Texas Abortion Clinic Ruling

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o. l4-50928

WHO!I WOMA'S HIA!TH; A!STI WOMI'S HIA!TH CITI!;
KI!!II WOMI'S HIA!TH CITI!; OVA HIA!TH SYSTIMS,
doIng busInoss ns !oroducfIvo SorvIcos; SHI!WOO C. !Y, J!., M..,
on bohnIf of fhomsoIvos nnd fhoIr nfIonfs; IAMI!A J. !ICHTI!, .O., on
bohnIf of fhomsoIvos nnd fhoIr nfIonfs; !IO! !. AVIS, M.., on bohnIf
of fhomsoIvos nnd fhoIr nfIonfs,

IInInfIffs - AoIIoos - Cross-AoIInnfs

v.

AVI !AKIY, M.., CommIssIonor of fho Toxns onrfmonf of Sfnfo
HonIfh SorvIcos, In hIs OffIcInI CnncIfy; MA!I !OIISO, IxocufIvo
Irocfor of fho Toxns ModIcnI Ionrd, In hor OffIcInI CnncIfy,

ofondnnfs - AoIInnfs - Cross-AoIIoos

AonIs from fho !nIfod Sfnfos IsfrIcf Courf
for fho Wosforn IsfrIcf of Toxns

Ioforo SMITH, I!!O, nnd HICCISO, CIrcuIf Judgos.
JIIII! WA!KI! I!!O, CIrcuIf Judgo:
IInInfIffs
l
fIIod fhIs InwsuIf sookIng docInrnfory roIIof nnd ormnnonf
InjuncfIons ngnInsf fho onforcomonf of fwo roconf nmondmonfs fo Toxns`s
l
IInInfIffs In fhIs InwsuIf nro somo of fho nborfIon rovIdors In Toxns: WhoIo
Womnn`s HonIfh; AusfIn Womon`s HonIfh Confor; KIIIoon Womon`s HonIfh Confor; ovn
United States Court of Appeals
Fifth Circuit
FILED
October 2, 2014

Lyle W. Cayce
Clerk

Case: l4-50928 Document: 005l279l273 Page: l Date Filed: l0/02/20l4
! #$ %&
l4-50928

Inws orfnInIng fo fho orformIng of nborfIons. See 20l3 Toxns Houso IIII
o. 2 (H.I. 2).
2
Tho InwsuIf wns fIIod In ArII 20l4, nnd fho dIsfrIcf courf
conducfod n four-dny bonch frInI Augusf 4?, 20l4. Throo wooks Infor, nf
4:39 .m. on Augusf 29, 20l4, fho Insf busInoss dny boforo fho nmbuInfory
surgIcnI confor rovIsIon wouId go Info offocf, fho dIsfrIcf courf doIIvorod Ifs
oInIon nnd Issuod n fInnI judgmonf onjoInIng fho ndmIffIng rIvIIogos
roquIromonf nnd nmbuInfory surgIcnI confor rovIsIon of H.I. 2 ns fo nII
nborfIon fncIIIfIos In Toxns. Tho dIsfrIcf courf nIso onjoInod ofhor socIfIc
nIIcnfIons of H.I. 2. Tho dIsfrIcf courf oInod fhnf fogofhor fhoso
roquIromonfs cronfo n brufnIIy offocfIvo sysfom of nborfIon roguInfIon fhnf
Is unconsfIfufIonnI.
AoIInnfs (coIIocfIvoIy fho Sfnfo) nonIod fo fho IIffh CIrcuIf nnd
fIIod nn omorgoncy mofIon fo sfny fho dIsfrIcf courf`s InjuncfIons ondIng fho
rosoIufIon of fhoIr nonI. IInInfIffs fIIod n rosonso, fho Sfnfo roIIod, nnd
HonIfh Sysfoms d/b/n !oroducfIvo SorvIcos; nnd Shorwood C. !ynn, Jr., M.., InmoIn J.
!Ichfor, .O., nnd !ondoI !. nvIs, M.., on bohnIf of fhomsoIvos nnd fhoIr nfIonfs.
IInInfIffs InrgoIy ovorIn wIfh fho InInfIffs In n rovIous chnIIongo fo H.I.
2. See PlonneJ Poren/looJ of Greo/er Tex. Surgicol Heol/l Serte. t. AIIo//, 95l I. Su.
2d 89l (W.. Tox. 20l3). WhoIo Womnn`s HonIfh, AusfIn Womon`s HonIfh Confor, KIIIoon
Womon`s HonIfh Confor, nnd r. !Ichfor nII woro InInfIffs In fho rIor InwsuIf. ocfors
!ynn nnd nvIs woro nof nrfIos fo fho onrIIor rocoodIng, buf WhoIo Womnn`s HonIfh nnd
AusfIn Womon`s HonIfh Confor, rosocfIvoIy, suod on fhoIr bohnIf In AIIo//. See ComInInf
l3l4, AIIo//, o. l:l3-CV-862-!Y (sfnfIng fhnf cIInIcs woro suIng on bohnIf of fhoIr
hysIcInns). !oroducfIvo SorvIcos wns nof n InInfIff In AIIo//, buf r. !Ichfor, Ifs
modIcnI dIrocfor, wns n InInfIff In AIIo//. See iJ. 2l.
!nmnr !obInson, M.. wns n nnmod InInfIff In AIIo// nnd wns orIgInnIIy n nnmod
InInfIff In fhIs cnso. Howovor, on Juno 3, 20l4, ho nnd formor InInfIff AborfIon
Advnnfngo fIIod n ofIco of VoIunfnry IsmIssnI. Af ornI nrgumonf In fhIs cnso, fho nrfIos
ndvIsod fho nnoI fhnf r. !obInson voIunfnrIIy dIsmIssod hIs cInIms bocnuso ho obfnInod
ndmIffIng rIvIIogos nf n hosIfnI wIfhIn fhIrfy mIIos of fho cIInIc nf whIch ho rovIdod
nborfIons. IInnnod Inronfhood, fho Inrgosf rovIdor of nborfIon sorvIcos In Toxns, Is nof n
nrfy fo fhIs InwsuIf, nIfhough If wns n nnmod InInfIff In AIIo//.

2
Acf of JuIy l2, 20l3, 83rd !og., 2d C.S., ch. l, ll2, 20l3 Tox. Soss. !nw Sorv.
4?95802 (Wosf) (codIfIod nf Tox. HonIfh & Snfofy Codo Ann. l?l.003l, l?l.04l.048,
l?l.06l.064, & nmondIng 245.0l0.0ll; Tox. Occ. Codo Ann. nmondIng l64.052 &
l64.055).
2

Case: l4-50928 Document: 005l279l273 Page: 2 Date Filed: l0/02/20l4
' #$ %&
l4-50928

wo honrd ornI nrgumonf on fho mofIon fo sfny on Sofombor l2, 20l4. Wo
C!AT, In nrf, nnd IY, In nrf, fho mofIon fo sfny fho dIsfrIcf courf`s
InjuncfIons ondIng nonI.
!1
On JuIy l2, 20l3, fho Toxns !ogIsInfuro nssod H.I. 2. Tho roosod
IogIsInfIon for whnf bocnmo H.I. 2 wns fIrsf fIIod In fho Toxns Houso of
!orosonfnfIvos In Juno 20l3. Tho Houso consIdorod fho bIII In fwo ubIIc
honrIngs. Affor fhroo rondIngs of fho bIII boforo fho onfIro Houso, H.I. 2
nssod wIfh n 96-49 vofo.
3
Tho bIII wns fhon sonf fo fho Toxns Sonnfo, whIch
nIso hoId n ubIIc honrIng nnd rond fho bIII fhroo fImos.
4
Tho Sonnfo ongngod
In n dobnfo In whIch n numbor of sonnfors gnvo soochos for nnd ngnInsf fho
bIII, nnd uIfImnfoIy nssod H.I. 2 wIfh n fInnI vofo of l9-ll.
5

Two of H.I. 2`s rovIsIons nro nf Issuo horo. Tho fIrsf roquIros nny
hysIcInn orformIng nn nborfIon fo hnvo ncfIvo ndmIffIng rIvIIogos nf n
hosIfnI wIfhIn fhIrfy mIIos of fho IocnfIon whoro fho nborfIon Is orformod.
Tox. HonIfh & Snfofy Codo Ann. l?l.003l. Tho ndmIffIng rIvIIogos
roquIromonf wonf Info offocf on Ocfobor 3l, 20l3.
6
Tho socond rovIsIon
3
83rd !og., Socond CnIIod SossIon, Houso JournnI nf 63, l0 JuI. 20l3, otoiloIle o/
hff://www.journnIs.houso.sfnfo.fx.us/hjrnI/832/df/83C2AY03IIA!.II#ngo=l3.

4
83rd !og., Socond CnIIod SossIon, otoiloIle o/
hff://www.IogIs.sfnfo.fx.us/IIII!ooku/HIsfory.nsx!ogSoss=832&IIII=HI2.

5
83rd !og., Socond CnIIod SossIon, Sonnfo JournnI nf 46, l2 JuI. 20l3, otoiloIle o/
hff://www.journnIs.sonnfo.sfnfo.fx.us/sjrnI/832/df/83S20?-l2-I.II#ngo=2.

