4th U.S. Circuit Court of Appeals -- North Carolina abortion law

8/10/2019 4th U.S. Circuit Court of Appeals -- North Carolina abortion law

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PUBLISHED

UNI TED STATES COURT OF APPEALSFOR THE FOURTH CI RCUI T

No. 14-1150

GRETCHEN S. STUART, MD, on behal f of her sel f and herpat i ent s seeki ng abor t i ons; J AMES R. DI NGFELDER, MD, onbehal f of hi msel f and hi s pat i ent s seeki ng abor t i ons; DAVI DA. GRI MES, MD, on behal f of hi msel f and hi s pat i ent sseeki ng abor t i ons; AMY BRYANT, MD, on behal f of hersel f andher pat i ent s seeki ng abort i ons; SERI NA FLOYD, MD, on behal fof her sel f and her pat i ent s seeki ng abort i ons; DECKER &WATSON, I NC. , d/ b/ a Pi edmont Carol i na Medi cal Cl i ni c;

PLANNED PARENTHOOD OF CENTRAL NORTH CAROLI NA; A WOMAN' SCHOI CE OF RALEI GH, I NC. ; PLANNED PARENTHOOD HEALTH SYSTEMS,I NC. ; TAKEY CRI ST, on behal f of hi msel f and hi s pat i ent sseeki ng abor t i ons; TAKEY CRI ST, M. D. , P. A. , d/ b/ a Cr i stCl i ni c f or Women,

Pl ai nt i f f s - Appel l ees,

v.

PAUL S. CAMNI TZ, MD, i n hi s of f i ci al capaci t y as Presi dent

of t he Nort h Carol i na Medi cal Boar d and hi s empl oyees,agent s and successor s; ROY COOPER, i n hi s of f i ci al capaci t yas At t orney Gener al of Nor t h Carol i na and hi s empl oyees,agent s and successors; ALDONA ZOFI A WOS, i n her of f i ci alcapaci t y as Secr et ar y of t he Nort h Car ol i na Depar t ment ofHeal t h and Human Servi ces and her empl oyees, agent s andsuccessor s; J I M WOODALL, i n hi s of f i ci al capaci t y asDi st r i ct At t or ney ( "DA") f or Pr osecut or i al Di st r i ct ( "PD")15B and hi s empl oyees, agent s and successor s; LEON STANBACK,i n hi s of f i ci al capaci t y as DA f or PD 14 and hi s empl oyees,agent s and successor s; DI STRI CT ATTORNEY DOUGLAS HENDERSON,

i n hi s of f i ci al capaci t y as DA f or PD 18 and hi s empl oyees,agent s and successors ; BI LLY WEST, i n hi s of f i ci al capaci t yas DA f or PD 12 and hi s empl oyees, agent s and successors; C.COLON WI LLOUGHBY, J R. , i n hi s of f i ci al capaci t y as DA f or PD10 and hi s empl oyees, agent s and successors; BENJ AMI N R.DAVI D, i n hi s of f i ci al capaci t y as DA f or PD 5 and hi sempl oyees, agent s and successors; ERNI E LEE, i n hi s of f i ci alcapaci t y as DA f or PD 4 and hi s empl oyees, agent s and

Appeal: 14-1150 Doc: 73 Filed: 12/22/2014 Pg: 1 of 37


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successor s; J I M O' NEI LL, i n hi s of f i ci al capaci t y as DA f orPD 21 and hi s empl oyees, agent s and successor s,

Def endant s - Appel l ant s,

J OHN THORP,

I nt er venor / Def endant ,

FRANCI S J . BECKWI TH, MJ S, PhD; GERARD V. BRADLEY; TERESA S.COLLETT; DAVI D K. DEWOLF; RI CK DUNCAN; EDWARD M. GAFFNEY;STEPHEN GI LLES; MI CHAEL STOKES PAULSEN; RONALD J . RYCHLAK;RI CHARD STI TH; RUTH SAMUELSON; PAT MCELRAFT; PAT HURLEY;MARI LYN AVI LA; SUSAN MARTI N; CAROLYN M J USTI CE; RENA W.TURNER; MI CHELE D. PRESNELL; SARAH STEVENS; J ACQUELI NEMI CHELLE SCHAFFER; DEBRA CONRAD; MARK BRODY; CHRI S WHI TMI RE;ALLEN MCNEI LL; DONNY LAMBETH; GEORGE CLEVELAND; LI NDA

J OHNSON; DAVI D CURTI S; J OYCE KRAWI EC; SHI RLEY RANDLEMEN; DANSOUCEK; NORMAN SANDERSON; WARREN DANI EL; BUCK NEWTON; KATHYL. HARRI NGTON; ANDREW BROCK,

Ami ci Suppor t i ng Appel l ant ,

AMERI CAN COLLEGE OF OBSTETRI CI ANS AND GYNECOLOGI STS;AMERI CAN MEDI CAL ASSOCI ATI ON; AMERI CAN PUBLI C HEALTHASSOCI ATI ON,

Ami ci Suppor t i ng Appel l ee.

Appeal f r om t he Uni t ed St at es Di st r i ct Cour t f or t he Mi ddl eDi st r i ct of Nor t h Car ol i na, at Gr eensbor o. Cat her i ne C. Eagl es,Di st r i ct J udge. ( 1: 11- cv- 00804- CCE- LPA)

Ar gued: Oct ober 29, 2014 Deci ded: December 22, 2014

Bef ore TRAXLER, Chi ef J udge, and WI LKI NSON and DUNCAN, Ci r cui tJ udges.



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Af f i r med by publ i shed opi ni on. J udge Wi l ki nson wr ot e t heopi ni on, i n whi ch Chi ef J udge Tr axl er and J udge Duncan j oi ned.

ARGUED: J ohn Fost er Maddr ey, NORTH CAROLI NA DEPARTMENT OFJ USTI CE, Ral ei gh, Nor t h Car ol i na, f or Appel l ant s. J ul i eRi kel man, CENTER FOR REPRODUCTI VE RI GHTS, New Yor k, New Yor k,f or Appel l ees. ON BRIEF: Roy Cooper , At t orney Gener al , Gary R.Gover t , Assi st ant Sol i ci t or Gener al , I . Fai son Hi cks, Speci alDeputy At t or ney General , NORTH CAROLI NA DEPARTMENT OF J USTI CE,Ral ei gh, Nor t h Car ol i na, f or Appel l ant s. Chr i st opher Br ook,AMERI CAN CI VI L LI BERTI ES UNI ON OF NORTH CAROLI NA LEGALFOUNDATI ON, Ral ei gh, Nor t h Carol i na; Andr ew D. Beck, AMERI CANCI VI L LI BERTI ES UNI ON FOUNDATI ON, New Yor k, New Yor k; J enni f erSokol er , CENTER FOR REPRODUCTI VE RI GHTS, New Yor k, New Yor k;Wal t er Del l i nger , Ant on Met l i t sky, Leah Godesky, O' MELVENY &MYERS LLP, Washi ngt on, D. C. ; Di ana O. Sal gado, New Yor k, New

Yor k, Hel ene T. Krasnof f , PLANNED PARENTHOOD FED. OF AMERI CA,Washi ngt on, D. C. , f or Appel l ees. Anna R. Franzonel l o, Mai l ee R.Smi t h, Wi l l i am L. Saunder s, Deni se M. Bur ke, AMERI CANS UNI TEDFOR LI FE, Washi ngt on, D. C. , f or Ami ci Franci s J . Beckwi t h, MJ S,PhD, Ger ar d V. Br adl ey, Ter esa S. Col l et t , Davi d K. Dewol f , Ri ckDuncan, Edward M. Gaf f ney, St ephen Gi l l es, Mi chael St okesPaul sen, Ronal d J . Rychl ak, and Ri char d St i t h. Scot t W.Gayl or d, J enni ngs Prof essor, Thomas J . Mol ony, Associ at ePr of essor of Law, ELON UNI VERSI TY SCHOOL OF LAW, Gr eensboro,Nor t h Car ol i na, f or Ami ci Rut h Samuel son, Pat McEl r af t , PatHur l ey, Mar i l yn Avi l a, Susan Mar t i n, Car ol yn M. J ust i ce, Rena W.

Turner , Mi chel e D. Pr esnel l , Sarah St evens, J acquel i ne Mi chel l eSchaf f er , Debr a Conr ad, Mar k Br ody, Chr i s Whi t mi r e, Al l enMcNei l l , Donny Lambet h, George Cl evel and, Li nda J ohnson, Davi dCur t i s, J oyce Kr awi ec, Shi r l ey Randl emen, Dan Soucek, NormanSander son, Warr en Dani el , Buck Newt on, Kathy L. Harr i ngt on, andAndr ew Br ock. Ki mber l y A. Par ker , Al at hea E. Por t er , Thai l a K.Sundar esan, Ti f f any E. Payne, WI LMER CUTLER PI CKERI NG HALE ANDDORR LLP, Washi ngt on, D. C. , f or Ami ci Amer i can Col l ege ofObst et r i ci ans and Gynecol ogi st s and Amer i can Medi calAssoci at i on. Shannon Rose Sel den, Cour t ney M. Dankwor t h,DEBEVOI SE & PLI MPTON LLP, New Yor k, New Yor k, f or Ami cus

Amer i can Publ i c Heal t h Associ at i on.



