 F .3d 786 (7t h Cir . 2013), discu ssed infr a . Addit ion a lly, t h e Sixt h Cir cu ita ffir m ed su m m a r y judgm en t for t h e St a t e in DeWin e on t h r ee of t h e fou r claim s, t h ou gh t heissu e of wh et h er t h e St a t e's r egu la t ion of m edica t ion a bor t ion bu r dens a wom a n 's r igh t t oh ea lt h a n d life u n der t h e F our t eent h Am en dm en t h as been h eld for t r ia l. P la n nedP a r en th ood Sw. Ohio Region v. DeWin e, 696 F .3d 490 (6t h Cir . 2012). Th e pr elim in ar yin ju n ct ion en t er ed by t h e dist r ict cour t in Cu r r ier h a s been st a yed pendin g it s a ppeal befor et h is cour t . J a ckson Wom en ’s H ea lth Or g. v. Cu r r ier , No. 13-60599, (5t h Cir ., filed Au g. 27,2013).3Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:314DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008a bor t ion r egu la t ion .P la n n ed P a r en th ood of Gr ea ter Tex. S u r gica l H ea lthS er vs. v. Abbott, 734 F .3d 406, 416, 418 (5t h Cir . 2013). F in din g t h e ot h err equ ir em en t s for a st a y pen din g a ppea l t o be sa t isfied, t h e cou r t of a ppea lsst a yed t h e dist r ict cou r t ’s ju dgm en t in pa r t . Id . a t 419.Th e a ppea l wa sexpedit ed for t h is cou r t ’s fu ll con sider a t ion of t h e m er it s. Id .P la n n ed P a r en t h ood a ppea led t o t h e Su pr em e Cou r t for em er gen cyr elief. 5 In a five–fou r decision , wit h wr it in gs on bot h sides, t h e Cou r t r efu sedt o va ca t e t h is cou r t ’s st a y. P la n n ed P a r en th ood of Gr ea ter Tex. S u r gica l H ea lthS er vs. v. Abbott, 134 S. Ct . 506 (2013).In t h is a ppea l, t h e St a t e m a in t a in s t h a t t h e dist r ict cou r t er r ed in fou rr espect s: gr a n t in g st a n din g t o a bor t ion pr ovider s t o a sser t ph ysicia n s’ a n dpa t ien t s’ r igh t s vis-à -vis t h e issu es r a ised; fa cia lly in va lida t in g t h e a dm it t in gpr ivileges r egu la t ion ; cr ea t in g a “br oa d a n d va gu e ‘h ea lt h ’ except ion ” t o t h em edica t ion a bor t ion r egu la t ion s; a n d en for cin g a n in ju n ct ion beyon d t h e r igh t sof t h e pla in t iffs in t h is ca se. We a ddr ess t h ese issu es in t u r n .II.P r e lim i n a r y I s s u e sA. S t a n d a r d s o f R e v ie wAt t h e ou t set , we a r e con fr on t ed by t h e dist r ict cou r t ’s pr e–en for cem en tfa cia l in va lida t ion of t h ese st a t e la w pr ovision s in toto. St a n da r d pr in ciples ofcon st it u t ion a l a dju dica t ion r equ ir e cou r t s t o en ga ge in fa cia l in va lida t ion on lyif n o possible a pplica t ion of t h e ch a llen ged la w wou ld be con st it u t ion a l. S eeVotin g for Am ., In c. v. S teen , 732 F .3d 382, 387 (5t h Cir . 2013) (cit in g Un itedS ta tes v. S a ler n o, 481, U.S. 739, 745 (1987)). Th is cou r t a pplied t h e pr in cipleIn it s br ief filed wit h t h e Su pr em e Cou r t in suppor t of t h e em er gency a pplicat ion t ova ca t e st a y, P la n n ed P ar en t h ood on ly a ddr essed t he h ospit a l a dm it t in g pr ivileges in ju n ct iona n d fa iled t o ch allen ge t h e off–la bel pr ot ocol inju n ct ion a s t h is cou r t ha d r efr a m ed it . S eeBr ief for Applica nt , Pla n n ed P a r en th ood of Gr ea ter Tex. S u r gica l H ea lth S er vs. v. Abbott,134 S. Ct . 506 (2013) (No. 13A452).54Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:325DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008in Ba r n es v. Mississippi wh en con st r u in g a Mississippi a bor t ion st a t u t e.992 F .2d 1335, 1342 (5t h Cir . 1993). H owever , wh et h er t h e Su pr em e Cou r ta pplies t h is r u le in t h e sa m e wa y in a bor t ion ca ses a s in ot h er s is u n cer t a in .In Gon za les v. Ca r h a r t, 550 U.S. 124 (2007), t h e Cou r t n ot ed t h e im plica t ionin P la n n ed P a r en th ood of S ou th ea ster n P en n sylva n ia v. Ca sey, 505 U.S. 833,895 (1992), t h a t a n a bor t ion –r egu la t in g st a t u t e wou ld fa il con st it u t ion a lm u st er if it er ect ed a n u n du e bu r den on wom en ’s decision s t o ch oose a bor t ionin a “la r ge fr a ct ion ” of ca ses. As in t h e st a y opin ion , we will a pply t h e “la r gefr a ct ion ” n om en cla t u r e for t h e sa ke of a r gu m en t on ly, wit h ou t ca st in g dou bton t h e gen er a l r u le. Cf. Abbott, 734 F .3d a t 414.To a ssess t h e cou r t ’s r en dit ion of in ju n ct ive r elief, we r eview it s lega lcon clu sion s d e n ovo, fa ct fin din gs for clea r er r or , a n d t h e u lt im a t e decision t oen join en for cem en t of H .B. 2 for a bu se of discr et ion . Votin g for Am ., 732 F .3da t 386.We a lso m u st con sider t h e pr oper pla ce of H .B. 2’s com pr eh en sive a n dca r efu l sever a bilit y pr ovision , t o wh ich t h e dist r ict cou r t ba r ely r efer r ed.F eder a l cou r t s a r e bou n d t o a pply st a t e la w sever a bilit y pr ovision s. Lea vitt v.J a n e L., 518 U.S. 137, 138-39 (1996).E ven wh en con sider in g fa cia lin va lida t ion of a st a t e st a t u t e, t h e cou r t m u st pr eser ve t h e va lid scope of t h epr ovision t o t h e gr ea t est ext en t possible.La t er a s-a pplied ch a llen ges ca na lwa ys dea l wit h su bsequ en t , con cr et e con st it u t ion a l issu es.B . S t a n d in gTh e dist r ict cou r t r u led per fu n ct or ily t h a t a bor t ion pr ovider s h a ve n everbeen den ied st a n din g t o a sser t t h e r igh t s of pa t ien t s. P la n n ed P a r en th ood ofGr ea ter Tex. S u r gica l H ea lth S er vs v. Abbott, 951 F . Su pp. 2d 891, 897 (W.D.Tex. 2013). Th e r u le for t h ir d–pa r t y st a n din g r equ ir es t h e n a m ed pla in t iff t oh a ve su ffer ed a n in ju r y in fa ct a n d t o sh a r e a “close” r ela t ion sh ip wit h t h ir d–5Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:336DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008pa r t ies wh o fa ce a n obst a cle in h ibit in g t h em fr om br in gin g t h e cla im on t h eirown beh a lf.Kowa lski v. Tesm er , 543 U.S. 125, 129-30 (2004).H er e, t h er equ ir em en t s for t h ir d–pa r t y st a n din g a r e m et in r ela t ion t o t h e cla im sa sser t ed by t h e ph ysicia n –pla in t iffs on beh a lf of t h eir pa t ien t s beca u se (1) t h eph ysicia n s fa ce pot en t ia l a dm in ist r a t ive a n d cr im in a l pen a lt ies for fa ilin g t ocom ply wit h H .B. 2, 6 (2) doct or s wh o per for m a bor t ion s sh a r e a su fficien t lyclose r ela t ion sh ip wit h t h eir pa t ien t s, 7 a n d (3) a pr egn a n t wom a n seekin g t oa sser t h er r igh t t o a bor t ion fa ces obviou s h in dr a n ces in t im ely br in in g ala wsu it t o fr u it ion . 8Beca u se t h e ph ysicia n –pla in t iffs h a ve t h ir d–pa r t yst a n din g t o a sser t t h e r igh t s of t h eir pa t ien t s in t h is lit iga t ion , a s well a sst a n din g t o a sser t t h eir own r igh t s, 9 we n eed n ot con sider t h e issu e of st a n din ga s it r ela t es t o t h e r em a in in g pla in t iffs. S ee Wa tt v. E n er gy Action E d u c.F ou n d . 454 U.S. 151, 160 (1981); Alla n d a le Neigh bor h ood Ass’n v. Au stinTr a n sp. S tu d y P olicy Ad visor y Com m ., 840 F .2d 258, 263 (5t h Cir . 1988).C . S u b s t a n t iv e D u e P r o c e s s S t a n d a r dA t r io of widely-kn own Su pr em e Cou r t decision s pr ovides t h e fr a m ewor k forr u lin g on t h e con st it u t ion a lit y of H .B. 2. In Roe v. Wa d e, t h e Cou r t h eld t h a tt h e F ou r t een t h Am en dm en t ’s con cept of per son a l liber t y en com pa sses aS ee T E X. H E ALTH & S AF E TY C ODE §§ 171.0031(b), 171.064 (West 2013); Doe v. Bolton ,410 U.S. 179, 188 (1973) (“Th e ph ysicia n is t h e on e a ga in st wh om [H .B. 2] dir ect ly oper at e[s]in t he even t h e pr ocur es a n a bor t ion t h at does n ot m eet t h e st a t u t or y except ion s a ndcon dit ion s. Th e [ph ysicia n ], t h er efor e, asser t [s] a sufficien t ly dir ect t h r ea t of per son a ldet r im en t .”).7 S in gleton v. Wu ff, 428 U.S. 106, 117 (1976) (“Aside fr om t h e wom a n h er self, . . . t h eph ysicia n is u n iqu ely qu a lified t o lit iga t e t h e con st it u t ion alit y of t h e St a t e’s in t er fer en cewit h, or discr im in a t ion a ga in st , [t h e con st it ut ion a lly pr ot ect ed a bor t ion] decision .”).8 Id . at 117-18.9 Th e St at e a r gu es t h a t , wh er e t h ir d–pa r t y st an din g is con cer n ed, t h er e m a y be apoin t a t wh ich t he doct or ’s int er est s begin t o con flict wit h his pat ien t ’s. F or exam ple, t h edoct or ’s econ om ic incent ives r ega r din g t h e per for m a nce of a bor t ion s m a y n ot a lwa ys alignwit h a wom a n ’s r igh t t o ch oose t o h a ve a n a bor t ion. We ar e con vin ced t h a t su ch n o su chcon flict exist s her e, h owever .66Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:347DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008wom a n ’s r igh t t o en d a pr egn a n cy by a bor t ion . Roe v. Wa d e, 410 U.S. 113, 153(1973). In Ca sey, t h e Cou r t r ea ffir m ed wh a t it r ega r ded a s Roe’s “essen t ia lh oldin g,” t h e r igh t t o a bor t befor e via bilit y, t h e poin t a t wh ich t h e u n bor n lifeca n su r vive ou t side of t h e wom b. Ca sey, 505 U.S. a t 870, 878. Befor e via bilit y,t h e St a t e m a y n ot im pose a n “u n du e bu r den ,” defin ed a s a n y r egu la t ion t h a th a s t h e pu r pose or effect of cr ea t in g a “su bst a n t ia l obst a cle” t o a wom a n ’sch oice. Id . a t 874, 878. In Gon za lez, t h e Cou r t a dded t h a t a bor t ion r est r ict ion sm u st a lso pa ss r a t ion a l ba sis r eview. Gon za lez, 550 U.S. a t 158 (h oldin g t h a tt h e St a t e m a y ba n cer t a in a bor t ion pr ocedu r es a n d su bst it u t e ot h er s pr ovidedt h a t “it h a s a r a t ion a l ba sis t o a ct , a n d it does n ot im pose a n u n du e bu r den ”(em ph a sis a dded)).P la n n ed P a r en t h ood u r ges a st r ict er st a n da r d of r eview for t h e st a t e’sa dm it t in g–pr ivileges r egu la t ion t h a n Ca sey’s u n du e bu r den st a n da r d beca u set h is r egu la t ion a llegedly pr ot ect s on ly t h e m ot h er ’s h ea lt h r a t h er t h a n fet a