6
Tho ndmIffIng rIvIIogos roquIromonf wns orIgInnIIy schoduIod fo fnko offocf on
Ocfobor 29, 20l3, buf fho dIsfrIcf courf onjoInod fho roquIromonf on Ocfobor 28, 20l3. See
PlonneJ Poren/looJ of Greo/er Tex. Surgicol Heol/l Serte. t. AIIo// (AIIo// 1), ?34 I.3d
406, 409l0 (5fh CIr. 20l3). Wo sfnyod fho dIsfrIcf courf`s InjuncfIon ns fo fho ndmIffIng
rIvIIogos roquIromonf on Ocfobor 3l, 20l3, fhus roInsfnfIng fho ndmIffIng rIvIIogos
roquIromonf oxcof ns fo nborfIon rovIdors who nIIod for ndmIffIng rIvIIogos wIfhIn
fho grnco orIod nIIowod undor H.I. 2, buf |woro] nwnIfIng n rosonso from n hosIfnI.
3

% #$ %&
l4-50928

roquIros fhnf nII nborfIon cIInIcs oxIsfIng on or nffor Sofombor l, 20l4,
comIy wIfh fho snmo mInImum sfnndnrds roquIrod of nmbuInfory surgIcnI
confors. Tox. HonIfh & Snfofy Codo Ann. 245.0l0.
?
Tho roguInfory
sfnndnrds for nmbuInfory surgIcnI confors confnIn fwo mnIn cnfogorIos: (l)
hysIcnI Innf, whIch IncIudos nrchIfocfurnI, oIocfrIcnI, IumbIng, nnd HVAC
roquIromonfs, eee 25 Tox. AdmIn. Codo l35.5l.56, nnd (2) oornfIons,
whIch IncIudos roquIromonfs for modIcnI rocords sysfoms, frnInIng, sfnffIng,
nnd cIonnIInoss, eee 25 Tox. AdmIn. Codo l35.4.l?, l35.26.2?.
Wo nro fnmIIInr wIfh IognI chnIIongos fo H.I. 2. In 20l3, fho dIsfrIcf
courf onjoInod onforcomonf of H.I. 2`s ndmIffIng rIvIIogos roquIromonf nnd
modIcnfIon nborfIon rovIsIon, nnd fho Sfnfo chnIIongod fho InjuncfIon on
nonI. PlonneJ Poren/looJ of Greo/er Tex. Surgicol Heol/l Serte. t. AIIo//,
95l I. Su. 2d 89l, 909 (W.. Tox. 20l3). In fhnf cnso, wo grnnfod In nrf
8

fho Sfnfo`s omorgoncy mofIon fo sfny fho ormnnonf InjuncfIon, PlonneJ
Poren/looJ of Greo/er Tex. Surgicol Heol/l Serte. t. AIIo// (AIIo// 1), ?34
I.3d 406, 4l9 (5fh CIr. 20l4), nnd Infor uhoId bofh fho ndmIffIng rIvIIogos
roquIromonf nnd fho modIcnfIon nborfIon rovIsIon ns fncInIIy consfIfufIonnI.
PlonneJ Poren/looJ of Greo/er Tex. Surgicol Heol/l Serte. t. AIIo// (AIIo// 11), ?48 I.3d
583, 600 (5fh CIr. 20l4).

?
Thoso sfnndnrds nro codIfIod nf Tox. HonIfh & Snfofy Codo 243.0l0. CIvon H.I.
2`s onncfmonf dnfo, JuIy l2, 20l3, cIInIcs hnd fourfoon monfhs wIfhIn whIch fo comIy wIfh
fhoso sfnndnrds boforo fho nmbuInfory surgIcnI confor rovIsIon bocnmo offocfIvo.

8
Wo grnnfod n sfny of fho dIsfrIcf courf`s doformInnfIon fhnf fho ndmIffIng
rIvIIogos roquIromonf wns fncInIIy InvnIId. Wo donIod n roquosf for n sfny of fho dIsfrIcf
courf`s docIsIon fo cronfo n honIfh oxcofIon fo fho modIcnfIon nborfIon rovIsIon. In
donyIng fho sfny of fho modIcnfIon nborfIon rovIsIon, wo nofod fhnf wo do nof rojudgo
fho oufcomo of fhoso Issuos on nonI. Wo concIudo onIy fhnf n sfny of fho InjuncfIon on
fhoso grounds ondIng nonI Is nof nrorInfo. AIIo// 1, ?34 I.3d nf 4l8. Indood, nf fho
morIfs sfngo, wo concIudod fhnf fho sfnfufo roguInfIng modIcnfIon nborfIons dId nof fncInIIy
roquIro n courf-Imosod oxcofIon. AIIo// 11, ?48 I.3d nf 60004.
4

( #$ %&
l4-50928

PlonneJ Poren/looJ of Greo/er Texoe Surgicol Heol/l Serte. t. AIIo// (AIIo//
11), ?48 I.3d 583, 605 (5fh CIr. 20l4).
In fho Insfnnf InwsuIf, IInInfIffs chnIIongo fho ndmIffIng rIvIIogos
roquIromonf, fhIs fImo nof on Ifs fnco, buf ns nIIod fo fwo socIfIc cIInIcs.
WhoIo Womnn`s HonIfh nnd r. Shorwood C. !ynn, Jr. chnIIongo fho
roquIromonf ns nIIod fo fho cIInIc oornfod by WhoIo Womnn`s HonIfh In
McAIIon. ovn HonIfh Sysfoms nnd r. InmoIn J. !Ichfor chnIIongo fho
roquIromonf ns nIIod fo fho cIInIc oornfod by !oroducfIvo SorvIcos In II
Inso. IInInfIffs nIso chnIIongo fho nmbuInfory surgIcnI confor rovIsIon ns
unconsfIfufIonnI on Ifs fnco, nnd ns nIIod fo fho cIInIcs In McAIIon nnd II
Inso, nnd ns nIIod fo modIcnfIon nborfIon.
Tho dIsfrIcf courf`s judgmonf oxfondod boyond IInInfIffs` cInIms nnd
fho roIIof roquosfod.
9
of onIy dId fho dIsfrIcf courf onjoIn fho ndmIffIng
rIvIIogos roquIromonf ns nIIod fo fho McAIIon nnd II Inso cIInIcs, ns
IInInfIffs soughf, fho dIsfrIcf courf doformInod fhnf fho ndmIffIng rIvIIogos
roquIromonf cronfo|d] nn ImormIssIbIo obsfncIo oe opplieJ /o oll uonen
sookIng n rovInbIIIfy nborfIon. Wlole Wononè Heol/l t. Lo/e,, o. l:l4-
CV-284-!Y, 20l4 W! 4346480 nf *2 (W.. Tox. Aug. 29, 20l4) (horoInnffor
|Wlole Wononè Heol/l JuJgnen/] (omhnsIs nddod); eee oleo Wlole
Wononè Heol/l t. Lo/e,, o. l:l4-CV-284-!Y, sII o. nf 4 (W.. Tox. Aug.
29, 20l4) (Tho fwo roquIromonfs oornfo fogofhor fo Inco nn
unconsfIfufIonnI unduo burdon on womon fhroughouf Toxns.).
As fo fho nmbuInfory surgIcnI confor rovIsIon, fho dIsfrIcf courf`s
oInIon nnd fInnI judgmonf nro uncIonr. Tho fInnI judgmonf docInros fhnf fho
nmbuInfory surgIcnI confor rovIsIon Is unconsfIfufIonnI ns fo nII nborfIon
9
Moroovor, fho dIsfrIcf courf`s ruIIng confrnvonod AIIo// 11, whIch hnd nIrondy
uhoId fho ndmIffIng rIvIIogos roquIromonf ns fncInIIy consfIfufIonnI.

5

) #$ %&
l4-50928

fncIIIfIos In fho Sfnfo wIfh fwo oxcofIons: (l) fncIIIfIos nIrondy IIconsod nnd
moofIng fho mInImum sfnndnrds; nnd (2) nII fufuro nborfIon fncIIIfIos
commoncIng oornfIon nffor fho offocfIvo dnfo. Wlole Wononè Heol/l
JuJgnen/ nf *l. ConfusIngIy, fho judgmonf furfhor docInros fhnf fho
nmbuInfory surgIcnI confor rovIsIon Is unconsfIfufIonnI nnd fhnf whon
consIdorod fogofhor wIfh fho ndmIffIng rIvIIogos roquIromonf, cronfo|s] nn
ImormIssIbIo obsfncIo ns nIIod fo nII womon sookIng n rovInbIIIfy
nborfIon. 1J. nf *2. In fhoIr brIofs nnd nf ornI nrgumonf, fho nrfIos
oxrossod uncorfnInfy ns fo whofhor fho dIsfrIcf courf Infondod fo InvnIIdnfo
fhIs rovIsIon on Ifs fnco or, nccordIng fo fho onrIIor Inngungo, ns nIIod fo
somo cIInIcs In fho sfnfo.
If Is nIso uncIonr whofhor fho dIsfrIcf courf socIfIcnIIy doformInod fhnf
fho rovIsIon Is unconsfIfufIonnI ns nIIod fo fho McAIIon nnd II Inso
cIInIcs. WhIIo IInInfIffs mndo fhoso ns-nIIod chnIIongos, fho dIsfrIcf courf
dId nof dIrocfIy nddross fhom In oIfhor fho docInrnfIons socfIon of Ifs fInnI
judgmonf or fho concIusIon of Ifs oInIon.
l0
Howovor, fho dIsfrIcf courf
IndIcnfod In fho Infroducfory nrfs of Ifs oInIon nnd judgmonf fhnf If
Infondod fo do so. See Wlole Wononè Heol/l JuJgnen/ nf *l (|T]ho . . .
nmbuInfory-surgIcnI-confor roquIromonfs of Houso IIII 2 ns nIIod fo |fho]
cIInIc|s] In McAIIon |nnd] II Inso . . . nro unconsfIfufIonnI); Wlole Wononè
Heol/l, sII o. nf 4 (docInrIng fhnf fho nmbuInfory surgIcnI confor rovIsIon,
ns nIIod fo fho McAIIon nnd II Inso cIInIcs, Inco|s] nn unconsfIfufIonnI
unduo burdon on womon); iJ. nf l6 (sfnfIng fhnf fho roquIromonf, ns
nIIod fo fho !Io Crnndo VnIIoy nnd II Inso cIInIcs, |Is] consfIfufIonnIIy

l0
A sImIInr Issuo nroso In fho AIIo// cnso, whon fho dIsfrIcf courf Issuod n judgmonf
brondor In scoo fhnn fho doformInnfIons In Ifs oInIon. AIIo// 1, ?34 I.3d nf 4l0 (Tho
fInnI judgmonf onjoInod fho modIcnfIon nborfIons rovIsIon fo n gronfor oxfonf fhnn fho
courf hnd IndIcnfod If wouId In Ifs Momornndum OInIon.). In fhnf cnso, wo nnrrowod fho
InjuncfIon In fho judgmonf. 1J. nf 4l9.
6