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WI LKI NSON, Ci r cui t J udge:

At i ssue her e i s a Nor t h Car ol i na st at ut e t hat r equi r es

physi ci ans t o per f or m an ul t r asound, di spl ay the sonogr am, and

descr i be t he f et us t o women seeki ng abort i ons. A physi ci an must

di spl ay and descr i be t he i mage dur i ng t he ul t r asound, even i f

t he woman act i vel y aver t [ s] her eyes and r ef us[ es] t o hear .

N. C. Gen. St at . 90- 21. 85( b) . Thi s compel l ed speech, even

t hough i t i s a regul at i on of t he medi cal pr of essi on, i s

i deol ogi cal i n i nt ent and i n ki nd. The means used by Nor t h

Carol i na ext end wel l beyond t hose st at es have cust omar i l y

empl oyed t o ef f ect uat e t hei r undeni abl e i nt er est s i n ensur i ng

i nf or med consent and i n pr ot ect i ng t he sanct i t y of l i f e i n al l

i t s phases. We t hus af f i r m t he di st r i ct cour t s hol di ng t hat

t hi s compel l ed speech pr ovi si on vi ol at es t he Fi r st Amendment .

I .

I n J ul y 2011, t he Nort h Carol i na Gener al Assembl y passed

t he Woman s Ri ght t o Know Act over a gubernat or i al vet o. The Act

amended Chapt er 90 of t he Nor t h Carol i na General St at ut es, whi ch

gover ns medi cal and r el at ed pr of essi ons, addi ng a new art i cl e

r egul at i ng t he st eps t hat must pr ecede an abor t i on.

Physi ci ans and abor t i on pr ovi der s f i l ed sui t af t er t he

Act s passage but bef or e i t s ef f ect i ve dat e, aski ng t he cour t t o

enj oi n enf or cement of t he Act and decl ar e i t unconst i t ut i onal .

I n Oct ober 2011, t he di st r i ct cour t i ssued a pr el i mi nar y



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i nj unct i on bar r i ng enf or cement of one pr ovi si on of t he Act , t he

Di spl ay of Real - Ti me Vi ew Requi r ement ( t he Requi r ement ) ,

codi f i ed at N. C. Gen. St at . 90- 21. 85. J . A. 143- 44. The cour t

subsequent l y al l owed t he pl ai nt i f f s t o amend t hei r compl ai nt .

The Thi r d Amended Compl ai nt asser t ed t hat t he Di spl ay of Real -

Ti me Vi ew Requi r ement vi ol at ed t he physi ci ans Fi r st Amendment

f r ee speech r i ght s and t he physi ci ans and t he pat i ent s

Four t eent h Amendment due pr ocess r i ght s. J . A. 282. 1

The Di spl ay of Real - Ti me Vi ew Requi r ement obl i gat es doct or s

( or t echni ci ans) t o per f or m an ul t r asound on any woman seeki ng

an abort i on at l east f our but not more t han sevent y- t wo hour s

bef or e t he abor t i on i s t o t ake pl ace. N. C. Gen. St at . 90-

21. 85( a) ( 1) . The physi ci an must di spl ay t he sonogr am so t hat t he

woman can see i t , i d. 90- 21. 85( a) ( 3) , and descr i be t he f et us

i n det ai l , i ncl ud[ i ng] t he pr esence, l ocat i on, and di mensi ons

of t he unborn chi l d wi t hi n t he ut er us and the number of unborn

chi l dr en depi ct ed, i d. 90- 21. 85( a) ( 2) , as wel l as t he

pr esence of ext er nal member s and i nt er nal organs, i f pr esent and

vi ewabl e, i d. 90- 21. 85( a) ( 4) . The physi ci an al so must of f er

1 The Thi r d Amended Compl ai nt al so chal l enged bot h t heDi spl ay of Real - Ti me Vi ew Requi r ement and t he I nf ormed Consentt o Abor t i on pr ovi si on, N. C. Gen. St at . 90- 21. 82, asunconst i t ut i onal l y vague. J . A. 281. The par t i es and t he di st r i ctcour t agr eed on savi ngs const r uct i ons so t hat t he Act was notvoi d f or vagueness, and t he pl ai nt i f f s di d not appeal t hatr ul i ng. St uar t v. Loomi s, 992 F. Supp. 2d 585, 611 ( M. D. N. C.2014) ( di st r i ct cour t opi ni on) .



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t o al l ow t he woman to hear t he f et al hear t t one. I d. 90-

21. 85( a) ( 2) . The woman, however , may aver t [ ] her eyes f r om t he

di spl ayed i mages and r ef us[ e] t o hear t he si mul t aneous

expl anat i on and medi cal descr i pt i on by pr esumabl y cover i ng her

eyes and ear s. I d. 90- 21. 85( b) .

The Act provi des an except i on t o t hese r equi r ement s onl y i n

cases of medi cal emer gency. I d. 90- 21. 86. Physi ci ans who

vi ol ate t he Act are l i abl e f or damages and may be enj oi ned f r om

pr ovi di ng f ur t her abor t i ons t hat vi ol at e t he Act i n Nor t h

Car ol i na. I d. 90- 21. 88. Vi ol at i on of t he Act al so may r esul t

i n t he l oss of t he doct or s medi cal l i cense. See i d. 90-

14( a) ( 2) ( The Nor t h Carol i na Medi cal Boar d may i mpose

di sci pl i nar y measur es, i ncl udi ng l i cense revocat i on, upon a

doct or who [ p] r oduc[ es] or at t empt [ s] t o pr oduce an abor t i on

cont r ar y t o l aw. ) .

Not at i ssue i n t hi s appeal ar e sever al ot her i nf or med

consent pr ovi si ons t o whi ch physi ci ans, i ndependent l y of t he

Di spl ay of Real - Ti me Vi ew Requi r ement , ar e subj ect . The f i r st i s

t he i nf or med consent pr ovi si on of t he Act i t sel f . I d. 90-

21. 82. I t r equi r es t hat , at l east t went y- f our hour s bef or e an

abor t i on i s t o be per f or med, a doct or or qual i f i ed pr of essi onal

expl ai n to t he woman seeki ng t he abor t i on the r i sks of t he

pr ocedur e, t he r i sks of car r yi ng t he chi l d t o t er m, and any

adver se psychol ogi cal ef f ect s associ at ed wi t h t he abor t i on. I d.



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90- 21. 82( 1) ( b) , ( d) . The physi ci an must al so convey t he

pr obabl e gest at i onal age of t he unbor n chi l d, i d. 90-

21. 82( 1) ( c) , t hat f i nanci al assi st ance f or t he pr egnancy may be

avai l abl e, t hat t he f at her of t he chi l d i s obl i gat ed t o pay

chi l d suppor t , and t hat t her e ar e al t er nat i ves t o abor t i on, i d.

90- 21. 82( 2) ( a) - ( d) . Fur t her mor e, t he doct or must i nf or m t he

woman t hat she can vi ew on a st at e- sponsor ed websi t e mat er i al s

publ i shed by t he st at e whi ch descr i be t he f et us. The doct or must

al so gi ve or mai l t he woman physi cal copi es of t he mat er i al s i f

she wi shes, and must l i st agenci es t hat of f er al t er nat i ves t o

abor t i on. I d. 90- 21. 82( 2) ( e) .

Bef or e t hi s Act , physi ci ans wer e st i l l subj ect t o Nor t h

Carol i na s gener al i nf ormed consent r equi r ement s when conduct i ng

abor t i ons. See i d. 90- 21. 13( a) ; 10A N. C. Admi n. Code

14E. 0305( a) ; Appel l ees Br . 6. Pr i or t o i t s enact ment , t he

physi ci ans chal l engi ng t he Act cl ai m t hey wer e i nf or m[ i ng] each

pat i ent about t he nat ur e of t he abor t i on pr ocedur e, i t s r i sks

and benef i t s, and t he al t er nat i ves avai l abl e t o the pat i ent and

t hei r r espect i ve r i sks and benef i t s and counsel [ i ng] t he

pat i ent t o ensur e t hat she was cer t ai n about her deci si on t o

have an abor t i on. Appel l ees Br . 6.

Bot h par t i es moved f or summary j udgment . Appl yi ng

hei ght ened, i nt er medi at e scr ut i ny, St uar t v. Loomi s, 992 F.

Supp. 2d 585, 600- 01 ( M. D. N. C. 2014) , t he di st r i ct cour t hel d



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t hat t he Di spl ay of Real - Ti me Vi ew Requi r ement vi ol ated t he

physi ci ans Fi r st Amendment r i ght s t o f r ee speech. I d. at 607-

09. I t t hus gr ant ed t he pl ai nt i f f s mot i on f or summar y j udgment

and ent er ed a per manent i nj unct i on. I d. at 610- 11. The cour t

decl i ned t o reach t he mer i t s of t he due pr ocess cl ai m, f i ndi ng

i t moot i n l i ght of t he cour t s r ul i ng on t he Fi r st Amendment

cl ai m. I d. at 611. 2

We r evi ew a gr ant of summar y j udgment de novo. S.