llife. Appellees cit e City of Akr on v. Akr on Ctr . for Repr od . H ea lth , 462 U.S.416, 431 (1983), t o su ppor t t h eir posit ion . Th is a r gu m en t is wr on g on sever a lgr ou n ds. F ir st , n o su ch bifu r ca t ion h a s been r ecogn ized by t h e Su pr em e Cou r t .Secon d, Akr on ’s a pplica t ion of st r ict scr u t in y wa s r epla ced by Ca sey’s u n du ebu r den ba la n cin g t est , 505 U.S. a t 871. Th ir d, P la n n ed P a r en t h ood’s pr oposedst a n da r d wa s n ot a pplied even by t h e dist r ict cou r t in t h is ca se, n or doa ppellees cit e a sin gle Su pr em e Cou r t or lower cou r t opin ion t h a t h a sa t t em pt ed t o m odify Ca sey in t h e wa y t h ey pr opose.F ou r t h , t h e st a t e’sr egu la t or y in t er est ca n n ot be bifu r ca t ed sim ply bet ween m ot h er s’ a n dch ildr en ’s h ea lt h ; ever y lim it on a bor t ion t h a t fu r t h er s a m ot h er ’s h ea lt h a lsopr ot ect s a n y exist in g ch ildr en a n d h er fu t u r e a bilit y t o bea r ch ildr en even if itfa cilit a t es a pa r t icu la r a bor t ion . In su m , t h e gover n in g t est a r t icu la t ed byCa sey a pplies h er e, a n d t h e fu n da m en t a l qu est ion is wh et h er P la n n ed7Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:358DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008P a r en t h ood h a s m et it s bu r den t o pr ove t h a t t h e a dm it t in g pr ivilegesr egu la t ion im poses a n u n du e bu r den on a wom a n 's a bilit y t o ch oose a na bor t ion ; on ly in t h a t sit u a t ion does t h e st a t e a br idge “t h e h ea r t of t h e liber t ypr ot ect ed by t h e Du e P r ocess Cla u se.” Ca sey, 505 U.S. a t 874.III.Ad m it t in g P r iv ile g e s R e q u ir e m e n tTh e St a t e’s a ppea l of t h e r u lin g in va lida t in g t h e a dm it t in g–pr ivilegesr equ ir em en t t u r n s on t h e dist r ict cou r t opin ion ’s a n a lysis of P la n n edP a r en t h ood’s su bst a n t ive du e pr ocess cla im .P la n n ed P a r en t h ood a r gu ed a tt r ia l t h a t t h e a dm it t in g–pr ivileges r equ ir em en t la cked a r a t ion a l ba sis a n dim posed a n u n du e bu r den on a wom a n ’s r igh t t o ch oose a n a bor t ion . Th eopin ion a gr eed wit h bot h pa r t s of P la n n ed P a r en t h ood’s a r gu m en t .Th eopin ion , h owever , a pplied t h e wr on g lega l st a n da r ds u n der r a t ion a l ba sisr eview a n d er r ed in fin din g t h a t t h e a dm it t in g–pr ivileges r equ ir em en ta m ou n t s t o a n u n du e bu r den for a “la r ge fr a ct ion ” of t h e wom en t h a t it a ffect s.A.To sh ow t h a t t h e a dm it t in g–pr ivileges r equ ir em en t la cked a r a t ion a lba sis, Dr . P a u l F in e, a boa r d–cer t ified obst et r icia n a n d gyn ecologist (“Ob/Gyn ”)a n d dir ect or of on e of t h e pla in t iff clin ics, t est ified t h a t wom en fa ce a n“ext r em ely low” r isk of exper ien cin g som e t ype of com plica t ion a ft er a na bor t ion . Accor din g t o t h e st u dies r efer r ed t o by Dr . F in e, on ly 2.5 per cen t ofwom enwh o h a ve afir st –t r im est ersu r gica l a bor t ionu n der go m in orcom plica t ion s, wh ile fewer t h a n 0.3 per cen t exper ien ce a com plica t ion t h a tr equ ir es h ospit a liza t ion . As for t h ose a bor t ion pa t ien t s wh o n eed h ospit a l ca r e,Dr . F in e in dica t ed t h a t “t h e a ppr opr ia t e cou r se of a ct ion wou ld be t o r efer t h ewom a n t o a n ea r by em er gen cy r oom ” beca u se, fr om h is per spect ive, E Rph ysicia n s a r e qu a lified t o t r ea t m ost post -a bor t ion com plica t ion s, a n d ca ncon su lt wit h t h e Ob/Gyn on -ca ll in t h e even t t h a t t h ey det er m in e t h a t a8Case:Case:13-5100813-51008Document:Document:0051259206200512576152Page:Page:369DateDateFiled:Filed:03/27/201404/10/2014No. 13-51008specia list is r equ ir ed.Sim ila r ly, Dr . J en n ifer Ca r n ell, a boa r d–cer t ifiedem er gen cy m edicin e pr a ct it ion er , expla in ed t h a t E R ph ysicia n s h a veexper ien ce in t r ea t in g a bor t ion -r ela t ed com plica t ion s, wh ich a r e ver y sim ila rt o t h e sym pt om s of m isca r r ia ge, a con dit ion com m on ly seen in E Rs.Con sequ en t ly, t h e a bor t ion pr a ct it ion er s do n ot n eed a dm it t in g pr ivileges.Dr . F in e fu r t h er t est ified t h a t t h e a dm it t in g–pr ivileges pr ovision h a s t h eeffect of r est r ict in g t h e a va ila bilit y of a bor t ion in t h e st a t e. J oseph P ot t er , asociology pr ofessor , t est ified t h a t t h e r equ ir em en t will close on e–t h ir d of t h est a t e’s a bor t ion fa cilit ies, a n d, a s a r esu lt , pr even t a t lea st 22,286 wom ena n n u a lly—sligh t ly less t h a n a t h ir d of t h e n u m ber of wom en wh o seeka bor t ion s in t h e st a t e ea ch yea r —fr om pr ocu r in g a n a bor t ion . 10An dr eaF er r ign o, cor por a t e vice pr esiden t of pla in t iff Wh ole Wom a n ’s H ea lt h(“WWH ”), in dica t ed t h a t h er or ga n iza t ion ’s clin ic in McAllen wou ld close du et o t h e a dm it t in g-pr ivileges r equ ir em en t . Sepa r a t e fr om t h e pr ovision ’s a llegedeffect s on a bor t ion a ccess in t h e Rio Gr a n de Va lley, Am y H a gst r om –Miller , a nown er of WWH , a n d F er r ign o t est ified t h a t t h eir clin ics in F or t Wor t h a n d Sa nAn t on io wou ld close, a n d Dr . Da r r ell J or da n , ch ief m edica l officer of pla in t iffP la n n ed P a r en t h ood of Gr ea t er Texa s, t est ified t h a t h is or ga n iza t ion ’s clin icsin Au st in , Wa co, a n d Da lla s wou ld sh u t t h eir door s.To expla in t h e ch a llen ges t h a t pr ovider s fa ced in com plyin g wit h t h ea dm it t in g–pr ivileges r equ ir em en t , H a gst r om –Miller t est ified t h a t eleven oft h e fou r t een ph ysicia n s a t h er clin ics a r e over t h e a ge of sixt y, a n d six a r e overt h e a ge of seven t y. H a gst r om –Miller fu r t h er t est ified t h a t WWH r ecen t lya t t em pt ed t o r ecr u it five ph ysicia n s. In H a gst r om –Miller ’s wor ds, t h r ee ofAccor din g t o t h e Texas Depar t m en t of St a t e H ea lt h Ser vices, 72,470 a bor t ions wer eper for m ed in Texa s in 2011, wit h 70,003 obt a in ed by Texa s r esiden t s. Ta ble 33: Select edCh a r a ct er ist ics of In duced Ter m in a t ion s of P r egn a n cy, Texa s Residen t s, 2011, a va ila ble a th t t p://www.dshs.st a t e.t x.u s/ch s/vst at /vs11/t 33.sh t m .109Case: 13-51008Document: 0051259206200512576152Page: 3710Date Filed: 04/10/201403/27/2014No. 13-51008t h em “wer e u n a ble t o join WWH st a ff beca u se t h eir pr im a r y pr a ct ice orh ospit a ls ba r r ed t h em fr om wor kin g a s a bor t ion ca r e pr ovider s.” Th e fou r t hwa s r elu ct a n t t o join a ft er t h e 2009 m u r der of Dr . Geor ge Tiller , a Ka n sa s–ba sed ph ysicia n wh o per for m ed a bor t ion s. Th e fift h wa s for bidden beca u se t h ech a ir of h is depa r t m en t does n ot per m it m oon ligh t in g in gen er a l a n d did n otwa n t t h e doct or t o be a ffilia t ed wit h a bor t ion pr a ct ice.Addit ion a lly, H a gst r om –Miller st a t ed t h a t WWH wa s in con t a ct wit hsever a l ph ysicia n s wh o h a d pr eviou sly don e som e wor k wit h h er clin ics. Twoof t h ese doct or s cla im ed t h a t t h ey wer e n ot in t er est ed in join in g WWH beca u seof t h eir con cer n t h a t fu t u r e ch a n ges in t h e la w wou ld m a k e it im possible t opr ovide a bor t ion s in t h e st a t e. On e declin ed beca u se h e pla n n ed t o open a nobst et r ics pr a ct ice a n d fea r ed t h a t in volvin g h im self in a bor t ion pr a ct ice wou ldcost h im bu sin ess; u lt im a t ely t h is ph ysicia n join ed a pr a ct ice own ed by aCa t h olic a ssocia t ion wh ich for bids a n y a ffilia t ion wit h a bor t ion pr ovider s.An ot h er ph ysicia n wa s a t a Ca t h olic h ospit a l wh ich a llegedly dir ect ed t h edoct or t o sever con t a ct wit h WWH , a n d u lt im a t ely fir ed h im du e t o h is“ou t spok en su ppor t ” for a bor t ion r igh t s. An ot h er , wh o h a d spen t on e da y–a –week wor kin g wit h WWH , decided t o t a ke a posit ion in New Yor k du e t o t h epa ssin g of a bor t ion r est r ict ion s, in clu din g H .B. 2, a n d t h e n eed t o pa y st u den tloa n s. F in a lly, on e ph ysicia n , wh o wor k ed wit h WWH , decided n ot t o con t in u ewit h t h e or ga n iza t ion a ft er t h e pa ssa ge of H .B. 2, con clu din g t h a t it wou ld beim possible t o obt a in a dm it t in g pr ivileges given t h e ca seloa d r equ ir em en t s a ton e of t h e loca l h ospit a ls a n d t h e fa ct t h a t t h e ot h er is a Ca t h olic h ospit a l t h a t ,in a ppa r en t viola t ion of feder a l a n d st a t e la w, declin es t o gr a n t pr ivileges ont h e ba sis of a n a pplica n t ’s a ssocia t ion wit h a bor t ion pr a ct ice.10Case: 13-51008Document: 0051259206200512576152Page: 3811Date Filed: 04/10/201403/27/2014No. 13-51008In r espon se t o P la n n ed P a r en t h ood, Dr . J oh n Th or p, a boa r d-cer t ifiedOb/Gyn , offer ed t h e m ost com pr eh en sive st a t em en t of t h e r equ ir em en t ’sr a t ion a le:Th er e a r e fou r m a in ben efit s su ppor t in g t h e r equ ir em en t t h a toper a t in g su r geon s h old loca l h ospit a l a dm it t in g a n d st a ffpr ivileges: (a ) it pr ovides a m or e t h or ou gh eva lu a t ion m ech a n ismof ph ysicia n com pet en cy wh ich bet t er pr ot ect s pa t ien t sa fet y; (b) ita ckn owledges a n d en a bles t h e im por t a n ce of con t in u it y of ca r e;(c) it en h a n ces in t er –ph ysicia n com m u n ica t ion a n d opt im izespa t ien t in for m a t ion t r a n sfer a n d com plica t ion m a n a gem en t ; a n d(d) it su ppor t s t h e et h ica l du t y of ca r e for t h e oper a t in g ph ysicia nt o pr even t pa t ien t a ba n don m en t .Th e St a t e focu sed it s defen se of t h e a dm it t in g-pr ivileges r equ ir em en t on t woof t h ese fa ct or s: con t in u it y of ca r e a n d cr eden t ia lin g. To dem on st r a t e t h eim por t a n ce of t h e for m er , Dr . Th or p r efer r ed t o sever a l st u dies, in clu din g ar epor t of a join t com m ission of h ospit