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ImormIssIbIo); eee oleo iJ. nf l9 (In nII ofhor nIIcnfIons, fho courf fInds
fhnf fho nmbuInfory-surgIcnI-confor roquIromonf Imosos nn unduo burdon
on Toxns womon of roroducfIvo ngo.). Wo nofo fhnf fho brond judgmonf ns
nIIod fo nII womon IogIcnIIy wouId IncIudo fho McAIIon nnd II Inso cIInIcs,
ovon fhough fho dIsfrIcf courf dId nof socIfIcnIIy nddross In Ifs concIusIons
nnd judgmonf IInInfIffs` ns-nIIod cInIms for fhoso IocnfIons.
To nIIovInfo confusIon nnd fo fnIrIy nddross fho Sfnfo`s omorgoncy
mofIon nnd IInInfIffs` rosonso, wo consIdor whofhor fo sfny InjuncfIons of
bofh fho ndmIffIng rIvIIogos roquIromonf nnd fho nmbuInfory surgIcnI
confor rovIsIon on fhoIr fncoor In fho dIsfrIcf courf`s words, ns nIIod fo
nII womon In Toxnsnnd ns nIIod fo fho McAIIon nnd II Inso cIInIcs. In
nddIfIon, wo wIII nddross fho InjuncfIon of fho nmbuInfory surgIcnI confor
rovIsIon ns nIIod fo modIcnfIon nborfIons. See Wlole Wononè Heol/l
JuJgnen/ nf *2.
!!1
IncfunI fIndIngs by fho dIsfrIcf courf nro fyIcnIIy rovIowod for cIonr
orror. Ci/, of AlexonJrio t. Broun, ?40 I.3d 339, 352 (5fh CIr. 20l4). Tho
dIsfrIcf courf found, nffor frInI wIfh wIfnoss crodIbIIIfy doformInnfIons, fhnf
Toxns hnd ovor forfy nborfIon cIInIcs rIor fo fho onncfmonf of H.I. 2, nnd
fhnf nffor fho nmbuInfory surgIcnI confor rovIsIon fnkos offocf, onIy sovon or
oIghf cIInIcs wIII romnIn, rorosonfIng moro fhnn nn 80 roducfIon In cIInIcs
sfnfowIdo In nonrIy fourfoon monfhs, wIfh n l00 roducfIon In cIInIcs wosf
nnd soufh of Snn AnfonIo. Tho dIsfrIcf courf furfhor found fhnf fhoro wns no
crodIbIo ovIdonco of modIcnI or honIfh bonofIf nssocInfod wIfh fho nmbuInfory
surgIcnI confor rovIsIon In fho nborfIon confoxf.
Tho dIsfrIcf courf nIso found: (l) fho consfrucfIon cosfs of brIngIng
oxIsfIng cIInIcs Info comIInnco wIfh fho mInImum sfnndnrds for nmbuInfory
?

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surgIcnI confors wIII undIsufodIy nronch l mIIIIon doIInrs nnd wIII mosf
IIkoIy oxcood l.5 mIIIIon doIInrs; (2) fho cosf of ncquIrIng Innd nnd
consfrucfIng n now comIInnf cIInIc wIII IIkoIy oxcood fhroo mIIIIon doIInrs
for oxIsfIng cIInIcs fhnf cnnnof comIy duo fo hysIcnI snco IImIfnfIons; (3)
fho onforcomonf of bofh chnIIongod H.I. 2 rovIsIons wIII Incronso womon`s
frnvoI dIsfnncos fo cIInIcs; for oxnmIo, l.3 mIIIIon womon of roroducfIvo ngo
In Toxns wIII IIvo moro fhnn l00 mIIos from n cIInIc, 900,000 womon wIII IIvo
moro fhnn l50 mIIos from n cIInIc, ?50,000 womon wIII IIvo moro fhnn 200
mIIos from n cIInIc, nnd somo womon wIII IIvo ns fnr ns 500 mIIos from n
cIInIc; (4) fho burdons of Incronsod frnvoI combIno wIfh rncfIcnI concorns
IncIud|Ing] Inck of nvnIInbIIIfy of chIId cnro, unroIInbIIIfy of frnnsorfnfIon,
unnvnIInbIIIfy of noInfmonfs nf nborfIon fncIIIfIos, unnvnIInbIIIfy of fImo off
from work, ImmIgrnfIon sfnfus nnd InnbIIIfy fo nss bordor chockoInfs,
ovorfy IovoI, |nnd] fho fImo nnd oxonso InvoIvod In frnvoIIng Iong
dIsfnncos; nnd (5) fho romnInIng sovon or oIghf cIInIcs IIkoIy wIII nof hnvo
fho cnncIfy fo orform 60,000?2,000 nborfIons or yonr In Toxns.
!!!1
Wo consIdor four fncfors In docIdIng whofhor fo grnnf n sfny ondIng
nonI:
(l) whofhor fho sfny nIIcnnf hns mndo n sfrong showIng fhnf ho
Is IIkoIy fo succood on fho morIfs; (2) whofhor fho nIIcnnf wIII
bo IrronrnbIy Injurod nbsonf n sfny; (3) whofhor Issunnco of fho
sfny wIII subsfnnfInIIy Injuro fho ofhor nrfIos Inforosfod In fho
rocoodIng; nnd (4) whoro fho ubIIc Inforosf IIos.

AIIo// 1, ?34 I.3d nf 4l0 (quofIng A/en t. HolJer, 556 !.S. 4l8, 42526
(2009)). A sfny Is nof n mnffor of rIghf, ovon If IrronrnbIo Injury mIghf
ofhorwIso rosuIf fo fho noIInnf.

A/en, 556 !.S. nf 42?.
Tho Sfnfo InIfInIIy fIIod n mofIon fo sfny In fhIs courf nnd, shorfIy
fhoronffor, fIIod fho snmo mofIon wIfh fho dIsfrIcf courf. Tho dIsfrIcf courf
8

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donIod fho mofIon for subsfnnfInIIy fho ronsons sfnfod In Ifs momornndum
oInIon. IInInfIffs do nof objocf fo fho ordor In whIch fho Sfnfo fIIod Ifs
mofIons nnd ngroo fhnf fho rosonf mofIon Is roorIy boforo us. See AIIo//
1, ?34 I.3d nf 4l0.
!21
Ioforo vInbIIIfy, n Sfnfo mny nof rohIbIf nny womnn from mnkIng
fho uIfImnfo docIsIon fo formInnfo hor rognnncy. Goncolee t. Corlor/, 550
!.S. l24, l46 (200?) (InfornnI quofnfIon mnrks omIffod). or mny n Sfnfo
Imoso uon fhIs rIghf nn unduo burdon, whIch oxIsfs If n roguInfIon`s
uroso or offocf Is fo Inco n subsfnnfInI obsfncIo In fho nfh of n womnn
sookIng nn nborfIon boforo fho fofus nffnIns vInbIIIfy. 1J. (InfornnI quofnfIon
mnrks omIffod); eee oleo PlonneJ Poren/looJ of Se. Po. t. Coee,, 505 !.S.
833, 846 (l992)). To doformIno fho consfIfufIonnIIfy of n sfnfo Inw, wo nsk
whofhor fho Acf, monsurod by Ifs foxf In fhIs fncInI nffnck, Imosos n
subsfnnfInI obsfncIo fo . . . rovInbIIIfy|] nborfIons. Corlor/, 550 !.S. nf l56.
IoIIowIng Corlor/ nnd Coee,, our cIrcuIf conducfs n fwo-sfo nronch,
fIrsf nIyIng n rnfIonnI bnsIs fosf, fhon IndoondonfIy doformInIng If fho
burdon on n womnn`s choIco Is unduo. See AIIo// 11, ?48 I.3d nf 59394, 59?
(Ivon fhough fho sfnfo nrfIcuInfod n rnfIonnI bnsIs for fho Inw . . . |IInInfIff]
couId succood If fho offocf of fho Inw subsfnnfInIIy burdonod womon`s nccoss
fo nborfIon In Toxns.); eee oleo Corlor/, 550 !.S. nf l58 (Whoro If hns n
rnfIonnI bnsIs fo ncf, nnd If doos nof Imoso nn unduo burdon, fho Sfnfo mny
uso Ifs roguInfory owor . . . In furfhornnco of Ifs IogIfImnfo Inforosfs . . . .).
*1
Though IInInfIffs soughf onIy ns-nIIod roIIof from fho ndmIffIng
rIvIIogos roquIromonf, IImIfod fo fwo nborfIon cIInIcsono In II Inso nnd
ono In McAIIonfho dIsfrIcf courf, In Ifs fInnI judgmonf, nonrs fo hnvo
9