Appal achi an Mountai n St ewards v. A & G Coal Corp. , 758 F. 3d 560,

562 ( 4t h Ci r . 2014) . I n so doi ng, we vi ew t he f act s i n t he l i ght

most f avor abl e t o the st at e. Moor e- Ki ng v. Cnt y. of

Chest er f i el d, Va. , 708 F. 3d 560, 566 ( 4t h Ci r . 2013) .

I I .

A.

Congr ess shal l make no l aw . . . abr i dgi ng t he f r eedom of

speech. U. S. Const . amend. I . Thi s concept sounds s i mpl e, but

pr oves more compl i cated on cl oser i nspect i on. Laws t hat i mpi nge

upon speech r ecei ve di f f er ent l evel s of j udi ci al scrut i ny

dependi ng on t he t ype of r egul at i on and t he j ust i f i cat i ons and

pur poses under l yi ng i t . On t he one hand, r egul at i ons t hat

2 Af t er t he di st r i ct cour t s or der gr ant i ng t he pr el i mi nar yi nj unct i on, sever al i ndi vi dual s and pr egnancy counsel i ng cent er smoved t o i nt er vene as def endant s. The di st r i ct cour t deni ed t hemot i on, St uar t v. Huf f , 2011 WL 6740400 ( M. D. N. C. Dec. 22,2011) , and t hi s cour t af f i r med, St uar t v. Huf f , 706 F. 3d 345( 4t h Ci r . 2013) .



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di scr i mi nat e agai nst speech based on i t s cont ent are

pr esumpt i vel y i nval i d, R. A. V. v. Ci t y of St . Paul , Mi nn. , 505

U. S. 377, 382 ( 1992) , and cour t s usual l y appl y t he most

exact i ng scr ut i ny, Tur ner Br oad. Sys. , I nc. v. FCC, 512 U. S.

622, 642 ( 1994) ; see al so Uni t ed St at es v. Pl ayboy Ent m t Gr p. ,

I nc. , 529 U. S. 803, 814 ( 2000) . On t he ot her hand, area[ s]

t r adi t i onal l y subj ect t o gover nment r egul at i on, such as

commer ci al speech and pr of essi onal conduct , t ypi cal l y r ecei ve a

l ower l evel of r evi ew. Cent . Hudson Gas & El ec. Cor p. v. Pub.

Ser v. Comm n of N. Y. , 447 U. S. 557, 562- 63 ( 1980) ( r egul at i on of

commer ci al speech) ; see al so Kel l er v. St at e Bar of Cal . , 496

U. S. 1, 13- 16 ( 1990) ( r egul at i on of l egal pr of essi on) .

We thus must f i r st exami ne the type of r egul at i on at i ssue

t o det er mi ne t he r equi si t e l evel of scrut i ny t o appl y. Tur ner ,

512 U. S. at 637 ( expl ai ni ng t hat because not ever y i nt er f er ence

wi t h speech t r i gger s t he same degr ee of scr ut i ny under t he Fi r st

Amendment , we must deci de at t he out set t he l evel of scr ut i ny

appl i cabl e) . As we do, we are mi ndf ul of t he Fi r st Amendment s

command t hat government r egul at i on of speech must be measured i n

mi ni mums, not maxi mums. Ri l ey v. Nat l Fed n of t he Bl i nd of

N. C. , I nc. , 487 U. S. 781, 790 ( 1988) .

The physi ci ans urge us t o f i nd t hat t he r egul at i on must

r ecei ve st r i ct scrut i ny because i t i s cont ent - based and

i deol ogi cal . See Appel l ees Br . 36- 40. The st at e count er s t hat



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t he Requi r ement must be t r eated as a r egul at i on of t he medi cal

pr of essi on i n t he cont ext of abor t i on and t hus subj ect onl y t o

r at i onal basi s r evi ew. See Appel l ant s Br . 7- 15, 20- 28. The

di st r i ct cour t chose a di f f er ent pat h. Recogni zi ng t hat t he

Requi r ement bot h compel l ed speech and r egul at ed t he medi cal

pr of essi on, t he cour t appl i ed nei t her st r i ct scr ut i ny nor

r at i onal basi s r evi ew, but r at her t he i nt er medi at e scr ut i ny

st andard normal l y used f or cer t ai n commer ci al speech

r egul at i ons. See St uar t v. Loomi s, 992 F. Supp. 2d 585, 598- 601

( M. D. N. C. 2014) . For t he reasons out l i ned bel ow, we agr ee wi t h

t he di st r i ct cour t t hat t he Requi r ement i s a cont ent - based

r egul at i on of a medi cal pr of essi onal s speech whi ch must sat i sf y

at l east i nt er medi at e scrut i ny t o sur vi ve.

B.

The Di spl ay of Real - Ti me Vi ew Requi r ement r egul at es bot h

speech and conduct . The physi ci an must convey t he descr i pt i ons

mandat ed by t he st at ut e i n hi s or her own voi ce. The sonogr am

di spl ay i s al so i nt i mat el y connect ed wi t h t he descr i bi ng

r equi r ement . The t wo ar e t hus best vi ewed as a si ngl e whol e. I n

deci di ng whet her an act i vi t y possesses suf f i ci ent communi cat i ve

el ement s t o br i ng t he Fi r st Amendment i nt o pl ay, we have asked

whet her [ a] n i nt ent t o convey a part i cul ar i zed message was

pr esent , and [ whet her ] t he l i kel i hood was gr eat t hat t he message

woul d be under st ood by t hose who vi ewed i t . Texas v. J ohnson,



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491 U. S. 397, 404 ( 1989) ( quot i ng Spence v. Washi ngton, 418 U. S.

405, 41011 ( 1974) ) . The st at e s avowed i nt ent and the

ant i ci pat ed ef f ect of al l aspect s of t he Requi r ement ar e to

di scour age abort i on or at t he ver y l east cause t he woman t o

r econsi der her deci si on. See Appel l ant s Br . 29- 32. The cl ear

i mpor t of di spl ayi ng t he sonogr am i n t hi s cont ext - - whi l e t he

woman who has r equest ed an abor t i on i s par t i al l y di sr obed on an

exami nat i on t abl e - - i s t o use t he vi sual i mager y of t he f et us

t o di ssuade t he pat i ent f r om cont i nui ng wi t h t he pl anned

pr ocedur e. I f t he st at e s i nt ent i s t o convey a di st i nct

message, t he message does not l ose i t s expr essi ve character

because i t happens t o be del i ver ed by a pr i vat e part y. Whet her

one agr ees or di sagr ees wi t h t he st ate s appr oach her e cannot be

t he quest i on. I n t hi s cont ext , t he di spl ay of t he sonogr am i s

pl ai nl y an expr essi ve act ent i t l ed t o Fi r st Amendment

pr ot ect i on. See, e. g. , J ohn Doe No. 1 v. Reed, 561 U. S. 186,

194- 95 ( 2010) ( r ecogni zi ng Fi r st Amendment pr otect i ons f or

si gni ng a r ef er endum pet i t i on) ; J oseph Bur st yn, I nc. v. Wi l son,

343 U. S. 495, 501- 02 ( 1952) ( commer ci al f i l m) .

The Fi r st Amendment not onl y prot ect s agai nst prohi bi t i ons

of speech, but al so agai nst r egul at i ons t hat compel speech.

Si nce al l speech i nher ent l y i nvol ves choi ces of what t o say and

what t o l eave unsai d, one i mpor t ant mani f est at i on of t he

pr i nci pl e of f r ee speech i s t hat one who chooses t o speak may



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al so deci de what not t o say. Hur l ey v. I r i sh- Am. Gay, Lesbi an &

Bi sexual Gr p. of Bos. , 515 U. S. 557, 573 ( 1995) ( ci t at i ons

omi t t ed) ( i nt er nal quot at i on mar ks omi t t ed) ; see al so Wool ey v.

Maynard, 430 U. S. 705, 714 (1977) ( [ T]he Fi r st Amendment . . .

i ncl udes bot h t he r i ght t o speak f r eel y and t he r i ght t o r ef r ai n

f r om speaki ng at al l . ) . A r egul at i on compel l i ng speech i s by

i t s ver y nat ur e cont ent - based, because i t r equi r es t he speaker

t o change the cont ent of hi s speech or even t o say somethi ng

wher e he woul d ot her wi se be si l ent . Ri l ey, 487 U. S. at 795

( Mandat i ng speech t hat a speaker woul d not ot her wi se make

necessar i l y al t er s t he cont ent of t he speech. ) ; Cent r o Tepeyac

v. Mont gomery Cnty. , 722 F. 3d 184, 189 ( 4t h Ci r . 2013) ( en banc)

( same) . Compel l ed speech i s par t i cul ar l y suspect because i t can

di r ect l y af f ect l i st ener s as wel l as speaker s. Li st ener s may

have di f f i cul t y di scer ni ng t hat t he message i s t he st at e s, not

t he speaker s, especi al l y wher e t he speaker [ i s] i nt i mat el y

connect ed wi t h t he communi cat i on advanced. Hur l ey, 515 U. S. at

576.

The Requi r ement i s qui nt essent i al compel l ed speech. I t

f or ces physi ci ans t o say t hi ngs t hey ot her wi se woul d not say.