a ls, in clu din g J oh n s H opkin s, Ma yoClin ic, a n d New Yor k P r esbyt er ia n , wh ich con clu ded t h a t “80 per cen t of ser iou sm edica l er r or s in volve m iscom m u n ica t ion bet ween ca r egiver s wh en pa t ien t sa r e t r a n sfer r ed or h a n ded–off.” Dr . J a m es An der son , a n E R ph ysicia n , a lsot est ified t h a t a n a bor t ion pr ovider wit h a dm it t in g pr ivileges is bet t er su it edt h a n on e n ot a dm it t ed t o kn ow wh ich specia list a t t h e h ospit a l t o con su lt inca ses wh er e a n a bor t ion pa t ien t pr esen t s h er self a t a n E R wit h ser iou scom plica t ion s.F u r t h er , Dr . Th or p dou bt ed t h a t wit h ou t t h e a dm it t in g-pr ivileges r equ ir em en t h ospit a ls in Texa s cou ld, a s Dr . F in e su ggest ed,pr om pt ly t r ea t wom en wit h a bor t ion -r ela t ed com plica t ion s. Th is wa s beca u se73 per cen t of E Rs n a t ion wide, a ccor din g t o a st a t ist ic cit ed by Dr . Th or p, la cka dequ a t e on -ca ll cover a ge by specia list ph ysicia n s, in clu din g Ob/Gyn s. Th u s,r equ ir in g a bor t ion pr ovider s t o obt a in a dm it t in g pr ivileges will r edu ce t h edela y in t r ea t m en t a n d decr ea se h ea lt h r isk for a bor t ion pa t ien t s wit h cr it ica lcom plica t ion s.11Case: 13-51008Document: 0051259206200512576152Page: 3912Date Filed: 04/10/201403/27/2014No. 13-51008Dr . Th or p a lso opin ed t h a t t h e a dm it t in g–pr ivileges r equ ir em en t wou lden su r e t h a t on ly ph ysicia n s “cr eden t ia led a n d boa r d cer t ified t o per for mpr ocedu r es gen er a lly r ecogn ized wit h in t h e scope of t h eir m edica l t r a in in g a n dcom pet en ce” wou ld pr ovide a bor t ion s.Dr . Mikea l Love, a boa r d–cer t ifiedOb/Gyn , con cu r r ed t h a t t h e a dm it t in g–pr ivileges pr ovision en list s h ospit a ls t o“scr een ou t ” u n t r a in ed a n d in com pet en t a bor t ion pr ovider s, wh o cou ld n otcon t in u e in t h e a bor t ion pr a ct ice if t h ey wer e n ot a ble t o obt a in a dm it t in gpr ivileges. E ch oin g t h is sen t im en t , Dr . An der son a gr eed t h a t cr eden t ia lin gwou ld en h a n ce t h e qu a lit y of ca r e, n ot in g t h a t “h ospit a l cr eden t ia lin g a ct s a sa n ot h er la yer of pr ot ect ion for pa t ien t sa fet y.”F in a lly, Dr . Th or p dispu t ed Dr . F in e’s con clu sion s a s t o t h e per cen t a geof a bor t ion s t h a t r esu lt in com plica t ion s. Accor din g t o Dr . Th or p, t h e 0.3per cen test im a t eofwom enr equ ir in gh ospit a liza t ionfr omcom plica t ion s is ba sed on da t a t h a t a r e t h ir t y-eigh t yea r s old.a bor t ionDr . Th or pfu r t h er t est ified t h a t com plica t ion s fr om a bor t ion a r e u n der r epor t ed, a n d h ecit ed a st u dy in dica t in g t h a t on ly on e–t h ir d t o on e–h a lf of a bor t ion pa t ien t sr et u r n t o t h eir clin ic for follow–u p ca r e.Th e St a t e a lso a t t a cked P la n n ed P a r en t h ood’s eviden ce a s t o t h e effect sof t h e a dm it t in g–pr ivileges r equ ir em en t . Du r in g it s exa m in a t ion of Dr . P ot t er ,t h e St a t e elicit ed t est im on y t h a t Dr . P ot t er r elied on st a t em en t s of pr edict edclin ic closu r es pr ovided by t h e pla in t iffs, t h eir a t t or n eys, a n d ot h er u n kn ownin dividu a ls wh o wer e in t er viewed by Dr . Da n iel Gr ossm a n , a n a bor t ionpr ovider wit h wh om Dr . P ot t er wor ks. As Dr . P ot t er expla in ed: “We a r e u sin gin for m a t ion t h a t wa s obt a in ed by—fr om P la in t iffs a n d by Dr . Gr ossm a n fr ompr ovider s. Th er e’s n o scien ce t h er e.” P et er Uh len ber g, a sociology pr ofessor ,a lso t est ified t h a t Dr . P ot t er ’s est im a t e wa s in a ccu r a t e beca u se P ot t er a ssu m edt h a t a bor t ion fa cilit ies u n a ffect ed by t h e a dm it t in g–pr ivileges r est r ict ion12Case: 13-51008Document: 0051259206200512576152Page: 4013Date Filed: 04/10/201403/27/2014No. 13-51008wou ld per for m t h e sa m e n u m ber of a bor t ion s a s t h ey did befor e t h e pr ovisionpa ssed. Dr . U h len ber g a r gu ed t h a t it wa s m or e likely t h a t t h ese clin ics wou ldper for m m or e a bor t ion s in t h e fa ce of h igh er dem a n d if wom en t r a velled fr ompa r t s of t h e st a t e wh er e fewer a bor t ion fa cilit ies r em a in ed a s a con sequ en ce ofH .B. 2.B.Accor din g t o it s in t er pr et a t ion of t h e Su pr em e Cou r t ’s h oldin gs, t h edist r ict cou r t ’s opin ion fou n d n o r a t ion a l ba sis for t h e n ew pr ovision a n dcon dem n ed it a s h a vin g a pu r pose or effect t o st ym ie wom en ’s a bor t ion a ccess.Th e opin ion r epea t edly st a t ed t h a t t h e St a t e pr odu ced “n o eviden ce” t h a t ar a t ion a l r ela t ion sh ip exist s bet ween a n a bor t ion pr ovider ’s a dm it t in gpr ivileges t o a h ospit a l a n d im pr oved pa t ien t ca r e a t em er gen cy fa cilit iesh a n dlin g pa t ien t com plica t ion s. Mor eover , t h e opin ion fou n d “n o eviden ce”t h a t a dm it t in g pr ivileges t o a h ospit a l wit h in t h ir t y m iles of t h e a bor t ionpr ovider 's clin ic “a ddr ess issu es of pa t ien t a ba n don m en t , h ospit a l cost s, ora ccou n t a bilit y.”Th e opin ion n ext con clu ded t h a t t h e st a t u t e pla ces a n u n du e bu r den onwom en seek in g a n a bor t ion . In a br ief fou r –pa r a gr a ph discu ssion , t h e opin ionfou n d t h a t som e (u n iden t ified) a bor t ion clin ics will close a n d “24 cou n t ies int h e Rio Gr a n de Va lley wou ld be left wit h n o a bor t ion pr ovider beca u se t h osea bor t ion pr ovider s do n ot h a ve a dm it t in g pr ivileges a n d a r e u n lik ely t o gett h em .”Dr a win g on H a gst r om –Miller ’s t est im on y, t h e opin ion expr essedcon cer n t h a t older ph ysicia n s a ssocia t ed wit h pa r t icu la r clin ics will be u n a blet o qu a lify for h ospit a l–a dm it t in g pr ivileges a n d dism issed a s over ly opt im ist ict h e n ot ion t h a t a bor t ion pr ovider s wou ld be a ble t o fin d qu a lified r epla cem en tph ysicia n s. Th e opin ion a lso n ot ed eviden ce sh owin g t h a t “t h e va st m a jor it y”of a bor t ion pr ovider s do n ot en ga ge in en ou gh su r gica l pr ocedu r es t o qu a lify13Case: 13-51008Document: 0051259206200512576152Page: 4114Date Filed: 04/10/201403/27/2014No. 13-51008for a dm ission t o h ospit a l st a ffs. Th u s, by t h e opin ion ’s pr edict ion , t h e closu r eof fa cilit ies wa s essen t ia lly im m in en t a n d ir r ever sible.Th e opin ion a lso h eld, in on e sen t en ce, t h a t t h e St a t e “fa ils t o sh ow ava lid pu r pose for r equ ir in g t h a t a bor t ion pr ovider s h a ve h ospit a l pr ivilegeswit h in 30 m iles of t h e clin ic wh er e t h ey pr a ct ice.” Accor din gly, t h e “pu r pose”pr on g of t h e Ca sey in qu ir y wa s n ot sa t isfied a s t o t h is pr ovision .C.Th e dist r ict cou r t ’s opin ion t ook t h e wr on g a ppr oa ch t o t h e r a t ion a l ba sist est . Not h in g in t h e Su pr em e Cou r t ’s a bor t ion ju r ispr u den ce devia t es fr om t h eessen t ia l a t t r ibu t es of t h e r a t ion a l ba sis t est , wh ich a ffir m s a vit a l pr in ciple ofdem ocr a t ic self–gover n m en t . It is n ot t h e cou r t s’ du t y t o secon d gu esslegisla t ive fa ct fin din g, “im pr ove” on , or “clea n se” t h e legisla t ive pr ocess bya llowin g r elit iga t ion of t h e fa ct s t h a t led t o t h e pa ssa ge of a la w. H eller v. Doe,509 U.S. 312, 320 (1993) (pr ovidin g t h a t a st a t e “h a s n o obliga t ion t o pr odu ceeviden ce t o su st a in t h e r a t ion a lit y of a st a t u t or y cla ssifica t ion ”).U n derr a t ion a l ba sis r eview, cou r t s m u st pr esu m e t h a t t h e la w in qu est ion is va lida n d su st a in it so lon g a s t h e la w is r a t ion a lly r ela t ed t o a legit im a t e st a t ein t er est . City of Clebu r n e v. Clebu r n e Livin g Ctr ., 473 U.S. 432, 440 (1985). Ast h e Su pr em e Cou r t h a s oft en st r essed, t h e r a t ion a l ba sis t est seek s on ly t odet er m in e wh et h er a n y con ceiva ble r a t ion a le exist s for a n en a ct m en t . F .C.C.v. Bea ch Com m c’n s, In c., 508 U.S. 307, 313 (1993) (cit in g ca ses). Beca u se t h edet er m in a t ion does n ot len d it self t o a n eviden t ia r y in qu ir y in cou r t , t h e st a t eis n ot r equ ir ed t o “pr ove” t h a t t h e object ive of t h e la w wou ld be fu lfilled. Id . a t315 (h oldin g t h a t “a legisla t ive ch oice is n ot su bject t o cou r t r oom fa ct –fin din g”).Most legisla t ion dea ls u lt im a t ely in pr oba bilit ies, t h e est im a t ion of t h e people’sr epr esen t a t ives t h a t a la w will be ben eficia l t o t h e com m u n it y. Su ccess oft enca n n ot be “pr oven ” in a dva n ce.Th e cou r t m a y n ot r epla ce legisla t ive14Case: 13-51008Document: 0051259206200512576152Page: 4215Date Filed: 04/10/201403/27/2014No. 13-51008pr edict ion s or ca lcu la t ion s of pr oba bilit ies wit h it s own , else it u su r ps t h elegisla t ive power . H eller , 509 U.S. a t 319 (st a t in g t h a t r a t ion a l ba sis r eview“is n ot a licen se for cou r t s t o ju dge t h e wisdom , fa ir n ess, or logic of legisla t ivech oices”); Bea ch Com m c’n s, 508 U .S. a t 315 (expla in in g t h a t ju dicia l defer en cet o legisla t ive ch oice “pr eser ve[s] t o t h e legisla t ive br a n ch it s r igh t fu lin depen den ce a n d it s a bilit y t o fu n ct ion ”).A la w “ba sed on r a t ion a lspecu la t ion u n su ppor t ed by eviden ce or em pir ica l da t a ” sa t isfies r a t ion a l ba sisr eview. Bea ch Com m c’n s, 508 U.S. a t 315. Th e fa ct t h a t r ea son a ble m in ds ca ndisa gr ee on legisla t ion , m or eover , su ffices t o pr ove t h a t t h e la w h a s a r a t ion a lba sis. F in a lly, t h er e is n o lea st r est r ict ive m ea n s com pon en t t o r a t ion a l ba sisr eview. H eller , 509 U.S. a t 321 (h oldin g t h a t cou r t s m u st a ccept a legisla t u r e’sgen er a liza t ion s u n der r a t ion a l ba sis r eview “even wh en t h er e is a n im per fectfit bet ween m ea n s a n d en ds” or wh er e t h e cla