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fncInIIy InvnIIdnfod fho ndmIffIng rIvIIogos roquIromonf fhroughouf Toxns.
See Wlole Wononè Heol/l JuJgnen/ nf *2 (|T]ho fwo orfIons of Toxns
HonIfh nnd Snfofy Codo, SocfIons 245.0l0(n) |nmbuInfory surgIcnI confor
rovIsIon] nnd l?l.003l(n)(l) |ndmIffIng rIvIIogos roquIromonf], cronfo nn
ImormIssIbIo obsfncIo oe opplieJ /o oll womon sookIng n rovInbIIIfy
nborfIon.) (omhnsIs nddod); eee oleo Wlole Wononè Heol/l, sII o. nf 2l
(nofIng fhnf fho ndmIffIng rIvIIogos roquIromonf nnd nmbuInfory surgIcnI
confor rovIsIon nro unconsfIfufIonnI ns fo oll uonen in /le e/o/e sookIng n
rovInbIIIfy nborfIon bocnuso fhoy ncf fogofhor fo cronfo nn unduo burdon on
n womnn sookIng n rovInbIIIfy nborfIon by rosfrIcfIng nccoss fo rovIousIy
nvnIInbIo IognI fncIIIfIos). ThIs wns InnrorInfo bocnuso IInInfIffs dId nof
roquosf fhnf roIIof. See Joc/eon Wonenè Heol/l Org. t. Currier, ?60 I.3d
448, 458 (5fh CIr. 20l4) (nnrrowIng fho dIsfrIcf courf`s InjuncfIon fo
corrosond wIfh fho scoo of fho InInfIffs` roquosfod roIIof). Iurfhormoro,
fho dIsfrIcf courf`s fncInI InvnIIdnfIon of fho ndmIffIng rIvIIogos roquIromonf
Is dIrocfIy confrnry fo fhIs cIrcuIf`s rocodonf. AIIo// 11 socIfIcnIIy uhoId
fho fncInI consfIfufIonnIIfy of fho ndmIffIng rIvIIogos roquIromonf. ?48 I.3d
nf 599600.
31
Wo now furn fo fho confrnI quosfIon rosonfod by fhIs omorgoncy
mofIon: whofhor fho Sfnfo hns shown n IIkoIIhood of succoss rognrdIng
whofhor fho nmbuInfory surgIcnI confor rovIsIon Is unconsfIfufIonnI on Ifs
fnco. Wo concIudo fhnf If hns.
As oxInInod In AIIo// 11, If fho Sfnfo osfnbIIshos fhnf n Inw Is
rnfIonnIIy roInfod fo n IogIfImnfo sfnfo Inforosf, wo do nof socond guoss fho
IogIsInfuro rognrdIng fho Inw`s wIsdom or offocfIvonoss. ?48 I.3d nf 594. or
l0

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Is fho Sfnfo roquIrod fo rovo fhnf fho objocfIvo of fho Inw wouId bo fuIfIIIod.
1J. (InfornnI quofnfIon mnrks omIffod).
Tho dIsfrIcf courf concIudod fhnf H.I. 2, IncIudIng bofh rovIsIons nf
Issuo horo, surmounf|od] fho Iow bnr of rnfIonnI-bnsIs rovIow. Wlole
Wononè Heol/l, sII o. nf 6. Wo ngroo wIfh fho dIsfrIcf courf`s concIusIon
fhnf fho nmbuInfory surgIcnI confor rovIsIon snfIsfIos rnfIonnI bnsIs rovIow.
In nddIfIon, no nrfy chnIIongos fho dIsfrIcf courf`s concIusIon.
Thus, our rovIow wIII focus on fho socond sfo of fhIs cIrcuIf`s nronch;
nnmoIy, whofhor fhIs rovIsIon Imosos nn unduo burdon. Tho unduo burdon
InquIry Iooks fo whofhor fho chnIIongod rovIsIon hns oIfhor fho purpoee or
effec/ of IncIng n subsfnnfInI obsfncIo In fho nfh of n womnn sookIng nn
nborfIon of n nonvInbIo fofus. Coee,, 505 !.S. nf 8?? (omhnsIs nddod). If If
doos, If Is unconsfIfufIonnI. 1J.
41
Wo bogIn wIfh fho uroso InquIry. |I]InInfIffs boro fho burdon of
nffnckIng fho Sfnfo`s uroso horo, nnd fho Sfnfo hns shown n sfrong
IIkoIIhood fhnf IInInfIffs fnIIod fo moof fhnf burdon. AIIo// 11, ?48 I.3d nf
59?; eee oleo AIIo// 1, ?34 I.3d nf 4l3.
Tho dIsfrIcf courf doformInod fhnf fho nmbuInfory-surgIcnI-confor
roquIromonf wns Infondod fo cIoso oxIsfIng IIconsod nborfIon cIInIcs. Wlole
Wononè Heol/l, sII o. nf l6. To suorf Ifs concIusIon, fho dIsfrIcf courf
doformInod fhnf H.I. 2 fronfs nborfIon fncIIIfIos In n dIsnrnfo nnd
nrbIfrnry mnnnor by nof IncIudIng nn oxcofIon fo fho nmbuInfory surgIcnI
confor rovIsIon for rovIousIy IIconsod nborfIon rovIdors. AccordIng fo fho
dIsfrIcf courf, ofhor fyos of nmbuInfory-surgIcnI fncIIIfIos nro froquonfIy
grnnfod wnIvors or nro grnndfnfhorod duo fo consfrucfIon dnfos fhnf rodnfo
ll

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fho nowor consfrucfIon roquIromonfs. 1J. nf l0 (cIfIng 25 Tox. AdmIn. Codo
l35.5l(n)).
Tho Sfnfo nrguos fhnf fho dIsfrIcf courf mIsundorsfood fho roIovnnf
rovIsIon In fho govornIng Toxns roguInfIon. As fho Sfnfo ronds fho
rovIsIon, H.I. 2 doos nof fronf nborfIon fncIIIfIos dIsnrnfoIy from ofhor
nmbuInfory surgIcnI confors In fhIs rosocf. See 25 Tox. AdmIn. Codo
l35.5l(n). AccordIng fo fho Sfnfo, fhoro Is no nmbuInfory surgIcnI confor
oxomfIon for nny fncIIIfy wIfhIn fho sfnfuforIIy-dofInod subsof roquIrIng
IIconsuro, rognrdIoss of whofhor If rovIdos nborfIons. Tho rovIsIon cIfod by
fho dIsfrIcf courf rovIdos nn oxomfIon fo on, fncIIIfy rovIousIy IIconsod ns
nn nmbuInfory surgIcnI confor fhnf fnIIod fo comIy wIfh now buIIdIng codo
roquIromonfs nmondod In Juno 2009. Any such fncIIIfy, rognrdIoss of
whofhor If rovIdos nborfIons, qunIIfIos for fho oxomfIon. Insod on our
rovIow of fho roIovnnf rovIsIon, wo ngroo wIfh fho Sfnfo fhnf nmbuInfory
surgIcnI confors rovIdIng nborfIons nro nof fronfod dIfforonfIy from ofhor
nmbuInfory surgIcnI confors.
IosIdos Ifs vIow of fho nbovo roguInfIon, fho dIsfrIcf courf cIfod no
rocord ovIdonco fo suorf Ifs doformInnfIon fhnf fho nmbuInfory surgIcnI
confor rovIsIon wns onncfod for fho uroso of ImosIng nn unduo burdon on
womon sookIng nborfIons, nor dId If mnko nny fncfunI fIndIng rognrdIng nn
Imroor uroso. Tho Toxns !ogIsInfuro`s sfnfod uroso wns fo Imrovo
nfIonf snfofy. See, e.g., Sonnfo Comm. On HonIfh & Humnn Sorvs., IIII
AnnIysIs, Tox. H.I. 2, 83d !og., 2d C.S. l2 (20l3) (H.I. 2 sooks fo Incronso
fho honIfh nnd snfofy of nborfIon nfIonfs nnd fo rovIdo fhom wIfh fho
hIghosf sfnndnrd of honIfh cnro). As wo obsorvod In AIIo// 1, fho Sfnfo of
Toxns hns nn Inforosf In rofocfIng fho honIfh of womon who undorgo
nborfIon rocoduros. ?34 I.3d nf 4l3; eee oleo Corlor/, 550 !.S. nf l5?
l2

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(Thoro cnn bo no doubf fho govornmonf hns nn Inforosf In rofocfIng fho
InfogrIfy nnd ofhIcs of fho modIcnI rofossIon. (InfornnI quofnfIon mnrks
omIffod)). Courfs nro nof ormIffod fo socond guoss n IogIsInfuro`s sfnfod
urosos nbsonf cIonr nnd comoIIIng ovIdonco fo fho confrnry. See Koneoe t.
HenJric/e, 52l !.S. 346, 36l (l99?) (|W]o ordInnrIIy dofor fo fho
IogIsInfuro`s sfnfod Infonf.); Ilenning t. Aee/or, 363 !.S. 603, 6l? (l960)
(|O]nIy fho cIonrosf roof couId suffIco fo osfnbIIsh fho unconsfIfufIonnIIfy of
n sfnfufo on |fho] ground of |Imroor IogIsInfIvo mofIvo].). Such ovIdonco
sImIy doos nof nonr In fho rocord horo.
AIfornnfIvoIy, fho dIsfrIcf courf oInod fhnf If wns nof roquIrod fo fInd
ncfunI ovIdonco of Imroor uroso bocnuso H.I. 2`s nmbuInfory surgIcnI
confor rovIsIon hns fho effec/ of cronfIng nn unduo burdon. Wlole Wononè
Heol/l, sII o. nf l6. To fho oxfonf fho dIsfrIcf courf found nn Imroor
uroso bnsod on fho Inw`s effec/, fho Sfnfo Is IIkoIy fo succood on fho morIfs.
Mocure/ t. Arne/rong, 520 !.S. 968, 9?2 (l99?) (nofIng fhnf fho uroso nnd
offocf of unduo burdon nro fwo dIfforonf InquIrIos nnd fhoro musf bo eone
ovIdonco of fhnf Imroor uroso); AIIo// 11, ?48 I.3d nf 59? (|T]ho
InInfIffs offorod no ovIdonco ImIyIng fhnf fho Sfnfo onncfod fho ndmIffIng
rIvIIogos rovIsIon In ordor fo IImIf nborfIons . . . . Thoro Is fhus no bnsIs for
n fIndIng of ImormIssIbIo uroso undor Coee,.).
51
Wo now ovnIunfo whofhor fho Sfnfo hns shown n IIkoIIhood of succoss
on fho morIfs of whofhor fho nmbuInfory surgIcnI confor rovIsIon hns fho
effec/ of ImosIng nn unconsfIfufIonnI burdon suffIcIonf fo jusfIfy n fncInI
InvnIIdnfIon. Corlor/, 550 !.S. nf l6l (omhnsIs nddod). Tho Sfnfo hns
mndo such n showIng.
l3