Mor eover , t he st at ement compel l ed her e i s i deol ogi cal ; i t

conveys a par t i cul ar opi ni on. The st at e f r eel y admi t s t hat t he

pur pose and ant i ci pat ed ef f ect of t he Di spl ay of Real - Ti me Vi ew

Requi r ement i s t o convi nce women seeki ng abor t i ons t o change



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t hei r mi nds or r eassess t hei r deci si ons. See Appel l ant s Br . 29-

32.

I t may be t r ue, as t he Fi f t h Ci r cui t has not ed, t hat t he

r equi r ed di scl osur es . . . ar e t he epi t ome of t r ut hf ul , non-

mi sl eadi ng i nf or mat i on. Tex. Med. Pr ovi der s Per f or mi ng Abor t i on

Ser vs. v. Lakey, 667 F. 3d 570, 577- 78 ( 5t h Ci r . 2012) . But an

i ndi vi dual s r i ght t o t ai l or [ hi s] speech or t o not speak at

al l appl i es . . . equal l y t o st at ement s of f act t he speaker

woul d r at her avoi d. Hur l ey, 515 U. S. at 573; see al so Sor r el v.

I MS Heal t h I nc. , 131 S. Ct . 2653, 2667 ( 2011) ; Tur ner , 512 U. S.

at 645; Ri l ey, 487 U. S. at 797- 98. Whi l e i t i s t r ue t hat t he

wor ds t he st at e put s i nt o t he doct or s mout h ar e f act ual , t hat

does not di vor ce t he speech f r om i t s mor al or i deol ogi cal

i mpl i cat i ons. [ C] ont ext mat t er s. Gr eat er Bal t . Ct r . f or

Pregnancy Concer ns, I nc. v. Mayor of Bal t . , 721 F. 3d 264, 286

( 4t h Ci r . 2013) ( en banc) . Of cour se we need not go so f ar as t o

say t hat ever y r equi r ed descri pt i on of a t ypi cal f et us i s i n

ever y cont ext i deol ogi cal . But t hi s Di spl ay of Real - Ti me Vi ew

Requi r ement expl i ci t l y pr omot es a pr o- l i f e message by demandi ng

t he pr ovi si on of f act s t hat al l f al l on one si de of t he abor t i on

debate - - and does so short l y bef ore t he t i me of deci si on when

t he i nt ended r eci pi ent i s most vul ner abl e.

The st at e prot est s t hat t he Requi r ement does not di ct at e a

speci f i c scri pt and t hat t he doct or i s f r ee t o suppl ement t he



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i nf or mat i on wi t h hi s own opi ni on about abor t i on. Repl y Br . 14-

16. That i s t r ue; t he st ate does not demand t hat t he doctor use

part i cul ar words. But t hat does not mean t hat t he Requi r ement i s

not desi gned t o f avor or di sadvant age speech of any par t i cul ar

cont ent . Tur ner , 512 U. S. at 652. I n f act , t he cl ear and

conceded pur pose of t he Requi r ement i s t o support t he st ate s

pr o- l i f e posi t i on. That t he doct or may suppl ement t he compel l ed

speech wi t h hi s own per spect i ve does not cur e t he coer ci on - -

t he gover nment s message st i l l must be del i ver ed ( t hough not

necessar i l y recei ved) .

Cont ent - based r egul at i ons of speech t ypi cal l y r ecei ve

st r i ct scrut i ny. I d. at 642. The st at e, however , mai nt ai ns t hat

t he Requi r ement i s mer el y a r egul at i on of t he pr act i ce of

medi ci ne t hat need onl y sat i sf y rat i onal basi s r evi ew. We t ur n

now t o that cont ent i on. 3

C.

The st at e s power t o prescr i be r ul es and r egul at i ons f or

pr of essi ons, i ncl udi ng medi ci ne, has an extensi ve hi st or y. See

3 Pl ai nt i f f s seem t o suggest t hat t he Di spl ay of Real - Ti meVi ew Requi r ement const i t ut es vi ewpoi nt di scr i mi nat i on and t hatwe shoul d st r i ke t he pr ovi si on down on t hat basi s. SeeAppel l ees Br . 2, 54. Because we f i nd t hat t he Requi r ement f ai l seven i nt er medi at e scr ut i ny, i nf r a Par t I I I , i t i s unnecessar yf or us t o def i ni t i vel y det er mi ne whet her t he compel l ed speechher e r equi r es st r i ct scrut i ny. See Gr eat er Bal t . , 721 F. 3d at288 ( caut i oni ng agai nst pr eci pi t at el y concl udi ng t hat t he[ pr ovi si on] i s an exer ci se of vi ewpoi nt di scri mi nat i on) .



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Dent v. West Vi r gi ni a, 129 U. S. 114, 122 ( 1889) ( [ I ] t has been

t he pr act i ce of di f f er ent st at es, f r om t i me i mmemor i al , t o exact

i n many pur sui t s a cer t ai n degr ee of ski l l and l ear ni ng upon

whi ch t he communi t y may conf i dent l y r el y. ) . Li censi ng and

r egul at i on by t he stat e pr ovi de cl i ent s wi t h t he conf i dence

t hey r equi r e t o put t hei r heal t h or t hei r l i vel i hood i n t he

hands of t hose who ut i l i ze knowl edge and met hods wi t h whi ch the

cl i ent s or di nar i l y have l i t t l e or no f ami l i ar i t y. Ki ng v. Gov.

of N. J . , 767 F. 3d 216, 232 ( 3d Ci r . 2014) . The st at e may

est abl i sh l i censi ng qual i f i cat i ons, Dent , 129 U. S. at 122,

obl i ge the payment of dues t o a pr of essi onal or gani zat i on f or

pur poses such as di sci pl i ni ng member s and proposi ng et hi cal

codes, Kel l er , 496 U. S. at 16, and even set st andar ds f or t he

conduct of pr of essi onal act i vi t i es, Bar sky v. Bd. of Regent s of

Uni v. of St at e of N. Y. , 347 U. S. 442, 449- 50 ( 1954) . I n t he

medi cal cont ext , t he st at e may r equi r e t he pr ovi si on of

i nf or mat i on suf f i ci ent f or pat i ent s t o gi ve t hei r i nf or med

consent t o medi cal pr ocedur es, see Cant erbur y v. Spence, 464

F. 2d 772, 781 (D. C. Ci r . 1972) , and pat i ent s may seek damages

when doct or s f ai l t o f ol l ow st at ut or y and pr of essi onal l y

r ecogni zed nor ms, see, e. g, N. C. Gen. St at . 90- 21. 88. Si mpl y

put , [ t ] he power of gover nment t o r egul at e t he pr of essi ons i s

not l ost whenever t he pr act i ce of a pr of essi on ent ai l s speech.



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f r om publ i c di al ogue on one end t o r egul at i on of pr of essi onal

conduct on t he ot her . Pi ckup v. Br own, 740 F. 3d 1208, 1227,

1229 ( 9t h Ci r . 2013) ( emphasi s i n or i gi nal ) . Ot her ci r cui t s have

r ecent l y r el i ed on t he di st i nct i on bet ween pr of essi onal speech

and pr of essi onal conduct when deci di ng on the appr opr i at e l evel

of scrut i ny t o appl y t o r egul at i ons of t he medi cal pr of essi on.

See Ki ng, 767 F. 3d at 224- 29, 233- 37; Wol l schl aeger v. Gov. of

Fl a. , 760 F. 3d 1195, 1217- 25 ( 11t h Ci r . 2014) .

The Di spl ay of Real - Ti me Vi ew Requi r ement r esi des somewhere

i n t he mi ddl e on t hat sl i di ng scal e. I t i s a r egul at i on of

medi cal t r eat ment i nsof ar as i t di r ect s doct or s t o do cer t ai n

t hi ngs i n t he cont ext of t r eat i ng a pat i ent . I n t hat sense, t he

gover nment can l ay cl ai m t o i t s st r onger i nt er est i n t he

r egul at i on of pr of essi onal conduct . But t hat i s har dl y the end

of t he mat t er . The gover nment s r egul at or y i nt er est i s l ess

pot ent i n t he cont ext of a sel f - r egul at i ng pr of essi on l i ke

medi ci ne. Moor e- Ki ng v. Cnt y. of Chest er f i el d, Va. , 708 F. 3d

560, 570 ( 4t h Ci r . 2013) . Mor eover , t he Requi r ement i s a cl ear l y

cont ent - based r egul at i on of speech; i t r equi r es doct or s t o say

as wel l as do. As t he di st r i ct cour t f ound, t he conf l uence of

t hese f act or s poi nt s t owar d bor r owi ng a hei ght ened i nt er medi at e

scr ut i ny st andar d used i n cer t ai n commer ci al speech cases.

St uart , 992 F. Supp. 2d at 600. Thus, we need not concl usi vel y

det er mi ne whet her st r i ct scrut i ny ever appl i es i n si mi l ar



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si t uat i ons, because i n t hi s case t he out come i s t he same

whet her a speci al commer ci al speech i nqui r y or a st r i ct er f or m

of j udi ci al scr ut i ny i s appl i ed. Sor r el , 131 S. Ct . at 2667.

D.

I nsof ar as our deci si on on t he appl i cabl e st andar d of

r evi ew di f f er s f r om t he posi t i ons t aken by t he Fi f t h and Ei ght h

Ci r cui t s i n cases exami ni ng t he const i t ut i onal i t y of abor t i on

r egul at i ons under t he Fi r st Amendment , we r espect f ul l y di sagr ee.