ssifica t ion “is n ot m a de wit hm a t h em a t ica l n icet y”).Th is r u le of r est r a in t is pa r t icu la r ly im por t a n t in t h e r ea lm ofcon st it u t ion a l a dju dica t ion for a sim ple r ea son . If legisla t or s’ pr edict ion s a bou ta la w fa il t o ser ve t h eir pu r pose, t h e la w ca n be ch a n ged. On ce t h e cou r t s h a veh eld a la w u n con st it u t ion a l, h owever , on ly a con st it u t ion a l a m en dm en t , or t h ewisdom of a m a jor it y of ju st ices over com in g t h e st r on g pu ll of sta r e d ecisis, willper m it t h a t or sim ila r la ws t o a ga in t a k e effect .Viewed fr om t h e pr oper per spect ive, t h e St a t e’s a r t icu la t ion of r a t ion a llegisla t ive object ives, wh ich wa s ba cked by eviden ce pla ced befor e t h e st a t elegisla t u r e, ea sily su pplied a con n ect ion bet ween t h e a dm it t in g–pr ivileges r u lea n d t h e desir a ble pr ot ect ion of a bor t ion pa t ien t s’ h ea lt h . Dr . Love, wh o t r a in eda t a n a bor t ion fa cilit y a n d ser ved a s t h e Ch a ir m a n of t h e Ob/Gyn sect ion of St .Da vid’s Medica l Cen t er in Au st in , t est ified befor e t h e Texa s Legisla t u r e t h a tt h e gen er a l st a n da r d of ca r e r equ ir es h ospit a l pr ivileges for ph ysicia n s wh o15Case: 13-51008Document: 0051259206200512576152Page: 4316Date Filed: 04/10/201403/27/2014No. 13-51008per for m a bor t ion s.At t r ia l, m or eover , t h e St a t e est a blish ed t h a t t h ea dm it t in g–pr ivileges r equ ir em en t wa s ba sed on t h e “r a t ion a l specu la t ion ,” ifn ot em pir ica l da t a , t h a t t h e r egu la t ion “wou ld a ssist in pr even t in g pa t ien ta ba n don m en t by t h e ph ysicia n wh o per for m ed t h e a bor t ion a n d t h en left t h epa t ien t t o h er own devices t o obt a in ca r e if com plica t ion s developed.” Abbott,734 F .3d a t 411.Du r in g t h ese pr oceedin gs, P la n n ed P a r en t h ood con ceded t h a t a t lea st210 wom en in Texa s a n n u a lly m u st be h ospit a lized a ft er seekin g a n a bor t ion .Wit n esses on bot h sides fu r t h er t est ified t h a t som e of t h e wom en wh o a r eh ospit a lized a ft er a n a bor t ion h a ve com plica t ion s t h a t r equ ir e a n Ob/Gynspecia list ’s t r ea t m en t . Aga in st P la n n ed P a r en t h ood’s cla im s t h a t t h ese wom enca n be a dequ a t ely t r ea t ed wit h ou t t h e a dm it t in g–pr ivileges r equ ir em en t , t h eSt a t e sh owed t h a t m a n y h ospit a ls la ck a n Ob/Gyn on ca ll for em er gen cies.Requ ir in g a bor t ion pr ovider s t o h a ve a dm it t in g pr ivileges wou ld a lso pr om ot et h e con t in u it y of ca r e in a ll ca ses, r edu cin g t h e r isk of in ju r y ca u sed bym iscom m u n ica t ion a n d m isdia gn osis wh en a pa t ien t is t r a n sfer r ed fr om on eh ea lt h ca r e pr ovider t o a n ot h er . As Dr . Th or p t est ified, t h e a bor t ion pr ovideris m ost fa m ilia r wit h t h e pa t ien t ’s m edica l h ist or y a n d t h er efor e in t h e bestposit ion t o dia gn ose a n d cor r ect a com plica t ion t h a t a r ises fr om t h e a bor t ion .Th e St a t e’s wit n esses a lso expla in ed t h a t a dm it t in g–pr ivileges r equ ir em en twa s n eeded t o m a in t a in t h e st a n da r d of ca r e wit h in t h e a bor t ion pr a ct ice. Th espect er of Dr . Ker m it Gosn ell in for m ed t h e t est im on y of Dr . Love a n dDr . An der son , bot h of wh om expla in ed t h a t t h e cr eden t ia lin g pr ocess en t a iledin t h e r egu la t ion r edu ces t h e r isk t h a t a bor t ion pa t ien t s will be su bject ed t owoefu lly in a dequ a t e t r ea t m en t . Applyin g t h e r a t ion a l ba sis t est cor r ect ly, weh a ve t o con clu de t h a t t h e St a t e a ct ed wit h in it s pr er oga t ive t o r egu la t e t h e16Case: 13-51008Document: 0051259206200512576152Page: 4417Date Filed: 04/10/201403/27/2014No. 13-51008m edica l pr ofession by h eedin g t h ese pa t ien t –cen t er ed con cer n s a n d r equ ir in ga bor t ion pr a ct it ion er s t o obt a in a dm it t in g pr ivileges a t a n ea r by h ospit a l.Th is con clu sion is con sist en t wit h r u lin gs fr om t h e F ou r t h a n d E igh t hCir cu it s su st a in in g a dm it t in g-pr ivileges r egu la t ion s sim ila r t o t h e on e a t issu eh er e. 11Alt h ou gh P la n n ed P a r en t h ood poin t s ou t t h a t t h e la w u ph eld by t h eE igh t h Cir cu it la ck ed a r est r ict ion sim ila r t o H .B. 2’s r equ ir em en t t h a t t h epr ovider h a ve pr ivileges wit h in 30 m iles of t h e a bor t ion fa cilit y, t h is is adist in ct ion wit h ou t a differ en ce. Th er e is su fficien t eviden ce h er e t h a t t h egeogr a ph ic r est r ict ion h a s a r a t ion a l ba sis. F or exa m ple, t h e St a t e cit es t h er ecom m en da t ion fr om t h e N a t ion a l Abor t ion F ou n da t ion t h a t a bor t ionpa t ien t s sea r ch in g for a doct or sh ou ld fin d on e wh o “[i]n t h e ca se of a nem er gen cy” ca n “a dm it pa t ien t s t o a n ea r by h ospit a l (n o m or e t h a n 20 m in u t esa wa y).” N a t ion a l Abor t ion F eder a t ion , H a vin g a n Abor tion ? You r Gu id e toGood Ca r e (2000). Th e r a t ion a le is fu r t h er su ppor t ed by Dr . Love’s t est im on yt h a t a n a bor t ion pa t ien t is likely t o ca ll h er ph ysicia n , wh o t h en “t ells t h epa t ien t t o m eet t h e ph ysicia n a t t h e h ospit a l wh er e h e or sh e h a s pr ivileges.”Th e geogr a ph ic r est r ict ion a llows t h is m eet in g t o occu r wit h in 30 m iles ofwh er e t h e a bor t ion wa s per for m ed.In a n y ca se, t h e St a t e is n ot r equ ir edu n der r a t ion a l ba sis r eview t o ch oose t h e lea st r est r ict ive m ea n s t o a ch ieve alegit im a t e goa l. Cf. H eller , 509 U .S. a t 321. Th u s, t h e geogr a ph ic r est r ict iondoes n ot a ffect ou r con clu sion t h a t t h e a dm it t in g–pr ivileges r equ ir em en t , a sen a ct ed, h a s a r a t ion a l ba sis.Gr eenville Wom en’s Clin ic v. Com m ’r , S .C. Dep’t of H ea lth & E n vlt. Contr ol, 317 F .3d357, 360, 363 (4t h Cir . 2002) (holdin g a Sout h Ca r olin a r egu la t ion r equir in g a bor t ionpr ovider s t o h a ve adm it t in g pr ivileges at a loca l h ospit a l t o be “so obviou sly ben eficia l t opa t ien t s”); Wom en' s H ea lth Ctr . of W. Cn ty., In c. v. Webster , 871 F .2d 1377, 1381 (8t h Cir .1989) (r u lin g t h at a Missou r i st a t ut e r equ ir in g a bor t ion pr ovider s t o h a ve adm it t ingpr ivileges “fu r t her s im por t a n t st a t e h ea lt h object ives”).1117Case: 13-51008Document: 0051259206200512576152Page: 4518Date Filed: 04/10/201403/27/2014No. 13-51008Th e Seven t h Cir cu it r ecen t ly qu est ion ed t h e con st it u t ion a lit y of aWiscon sin a dm it t in g–pr ivileges la w. P la n n ed P a r en th ood of Wiscon sin , In c. v.Va n H ollen , 738 F .3d 786 (7t h Cir . 2013). Th e cou r t wa s a sked, h owever , on lywh et h er t h e dist r ict ju dge wa s ju st ified in en t er in g a pr elim in a r y in ju n ct iona ga in st t h e Wiscon sin r equ ir em en t . Id . a t 788 (“All we decide t oda y is wh et h ert h e dist r ict ju dge wa s ju st ified in en t er in g t h e pr elim in a r y in ju n ct ion .”). Th ediffer en ce bet ween t h e pr ocedu r a l post u r e of t h e Seven t h Cir cu it ca se a n d ou r sis cr u cia l for t wo r ea son s. F ir st , u n like ou r r eview of t h e en t r y of a per m a n en tin ju n ct ion a ft er a t r ia l on t h e m er it s, t h e Seven t h Cir cu it ’s r u lin g wa s ba sedon a pr e–t r ia l r ecor d, wh ich t h e cir cu it cou r t em ph a sized wa s “spa r se” a n dcou ld be “cr it ica lly a lt er ed” a n d “ca st . . . in a differ en t ligh t ” by t h epr esen t a t ion of eviden ce a t t r ia l. Id . a t 788, 789, 799. Secon d, u n lik e H .B. 2,wh ich a ffor ded a bor t ion pr ovider s a gr a ce per iod of m or e t h a n 100 da ys t oa pply for a dm it t in g–pr ivileges, t h e Wiscon sin pr ovision wa s sign ed in t o la w ona F r ida y a n d beca m e effect ive t h e followin g Mon da y.Id . a t 788.Th eim m edia t e effect ive da t e of t h e Wiscon sin la w fu r n ish ed “a com pellin g r ea sonfor t h e pr elim in a r y in ju n ct ion .” Id . a t 789. Sin ce it t a kes a t lea st t wo m on t h st o obt a in a dm it t in g pr ivileges in Wiscon sin , t h e Va n H ollen pa n el u n a n im ou slya gr eed t h a t t h e r equ ir em en t cou ld n ot h a ve been com plied wit h u n less t h epr elim in a r y in ju n ct ion wa s gr a n t ed.Id . a t 788–89, 793 (P osn er , J .), 799(Ma n ion , J ., con cu r r in g).To t h e ext en t t h a t Va n H ollen ’s len gt h y discu ssion of t h e m er it s of t h eWiscon sin la w con flict s wit h ou r r u lin g, h owever , we a r e u n per su a ded by t h econ cer n s of t h e m a jor it y.Va n H ollen fa u lt s t h e st a t e of Wiscon sin for n ota ddu cin g st a t ist ica l eviden ce t h a t t h e a dm it t in g–pr ivileges r equ ir em en t willm a ke a bor t ion s sa fer . It com pla in s t h a t t h e r ecor d in clu des n o eviden ce t h a ta bor t ion com plica t ion s a r e u n der r epor t ed, id . a t 790, t h a t t h ese com plica t ion s18Case: 13-51008Document: 0051259206200512576152Page: 4619Date Filed: 04/10/201403/27/2014No. 13-51008r equ ir e con t in u it y of ca r e m or e t h a n ot h er ou t pa t ien t ser vices, id . a t 793, ort h a t wom en wh o h a ve com plica t ion s fr om a n a bor t ion r eceiver bet t er ca r e ift h eir a bor t ion pr ovider h a s h ospit a l pr ivileges, id .Th e fir st –st ep in t h ea n a lysis of a n a bor t ion r egu la t ion , h owever , is r a tion a l ba sis r eview, n otem pir ica l ba sis r eview.Gon za les, 550 U.S. a t 158.By su ggest in g t h a tWiscon sin n eeded t o offer fa ct u a l or st a t ist ica l eviden ce, Va n H ollen ign or edca se la w fr om it s own cir cu it h oldin g, con sist en t wit h t h e Su pr em e Cou r t ’s oft r epea t ed gu ida n ce, t h a t t h er e is “n ever a r ole for eviden t ia r y pr oceedin gs”u n der r a t ion a l ba sis r eview. Na t’l P a in t & Coa tin gs Ass' n , 45 F .3d a t 1127.Va n H ollen a lso sees a n equ a l pr ot ect ion pr oblem lu r k in g a