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IncInI chnIIongos roIyIng on fho offocfs of n Inw Imoso|] n honvy
burdon uon fho nrf|y] mnInfnInIng fho suIf. AIIo// 1, ?34 I.3d nf 4l4
(socond nIfornfIon In orIgInnI) (quofIng Corlor/, 550 !.S. nf l6?) (InfornnI
quofnfIon mnrks omIffod); AIIo// 11, ?48 I.3d nf 604 (snmo). In Corlor/, fho
Suromo Courf rocognIzod fho oxIsfonco of dIvorgonf vIows ns fo |w]hnf fhnf
burdon consIsfs of In fho socIfIc confoxf of nborfIon sfnfufos . . . . 550 !.S.
nf l6?. If Is woII-soffIod In fhIs cIrcuIf fhnf |n] fncInI chnIIongo wIII succood
onIy whoro fho InInfIff shows fhnf fhoro Is no sof of cIrcumsfnncos undor
whIch fho sfnfufo wouId bo consfIfufIonnI. Bornee t. Mieeieeippi, 992 I.2d
l335, l342 (5fh CIr. l993); eee oleo AIIo// 11, ?48 I.3d nf 588 (Sfnndnrd
rIncIIos of consfIfufIonnI ndjudIcnfIon roquIro courfs fo ongngo In fncInI
InvnIIdnfIon onIy If no ossIbIo nIIcnfIon of fho chnIIongod Inw wouId bo
consfIfufIonnI.). Tho Suromo Courf usos fho snmo no sof of cIrcumsfnncos
ruIo In gonornI for fncInI chnIIongos. See Ini/eJ S/o/ee t. Solerno, 48l !.S.
?39, ?45 (l98?). Howovor, ns wo nofod In AIIo// 11, If Is nof cIonr whofhor
fho Suromo Courf nIIos fhIs gonornI ruIo In nborfIon cnsos. ?48 I.3d nf
588.
In Coee,, fho confroIIIng IurnIIfy hoId fhnf nn nborfIon-roguInfIng
sfnfufo wouId fnII consfIfufIonnI musfor If, In n lorge froc/ion of /le coeee In
whIch If Is roIovnnf, If wIII oornfo ns n subsfnnfInI obsfncIo fo n womnn`s
choIco fo undorgo nn nborfIon. 505 !.S. nf 895 (omhnsIs nddod). In onrIIor
nborfIon cnsos, fho Courf usod fho no sof of cIrcumsfnncos nronch. See,
e.g., Iue/ t. Sulliton, 500 !.S. l?3, l83 (l99l); Olio t. A/ron C/r. for IeproJ.
Heol/l, 49? !.S. 502, 5l4 (l990). Tho moro roconf Corlor/ mnjorIfy dId nof
chooso bofwoon no sof of cIrcumsfnncos nnd Inrgo frncfIon, buf Insfond
uhoId fho sfnfufo In quosfIon on fho bnsIs fhnf fho fncInI chnIIongo couId nof
snfIsfy oIfhor sfnndnrd. 550 !.S. nf l6?68 (Wo nood nof rosoIvo fhnf
l4

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dobnfo. 1J. nf l6?.). Wo wIII do fho snmo horo, ns wo dId In AIIo// 1 nnd
AIIo// 11, nnd nIy fho 'Inrgo frncfIon` nomoncInfuro for fho snko of
nrgumonf onIy, wIfhouf cnsfIng doubf on fho gonornI ruIo. AIIo// 11, ?48
I.3d nf 58889; eee oleo AIIo// 1, ?34 I.3d nf 4l4.
Tho nmbuInfory surgIcnI confor rovIsIon nIIos fo nII cIInIcs
orformIng nborfIons. Ivory womnn In Toxns who sooks nn nborfIon wIII bo
nffocfod fo somo dogroo by fhIs roquIromonf bocnuso If offocfIvoIy nnrrows hor
ofIons for whoro fo obfnIn nn nborfIon. As fho nrfIos sfIuInfod nf frInI, sIx
IIconsod nmbuInfory surgIcnI confors wIII nof bo rovonfod by fho
nmbuInfory surgIcnI confor |rovIsIon] of HI 2 from orformIng nborfIons.
Thoso nro Iocnfod In AusfIn, nIIns, Iorf Worfh, Housfon, nnd Snn AnfonIo.
Tho nrfIos nIso sfIuInfod fhnf IInnnod Inronfhood hns obfnInod n IIconso fo
oon n now nmbuInfory surgIcnI confor In nIIns, nnd nnnouncod Ifs InfonfIon
fo oon nnofhor ono In Snn AnfonIo. Howovor, fho nrfIos furfhor sfIuInfod
fhnf nII ofhor nborfIon fncIIIfIos now IIconsod by fho Sfnfo of Toxns cnnnof
curronfIy comIy wIfh fho rovIsIon. Tho dIsfrIcf courf concIudod fhnf fhIs
roducfIon In suIy of cIInIcs wns nn unduo burdon nnd fncInIIy InvnIIdnfod
fho nmbuInfory surgIcnI confor rovIsIon. In doIng so, fho dIsfrIcf courf
nIIod noIfhor fho IIffh CIrcuIf`s no sof of cIrcumsfnncos fosf nor Coee,`s
Inrgo frncfIon fosf. Insfond, fho dIsfrIcf courf found fhnf n eignificon/
nunIer of fho roroducfIvo-ngo fomnIo ouInfIon of Toxns wIII nood fo frnvoI
consIdornbIy furfhor In ordor fo oxorcIso Ifs rIghf fo n IognI rovInbIIIfy
nborfIon. Wlole Wononè Heol/l, sII o. nf 9 (omhnsIs nddod). Tho
dIsfrIcf courf concIudo|d] fhnf fho rncfIcnI Imncf on Toxns womon duo fo
fho cIInIcs` cIosuro sfnfowIdo wouId oornfo for n eignificon/ nunIer of
womon In Toxns jusf ns drnsfIcnIIy ns n comIofo bnn on nborfIon. 1J. nf ll
(omhnsIs nddod). Howovor, undor fhIs cIrcuIf`s rocodonf, nnd Corlor/, n
l5

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sIgnIfIcnnf numbor Is InsuffIcIonf unIoss If nmounfs fo n Inrgo frncfIon.
See AIIo// 11, ?48 I.3d nf 600 (|T]ho roguInfIon wIII nof nffocf n sIgnIfIcnnf
(much Ioss 'Inrgo`) frncfIon of such womon . . . .).
Tho dIsfrIcf courf nIso orrod whon If bnInncod fho offIcncy of fho
nmbuInfory surgIcnI confor rovIsIon ngnInsf fho burdons fho rovIsIon
Imosod. In fho dIsfrIcf courf`s vIow, fho sovorIfy of fho burdon Imosod by
bofh roquIromonfs Is nof bnInncod by fho woIghf of fho Inforosfs undorIyIng
fhom. Wlole Wononè Heol/l, sII o. nf l3. As suorf for fhIs roosIfIon,
fho courf ovnIunfod whofhor fho nmbuInfory surgIcnI confor rovIsIon wouId
ncfunIIy Imrovo womon`s honIfh nnd snfofy. 1J. nf l4l5 (Tho courf
concIudos fhnf If Is unIIkoIy fhnf fho sfnfod gonI of fho roquIromonf
ImrovIng womon`s honIfhwIII ncfunIIy como fo nss.). ThIs nronch
confrnvonos our rocodonf. In our cIrcuIf, wo do nof bnInnco fho wIsdom or
offocfIvonoss of n Inw ngnInsf fho burdons fho Inw Imosos. See AIIo// 11, ?48
I.3d nf 59394, 59? (conducfIng n fwo-sfo nronch, fIrsf doformInIng
whofhor fho Inw nf Issuo snfIsfIos rnfIonnI bnsIs, fhon whofhor If Incos n
subsfnnfInI obsfncIo In fho nfh of n Inrgo frncfIon of womon sookIng
nborfIons); eee oleo Horrie t. McIoe, 448 !.S. 29?, 32526 (l980) (If Is nof
fho mIssIon of fhIs Courf or nny ofhor fo docIdo whofhor fho bnInnco of
comofIng Inforosfs . . . Is wIso socInI oIIcy.).
Tho dIsfrIcf courf`s woIghIng of fho Inforosfs bnsIcnIIy boIIs down fo fho
dIsfrIcf courf`s own vIow fhnf fho fncIIIfIos nro nIrondy snfo for womon nnd
fhnf fho nmbuInfory surgIcnI confor rovIsIon, whon ImIomonfod, wIII nof
sorvo fo romofo womon`s honIfh. Howovor, AIIo// 11 dIscussos In dofnII fho
orIIs of socond-guossIng fho wIsdom of fho IogIsInfuro In n consfIfufIonnI
chnIIongo:
If IogIsInfors` rodIcfIons nbouf n Inw fnII fo sorvo fhoIr uroso,
fho Inw cnn bo chnngod. Onco fho courfs hnvo hoId n Inw
l6