Bot h cour t s r el i ed heavi l y on a si ngl e par agr aph i n Casey:

Al l t hat i s l ef t of pet i t i oner s' ar gument i s anasser t ed Fi r st Amendment r i ght of a physi ci an not t opr ovi de i nf or mat i on about t he r i sks of abor t i on, andchi l dbi r t h, i n a manner mandated by t he St ate. To besur e, t he physi ci an' s Fi r st Amendment r i ght s not t ospeak ar e i mpl i cated, see Wool ey v. Maynard, 430 U. S.705 ( 1977) , but onl y as par t of t he pr act i ce ofmedi ci ne, subj ect t o reasonabl e l i censi ng andr egul at i on by t he St at e, cf . Whal en v. Roe, 429 U. S.589, 603 ( 1977) . We see no const i t ut i onal i nf i r mi t y i n

t he r equi r ement t hat t he physi ci an pr ovi de t hei nf ormat i on mandat ed by t he St at e here.

505 U. S. at 884; see al so Lakey, 667 F. 3d at 574- 76; Pl anned

Par ent hood Mi nn. , N. D. , S. D. v. Rounds, 686 F. 3d 889, 893 ( 8t h

Ci r . 2012) ( en banc) ( Rounds I I ) ; Pl anned Par ent hood Mi nn. ,

N. D. , S. D. v. Rounds, 530 F. 3d 724, 733- 35 ( 8t h Ci r . 2008) ( en

banc) ( Rounds I ) . That i s t he sum of t he Fi r st Amendment

anal ysi s i n Casey.

I n consi der i ng an ul t r asound di spl ay- and- descr i be

r equi r ement si mi l ar t o t he one at i ssue her e, t he Fi f t h Ci r cui t



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i nt er pr et ed Casey as empl oyi ng t he ant i t hesi s of st r i ct

scrut i ny. Lakey, 667 F. 3d at 575. I t f ur t her not ed t hat i n

Gonzal es v. Carhar t , t he Supr eme Cour t uphel d a st ate s

si gni f i cant r ol e . . . i n regul at i ng the medi cal pr of essi on.

Lakey, 667 F. 3d at 575- 76 ( quot i ng Gonzal es v. Carhart , 550 U. S.

124, 157 ( 2007) ) . Ther ef or e, t he Lakey cour t r easoned,

pr ovi si ons such as t he one at i ssue her e - - t hat i s, l aws t hat

r equi r e t r ut hf ul , nonmi sl eadi ng, and r el evant di scl osur es, i d.

at 576 - - do not f al l under t he r ubr i c of compel l i ng

i deol ogi cal speech t hat t r i gger s Fi r st Amendment st r i ct

scrut i ny, i d. The Ei ght h Ci r cui t si mi l ar l y dr ew f r om Casey and

Gonzal es t he r ul e t hat t he Fi r st Amendment per mi t s t he st ate t o

use i t s r egul at or y aut hor i t y t o r equi r e a physi ci an t o pr ovi de

t r ut hf ul , nonmi sl eadi ng i nf or mat i on r el evant t o a pat i ent s

deci si on t o have an abor t i on. Rounds I , 530 F. 3d at 734- 35; see

al so Rounds I I , 686 F. 3d at 893.

Wi t h r espect , our si st er ci r cui t s r ead t oo much i nt o Casey

and Gonzal es. The si ngl e paragr aph i n Casey does not assert t hat

physi ci ans f or f ei t t hei r Fi r st Amendment r i ght s i n t he

pr ocedur es sur r oundi ng abort i ons, nor does i t announce t he

pr oper l evel of scrut i ny t o be appl i ed t o abor t i on r egul at i ons

t hat compel speech t o t he ext r aor di nary ext ent pr esent her e. The

pl ur al i t y opi ni on st at ed t hat t he medi cal pr of essi on i s subj ect

t o r easonabl e l i censi ng and r egul at i on by t he St at e and t hat



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physi ci ans speech i s par t of t he pr act i ce of medi ci ne. Casey,

505 U. S. at 884. But t he pl ur al i t y di d not hol d sweepi ngl y that

al l r egul at i on of speech i n t he medi cal cont ext mer el y recei ves

r at i onal basi s r evi ew. Rat her , havi ng not ed t he physi ci ans

Fi r st Amendment r i ght s and t he st at e s count er vai l i ng i nt er est

i n r egul at i ng t he medi cal pr of essi on, t he pl ur al i t y si mpl y

st at ed t hat i t saw no const i t ut i onal i nf i r mi t y i n t he

r equi r ement t hat t he physi ci an pr ovi de the i nf ormat i on mandated

by t he St at e her e. I d. ( emphasi s added) . That par t i cul ar i zed

f i ndi ng har dl y announces a gui di ng st andar d of scr ut i ny f or use

i n ever y subsequent compel l ed speech case i nvol vi ng abort i on.

Fur t her mor e, t he Fi f t h and Ei ght h Ci r cui t s r el i ance on

Gonzal es seems i napposi t e. Gonzal es was not a Fi r st Amendment

case; t he pl ai nt i f f s t her e di d not br i ng f r ee speech cl ai ms. See

Car har t v. Ashcr of t , 331 F. Supp. 2d 805, 814 ( D. Neb. 2004) ;

Pl anned Parent hood Fed n of Am. v. Ashcrof t , 320 F. Supp. 2d

957, 967 ( N. D. Cal . 2004) . Thus Gonzal es does not el uci date t he

Fi r st Amendment st andard appl i ed i n Casey. Gonzal es pr ovi des

val uabl e i nsi ght i nt o t he r el at i onshi p bet ween t he st at e and t he

medi cal pr of essi on and t he rol e the st at e may pl ay i n ensur i ng

t hat women are pr oper l y i nf ormed bef ore maki ng what i s

i ndi sput abl y a pr of ound choi ce wi t h per manent and pot ent i al l y

har mf ul i mpact s. See i nf r a Par t I I I . But i t says not hi ng about

t he l evel of scr ut i ny cour t s shoul d appl y when r evi ewi ng a cl ai m



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t hat a r egul at i on compel l i ng speech i n t he abor t i on cont ext

vi ol at es physi ci ans Fi r st Amendment f r ee speech r i ght s. The

f act t hat a regul at i on does not i mpose an undue bur den on a

woman under t he due pr ocess cl ause does not answer t he quest i on

of whet her i t i mposes an i mper mi ss i bl e bur den on t he physi ci an

under t he Fi r st Amendment . A hei ght ened i nt er medi ate l evel of

scr ut i ny i s t hus consi st ent wi t h Supr eme Cour t pr ecedent and

appr opr i at el y r ecogni zes t he i nt er sect i on her e of r egul at i on of

speech and r egul at i on of t he medi cal pr of essi on i n t he cont ext

of an abort i on pr ocedur e. 4

I I I .

Under an i nt er medi at e st andar d of scr ut i ny, t he st at e bear s

t he bur den of demonst r at i ng at l east t hat t he st at ut e di r ect l y

advances a subst ant i al gover nment al i nt er est and t hat t he

measur e i s drawn t o achi eve that i nt er est . Sor r el v. I MS Heal t h

I nc. , 131 S. Ct . 2653, 2667- 68 ( 2011) . Thi s f or mul at i on seeks t o

ensur e not onl y t hat t he St at e' s i nt er est s ar e pr opor t i onal t o

t he resul t i ng bur dens pl aced on speech but al so t hat t he l aw

4 The st at e s ami ci i nsi st t hat t he deci si on we r each t odaywi l l per mi t f ut ur e l i t i gant s t o use the Fi r st Amendment as a t r ump car d i n a mul t i t ude of chal l enges t o abor t i onr egul at i ons, al l owi ng abor t i on pr oponent s t o pr ovoke a back-door , st r i ct scrut i ny appr oach t hat wi l l over r i de Casey sundue bur den st andar d. Law Pr of essor s Br . 27. We t hi nk t hi sconcer n i s over dr awn. The gr eat maj or i t y of abor t i on r egul at i onsdo not compel anyone s speech, and t he gr eat maj or i t y ofl i t i gant s do not r ai se Fi r st Amendment concer ns.



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does not seek t o suppr ess a di sf avored message. I d. at 2668.

The cour t can and shoul d t ake i nt o account t he ef f ect of t he

r egul at i on on t he i nt ended r eci pi ent of t he compel l ed speech,

especi al l y wher e she i s a capt i ve l i st ener . See Hi l l v.

Col orado, 530 U. S. 703, 716- 18 ( 2000) ; Va. St ate Bd. of Pharmacy

v. Va. Ci t i zens Consumer Counci l , I nc. , 425 U. S. 748, 756- 57

( 1976) ; Gr eat er Bal t . Ct r . For Pr egnancy Concer ns, I nc. v. Mayor

of Bal t . , 721 F. 3d 264, 286 ( 4t h Ci r . 2013) ( en banc) ; cf . Lee

v. Wei sman, 505 U. S. 577, 598 (1992) .