bou t t h e Wiscon sinlegisla t u r e’s ch oice n ot t o r equ ir e t h a t doct or s wh o per for m ou t pa t ien t ser vicesot h er t h a n a bor t ion s a lso h a ve a dm it t in g pr ivileges. Va n H ollen , 738 F .3d a t790. Th e a ppella t e cou r t posit s t h a t Wiscon sin ’s a bor t ion pr ovider s h a ve beensin gled ou t by t h e st a t e’s legisla t u r e despit e t h e fa ct t h a t pla in t iffs su bm it t edn o eviden ce t h a t ot h er ou t pa t ien t doct or s a r e a ct u a lly t r ea t ed differ en t ly u n derWiscon sin la w. Id . a t 802 (Ma n ion , J ., con cu r r in g). Th er e is n o r equ ir em en t ,m or eover , t h a t a st a t e legisla t u r e a ddr ess a ll su r gica l pr ocedu r es if it ch oosest o a ddr ess on e. St a t es “m a y select on e ph a se of on e field a n d a pply a r em edyt h er e, n eglect in g t h e ot h er s.” Willia m son v. Lee Optica l of Okla . In c., 348 U.S.483, 489 (1955).19Case: 13-51008Document: 0051259206200512576152Page: 4720Date Filed: 04/10/201403/27/2014No. 13-51008D.Th e dist r ict cou r t ’s opin ion a lso er r ed in it s a pplica t ion of t h e pu r posea n d effect pr on gs of t h e u n du e bu r den t est . Ca sey h olds t h a t t h e legisla t u r em a y n ot en a ct a n a bor t ion r egu la t ion wh ose pu r pose is t o cr ea t e a su bst a n t ia lobst a cle t o a wom a n seekin g a n a bor t ion . Th e pla in t iffs bor e t h e bu r den ofa t t a ckin g t h e St a t e’s pu r pose h er e, yet t h e cou r t im posed t h e bu r den on t h eSt a t e t o dispr ove a n im pr oper pu r pose. Th is is pla in ly ba ckwa r ds. As inlit iga t ion gen er a lly, t h e bu r den of pr ovin g t h e u n con st it u t ion a lit y of a bor t ionr egu la t ion s fa lls squ a r ely on t h e pla in t iffs.Ma zu r ek v. Ar m str on g, 520 U.S.968, 972 (1997) (r ever sin g a ppella t e cou r t for en join in g a bor t ion r est r ict ionwh er e pla in t iffs h a d n ot pr oven t h a t t h e r equ ir em en t im posed a n u n du ebu r den ); Ca sey, 505 U.S. a t 884 (a ffir m in g pr ovision wh er e “t h er e is n oeviden ce on t h is r ecor d” t h a t t h e r est r ict ion wou ld a m ou n t t o a n u n du ebu r den ). Mor eover , t h e pla in t iffs offer ed n o eviden ce im plyin g t h a t t h e St a t een a ct ed t h e a dm it t in g pr ivileges pr ovision in or der t o lim it a bor t ion s; in fa ct ,a s t h eir r eply br ief st a t es, t h ey did n ot a t t a ck t h e St a t e's pu r pose a t a ll. Th er eis t h u s n o ba sis for a fin din g of im per m issible pu r pose u n der Ca sey.E ven t h ou gh t h e St a t e a r t icu la t ed r a t ion a l ba ses for t h is la w, a n d event h ou gh it s pu r pose wa s n ot im pu gn ed, P la n n ed P a r en t h ood cou ld su cceed ift h e effect of t h e la w su bst a n t ia lly bu r den ed wom en 's a ccess t o a bor t ion s inTexa s. In t h is r espect a s well, h owever , t h e opin ion er r ed. It s fin din gs a r eva gu e a n d im pr ecise, fa il t o cor r ela t e wit h t h e eviden ce, a n d even if cr edit ed,fa il t o est a blish a n u n du e bu r den a ccor din g t o t h e Su pr em e Cou r t 's decision s.F ir st , t h e opin ion in va lida t ed t h e a dm it t in g–pr ivileges pr ovision a s itper t a in s t o t h e en t ir e st a t e of Texa s, bu t it s on ly r ecit a t ion of eviden cecon cer n ed “24 cou n t ies in t h e Rio Gr a n de Va lley,” wh ich it pr edict ed wou ld beleft wit h n o a bor t ion pr ovider . As a n in it ia l m a t t er , t h e st a t em en t t h a t both20Case: 13-51008Document: 0051259206200512576152Page: 4821Date Filed: 04/10/201403/27/2014No. 13-51008clin ics in t h e Rio Gr a n de Va lley will close m a y be disr ega r ded a s clea r lyer r on eou s ba sed on t h e t r ia l cou r t r ecor d. H a gst r om –Miller a n d F er r ign o ea cht est ified t h a t t h er e wer e t wo clin ics in t h e Rio Gr a n de Va lley, yet t h e dist r ictcou r t a ccept ed t est im on y r ega r din g on ly on e of t h em . 12 E ven if we wer e t oa ccept t h a t bot h clin ics in t h e Rio Gr a n de Va lley wer e a bou t t o close a s a r esu ltof t h e a dm it t in g pr ivileges pr ovision , h owever , t h is fin din g does n ot sh ow a nu n du e bu r den .To pu t t h is “fin din g” in t o per spect ive, of t h e 254 cou n t ies inTexa s on ly t h ir t een h a d a bor t ion fa cilit ies befor e H .B. 2 wa s t o t a ke effect . Th eRio Gr a n de Va lley, m or eover , h a s fou r cou n t ies, n ot t wen t y-fou r , a n d t r a velbet ween t h ose fou r cou n t ies a n d Cor pu s Ch r ist i, wh er e a bor t ion ser vices a r est ill pr ovided, t a kes less t h a n t h r ee h ou r s on Texa s h igh wa ys (dist a n ces u p t o150 m iles m a xim u m a n d m ost fa r less). In a ddit ion , Texa s exem pt s fr om it s24-h ou r wa it in g per iod a ft er in for m ed con sen t t h ose wom en wh o m u st t r a velm or e t h a n 100 m iles t o a n a bor t ion fa cilit y. Tex. H ea lt h & Sa fet y Code§ 171.012(a )(4).As t h e m ot ion s pa n el cor r ect ly con clu ded, ba sed on t h e t r ia l cou r t r ecor d,a n in cr ea se of t r a vel of less t h a n 150 m iles for som e wom en is n ot a n u n du ebu r den u n der Ca sey.Abbott, 734 F .3d a t 415.In deed, t h e dist r ict cou r tin Ca sey m a de a fin din g t h a t , u n der t h e P en n sylva n ia la w, wom en in 62 ofP en n sylva n ia ’s 67 cou n t ies wer e r equ ir ed t o “t r a vel for a t lea st on e h ou r , a n dsom et im eslon gerthant h r eeh ou r s,toobt a inana bor t ionfr omH a gst r om –Miller t est ified t h a t t h e own er of t he clinic in H a r lin gen —t h e on ly ot h era bor t ion pr ovider , aside fr om t h e McAllen clin ic, in t h e Rio Gr a n de Va lley—in for m ed h ert h a t h e wa s pla n n in g on closin g h is clin ic. Th e dist r ict cou r t , h owever , exclu ded t h isst a t em en t a s h ea r sa y. P la n n ed P a r en t h ood a lso su bm it t ed a wr it t en decla r a t ion fr omF er r ign o, wh ich cont a ined t h e sa m e h ea r sa y st a t em en t a s t o t h e H a r lin gen clin ic a nd wh icht h e St a t e object ed t o on h ea r sa y gr ou n ds befor e t r ia l. Th e dist r ict cou r t n ot ed t h e St at e’s pr et r ia l eviden t ia r y object ion s in it s opin ion. Wit hou t r u lin g on a n y of t h ese object ion s, t h e cou r tin dica t ed t h a t it s opin ion r elied on ly on a dm issible eviden ce. Abbott, 951 F . Supp. 2d a t 896n .3.1221Case: 13-51008Document: 0051259206200512576152Page: 4922Date Filed: 04/10/201403/27/2014No. 13-51008t h e n ea r est pr ovider .” P la n n ed P a r en th ood of S e. P a . v. Ca sey, 744 F . Su pp.1323, 1352 (E .D. P a . 1990), a ff’d in pa r t, r ev’d in pa r t, 947 F .2d 682 (3d Cir .1991), a ff’d in pa r t, r ev’d in pa r t, 505 U.S. 833 (1992). Uph oldin g t h e la w, t h eSu pr em e Cou r t r ecogn ized t h a t t h e 24-h ou r wa it in g per iod wou ld r equ ir e som ewom en t o m a ke t wo t r ips over t h ese dist a n ces.Th e Su pr em e Cou r tn on et h eless h eld t h a t t h e P en n sylva n ia r egu la t ion did n ot im pose a n u n du ebu r den . We t h er efor e con clu de t h a t Ca sey cou n sels a ga in st st r ikin g down ast a t u t e solely beca u se wom en m a y h a ve t o t r a vel lon g dist a n ces t o obt a ina bor t ion s. Th e r ecor d befor e u s does n ot in dica t e t h a t t h e a dm it t in g–pr ivilegesr equ ir em en t im poses a n u n du e bu r den by vir t u e of t h e pot en t ia l in cr ea se int r a vel dist a n ce in t h e Rio Gr a n de Va lley. Cf. Ca sey, 505 U .S. a t 887 (“H en ce,on t h e r ecor d befor e u s, a n d in t h e con t ext of t h is fa cia l ch a llen ge, we a r e n otcon vin ced t h a t t h e 24–h ou r wa it in g per iod con st it u t es a n u n du e bu r den .”).Secon d, t h e opin ion ’s fin din g t h a t “t h er e will be a bor t ion clin ics t h a t willclose” is t oo va gu e. Th e opin ion m a de n o “ba selin e” fin din g a s t o pr ecisely h owm a n y a bor t ion doct or s cu r r en t ly la ck a dm it t in g pr ivileges r equ ir ed by H .B. 2.P la n n ed P a r en t h ood ca n n ot r esu r r ect it s a sser t ion t h a t on e–t h ir d of t h e st a t e’sclin ics will close or over 22,000 wom en will be depr ived of a ccess t o a bor t ionser vices ea ch yea r beca u se t h e dist r ict cou r t a lso r efu sed t o a ccept t h esefin din gs. Alt h ou gh som e clin ics m a y be r equ ir ed t o sh u t t h eir door s, t h er e isn o sh owin g wh a t soever t h a t a n y wom a n will la ck r ea son a ble a ccess t o a clin icwit h in Texa s. All of t h e m a jor Texa s cit ies, in clu din g Au st in , Cor pu s Ch r ist i,Da lla s, E l P a so, H ou st on , a n d Sa n An t on io, con t in u e t o h a ve m u lt iple clin icswh er e m a n y ph ysicia n s will h a ve or obt a in h ospit a l a dm it t in g pr ivileges.E viden ce offer ed by P la n n ed P a r en t h ood sh owed t h a t m or e t h a n n in et yper cen t of t h e wom en seekin g a n a bor t ion in Texa s wou ld be a ble t o obt a in t h epr ocedu r e wit h in 100 m iles of t h eir r espect ive r esiden ces even if H .B. 2 wen t22Case: 13-51008Document: 0051259206200512576152Page: 5023Date Filed: 04/10/201403/27/2014No. 13-51008in t o effect . Abbott, 734 F .3d a t 415. As t h e m ot ion s pa n el r u led, “[t ]h is doesn ot con st it u t e a n u n du e bu r den in a la r ge fr a ct ion of t h e r eleva n t ca ses.” Id .Th ir d, t h e r ecor d does n ot sh ow t h a t a bor t ion pr a ct it ion er s will likely beu n a ble t o com ply wit h t h e pr ivileges r equ ir em en t . In a n u m ber of a r ea s inTexa s, ph ysicia n s wh o a r e per for m in g a bor t ion s a lr ea dy h a ve a dm it t in gpr ivileges. Bot h st a t e a n d feder a l la w pr oh ibit h ospit a ls fr om discr im in a t in ga ga in st ph ysicia n s wh o per for m a bor t ion s wh en t h ey gr a n t a dm it t in gpr ivileges. 