!* #$ %&
l4-50928

unconsfIfufIonnI, howovor, onIy n consfIfufIonnI nmondmonf, or
fho wIsdom of n mnjorIfy of jusfIcos ovorcomIng fho sfrong uII of
e/ore Jecieie, wIII ormIf fhnf or sImIInr Inws fo ngnIn fnko offocf.
AIIo// 11, ?48 I.3d nf 594. Moroovor, fho dIsfrIcf courf`s nronch rnfchofs
u rnfIonnI bnsIs rovIow Info n soudo-sfrIcf-scrufIny nronch by oxnmInIng
whofhor fho Inw ndvnncos fho Sfnfo`s nssorfod uroso.
ll
!ndor our
rocodonf, wo hnvo no nufhorIfy by whIch fo furn rnfIonnI bnsIs Info sfrIcf
scrufIny undor fho guIso of fho unduo burdon InquIry.
IInInfIffs nrguo fhnf fho dIsfrIcf courf`s bnInncIng nronch Is usod by
ofhor cIrcuIfs. Wo ngroo wIfh IInInfIffs fhnf somo cIrcuIfs hnvo usod fho
bnInncIng fosf fo onjoIn nborfIon roguInfIons; ofhor cIrcuIfsIncIudIng ours
hnvo nof. Conpore PlonneJ Poren/looJ Aric., 1nc. t. HunIle, ?53 I.3d 905,
9l4 (9fh CIr. 20l4), onJ PlonneJ Poren/looJ of Wiec., 1nc. t. Von Hollen, ?38
I.3d ?86, ?9l99 (?fh CIr. 20l3), ui/l AIIo// 11, ?48 I.3d nf 59394, 59?,
PlonneJ Poren/looJ Su. Olio Iegion t. DeWine, 696 I.3d 490, 5l5 (6fh CIr.
20l2), Greentille Wonenè Clinic t. Br,on/, 222 I.3d l5? (4fh CIr. 2000), onJ
Wonenè Heol/l Cen/er of W. Cn/,., 1nc. t. WeIe/er, 8?l I.2d l3?? (8fh CIr.
l989). Wo nro bound fo foIIow our cIrcuIf`s nronch.
In nddIfIon, IInInfIffs nrguo fhnf Bornee t. Mieeieeippi, 992 I.2d l335
(5fh CIr. l993) suorfs n bnInncIng nronch.
l2
Howovor, n cnrofuI rondIng
of Bornee osfnbIIshos fhnf If doos nof suorf IInInfIffs` nrgumonf.
In Bornee, wo cIfod Coee, for fho roosIfIon fhnf fho consfIfufIonnIIfy of nn

ll
ThIs Is nrfIcuInrIy robIomnfIc In n fncInI chnIIongo fo n nowIy onncfod Inw.
Mosf IogIsInfIon donIs uIfImnfoIy In robnbIIIfIos, fho osfImnfIon of fho ooIo`s
rorosonfnfIvos fhnf n Inw wIII bo bonofIcInI fo fho communIfy. Succoss offon cnnnof bo
'rovon` In ndvnnco. Tho courf mny nof roInco IogIsInfIvo rodIcfIons or cnIcuInfIons of
robnbIIIfIos wIfh Ifs own, oIso If usurs fho IogIsInfIvo owor. AIIo// 11, ?48 I.3d nf 594
(cIfIng Heller t. Doe, 509 !.S. 3l2, 3l9 (l993)).

l2
Tho concurrIng nnd dIssonfIng oInIon sooms fo ngroo wIfh IInInfIffs` nnd fho
dIsfrIcf courf`s vIows on fho bnInncIng nronch, ns woII ns fhoIr InforrofnfIon of Bornee.
l?

!+ #$ %&
l4-50928

nborfIon roguInfIon . . . furns on nn oxnmInnfIon of fho inpor/once of fho
sfnfo`s Inforosfs In fho roguInfIon nnd fho sovorIfy of fho burdon fhnf
roguInfIon Imosos on n womnn`s rIghf fo sook nn nborfIon. 992 I.2d nf l339
(omhnsIs nddod). Wo fhon nnnIyzod fho inpor/once of fho Sfnfo`s Inforosf In
nronfnI InvoIvomonf sfnfufos, wIfhouf consIdorIng fho oxfonf fo whIch fho
chnIIongod Inw ncfunIIy ndvnncod fhnf Inforosf. !IkowIso horo, fho honIfh of
womon sookIng nborfIons Is nn Imorfnnf uroso. See AIIo// 11, ?48 I.3d nf
59496. Our onIy romnInIng fnsk Is fo nnnIyzo fho sovorIfy of fho burdon fho
roguInfIon Imosos on womon`s rIghf fo sook nborfIons.
Tho dIsfrIcf courf`s fnIIuro fo nIy fho Inrgo frncfIon fosf, nnd Ifs
roIInnco on Ifs own bnInncIng of fho Sfnfo`s jusfIfIcnfIons ngnInsf fho burdons
Imosod by fho Inw, woIgh In fnvor of fho Sfnfo`s sfrong IIkoIIhood of succoss
on fho morIfs. Moroovor, nIIcnfIon of fho Inrgo frncfIon fosf fo fho
ovIdonco boforo us furfhor suorfs fho Sfnfo`s osIfIon fhnf fho ovIdonco nf
fho four-dny frInI Is InsuffIcIonf fo show fhnf n Inrgo frncfIon of womon
sookIng nborfIons wouId fnco nn unduo burdon on nccounf of fho nmbuInfory
surgIcnI confor rovIsIon.
IInInfIffs` oxorf, r. nnIoI Crossmnn, oInod fhnf fho nmbuInfory
surgIcnI confor rovIsIon wouId Incronso drIvIng dIsfnncos for womon
gonornIIy, nofIng fhnf nffor fho rovIsIon bocomos offocfIvo, 900,000 ouf of
nroxImnfoIy 5.4 mIIIIon womon of roroducfIvo ngo In Toxns wouId IIvo nf
Ionsf l50 mIIos from fho nonrosf cIInIc. Wlole Wononè Heol/l, sII o. nf 8
9. Ho dId nof fosfIfy socIfIcnIIy nbouf how mnny womon sookIng nborfIons
wouId hnvo fo drIvo moro fhnn l50 mIIos or whofhor fhnf numbor wouId
nmounf fo n Inrgo frncfIon. See AIIo// 11, ?48 I.3d nf 583 (|A]n Incronso of
frnvoI of Ioss fhnn l50 mIIos for somo womon Is nof nn unduo burdon undor
Coee,.) (cIfIng AIIo// 1, ?34 I.3d nf 4l5). AssumIng fhnf womon sookIng
l8

!, #$ %&
l4-50928

nborfIons nro roorfIonnIIy dIsfrIbufod ncross fho sfnfo, r. Crossmnn`s
ovIdonco suggosfs fhnf nroxImnfoIy ono ouf of sIx (l6.?) womon sookIng
nn nborfIon wIII IIvo moro fhnn l50 mIIos from fho nonrosf cIInIc.
l3

Ivon nssumIng, orguenJo, fhnf l50 mIIos Is fho roIovnnf cuf-off, fhIs Is
nowhoro nonr n Inrgo frncfIon. See AIIo// 11, ?48 I.3d nf 600. As dIscussod
nbovo, fho Coee, IurnIIfy, In usIng fho Inrgo frncfIon nomoncInfuro,
donrfod from fho gonornI sfnndnrd for fncInI chnIIongos. Tho gonornI
sfnndnrd for fncInI chnIIongos nIIows courfs fo fncInIIy InvnIIdnfo n sfnfufo
onIy If no ossIbIo nIIcnfIon of fho chnIIongod Inw wouId bo consfIfufIonnI.
AIIo// 11, ?48 I.3d nf 588. In ofhor words, fho Inw musf bo unconsfIfufIonnI
In l00 of Ifs nIIcnfIons. Wo docIIno fo Inforrof Coee, ns chnngIng fho
fhroshoId for fncInI chnIIongos from l00 fo l?.
l4

IInInfIffs nrguo fhnf fho nrorInfo donomInnfor In fho Inrgo frncfIon
nnnIysIs consIsfs onIy of womon who couId hnvo nccossod nborfIon sorvIcos In
Toxns rIor fo ImIomonfnfIon of fho chnIIongod roquIromonfs, buf who wIII
fnco Incronsod obsfncIos ns n rosuIf of fho Inw. To nnrrow fho donomInnfor
In fhIs wnyfo ossonfInIIy onIy fhoso womon who IInInfIffs nrguo wIII fnco
nn unduo burdonIgnoros rocodonf. Coee, IfsoIf counsoIs fhnf fho

l3
Tho Sfnfo`s oxorf, Todd CIborson, fosfIfIod fhnf 90.6 of Toxns womon ngos l5-
44 IIvo wIfhIn l50 mIIos of |nn nmbuInfory surgIcnI confor nborfIon fncIIIfy] or IIvo In nn
nron fhnf Is nof wIfhIn l50 mIIos of nn nborfIon rovIdor duo fo ronsons nof nIIogod fo bo
roInfod fo fho Acf. ThIs fosfImony wns nof robuffod, buf fho dIsfrIcf courf found Mr.
CIborson fo bo Ioss crodIbIo. Wlole Wononè Heol/l, sII o. nf 9 n.4. Ivon If wo Ignoro
Mr. CIborson`s fosfImony nnd roIy on fho l? fIguro gIonnod from r. Crossmnn`s
fosfImony, IInInfIffs cnnnof snfIsfy fho Inrgo frncfIon fosf.

l4
Tho concurrIng nnd dIssonfIng oInIon InoxIIcnbIy confonds fhnf, on fhIs rocord,
fho Inrgo frncfIon fosf Is snfIsfIod. ThIs Is bnffIIng nnd Ignoros fho bnsoIIno from whIch fho
Inrgo frncfIon fosf wns dorIvod. If nIso Ignoros AIIo// 11`s guIdnnco fhnf n burdon fhnf doos
nof fnII on fho vnsf mnjorIfy of Toxns womon doos nof moof fho Inrgo frncfIon fosf. ?48
I.3d nf 600. Moroovor, fho concurrIng nnd dIssonfIng oInIon fnIIs fo jusfIfy Ifs roIInnco on
fho Inrgo frncfIon fosf fo fho oxcIusIon of fho no sof of cIrcumsfnncos fosf, whIch, ns
dIscussod, Is fho Inw of our cIrcuIf. See Bornee, 992 I.2d nf l342; AIIo// 11, ?48 I.3d nf 588.