The pr ot ect i on of f et al l i f e, al ong wi t h t he compani on

i nt er est s of pr ot ect i ng t he pr egnant woman s psychol ogi cal

heal t h and ensur i ng t hat so gr ave a choi ce i s wel l i nf ormed,

Gonzal es, 550 U. S. at 159, i s undeni abl y an i mpor t ant st at e

i nt er est . The Supr eme Cour t has r epeat edl y af f i r med t he st at e s

i mpor t ant and l egi t i mat e i nt er est i n pr eser vi ng, pr omot i ng,

and pr ot ect i ng f et al l i f e. Roe v. Wade, 410 U. S. 113, 162 ( 1973)

( quot ed i n Casey, 505 U. S. at 871) ; see al so Gonzal es, 550 U. S.

at 145. We shal l pr esume f or t he pur pose of t hi s appeal t hat

t hi s stat ut e pr ot ects f et al l i f e by i ncreasi ng t he l i kel i hood

t hat a woman wi l l not f ol l ow t hr ough on t he deci si on t o have an

abort i on. Nonet hel ess, t he means used t o pr omot e a subst ant i al

st at e i nt er est must be dr awn so as t o di r ect l y advance the

i nt er est wi t hout i mpedi ng t oo gr eat l y on i ndi vi dual l i ber t y

i nt er est s or compet i ng st at e concer ns. Sor r el , 131 S. Ct . at



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2667- 68. The means empl oyed here ar e f ar - r eachi ng - - al most

unpr ecedent edl y so - - i n a number of r espect s and f ar out st r i p

t he pr ovi si on at i ssue i n Casey. See Casey, 505 U. S. at 881.

Thi s st at ut or y provi si on i nt er f er es wi t h t he physi ci an s r i ght

t o f r ee speech beyond t he ext ent per mi t t ed f or r easonabl e

r egul at i on of t he medi cal pr of essi on, whi l e si mul t aneousl y

t hr eat eni ng har m t o t he pat i ent s psychol ogi cal heal t h,

i nt er f er i ng wi t h t he physi ci an s pr of essi onal j udgment , and

compr omi si ng t he doct or - pat i ent r el at i onshi p. We must t her ef or e

f i nd t he Di spl ay of Real - Ti me Vi ew Requi r ement unconst i t ut i onal .

A.

Bef or e addr essi ng t he pr ovi si on s const i t ut i onal

i nf i r mi t i es, i t i s wel l wor t h i dent i f yi ng br i ef l y t he var i ous

st at e i nt er est s at st ake i n t hi s case. As we not ed above, t he

Supr eme Cour t has f or cef ul l y r ei t er at ed t hat t he st at e s

i nt er est i n pr ot ecti ng f et al l i f e i s i mpor t ant and pr of ound.

Thi s i nt er est der i ves f r om t he st at e s gener al i nt er est i n

pr ot ect i ng and pr omot i ng r espect f or l i f e, and has been

r ecogni zed i n abor t i on deci si ons wi t hout number . See, e. g. ,

Gonzal es, 550 U. S. at 158; Casey, 505 U. S. at 871; Gr eenvi l l e

Women s Cl i ni c v. Br yant , 222 F. 3d 157, 165- 66 ( 4t h Ci r . 2000) .

We do not quest i on t he subst ant i al st at e i nt er est at wor k her e.

As par t of i t s gener al i nt er est i n pr omot i ng t he heal t h of

i t s ci t i zens, t he st at e al so has an i nt er est i n pr omot i ng t he



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psychol ogi cal heal t h of women seeki ng abor t i ons. Appel l ant s Br .

17. The st ate may seek t o pr otect women both f r om t he

psychol ogi cal har m of com[ i ng] t o r egr et t hei r choi ce,

Gonzal es, 550 U. S. at 159, as wel l as t he psychol ogi cal har m

f r om t he pr ocess of obt ai ni ng an abor t i on i t sel f . The Supr eme

Cour t has al so recogni zed a st at e i nt er est i n mai nt ai ni ng t he

i nt egr i t y and et hi cs of t he medi cal pr of essi on, whi ch i ncl udes

pr omot i ng a heal t hy doct or - pat i ent r el at i onshi p, Washi ngt on v.

Gl ucksber g, 521 U. S. 702, 731 (1997) ; see al so Gonzal es, 550

U. S. at 157, and r espect i ng physi ci ans pr of essi onal j udgment ,

see Casey, 505 U. S. at 884.

However , t hat i mpor t ant st at e i nt er est s ar e i mpl i cat ed i n

t he abor t i on cont ext i s onl y t he st ar t i ng poi nt f or our

anal ysi s. Though physi ci ans and other pr of essi onal s may be

subj ect t o r egul at i ons by t he st at e t hat r est r i ct t hei r Fi r st

Amendment f r eedoms when act i ng i n t he cour se of t hei r

pr of essi ons, pr of essi onal s do not l eave t hei r speech r i ght s at

t he of f i ce door . See Lowe v. SEC, 472 U. S. 181, 229- 30 ( 1985)

( Whi t e, J . , concur r i ng i n t he j udgment ) . Any st at e r egul at i on

t hat l i mi t s t he f r ee speech r i ght s of pr of essi onal s must pass

t he r equi si t e const i t ut i onal t est . The Di spl ay of Real - Ti me Vi ew

Requi r ement must di r ect l y advance an i mpor t ant st at e i nt er est i n

a manner t hat i s dr awn t o t hat i nt er est and pr oport i onal t o t he

bur den pl aced on t he speech. See Sorr el , 131 S. Ct . at 2667- 68.



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B.

Nort h Car ol i na cont ends t hat t he Di spl ay of Real - Ti me Vi ew

Requi r ement i s mer el y r easonabl e . . . r egul at i on by t he St at e

of t he medi cal pr of essi on t hat does not vi ol at e t he physi ci ans

Fi r st Amendment r i ght s any more t han i nf ormed consent

r equi r ement s do. Appel l ant s Br . 22- 25 ( quot i ng Tex. Med.

Pr ovi der s Per f or mi ng Abor t i on Ser vs. v. Lakey, 667 F. 3d 570, 575

( 5t h Ci r . 2012) ( quot i ng Casey, 505 U. S. at 882) ) . The

r equi r ement s t he pr ovi si on i mposes on physi ci ans, however ,

r esembl e nei t her t r adi t i onal i nf or med consent nor t he var i at i on

f ound i n t he Pennsyl vani a st at ut e at i ssue i n Casey. The Nor t h

Car ol i na st at ut e goes much f ur t her , i mposi ng addi t i onal bur dens

on t he physi ci ans f r ee speech and r i ski ng t he compr omi se of

ot her i mpor t ant st at e i nt er est s.

Tr adi t i onal i nf or med consent r equi r ements der i ve f r om t he

pr i nci pl e of pat i ent aut onomy i n medi cal t r eat ment . Gr ounded i n

sel f - det er mi nat i on, obt ai ni ng i nf or med consent pr i or t o medi cal

t r eatment i s meant t o ensure t hat each pat i ent has t he

i nf ormat i on she needs t o meani ngf ul l y consent t o medi cal

pr ocedur es. Am. Col l . of Obst et r i ci ans & Gynecol ogi st s & t he

Am. Med. Ass n ( ACOG & AMA) Br . 5; see al so AMA, Op. 8. 08

I nf or med Consent ( 2006) . As t he t er m suggest s, i nf or med consent

consi st s of t wo essent i al el ement s: compr ehensi on and f r ee

consent . ACOG & AMA Br . 7; ACOG, Comm. Op. No. 439 - I nf or med



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Consent , at 2 ( 2012) . Compr ehensi on r equi r es t hat t he physi ci an

convey adequat e i nf or mat i on about t he di agnosi s, t he pr ognosi s,

al t er nat i ve t r eat ment opt i ons ( i ncl udi ng no t r eat ment ) , and t he

r i sks and l i kel y resul t s of each opt i on. ACOG & AMA Br . 7; ACOG,

Comm. Op. No. 439, at 3, 5; see al so J . A. 359 ( decl ar at i on of

Dr . Anne Dr apki n Lyer l y) ; Cant erbur y v. Spence, 464 F. 2d 772,

780- 81 (D. C. Ci r . 1972) . Physi ci ans det er mi ne t he adequat e

i nf ormat i on f or each pat i ent based on what a reasonabl e

physi ci an woul d convey, what a r easonabl e pat i ent woul d want t o

know, and what t he i ndi vi dual pat i ent woul d subj ect i vel y wi sh t o

know gi ven t he pat i ent s i ndi vi dual i zed needs and t r eat ment

ci r cumst ances. ACOG, Comm. Op. No. 439, at 5. Fr ee consent , as

i t suggest s, r equi r es t hat t he pat i ent be abl e t o exer ci se her

aut onomy f r ee f r om coer ci on. I d. at 3, 5. I t may even i ncl ude at

t i mes t he choi ce not t o r ecei ve cer t ai n per t i nent i nf or mat i on

and t o rel y i nst ead on t he j udgment of t he doct or . I d. at 7;

ACOG & AMA Br . 8. The physi ci an s r ol e i n t hi s process i s t o

i nf or m and assi st t he pat i ent wi t hout i mposi ng hi s or her own

per sonal wi l l and val ues on t he pat i ent . J . A. 359- 60

( decl arat i on of Dr . Anne Dr apki n Lyer l y) ; ACOG, Comm. Op. No.