13 F u r t h er , it is u n dispu t ed t h a t m a n y h ospit a ls ext en d a dm it t in gpr ivileges wit h ou t r ega r d t o t h e n u m ber of h ospit a l a dm ission s t h a t aph ysicia n h a s h a d in t h e pa st . To be su r e, t h e dist r ict cou r t ’s opin ion a lso fou n dt h a t t h e “va st m a jor it y” of a bor t ion pr ovider s cou ld n ot obt a in pr ivileges a th ospit a ls wit h a m in im u m a dm ission s r equ ir em en t beca u se a bor t ion pr ovider sdo “n ot gen er a lly yield a n y h ospit a l a dm ission s.” Abbott, 2013 WL 5781583, a t*5. Yet t h is fin din g pr oves lit t le for t h e r ea son expla in ed by t h e m ot ion s pa n el:E ven if som e h ospit a ls h a ve a n n u a l a dm ission r equ ir em en t s, it ish a r dly su r pr isin g t h a t t h e ph ysicia n s iden t ified by t h e pla in t iffsh a ve vir t u a lly n o h ist or y of h ospit a l a dm ission s sin ce t h e exper t spr esen t ed by t h e pla in t iffs a r gu ed t h a t it is t h e pr a ct ice of m a n ya bor t ion ph ysicia n s t o in st r u ct t h eir pa t ien t s t o seek ca r e fr om a nem er gen cy r oom if com plica t ion s a r ise.Texa s law specifica lly pr oh ibit s discr im in a t ion by h ospit a ls or h ea lt h ca r e fa cilit iesa ga in st ph ysicia ns who per for m a bor t ion s. “A h ospit a l or h ea lt h ca r e facilit y m a y n otdiscr im in at e a ga inst a ph ysicia n, n u r se, st a ff m em ber or em ployee beca u se of t he per son’swillin gn ess t o pa r t icipa t e in a n a bor t ion pr ocedur e at a n ot h er facilit y.” T E X. O CC . C ODE ANN .§ 103.002(b) (West 2013). Texa s law fu r t h er pr ovides a pr iva t e ca u se of a ct ion for a nin dividu a l t o enfor ce t his n on –discr im in a t ion r igh t . Id. § 1003.003. F eder a l law sim ila r lypr oh ibit s a n y en t it y t h at r eceives a “gr a n t , con t r a ct , loa n, or loa n gu a r an t ee u nder t h e P u blicH ea lt h Ser vice Act , t h e Com m u n it y Men t a l H ea lt h Cent er s Act , or t h e Developm entDisa bilit ies Ser vices a nd F a cilit ies Con st r u ct ion Act ” or a “gr a n t or con t r a ct for biom edica lor beh a vior a l r esea r ch u n der a n y pr ogr a m a dm in ist er ed by t h e Secr et a r y of H ea lt h a ndH u m a n Ser vices” fr om discr im in at in g “in t h e ext en sion of st aff of ot h er pr ivileges t o a n yph ysicia n or ot h er h ealt h ca r e per son n el . . . beca use h e per for m ed or a ssist ed in t h eper for m a nce of a lawfu l st er ilizat ion pr ocedu r e or a bor t ion.” 42 U.S.C. § 300a -7(c).1323Case: 13-51008Document: 0051259206200512576152Page: 5124Date Filed: 04/10/201403/27/2014No. 13-51008Abbott, 734 F .3d a t 416.Mor eover , t h e opin ion dr ew t h e wr on g lesson s fr om H a gst r om –Miller ’st est im on y wh en it r elied on h er “difficu lt ies get t in g t h e cu r r en t ph ysicia n s” a tWWH in com plia n ce wit h H .B. 2. Abbott, 951 F . Su pp. 2d a t 901. H a gst r om –Miller descr ibed h er effor t s in obt a in in g a dm it t in g pr ivileges for ju st t wo of h eror ga n iza t ion ’s cu r r en t ph ysicia n s—it s pr im a r y ph ysicia n in McAllen , wh o doesn ot qu a lify for a dm it t in g pr ivileges beca u se h e is n ot a boa r d–cer t ified Ob/Gyn ,a n d a ph ysicia n in Bea u m on t , wh ose a pplica t ion t h e h ospit a l h a d yet t opr ocess.Th e r em a in der of H a gst r om –Miller ’s t est im on y con cer n ed h erdifficu lt ies r ecr u it in g n ew ph ysicia n s a n d r et a in in g t h e ph ysicia n s wh o h a dpr eviou sly don e som e wor k for WWH . Th ese ch a llen ges wer e a lm ost en t ir elyu n r ela t ed t o H .B. 2. F ou r of t h e five ph ysicia n s t h a t sh e en dea vor ed t o r ecr u itcou ld n ot be per su a ded t o join WWH beca u se t h ey felt det er r ed by t h e t er m s oft h eir exist in g em ploym en t . Th e fift h fea r ed a n t i–a bor t ion violen ce. Non e oft h ese r ea son s is con n ect ed wit h H .B. 2. As t o t h e ot h er ph ysicia n s, wh o h a dpr eviou sly don e som e wor k wit h WWH , t wo wer e wor r ied a bou t t h e pa ssa ge offu tu r e legisla t ion (n ot H .B. 2), t h r ee wer e pr even t ed by t h eir em ployer s, a n don e fou n d wor k in New Yor k.All t old, on ly on e of t h e ph ysicia n s t h a tH a gst r om –Miller con t a ct ed declin ed t o pr ovide a bor t ion s in Texa s a s acon sequ en ce of H .B. 2.H er e a ga in , we a r e in su bst a n t ia l a ccor d wit h t h em ot ion s pa n el, wh ich con clu ded t h a t “m a n y fa ct or s ot h er t h a n t h e h ospit a l–a dm it t in g–pr ivileges r equ ir em en t ” a ffect ed a bor t ion a ccess in t h e Rio Gr a n deVa lley.Abbott, 734 F .3d a t 415.Th er e is even less pr oba t ive eviden cer ega r din g t h e r est of t h e st a t e. 14To t h e ext en t t h at t h e St a t e a n d P la n ned P a r en t h ood r ely on developm en t s sincet h e con clusion of t he ben ch t r ia l a n d du r in g t his appea l, we do not consider a n y a r gu m en t sba sed on t h ose fa ct s, n or do we r ely on a n y fa ct s a sser t ed in a m icu s br iefs. Th is opin ion s iscon fin ed t o t he r ecor d befor e t h e t r ia l cou r t .1424Case: 13-51008Document: 0051259206200512576152Page: 5225Date Filed: 04/10/201403/27/2014No. 13-51008E.In su m , t h e dist r ict cou r t ’s opin ion a pplied wr on g lega l st a n da r ds on t h er a t ion a l ba sis a n d pu r pose t est s a n d clea r ly er r ed in fin din g t h a t “24 cou n t iesin t h e Rio Gr a n de Va lley wou ld be left wit h n o a bor t ion pr ovider .” Wit h r ega r dt o t h e r em a in der of t h e st a t e, t h e dist r ict cou r t opin ion er r on eou sly con clu dedt h a t H .B. 2 im posed a n u n du e bu r den in a la r ge fr a ct ion of t h e ca ses. Th eeviden ce pr esen t ed t o t h e dist r ict cou r t dem on st r a t es t h a t if t h e a dm it t in g–pr ivileges r egu la t ion bu r den s a bor t ion a ccess by dim in ish in g t h e n u m ber ofdoct or s wh o will per for m a bor t ion s a n d r equ ir in g wom en t o t r a vel fa r t h er , t h ebu r den does n ot fa ll on t h e va st m a jor it y of Texa s wom en seekin g a bor t ion s.P u t ot h er wise, t h e r egu la t ion will n ot a ffect a sign ifica n t (m u ch less “la r ge”)fr a ct ion of su ch wom en , a n d it im poses on ot h er wom en in Texa s less of abu r den t h a n t h e wa it in g–per iod pr ovision u ph eld in Ca sey. Ca sey, 505 U.S. a t885-87. Th is su ffices t o su st a in t h e a dm it t in g–pr ivileges r equ ir em en t .F.Th e cou r t ’s opin ion r eject ed P la n n ed P a r en t h ood’s ch a llen ge t o t h ea dm it t in g–pr ivileges pr ovision on va gu en ess gr ou n ds a n d did n ot r u le onpla in t iffs’ pr ocedu r a l du e pr ocess a n d u n la wfu l delega t ion cla im s.It is n otn ecessa r y t o r em a n d eit h er of t h e u n r esolved a r gu m en t s t o t h e dist r ict cou r t .Th e u n la wfu l delega t ion a r gu m en t fa ils for t h e r ea son s set for t h in Wom en ’sH ea lth Cen ter of West Cou n ty, In c. v. Webster , wh er e t h e E igh t h Cir cu it h eld:Th e r equ ir em en t t h a t ph ysicia n s per for m in g a bor t ion s obt a insu r gica l pr ivileges, wh ich in volves t h e in depen den t a ct ion of apu blic or pr iva t e h ospit a l, poses n o m or e sign ifica n t t h r ea t t opla in t iffs’ du e pr ocess r igh t s t h a n t h e r equ ir em en t t h a t t h oseper for m in g a bor t ion s be licen sed ph ysicia n s, wh ich in volves t h ein depen den t a ct ion of a m edica l licen sin g boa r d.871 F .2d 1377, 1382 (8t h Cir . 1989).As for t h e pr ocedu r a l du e pr ocessa r gu m en t , P la n n ed P a r en t h ood con t en ds t h a t H .B. 2 did n ot offer a bor t ion25Case: 13-51008Document: 0051259206200512576152Page: 5326Date Filed: 04/10/201403/27/2014No. 13-51008pr ovider s a lon g en ou gh “gr a ce per iod” t o com ply wit h t h e a dm it t in g-pr ivilegespr ovision . H .B. 2, h owever , ga ve a bor t ion pr ovider s a ppr oxim a t ely 100 da ys t oa pply for a dm it t in g pr ivilege, wh ich , on it s fa ce, is a su fficien t gr a ce per iod.Atkin s v. P a r ker , 472 U.S. 115, 130-31 (1985) (m a in t a in in g t h a t “a gr a ce per iodof over 90 da ys” is a dequ a t e). By t h e sa m e t oken , it wou ld be a bsu r d t o en for ceH .B. 2 a ga in st ph ysicia n s wh o tim ely a pplied for a dm it t in g pr ivileges bu t h a ven ot h ea r d ba ck fr om t h e h ospit a l, wh ich ca n t a ke u p t o 170 da ys fr om t h e da t eof a pplica t ion u n der Texa s la w. S ee T E X. H E ALTH & S AF E TY C ODE § 41.101(set t in g dea dlin es by wh ich h ospit a ls m u st a ct on a dm it t in g-pr ivilegesa pplica t ion s).Obviou sly, it is u n r ea son a ble t o expect t h a t a ll a bor t ionpr ovider s will be a ble t o com ply wit h t h e a dm it t in g-pr ivileges pr ovision wit h in100 da ys wh er e r eceivin g a r espon se fr om a h ospit a l pr ocessin g a n a pplica t ionfor a dm it t in g pr ivileges ca n t a ke 170 da ys.Accor din gly, we con clu de t h a tpu r su a n t t o H .B. 2’s sever a bilit y pr ovision , § 10(b), t h e a dm it t in g–pr ivilegesr equ ir em en t m a y n ot be en for ced a ga in st a bor t ion pr ovider s wh o a pplied fora dm it t in g pr ivileges wit h in t h e gr a ce per iod a llowed u n der H .B. 2, bu t a r ea wa it in g a r espon se fr om a h ospit a l.I V.P r o t o c o l fo r Me d i c a t io n Ab o r t io n sIn a ddit ion t o r equ ir in g h ospit a l a dm it t in g pr ivileges, H .B. 2 m a n da t est h a t m edica t ion a bor t ion s sa t isfy t h e pr ot ocol a ppr oved for su ch a bor t ion s byt h e F DA a n d ou t lin ed in t h e fin a l pr in t ed la bel (“F P L”) for t h e a bor t ifa cien tdr u g m ifepr ist on e.Sin ce t h e F DA a u t h or ized t h e pr ot ocol for m edica t iona bor t ion s in 2000, doct or s per for m in g su ch a bor t ion s in Texa s, a n d a ppa r en t lya cr oss t h e cou n t r y, h a ve developed a n off–la bel pr ot ocol t h a t differ s fr om t h eF DA–a ppr oved ver sion in t er m s of dosa ge a m ou n t s a n d a dm in ist r a t ion of t h et wo a bor t ion dr u gs—m ifepr ist on e a n d m isopr ost ol. In pa r t icu la r , a lt h ou gh t h eF P L lim it s t h e a dm in ist r a t ion of a m edica t ion a bor t ion t o for t y–n in e da ys26Case: 13-51008Document: 0051259206200512576152Page: 5427Date Filed: 04/10/201403/27/2014No. 13-51008followin g a wom a n ’s la st m en st r u a l per iod (“LMP ”), doct or s r egu la r lya dm in ist er m edica t ion a bor t ion s u p t o sixt y–t h r ee da ys LMP , a n d som et im esa s la t e a s seven t y da ys LMP .In r u lin g on P la n n