l9

!& #$ %&
l4-50928

donomInnfor shouId oncomnss nII womon for whom fho Inw Is n rosfrIcfIon.
Coee,, 505 !.S. nf 894 (InvoIvIng n sousnI consonf roquIromonf fhnf nIIod
fo mnrrIod womon who dId nof wnnf fo obfnIn consonf). ThIs Is nIso fho
nronch fhnf our cIrcuIf usod In AIIo// 11. ?48 I.3d nf 598 (usIng n
donomInnfor of womon sookIng nn nborfIon In Toxns whon nddrossIng n
fncInI chnIIongo of H.I. 2 undor fho Inrgo frncfIon fosf). Horo, fho nmbuInfory
surgIcnI confor roquIromonf nIIos fo ovory nborfIon cIInIc In fho Sfnfo,
IImIfIng fho ofIons for nII womon In Toxns who sook nn nborfIon. Tho
nrorInfo donomInnfor fhus IncIudos nII womon nffocfod by fhoso IImIfod
ofIons. Moroovor, IInInfIffs` suggosfod nronch wouId mnko fho Inrgo
frncfIon fosf moroIy n fnufoIogy, nIwnys rosuIfIng In n Inrgo frncfIon. Tho
donomInnfor wouId bo womon fhnf IInInfIffs cInIm nro unduIy burdonod by
fho sfnfufo, nnd fho numornfor wouId bo fho snmo.
l5

Insod on unsocIfIc fosfImony nf frInI, fho dIsfrIcf courf nIso nofod
rncfIcnI concorns fhnf combIno wIfh Incronsod frnvoI dIsfnncos,
nrfIcuInrIy for dIsndvnnfngod, mInorIfy, nnd ImmIgrnnf ouInfIons. See
Wlole Wononè Heol/l, sII o. nf lll2 (IIsfIng Inck of nvnIInbIIIfy of chIId
cnro, unroIInbIIIfy of frnnsorfnfIon, unnvnIInbIIIfy of noInfmonfs nf
nborfIon fncIIIfIos, unnvnIInbIIIfy of fImo off from work, ImmIgrnfIon sfnfus
nnd InnbIIIfy fo nss bordor chockoInfs, ovorfy IovoI, fho fImo nnd oxonso
InvoIvod In frnvoIIng Iong dIsfnncos, nnd ofhor InnrfIcuInbIo sychoIogIcnI
obsfncIos. 1J. nf ll.). Wo do nof doubf fhnf womon In ovorfy fnco gronfor
dIffIcuIfIos. Howovor, fo susfnIn n fncInI chnIIongo, fho Suromo Courf nnd
fhIs cIrcuIf roquIro IInInfIffs fo osfnbIIsh fhnf fho Inw IfsoIf Imosos nn unduo
l5
Horo, wo uso fho snmo donomInnfor ns fho nnoI In AIIo// 11womon sookIng nn
nborfIon In Toxns. Wo nofo fhnf ovon If fho donomInnfor oxcIudod womon who wIII nof hnvo
fo chnngo cIInIcs ns n rosuIf of fho nmbuInfory surgIcnI confor rovIsIonfor whom fho
rovIsIon nrgunbIy Is nof n rosfrIcfIonIInInfIffs offorod no ovIdonco from whIch wo couId
concIudo fhnf n Inrgo frncfIon of fho romnInIng womon wIII fnco nn unduo burdon.
20

'- #$ %&
l4-50928

burdon on nf Ionsf n Inrgo frncfIon of womon. IInInfIffs hnvo nof dono so
horo.
Tho dIsfrIcf courf nIso roIIod on Ifs own doformInnfIon fhnf fho
nmbuInfory surgIcnI confor rovIsIon wouId cnuso n shorfngo In cnncIfy for
fho romnInIng IIconsod cIInIcs. Tho dIsfrIcf courf found fhnf 60,000?2,000
nborfIons woro orformod nnnunIIy In rovIous yonrs. 1J. nf 8. Affor fho
nmbuInfory surgIcnI confor rovIsIon goos Info offocf, If Is undIsufod fhnf
sovon or oIghf cIInIcs wIII romnIn. 1J. nf ll. Insod on r. Crossmnn`s
fosfImony, fho dIsfrIcf courf fhon doformInod fhnf onch romnInIng cIInIc
wouId hnvo fo mnnngo, on nvorngo, ?,500l0,000 nfIonfs n yonr, ovor l,200
nfIonfs or monfh In somo cnsos. 1J. Tho dIsfrIcf courf found fhnf hnndIIng
fhIs hIgh n cnsoIond sfrofchos croduIIfy.
Howovor, fho dIsfrIcf courf dId nof mnko nny fIndIngs of fncf fo suorf
Ifs concIusIon. or couId If, gIvon fhnf r. Crossmnn`s fosfImony Is ipee Jixi/
nnd fho rocord Incks nny ncfunI ovIdonco rognrdIng fho curronf or fufuro
cnncIfy of fho oIghf cIInIcs.
l6
r. Crossmnn sImIy nssumos, wIfhouf
ovIdonco, fhnf fhoso confors nro curronfIy oornfIng nf fuII cnncIfy nnd wIII
bo unnbIo fo nccommodnfo nny Incronsod domnnd. !IkowIso, r. Crossmnn
dId nof consIdor how mnny hysIcInns wIfh ndmIffIng rIvIIogos from non-
nmbuInfory surgIcnI confors wIII bogIn rovIdIng nborfIons nf fho nmbuInfory
surgIcnI confor cIInIcs, fhoroby IncronsIng fhoso cIInIcs` cnncIfIos. If nIso
l6
In AIIo// 11, fho fosfImony of nn oxorf who wns nrf of fho snmo rosonrch fonm
ns r. Crossmnn offorod sImIInrIy unsuorfod conjocfuro whon rodIcfIng fhnf, ns n rosuIf
of fho oJni//ing pritilegee requirenen/, nroxImnfoIy 22,000 womon In Toxns wouId bo
unnbIo fo obfnIn nborfIons. On cross-oxnmInnfIon In fhIs cnso, r. Crossmnn ndmIffod fhnf
hIs coIIonguo`s onrIIor rodIcfIons rovod fo bo Innccurnfo. r. Crossmnn fosfIfIod In fhIs
cnso fhnf fhoro hnd boon n docronso of onIy 9,200 nborfIons nnd fhnf fho docronso couId nof
bo whoIIy nscrIbod fo fho ndmIffIng rIvIIogos roquIromonf. Indood, r. Crossmnn
ncknowIodgod on cross-oxnmInnfIon fhnf In hIs fonm`s ubIIshod, oor-rovIowod nrfIcIo, fho
rosonrchors qunIIfIod fhoIr fIndIngs by nofIng fhnf fhoy cnnnof rovo cnusnIIfy bofwoon fho
Sfnfo rosfrIcfIons nnd fnIIIng nborfIon rnfo.
2l

Case: l4-50928 Document: 005l279l273 Page: 2l Date Filed: l0/02/20l4
'! #$ %&
l4-50928

doos nof nonr from fho rocord fhnf r. Crossmnn consIdorod fho ossIbIIIfy
of nddIfIonnI cnncIfy rosuIfIng from now cIInIcs` boIng buIIf, nor dId ho
consIdor fhnf fho domnnd for nborfIon sorvIcos In Toxns mny docronso In fho
fufuro, ns If hns dono nnfIonnIIy ovor fho nsf sovornI yonrs. Iurfhormoro,
fho rocord Incks ovIdonco fhnf fho rovIous cIosuros rosuIfIng from fho
ndmIffIng rIvIIogos roquIromonf hnvo cnusod womon fo bo furnod nwny from
cIInIcs. WIfhouf nny ovIdonco on fhoso oInfs, IInInfIffs do nof nonr fo
hnvo mof fhoIr burdon fo show fhnf fho nmbuInfory surgIcnI confor rovIsIon
wIII rosuIf In InsuffIcIonf cIInIc cnncIfy fhnf wIII Imoso nn unduo burdon on
n Inrgo frncfIon of womon.
l?

Tho ovIdonco doos IndIcnfo, wIfhouf socIfIcIfy, fhnf by roquIrIng nII
nborfIon cIInIcs fo moof fho mInImum sfnndnrds of nmbuInfory surgIcnI
confors, fho ovornII cosf of nccossIng nn nborfIon rovIdor wIII IIkoIy Incronso.
Howovor, ns fho Suromo Courf rocognIzod In Corlor/, nnd wo obsorvod In
AIIo// 1, '|f]ho fncf fhnf n Inw whIch sorvos n vnIId uroso, ono nof dosIgnod
fo sfrIko nf fho rIghf IfsoIf, hns fho IncIdonfnI offocf of mnkIng If moro
dIffIcuIf or moro oxonsIvo fo rocuro nn nborfIon cnnnof bo onough fo
InvnIIdnfo If.` AIIo// 1, ?34 I.3d nf 4l3 (nIfornfIon In orIgInnI) (quofIng
Corlor/, 550 !.S. nf l5?58).
l?
Tho concurrIng nnd dIssonfIng oInIon socuInfos fhnf nfIonfs sookIng nborfIons
wIII fnco doInys comnrnbIo fo fhoso dIscussod by fho Sovonfh CIrcuIf In PlonneJ
Poren/looJ of Wiec., 1nc. t. Von Hollen, ?38 I.3d ?86 (?fh CIr. 20l3). Horo, fhoro Is no
ovIdonco In fho rocord fhnf womon hnvo fncod doInys, hnvo boon furnod nwny for Inck of
cnncIfy, or wIII fnco doInys In fho fufuro.