439, at 3. The i nf or med consent pr ocess t ypi cal l y i nvol ves a

conver sat i on bet ween t he pat i ent , f ul l y cl ot hed, and t he

physi ci an i n an of f i ce or si mi l ar r oom bef or e t he pr ocedur e

begi ns. ACOG & AMA Br . 8, 23; ACOG, Comm. Op. No. 439, at 4.



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Once the pat i ent has r ecei ved the i nf ormat i on she needs, she

si gns a consent f orm, and t r eatment may pr oceed. See, e. g. , N. C.

Gen. St at . 90- 21. 13( b) .

The Pennsyl vani a st at ut e chal l enged i n Casey prescr i bes a

modi f i ed f or m of i nf or med consent f or abor t i ons. To pr ovi de

i nf or med consent , t he st at ut e f i r st r equi r es t he physi ci an t o

or al l y i nf or m t he woman of t he nat ur e of t he abor t i on pr ocedur e,

t he r i sks and al t er nat i ves t o t he pr ocedur e . . . t hat a

r easonabl e pat i ent woul d consi der mat er i al t o t he deci si on

whet her t o have an abor t i on, t he r i sks of car r yi ng t he chi l d t o

t er m, and t he probabl e gest at i onal age of t he unbor n chi l d

when t he abor t i on i s t o be per f or med. 18 Pa. Cons. St at .

3205( a) ( 1) . The physi ci an must gi ve t hi s i nf or mat i on at l east

t went y- f our hour s pr i or t o t he abor t i on. I d. Asi de f r om t he

gest at i onal age of t he f et us, t hi s i nf or mat i on i s t he same t ype

t hat woul d be r equi r ed under t r adi t i onal i nf or med consent f or

any medi cal pr ocedur e.

The st at ut e cont i nues on, however , t o r equi r e t hat t he

physi ci an must i nf or m t he woman, at l east t went y- f our hour s i n

advance, t hat t he st at e pr i nt s mat er i al s t hat descr i be t he

unborn chi l d, and a copy must be pr ovi ded t o her i f she want s

i t . 18 Pa. Cons. St at . 3205( a) ( 2) - ( 3) . Fi nal l y, t he st at ut e

r equi r es t he physi ci an t o pr ovi de some addi t i onal i nf or mat i on

about f i nanci al and ot her assi st ance t hat may be avai l abl e f r om



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t he st at e and t he f at her . 18 Pa. Cons. St at . 3205( a) ( 2) . These

pr ovi si ons devi at e onl y modest l y f r om t r adi t i onal i nf or med

consent . They al so cl osel y resembl e t he i nf ormed consent

pr ovi si ons of Nor t h Carol i na s Woman s Ri ght t o Know Act t hat

ar e not under chal l enge i n thi s appeal . N. C. Gen. St at . 90-

21. 82( 1) - ( 2) . The chal l enged Di spl ay of Real - Ti me Vi ew

Requi r ement , N. C. Gen. St at . 90- 21. 85, however , r eaches beyond

t he modi f i ed f or m of i nf or med consent t hat t he Cour t appr oved i n

Casey. I n so doi ng, i t i mposes a vi r t ual l y unpr ecedent ed bur den

on t he r i ght of pr of essi onal speech t hat oper at es t o t he

det r i ment of bot h speaker and l i st ener .

C.

The bur dens t r ace i n par t f r om devi at i ons f r om t he

t r adi t i ons of i nf or med consent . The most ser i ous devi at i on f r om

st andar d pr act i ce i s r equi r i ng t he physi ci an t o di spl ay an i mage

and pr ovi de an expl anat i on and medi cal descr i pt i on t o a woman

who has t hr ough ear and eye cover i ng rendered her sel f

t empor ar i l y deaf and bl i nd. Thi s i s st ar kl y compel l ed speech

t hat i mpedes on t he physi ci an s Fi r st Amendment r i ght s wi t h no

count er bal anci ng pr omot i on of st ate i nt er est s. The woman does

not r ecei ve t he i nf or mat i on, so i t cannot i nf or m her deci si on.

I n f act , [ t ] he st at e s own exper t wi t ness agr ees t hat t he

del i ver y of t he st at e s message i n these ci r cumst ances does not

pr ovi de any i nf or mat i on t o t he pat i ent and does not ai d



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i n Pennsyl vani a need onl y i nf or m t he pat i ent t hat such

i nf or mat i on i s avai l abl e and, i f r equest ed, pr ovi de her wi t h a

copy of t he st at e- i ssued pamphl et . 18 Pa. Cons. St at .

3205( a) ( 2) ( i ) & ( a) ( 3) . I nf or mi ng a pat i ent t hat t her e ar e

st at e- i ssued mat er i al s avai l abl e i s not i deol ogi cal , because t he

vi ewpoi nt conveyed by t he pamphl et i s cl ear l y t he st at e s - - not

t he physi ci an s. I t i s no wonder t hen t hat t he Casey cour t f ound

no Fi r st Amendment i nf i r mi t i es i n t hat r equi r ement . By cont r ast ,

t he Nort h Carol i na st atut e compel s t he physi ci an t o speak and

di spl ay the ver y i nf or mat i on on a vol at i l e subj ect t hat t he

st at e woul d l i ke t o convey. See N. C. Gen. St at . 90-

21. 85( a) ( 2) - ( 4) . The coer ci ve ef f ect s of t he speech ar e

magni f i ed when t he physi ci an i s compel l ed t o del i ver t he st at e s

pr ef er r ed message i n hi s or her own voi ce. Thi s Requi r ement

t r eads f ar mor e heavi l y on t he physi ci ans f r ee speech r i ght s

t han t he st at e pamphl et pr ovi si ons at i ssue i n Casey.

Though t he i nf or mat i on conveyed may be st r i ct l y f act ual ,

t he cont ext sur r oundi ng t he del i ver y of i t pr omot es t he

vi ewpoi nt t he st at e wi shes t o encour age. As a mat t er of pol i cy,

t he st at e may cer t ai nl y expr ess a pr ef er ence f or chi l dbi r t h over

abor t i on, Webst er v. Repr od. Heal t h Ser vs. , 492 U. S. 490, 511

( 1989) , and use i t s agent s and wr i t t en mat er i al s t o convey t hat

message. However t he st at e cannot commandeer t he doct or - pat i ent

r el at i onshi p t o compel a physi ci an t o expr ess i t s pr ef er ence t o



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t he pat i ent . As t he di st r i ct cour t not ed, [ b] y r equi r i ng

pr ovi der s t o del i ver t hi s i nf or mat i on to a woman who t akes s t eps

not t o hear i t or woul d be har med by hear i ng i t , t he st at e has

. . . moved f r om encour agi ng t o l ect ur i ng, usi ng heal t h car e

pr ovi der s as i t s mout hpi ece. St uar t , 992 F. Supp. 2d at 609.

Tr ansf or mi ng t he physi ci an i nt o t he mout hpi ece of t he st at e

under mi nes t he t r ust t hat i s necessar y f or f aci l i t at i ng heal t hy

doct or - pat i ent r el at i onshi ps and, t hr ough t hem, successf ul

t r eat ment out comes. See Am. Pub. Heal t h Ass n ( APHA) Br . 9- 10.

The pat i ent seeks i n a physi ci an a medi cal prof ess i onal wi t h t he

capaci t y f or i ndependent medi cal j udgment t hat pr of essi onal

st at us i mpl i es. The rupt ur e of t r ust comes wi t h r epl aci ng what

t he doct or s medi cal j udgment woul d counsel i n a communi cat i on

wi t h what t he st at e wi shes t ol d. I t subver t s t he pat i ent s

expect at i ons when t he physi ci an i s compel l ed t o del i ver a st at e

message bear i ng l i t t l e connect i on t o t he sear ch f or pr of essi onal

ser vi ces t hat l ed t he pat i ent t o t he doct or s door .

Fur t her mor e, by f ai l i ng t o i ncl ude a t her apeut i c pr i vi l ege

except i on, t he Di spl ay of Real - Ti me Vi ew Requi r ement i nt er f er es

wi t h t he physi ci an s pr of essi onal j udgment and et hi cal

obl i gat i ons. The absence of a t her apeut i c except i on means t hat

t he st at e has sought not onl y to cont r ol t he cont ent of t he

physi ci an s speech, but t o di ct at e i t s t i mi ng. Under t he

Requi r ement , t he physi ci an must di spl ay and descr i be t he f et us



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si mul t aneousl y wi t h t he ul t r asound pr ocedur e, and he must do

t hi s at l east f our and not mor e t han sevent y- t wo hour s pr i or t o

t he abor t i on pr ocedur e. See N. C. Gen. St at . 90- 21. 85( a) .

Ther apeut i c pr i vi l ege, however , permi t s physi ci ans t o decl i ne or

at l east wai t t o convey rel evant i nf or mat i on as par t of i nf or med

consent because i n t hei r pr of essi onal j udgment del i ver i ng t he

i nf or mat i on t o t he pat i ent at a par t i cul ar t i me woul d r esul t i n

ser i ous psychol ogi cal or physi cal harm. ACOG, Comm. Op. 439, at

7. I t i s an i mpor t ant pr i vi l ege, al bei t a l i mi t ed one t o be used

spar i ngl y. See i d. I t pr ot ects t he heal t h of par t i cul ar l y

vul ner abl e or f r agi l e pat i ent s, and per mi t s t he physi ci an t o

uphol d hi s et hi cal obl i gat i ons of benevol ence.