ed P a r en t h ood’s fa cia l ch a llen ge of t h e m edica t iona bor t ion r egu la t ion s, t h e opin ion fou n d t h a t su ch r egu la t ion s do n ot im pose a nu n du e bu r den on a wom a n seekin g a n a bor t ion bet ween on e a n d for t y–n in eda ys LMP .15Neit h er pa r t y ch a llen ges t h e dist r ict cou r t ’s con clu sion on t h ispoin t . Th e opin ion wen t fu r t h er a n d fou n d t h a t H .B. 2 does pla ce a su bst a n t ia lobst a cle in t h e pa t h of a wom a n seekin g a n a bor t ion bet ween fift y a n d sixt y–t h r ee da ys LMP in sit u a t ion s wh er e su r gica l a bor t ion is n ot a m edica lly sou n dor sa fe a lt er n a t ive for h er . E n join in g a pplica t ion of t h e la w even beyon d t h isfin din g, h owever , t h e dist r ict cou r t r u led t h a t H .B. 2’s m edica t ion a bor t ionpr ovision s, t h ou gh con st it u t ion a l, cou ld n ot be en for ced a ga in st a n y ph ysicia nwh o det er m in ed t h a t u sin g a n off–la bel pr ot ocol for a m edica t ion a bor t ion (i.e.,per for m in g a m edica t ion a bor t ion bet ween fift y a n d sixt y–t h r ee da ys LMP )wa s n ecessa r y “for t h e pr eser va t ion of t h e life or h ea lt h of t h e m ot h er .” Abbott,951 F . Su pp. 2d a t 908–09.P la n n ed P a r en t h ood essen t ia lly con cedes t h e con st it u t ion a lit y of t h eF DA pr ot ocol a s it a pplies t o m edica t ion a bor t ion s bet ween on e a n d for t y–n in eda ys LMP . Beca u se we a r e r equ ir ed t o decide a con st it u t ion a l ca se on t h en a r r owest gr ou n ds pr esen t ed, we will a ssu m e t h e dist r ict cou r t m ea n t t o a lignRecent ly, t h e Sixt h Cir cu it u ph eld, in a 2-1 r u lin g, a n Oh io a bor t ion st a t u t e t h a tm a n da t ed a dh er en ce t o t he FDA–a ppr oved for t y–n in e da y LMP lim it for m edicat iona bor t ions. Pla n n ed Pa r en th ood S .W. Ohio Region v. DeWin e, 696 F .3d 490 (6t h Cir . 2012).Th e Sixt h Cir cuit r eason ed t h a t t h e const it u t ion pr ot ect s a wom a n ’s r igh t t o h a ve a n a bor t ion ,bu t it does n ot pr ot ect a wom a n ’s choice in t he m eth od of a bor t ion. Id . a t 514–15. Th e cou r tfou n d n o evidence t h a t ba n n in g m edica l a bor t ion s a ft er for t y–n in e da ys LMP im posed a nu n du e bu r den on a wom a n ’s r igh t t o bodily in t egr it y or t o ch oose a bor t ion , or t h at a n a llegedin cr ea se in cost s a n d m a n da t or y doct or visit s con st it u t ed a n u n du e bur den as com pa r ed t owh a t t h e Su pr em e Cou r t r eject ed in Ca sey. Id .1527Case: 13-51008Document: 0051259206200512576152Page: 5528Date Filed: 04/10/201403/27/2014No. 13-51008t h e scope of t h e in ju n ct ion wit h t h e n a r r ower scope of it s r ea son in g. P la n n edP a r en t h ood’s defen se of t h e in ju n ct ion a ccor ds wit h t h is view. Ou r discu ssionis t h u s con fin ed t o t h e qu est ion wh et h er t h e dist r ict cou r t er r ed in h oldin g t h a tH .B. 2’s r eject ion of t h e off–la bel pr ot ocol fr om fift y t o sixt y–t h r ee da ys LMPcon st it u t es a n u n du e bu r den on t h e a bor t ion r igh t s of wom en wh o, beca u se ofpa r t icu la r gyn ecologica l a bn or m a lit ies, ca n n ot sa fely u n der go su r gica la bor t ion du r in g t h a t per iod. S ee Gon za les, 550 U.S. a t 161.A.Du r in g t r ia l, bot h sides pr esen t ed exper t wit n ess t est im on y a n ddecla r a t ion s opin in g on t h e sa fet y a n d effica cy of m edica t ion a bor t ion s. F orP la n n ed P a r en t h ood, Dr . F in e st a t ed h is opin ion t h a t H .B. 2’s m edica t iona bor t ion r equ ir em en t s a r e m edica lly u n n ecessa r y a n d will n ot im pr ove pa t ien th ea lt h a n d sa fet y. In pa r t icu la r , Dr . F in e st a t ed t h a t off–la bel m edica t iona bor t ion s a r e ver y sa fe a n d h igh ly effect ive t h r ou gh sixt y–t h r ee da ys LMP a n dt h a t a lt h ou gh t h e F DA h a s pla ced cer t a in lim it a t ion s on t h e u se ofm ifepr ist on e, t h ose lim it a t ion s h a ve n ever r equ ir ed ph ysicia n s t o st op u sin g ita ft er for t y–n in e da ys LMP . Dr . F in e in dica t ed t h a t m edica t ion a bor t ion s a r epr efer a ble t o su r gica l a bor t ion s for wom en wh o wa n t t o h a ve m or e per son a lcon t r ol over t h e pr ocess or wh o fea r t h e in va sive n a t u r e of a su r gica l a bor t ion .Dr . F in e a lso a sser t ed t h a t som e wom en h a ve m edica l con dit ion s t h a t m a kefir st –t r im est er su r gica l a bor t ion ext r em ely difficu lt , if n ot im possible. Th esescen a r ios in clu de wom en wh o a r e ext r em ely obese, h a ve u t er in e fibr oidsdist or t in g n or m a l a n a t om y, h a ve a u t er u s t h a t is ver y flexed, or h a ve cer t a inu t er in e a n om a lies, su ch a s a m a lfor m ed u t er u s. Dr . F in e a lso opin ed t h a tm edica t ion a bor t ion s m a y be sign ifica n t ly sa fer t h a n su r gica l a bor t ion s forwom en wh o h a ve a st en ot ic cer vix or h a ve u n der gon e fem a le gen it a lm u t ila t ion . Th ese la t t er con dit ion s m a ke it ver y difficu lt t o dila t e a wom a n ’s28Case: 13-51008Document: 0051259206200512576152Page: 5629Date Filed: 04/10/201403/27/2014No. 13-51008cer vix, a n d Dr . F in e st a t ed t h a t per for m in g a su r gica l a bor t ion on a wom a nsu ffer in g fr om su ch con dit ion s wou ld pu t h er a t gr ea t er r isk of da m a ge t o h ercer vix a s well a s ot h er com plica t ion s, su ch a s u t er in e per for a t ion . Th e bot t omlin e, a ccor din g t o Dr . F in e, is t h a t for wom en wh o su ffer fr om cer t a in m edica lcon dit ion s t h a t m a k e su r gica l a bor t ion sign ifica n t ly m or e r isky, H .B. 2 a ct s a sa ba n t o pr evia bilit y a bor t ion a ft er for t y–n in e da ys LMP .Th e St a t e, on t h e ot h er h a n d, a ddu ced r ea son s for u ph oldin g t h e F DApr ot ocol in it s en t ir et y, ir r espect ive of a life a n d h ea lt h except ion . As t o t h eF DA–a ppr oved for t y–n in e da y LMP lim it , t h e St a t e’s exper t , Dr . Don n aH a r r ison , poin t ed ou t t h a t t h e F DA’s a ppr ova l of m ifepr ist on e a s a na bor t ifa cien t h in ged on t h e im posit ion of post –a ppr ova l r est r ict ion s, wh ichh a ve in clu ded r equ ir in g wom en t o sign a P a t ien t Agr eem en t befor e u sin gm ifepr ist on e. Am on g ot h er t h in gs, t h e P a t ien t Agr eem en t r equ ir es a wom a nt o con fir m pr ior t o t h e m edica t ion a bor t ion t h a t sh e believes sh e is n o m or et h a n for t y–n in e da ys pr egn a n t . Dr . H a r r ison a lso em ph a sized h ow m edica lr esea r ch h a s sh own t h a t dr u g–in du ced a bor t ion s pr esen t m or e m edica lcom plica t ion s a n d a dver se even t s t h a n su r gica l a bor t ion s, wit h six per cen t ofm edica t ion a bor t ion s even t u a lly r equ ir in g su r ger y t o com plet e t h e a bor t ion ,oft en on a n em er gen cy ba sis. Wit h t h is st a t ist ic in m in d, Dr . H a r r ison opin edt h a t wh en su r ger y is a lr ea dy con t r a in dica t ed for a wom a n , it wou ld bem edica lly ir r espon sible a n d con t r a r y t o h er best in t er est for a ph ysicia n t osu bm it h er t o a m edica t ion a bor t ion , for in t h e even t a n em er gen cy su r gica la bor t ion is la t er n eeded, sh e will be pla ced a t a n even h igh er r isk of a dver seh ea lt h r esu lt s.B.Con sider in g t h e eviden ce, t h e dist r ict cou r t opin ion fou n d t h a t “t h er e a r ecer t a in sit u a t ion s wh er e m edica t ion a bor t ion is t h e on ly sa fe a n d m edica lly29Case: 13-51008Document: 0051259206200512576152Page: 5730Date Filed: 04/10/201403/27/2014No. 13-51008sou n d opt ion for wom en wit h pa r t icu la r ph ysica l a bn or m a lit ies or pr eexist in gcon dit ion s.” Abbott, 951 F . Su pp. 2d a t 907. Th e opin ion a lso con clu ded, wh ilen ot in g it h a d n o specific eviden ce on t h e poin t , t h a t “it is possible t h a t a sizea blefr a ct ion of wom en m a y [fir st ] discover pr egn a n cy or elect a bor t ion du r in g t h eper iod fr om 50 t o 63 da ys LMP .” Id . a t 906 n .20. Accor din gly, t h e opin ionfou n d t h a t for wom en wh o discover or elect a bor t ion bet ween fift y a n d sixt y–t h r ee da ys LMP , bu t for wh om su r gica l a bor t ion r epr esen t s a sign ifica n t h ea lt hr isk, H .B. 2’s r egu la t ion s of m edica t ion a bor t ion “a ct a s a t ot a l m et h od ba na ft er 49 da ys LMP ,” t h er eby “pla c[in g] a su bst a n t ia l obst a cle” in t h e wa y of awom a n ’s r igh t t o a bor t ion . Id . a t 907. Th e opin ion em ph a sized t h a t H .B. 2 didn ot fa il con st it u t ion a l r eview du e t o t h e la ck of a specific h ea lt h –of–t h e–m ot h erexcept ion . Never t h eless, t h e cou r t en join ed en for cem en t of H .B. 2’s m edica t iona bor t ion r egu la t ion s “t o t h e ext en t t h ose pr ovision s pr oh ibit a m edica t iona bor t ion wh er e a ph ysicia n det er m in es in a ppr opr ia t e m edica l ju dgm en t , [t h a t ]su ch a pr ocedu r e is n ecessa r y for t h e pr eser va t ion of t h e life or h ea lt h of t h em ot h er .” Th e cou r t ’s in ju n ct ion a lso in discr im in a t ely en join ed t h e St a t e fr omen for cin g cer t a in H .B. 2 r equ ir em en t s t h a t P la n n ed P a r en t h ood n everch a llen ged a n d t h a t h a ve n ot h in g t o do wit h pa t ien t s’ a ccess t o dr u g-in du ceda bor t ion s. 16 In deed, P la n n ed P a r en t h ood does n ot seek t o a ffir m t h is pa r t oft h e in ju n ct ion on a ppea l.As su m m a r ized by t h is cou r t in it s pr ior opin ion ,Th e F in a l J u dgm ent . . . r em oves t he r equ ir em en t in [Texas H ea lt h a nd Sa fet y Code]§ 171.063(c) t h at befor e t he ph ysicia n m a y dispense or adm in ist er a n a bor t ion –in du cin g dr u g, h e or she m ust exa m in e t h e pr egn a n t wom a n a nd docu m en t , in t h epa t ien t ’s m edica l r ecor d, t h e gest at ion a l a ge, a nd in t r a u t er in e loca t ion of t h epr egn a n cy. Th e in jun ct ion sim ila r ly in explica bly r em oves t h e r equ ir em ent in§ 171.063(e) t h at t h e ph ysicia n sch edu le a