The Casey cour t f ound i t r el evant t hat t he Pennsyl vani a

st at ut e cont ai ned a t her apeut i c except i on so t hat i t does not

pr event t he physi ci an f r om exer ci si ng hi s or her medi cal

j udgment . 505 U. S. at 883- 84. Nor t h Car ol i na by cont r ast

r equi r es t he physi ci an t o [ d] i spl ay the i mages and [ p] r ovi de

a si mul t aneous expl anat i on of what t he di spl ay i s depi ct i ng

al ong wi t h a medi cal descr i pt i on of t he i mages, wi t h no

except i on. N. C. Gen. St at . 90- 21. 85( a) ( 2) - ( 4) . The l ack of a

pr ovi si on si mi l ar t o Pennsyl vani a s i n Nor t h Car ol i na s st at ut e

r uns cont r ar y to t he st at e s i nt er est i n pr ot ect i ng t he

i nt egr i t y and et hi cs of t he medi cal pr of essi on, Gonzal es, 550

U. S. at 157, and mor e gener al l y to i t s i nt er est i n t he



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psychol ogi cal and physi cal wel l - bei ng of t he af f ect ed women.

Par t i cul ar l y f or women who have been vi ct i ms of sexual assaul t s

or whose f et uses are nonvi abl e or have sever e, l i f e- t hr eat eni ng

devel opment al abnor mal i t i es, havi ng t o wat ch a sonogr am and

l i st en t o a descr i pt i on of t he f et us coul d pr ove psychol ogi cal l y

devast at i ng. See J . A. 332- 33 ( decl ar at i on of Dr . Gr et chen S.

St uar t ) ; Appel l ees Br . 12- 13; APHA Br . 8- 9. Requi r i ng t he

physi ci an t o pr ovi de t he i nf or mat i on r egar dl ess of t he

psychol ogi cal or emot i onal wel l - bei ng of t he pat i ent , see N. C.

Gen. St at . 90- 21. 85 & 90- 21. 86, can hardl y be consi der ed

cl osel y dr awn t o t hose st at e i nt er est s t he pr ovi si on i s supposed

t o pr omote.

I n sum, t hough t he St ate woul d have us vi ew t hi s provi si on

as si mpl y a r easonabl e r egul at i on of t he medi cal pr of essi on,

t hese r equi r ement s l ook not hi ng l i ke t r adi t i onal i nf or med

consent , or even t he ver si ons provi ded f or i n Casey and i n N. C.

Gen. St at . 90- 21. 82. As such, t hey i mpose an ext r aor di nar y

bur den on expr essi ve r i ght s. The thr ee el ement s di scussed so f ar

- - r equi r i ng t he physi ci an t o speak to a pat i ent who i s not

l i st eni ng, r ender i ng the physi ci an the mout hpi ece of t he st at e s

message, and omi t t i ng a t her apeut i c pr i vi l ege t o pr ot ect t he

heal t h of t he pat i ent - - mar kedl y depar t f r om st andar d medi cal

pr act i ce.

D.



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Ot her aspect s of t he Requi r ement are equal l y unusual . As

descr i bed above, i nf or med consent f r equent l y consi st s of a

f ul l y- cl ot hed conver sat i on bet ween t he pat i ent and physi ci an,

of t en i n t he physi ci an s of f i ce. I t i s dr i ven by t he pat i ent s

par t i cul ar needs and ci r cumst ances, J . A. 388 ( decl ar at i on of

Dr . Amy Wei l ) , so t hat t he pat i ent r ecei ves t he i nf or mat i on he

or she want s i n a set t i ng t hat pr omot es an i nf ormed and

t hought f ul choi ce.

Thi s provi si on, however , f i nds t he pat i ent hal f - naked or

di sr obed on her back on an exami nat i on t abl e, wi t h an ul t r asound

pr obe ei t her on her bel l y or i nser t ed i nt o her vagi na.

Appel l ees Br . 13; APHA Br . 8. I nf ormed consent has not

gener al l y been t hought t o requi r e a pat i ent t o vi ew i mages f r om

hi s or her own body, ACOG & AMA Br . 7, much l ess i n a set t i ng i n

whi ch per sonal j udgment may be al t er ed or i mpai r ed. Yet t hi s

pr ovi si on r equi r es t hat she do so or aver t [ ] her eyes. N. C.

Gen. St at . 90- 21. 85( a) ( 3) , ( b) . Rat her t han engagi ng i n a

conver sat i on cal cul at ed t o i nf or m, t he physi ci an must cont i nue

t al ki ng r egar dl ess of whet her t he pat i ent i s l i st eni ng. See

St uart , 992 F. Supp. 2d at 590 & 602 n. 34. The i nf ormat i on i s

pr ovi ded i r r espect i ve of t he needs or want s of t he pat i ent , i n

di r ect cont r avent i on of medi cal et hi cs and t he pr i nci pl e of

pat i ent aut onomy. [ F] or ci ng t hi s exper i ence on a pat i ent over

her obj ect i ons i n t hi s manner i nt er f er es wi t h t he deci si on of a



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pat i ent not t o recei ve i nf or mat i on t hat coul d make an

i ndescr i babl y di f f i cul t deci si on even mor e t r aumat i c and coul d

act ual l y cause har m t o t he pat i ent . J . A. 330 ( decl ar at i on of

Dr . Gr et chen S. St uar t ) . And i t i s i nt ended t o convey not t he

r i sks and benef i t s of t he medi cal pr ocedur e t o t he pat i ent s own

heal t h, but r at her t he f ul l wei ght of t he st at e s mor al

condemnat i on. Though t he st at e i s pl ai nl y f r ee t o expr ess such a

pr ef er ence f or chi l dbi r t h t o women, i t i s not t he f unct i on of

i nf or med consent t o r equi r e a physi ci an t o del i ver t he st at e s

pr ef er ence i n a set t i ng t hi s f r aught wi t h st r ess and anxi et y.

There ar e f ew absol ut es i n t he di f f i cul t ar ea of

pr of essi onal r egul at i on and pr of essi onal expr essi on. But t her e

do exi st const r ai nt s on t he per mi ssi bl e i nt er f er ence wi t h t he

doct or - pat i ent r el at i onshi p; t her e ar e l i mi t s on st at e at t empt s

t o compel physi ci ans t o del i ver i t s message, especi al l y when

t hat message r uns count er t o t he physi ci an s pr of essi onal

j udgment and t he pat i ent s autonomous deci si on about what

i nf ormat i on she want s. Though st at es may sur el y enact

l egi sl at i on t o ensur e t hat a woman s choi ce i s i nf or med and

t hought f ul when she el ect s t o have an abor t i on, st ates cannot so

compr omi se physi ci ans f r ee speech r i ght s, pr of essi onal

j udgment , pat i ent aut onomy, and ot her i mpor t ant st at e i nt er est s

i n t he process. The means here exceed what i s pr oper t o pr omot e

t he undeni abl y pr of ound and i mport ant pur pose of pr ot ect i ng



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f et al l i f e. See, e. g. , Sor r el , 131 S. Ct . at 2667- 68, 2670

( hol di ng t hat Ver mont st at ut e unconst i t ut i onal l y bur dened speech

because [ w] hi l e Ver mont s st ated pol i cy goal s may be pr oper ,

4631( d) does not advance t hem i n a per mi ssi bl e way under

i nt er medi at e scrut i ny) .

I V.

The r i ght t o speak and t he r i ght t o r ef r ai n f r om speaki ng

are compl ement ary components of t he broader concept of

i ndi vi dual f r eedom of mi nd. Wool ey v. Maynar d, 430 U. S. 705,

714 ( 1977) ( quot i ng W. Va. St at e Bd. of Educ. v. Bar net t e, 319

U. S. 624, 637 ( 1943) ) . Regul at i ons whi ch compel i deol ogi cal

speech pose t he i nherent r i sk t hat t he Government seeks not t o

advance a l egi t i mat e r egul at or y goal , but t o suppr ess unpopul ar

i deas or i nf or mat i on or mani pul at e t he publ i c debat e t hr ough

coer ci on r at her t han per suasi on. Tur ner Br oad. Sys. , I nc. v.

FCC, 512 U. S. 622, 641 (1994) . Abort i on may wel l be a speci al

case because of t he undeni abl e gr avi t y of al l t hat i s i nvol ved,

but i t cannot be so speci al a case t hat al l ot her pr of essi onal

r i ght s and medi cal norms go out t he wi ndow. Whi l e t he st at e

i t sel f may pr omote t hr ough var i ous means chi l dbi r t h over

abor t i on, i t may not coer ce doct ors i nt o voi ci ng t hat message on

behal f of t he st at e i n t he par t i cul ar manner and set t i ng

at t empt ed her e. The di st r i ct cour t di d not er r i n concl udi ng

t hat 90- 21. 85 of t he Nor t h Car ol i na Gener al St at ut es vi ol at es



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t he Fi r st Amendment and i n enj oi ni ng the enf orcement of t hat

pr ovi si on. I t s j udgment i s i n al l r espect s af f i r med.

AFFI RMED


4th U.S. Circuit Court of Appeals -- North Carolina abortion law

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