follow-u p visit for a wom a n wh o h asr eceived a n a bor t ion –indu cin g dr u g n ot m or e t ha n 14 da ys a ft er t h e a dm in ist r a t ion oft h e dr u g a nd t h e r equ ir em ent t h a t a t t h a t follow–up visit , t h e ph ysicia n m ustdet er m in e wh et her t he pr egn a n cy is com plet ely t er m in at ed a nd assess t h e degr ee ofbleedin g. Th e in ju n ct ion likewise r em oves t h e a pplica bilit y of § 171.063(f), which a lso1630Case: 13-51008Document: 0051259206200512576152Page: 5831Date Filed: 04/10/201403/27/2014No. 13-51008C.To eva lu a t e t h e dist r ict cou r t ’s pa r t ia l in ju n ct ion a ga in st H .B. 2’sm edica t ion a bor t ion r egu la t ion s, we t u r n on ce m or e t o Gon za les. In Gon za lest h e Su pr em e Cou r t con sider ed wh et h er t h e P a r t ia l–Bir t h Abor t ion Ba n Act of2003 (“t h e Act ”), wh ich ot h er wise pa ssed con st it u t ion a l m u st er a ga in st t h er espon den t s’ fa cia l ch a llen ges, h a d t h e effect of im posin g a n u n con st it u t ion a lbu r den on a wom a n ’s r igh t t o a bor t ion beca u se it did n ot a llow t h e u se of in t a ctdila t ion a n d eva cu a t ion (“D & E ”) wh er e “n ecessa r y, in a ppr opr ia t e m edica lju dgm en t , for t h e pr eser va t ion of t h e . . . h ea lt h of t h e m ot h er .” Gon za les,550 U.S. a t 161 (in t er n a l qu ot a t ion m a r ks om it t ed) (qu ot in g Ayotte v. P la n n edP a r en th ood of N. N ew E n g., 546 U.S. 320, 327-28 (2006)). In a ddr essin g t h isissu e, t h e Cou r t r ea son ed t h a t t h e la ck of a h ea lt h except ion in a n a bor t ionst a t u t e im poses a n u n con st it u t ion a l bu r den on a wom a n ’s r igh t t o a bor t ion ifit su bject s a wom a n t o sign ifica n t h ea lt h r isks. 17 Id .per t a ins t o t he follow–up visit . Th er e is n o indica t ion fr om t he dist r ict cou r t ’s opiniont h a t t h er e is a n y con st it u t ion a l infir m it y in t h ese sect ion s.P la n n ed P a r en th ood of Gr ea ter Tex. S ur gica l H ea lth S er vs. v. Abbott, 734 F .3d 406, 418-19(5t h Cir . 2013).17 Th e St at e su ggest s t h a t int r odu ct or y la n gua ge t o H .B. 2 specifies a gen er a lst a t ut or y in t en t t o pr eser ve t he life or h ea lt h of t h e m ot her , by st a t in g: “[T]his Act does n ota pply t o a bor t ions t h a t a r e n ecessa r y t o a ver t t h e dea t h or su bst a nt ia l a nd ir r ever sibleph ysica l im pa ir m en t of a m a jor bodily fu n ct ion of t h e pr egn a n t wom a n .” Sect ion 1(4)(B).Accor din g t o t h e St a t e, t h is la n gu a ge, plu s it s in -cou r t a ssu r a n ces t h at n o ph ysicia n wou ldbe pr osecut ed for a m edica t ion a bor t ion ou t side t h e FDA pr ot ocol if t h e h ea lt h of t he wom anwa s jeopa r dized as pr ovided, r ender s t h e dist r ict cou r t 's in clusion of it s own h ea lt h pr ovisionr edu n da nt . We dou bt t h a t t h e st at u t e cr eat es a gen er a l lim it a t ion . F ir st , t h e la n gu a gea ppea r s in a pr ovision t h a t descr ibes on ly H .B. 2’s pr oh ibit ion on la t e–t er m a bor t ions, wh ichis n ot at issu e in t h is ca se. It is ar gu a ble t h a t t h is h ealt h of t h e m ot her la n gu a ge con cer nson ly la t e–t er m a bor t ions. Secon d, even if a legisla t u r e’s st a t u t or y declar a t ions of pu r pose, asopposed t o it s a ffir m a t ive dict at es, apply in h olist ic in t er pr et a t ion of t h e en t ir e st a t ut e, t hisla n gu a ge does n ot a ppea r br oa d en ou gh t o cover t h e t ype of r epr odu ct ive syst ema bn or m a lit ies or con dit ion s t h at , accor din g t o Dr . F in e, r ender m edica t ion a bor t ions sa fer forcer t a in wom en du r in g t h e 50-63 da y LMP win dow a t issu e h er e. Beca u se of t h e a bovedisposit ion , h owever , we do n ot r esolve t h is issu e.31Case: 13-51008Document: 0051259206200512576152Page: 5932Date Filed: 04/10/201403/27/2014No. 13-51008Th e r espon den t s in Gon za les pr offer ed eviden ce con cer n in g in t a ct D &E , in clu din g t h a t it “wa s sa fer for wom en wit h cer t a in m edica l con dit ion s orwom en wit h fet u ses t h a t h a d cer t a in a n om a lies.” Id . Despit e t h is eviden ce,t h e Cou r t fou n d t h a t t h e Act ’s la ck of a h ea lt h except ion did n ot fa cia lly im posea n u n du e bu r den on t h e r igh t t o a bor t ion beca u se (1) t h er e wa s m edica ldisa gr eem en t a s t o wh et h er pr oh ibit in g in t a ct D & E a s a m et h od of a bor t ionwou ld a ct u a lly im pose a sign ifica n t h ea lt h r isk on wom en , 18 id . a t 162-64;(2) a lt er n a t ive m et h ods t o in t a ct D & E r em a in ed a va ila ble for wom en seekin ga bor t ion s, id . a t 164; a n d (3) t h e Act st ill a llowed per for m a n ce of a n ot h er“com m on ly u sed a n d gen er a lly a ccept ed” m et h od of a bor t ion , id . a t 165.In ligh t of t h is pr eceden t , we con clu de t h a t H .B. 2’s r egu la t ion s onm edica t ion a bor t ion , like t h e Act in Gon za les, do n ot fa cia lly r equ ir e a cou r t –im posed except ion for t h e life a n d h ea lt h of t h e wom a n . F ir st , we em ph a sizet h a t t h e con dit ion s t h a t su pposedly r equ ir e off-la bel pr ot ocol h a ve n ot beenclea r ly defin ed. Th e dist r ict cou r t ’s opin ion a sser t ed t h a t su ch ca ses in clu dewom en wh o a r e “ext r em ely obese” or wh o h a ve “cer t a in u t er in e a n om a lies.”Abbott, 951 F . Su pp. 2d a t 906 n .18.As t h e St a t e a r gu ed, gr a n t in g a nin ju n ct ion t o t h is va gu e gr ou p wou ld effect ively give doct or s wide la t it u de t opr escr ibe t h e m edica t ion bet ween 49 a n d 63 da ys LMP . Secon d, a lt h ou gh Dr .F in e ba ldly a sser t s t h a t su r gica l a bor t ion is n ea r ly, if n ot a ct u a lly, im possiblefor a pa r t icu la r su bset of wom en , P la n n ed P a r en t h ood h a s n ot poin t ed t h iscou r t t o a n y eviden ce of scien t ific st u dies or r esea r ch in t h e r ecor d sh owin g t h ist o be t r u e. S ee Gon za les, 550 U.S. a t 162. Mor eover , t h er e a ppea r s t o bedisa gr eem en t over wh et h er m edica t ion a bor t ion s a r e a ct u a lly sa fer for t h a tTh e pet it ion er s in Gonza les offer ed evidence fr om doct or s wh o h a d t est ified befor eCon gr ess a n d in t h e lower cour t s t h a t t h e a lleged h ea lt h adva n t a ges of int a ct D & E “wer eba sed on specu la t ion wit h ou t scien t ific st udies t o su ppor t t h em .” Gonza les, 550 U.S. at 162.1832Case: 13-51008Document: 0051259206200512576152Page: 6033Date Filed: 04/10/201403/27/2014No. 13-51008sa m e su bset of wom en , a t lea st wh en su bsequ en t em er gen cy su r gica l a bor t ion sa r e n ecessa r y. Th ir d, H .B. 2, u n lik e t h e Act in Gon za les, does n ot ba n a n en t ir ea bor t ion m et h od.Ra t h er , it m er ely sh or t en s t h e win dow du r in g wh ich awom a n m a y elect t o h a ve a m edica t ion a bor t ion , lea vin g open t h e possibilit yfor a n y wom a n t o h a ve a m edica t ion a bor t ion u p t o for t y–n in e da ys LMP .Alt h ou gh Dr . F in e m en t ion ed in pa ssin g t h a t m a n y wom en do n ot det ectpr egn a n cies u n t il t h ey a r e close t o for t y–n in e da ys LMP , t h er e is n o eviden cet h a t su ch wom en a r e u n a ble t o obt a in a m edica t ion a bor t ion befor e t h e for t y–n in e da y F DA–a ppr oved win dow closes.Th e dist r ict cou r t ’s opin ionspecu la t ed, a bsen t a n y eviden ce, t h a t a t lea st som e wom en for wh om su r gica la bor t ion is con t r a in dica t ed will lik ely n ot discover or ch oose a bor t ion u n t ila ft er for t y–n in e da ys LMP . Abbott, 951 F . Su pp. 2d a t 906 n .20. Cou r t s,h owever , m u st ba se decision s on fa ct s, n ot h ypot h esis a n d specu la t ion .Th is br in gs u s t o ou r fin a l poin t . Th e Gon za les cou r t n ot ed in closin gt h a t t h e r espon den t s’ fa cia l a t t a ck on t h e Act sh ou ld n ot h a ve been en t er t a in edin t h e fir st pla ce beca u se “t h e pr oper m ea n s t o con sider except ion s is by a s–a pplied ch a llen ge.” Gon za les, 550 U.S. a t 167. F a cia l ch a llen ges im pose a“‘h ea vy bu r den ’ u pon t h e pa r t ies m a in t a in in g t h e su it ” beca u se t h er e is oft ent oo lit t le eviden ce t o sh ow t h a t a pa r t icu la r con dit ion h a s in fa ct occu r r ed or isver y likely t o occu r . Id . Th a t is t h e ca se h er e. We follow in t h e Su pr em eCou r t ’s foot st eps by n ot in g t h a t in a n a s–a pplied ch a llen ge, wh ich is t h e pr operm ea n s of ch a llen gin g t h e la ck of a n except ion t o t h e r egu la t ion s a t issu e, “t h en a t u r e of t h e m edica l r isk ca n be bet t er qu a n t ified a n d ba la n ced t h a n in a fa cia la t t a ck.” Id . As t h is ca se cu r r en t ly st a n ds, H .B. 2 on it s fa ce does n ot im posea n u n du e bu r den on t h e life a n d h ea lt h of a wom a n , a n d t h e dist r ict cou r t er r edin fin din g t o t h e con t r a r y. We u n der scor e t h a t n ot h in g in ou r opin ion or t h ela w a s we h a ve a ffir m ed it det r a ct s fr om Ca sey’s r equ ir em en t r ega r din g33Case: 13-51008Document: 0051259206200512576152Page: 6134Date Filed: 04/10/201403/27/2014No. 13-51008a bor t ion r est r ict ion s wh er e t h e a bor t ion is n ecessa r y t o pr eser ve t h e life of t h em ot h er . Ca sey, 505 U.S. a t 879.Beca u se t h e dist r ict cou r t ’s opin ion er r ed in h oldin g t h a t H .B. 2’sr eject ion of t h e off–la bel pr ot ocol fr om fift y t o sixt y–t h r ee da ys LMP fa cia llyim poses a n u n du e bu r den on t h e a bor t ion r igh t s of cer t a in wom en , we n eed n ota ddr ess wh et h er t h e dist r ict cou r t en for ced t h e in ju n ct ion beyon d t h e scope oft h e eviden ce befor e it .V.F or t h ese r ea son s, t h e dist r ict cou r t ’s ju dgm en t is RE VE RSE D a n dRE NDE RE D for t h e St a t e of Texa s, except t h a t t h e a dm it t in g pr ivilegesr equ ir em en t , § 10(b), m a y n ot be en for ced a ga in st a bor t ion pr ovider s wh ot im ely a pplied for a dm it t in g pr ivileges u n der t h e st a t u t e bu t a r e a wa it in g ar espon se fr om t h e h ospit a l.34