22

'' #$ %&
l4-50928

In sum, fho Sfnfo hns mof Ifs burdon ns fo fho dIsfrIcf courf`s fncInI
InvnIIdnfIon of fho ndmIffIng rIvIIogos roquIromonf nnd fho nmbuInfory
surgIcnI confor rovIsIon.
l8

21
IInnIIy, wo nddross fho dIsfrIcf courf`s InjuncfIons of bofh roquIromonfs
ns nIIod fo cIInIcs In McAIIon nnd II Inso, ns woII ns fho nmbuInfory
surgIcnI confor rovIsIon ns nIIod fo modIcnfIon nborfIon, nnd fho Sfnfo`s
IIkoIIhood of succoss on fho morIfs of onch. Wo concIudo fhnf fho Sfnfo hns
mof Ifs burdon ns fo onch, wIfh fho oxcofIon of fho nmbuInfory surgIcnI
confor rovIsIon ns nIIod fo II Inso.
*1
Tho Sfnfo hns shown n sfrong IIkoIIhood of succoss on fho morIfs of Ifs
nrgumonf fhnf IInInfIffs` ns-nIIod chnIIongos fo fho ndmIffIng rIvIIogos
roquIromonf nro bnrrod by ros judIcnfn. In fho Inforosfs of offIcIoncy nnd
fInnIIfy, fho docfrIno of ros judIcnfn bnrs IIfIgnfIon of cInIms fhnf hnvo boon
IIfIgnfod or couId hnvo boon rnIsod In n rIor InwsuIf. In fho InwsuIf gIvIng
rIso fo AIIo// 1 nnd AIIo// 11, IInInfIffs fncInIIy chnIIongod fho ndmIffIng
rIvIIogos roquIromonf. Thoy nIso couId hnvo broughf, buf choso nof fo brIng,
ns-nIIod chnIIongos wIfh rognrd fo cIInIcs In II Inso nnd McAIIon.
l9
ThoIr
choIco nof fo IncIudo fho ns-nIIod chnIIongos In fhoIr rovIous InwsuIf IIkoIy
rocIudos fhom from ursuIng fhnf chnIIongo now. See Broun t. Ieleen, 442
!.S. l2?, l3l (l9?9) (!os judIcnfn rovonfs IIfIgnfIon of nII grounds for, or
l8
Ivon If fho fncInI InvnIIdnfIon of fho nmbuInfory surgIcnI confor rovIsIon woro
uhoId, fho InjuncfIon shouId sfIII bo sfnyod ns fo fho oornfIonnI roquIromonfs of fho
rovIsIon. See infro Inrf V.C.

l9
IInInfIffs dId brIng sImuIfnnoous fncInI nnd ns-nIIod chnIIongos fo fho
nmbuInfory surgIcnI confor roquIromonf of H.I. 2.

23

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l4-50928

dofonsos fo, rocovory fhnf woro rovIousIy nvnIInbIo fo fho nrfIos, rognrdIoss
of whofhor fhoy woro nssorfod or doformInod In fho rIor rocoodIng.).
To bo suro, ros judIcnfn bnrs n subsoquonf InwsuIf onIy If, in/er olio, fho
snmo cInIm or cnuso of ncfIon Is InvoIvod In bofh InwsuIfs. Pe/ro-Hun/,
L.L.C. t. Ini/eJ S/o/ee, 365 I.3d 385, 395 (5fh CIr. 2004).
20
To doformIno
whofhor fwo InwsuIfs InvoIvo fho snmo cInIm or cnuso of ncfIon for urosos
of ros judIcnfn, fho IIffh CIrcuIf nIIos fho frnnsncfIonnI fosf of fho
!osfnfomonf (Socond) of Judgmonfs, 24. 1J. !ndor fhnf fosf, fho crIfIcnI
Issuo Is whofhor fho fwo ncfIons undor consIdornfIon nro bnsod on 'fho eone
nucleue of opero/ite foc/e.` Sou/lnor/ Corp. t. Coopere & L,IronJ (1n re
Sou/lnor/ Corp.), l63 I.3d 925, 934 (5fh CIr. l999) (quofIng Bon/ of
Lofo,e//e t. BouJoin (1n re BouJoin), 98l I.2d ?36, ?43 (5fh CIr. l993)). If
fho fncfs on whIch fho socond InwsuIf Is bnsod nro fho snmo ns fhoso
rovnIIIng nf fho fImo of fho fIrsf InwsuIf, fho fwo InwsuIfs InvoIvo fho snmo
cInIm or cnuso of ncfIon for urosos of ros judIcnfn.
IInInfIffs confondod, nnd fho dIsfrIcf courf ngrood, fhnf fho rosonf
InwsuIf roIIos on n dIfforonf sof of oornfIvo fncfs fhnn dId fho ro-
onforcomonf chnIIongo bocnuso fho nborfIon cIInIcs In McAIIon nnd II Inso
hnvo now consod rovIdIng nborfIon sorvIcos. Howovor, our rocodonf
dIcfnfos fhnf chnngod cIrcumsfnncos rovonf fho nIIcnfIon of ros judIcnfn
onIy If fho chnngo Is sIgnIfIcnnf nnd cronfos now IognI condIfIons.
HernonJec t. Ci/, of Lofo,e//e, 699 I.2d ?34, ?3? (5fh CIr. l983). Tho cIosuro
of fho cIInIcs In McAIIon nnd II Inso doos nof cronfo now IognI condIfIons
bocnuso, In fho ro-onforcomonf chnIIongo, IInInfIffs nIIogod fhnf fho McAIIon
nnd II Inso cIInIcs wouId shuf down uon ImIomonfnfIon of H.I. 2.

20
!os judIcnfn nIso roquIros fhnf fho nrfIos nro IdonfIcnI fo, or In rIvIfy wIfh, fho
nrfIos In fho rovIous InwsuIf. IInInfIffs do nof dIsufo fhnf fhoy nro IdonfIcnI fo or In
rIvIfy wIfh fho InInfIffs In AIIo// 1 onJ 11.
24

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l4-50928

IInInfIffs couId hnvo roIIod on fhoso nIIognfIons fo brIng fho vory snmo ns-
nIIod chnIIongo fhoy now ursuo; fhoy sImIy choso nof fo do so.
Tho dIsfrIcf courf sfnfod fhnf If wns nof known In Info Ocfobor 20l3
|I.o., whon fho dIsfrIcf courf onforod Ifs judgmonf In AIIo//] fhnf fho McAIIon
nnd II Inso cIInIcs` hysIcInns wouId uIfImnfoIy bo unnbIo fo obfnIn
ndmIffIng rIvIIogos dosIfo offorfs fo socuro fhom. Howovor, fho ComInInf
In AIIo//, whIch wns fIIod In Sofombor 20l3, oxrossIy nIIogod fhnf fhoso
cIInIcs wouId cIoso If fho ndmIffIng rIvIIogos roquIromonf fook offocf.
Indood, fho hysIcInns who orformod nborfIons nf fhoso fwo fncIIIfIos woro
nnmod InInfIffs In AIIo//, furfhor undormInIng nny suggosfIon fhnf fho
cIosuro of fho cIInIcs wns n sIgnIfIcnnf or unoxocfod chnngo of fncfs.
2l
Thus,
IInInfIffs` ns-nIIod chnIIongos fo fho ndmIffIng rIvIIogos roquIromonf nro
IIkoIy bnrrod by ros judIcnfn.
31
Ivon If IInInfIffs` cInIms nro nof bnrrod by ros judIcnfn, fho Sfnfo Is
sfIII IIkoIy fo succood on fho morIfs of whofhor fho ndmIffIng rIvIIogos
roquIromonf nnd fho nmbuInfory surgIcnI confor rovIsIon, ns nIIod fo fho
McAIIon cIInIc, hnvo fho offocf of ImosIng nn unduo burdon on womon In fho
!Io Crnndo VnIIoy.
Tho ndmIffIng rIvIIogos roquIromonf wonf Info offocf In Ocfobor 20l3.
SInco fhnf fImo, nborfIon cIInIcs hnvo romnInod oon In nII of fho mnjor
mofrooIIfnn nrons ncross fho sfnfo. Tho dIsfrIcf courf found fhnf fho numbor
of fofnI cIInIcs In Toxns docronsod from moro fhnn forfy cIInIcs fo fowor fhnn
2l
In fho dIsfrIcf courf, InInfIffs nIso nrguod fhnf ros judIcnfn doos nof bnr fhoIr ns-
nIIod chnIIongo bocnuso fho nnoI`s docIsIon In AIIo// . . . Is nof yof fInnI. Howovor,
unIoss nnd unfII AIIo// 11 Is vncnfod, If Is bIndIng rocodonf fhnf fhIs nnoI Is nof nf IIborfy
fo Ignoro. !ndor fhIs cIrcuIf`s ruIo of ordorIInoss, onIy nn InforvonIng chnngo In fho Inw
(such ns by n Suromo Courf cnso) ormIfs n subsoquonf nnoI fo docIIno fo foIIow n rIor
IIffh CIrcuIf rocodonf. Ini/eJ S/o/ee t. Alcon/or, ?33 I.3d l43, l45 (5fh CIr. 20l3).
25

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fhIrfy cIInIcs IondIng u fo nnd In fho wnko of onforcomonf of fho ndmIffIng-
rIvIIogos roquIromonf. Wlole Wononè Heol/l, sII o. nf 8; Iu/ eee AIIo//
11, ?48 I.3d nf 599 (nofIng fhnf n numbor of fhoso cIInIcs hnd cIosod for
ronsons ofhor fhnn fho ndmIffIng rIvIIogos roquIromonf). ImorfnnfIy, r.
Crossmnn sfnfod In hIs docInrnfIon fhnf ho wns nof offorIng nny oInIon on
fho cnuso of fho docIIno In fho numbor of nborfIon fncIIIfIos from ovombor
20l2 fo ArII 20l4. Tho dIsfrIcf courf furfhor found fhnf no nborfIon
rovIdors nro In oornfIon In n numbor of cIfIos, IncIudIng, for oxnmIo,
McAIIon, !ubbock, MIdInnd, nnd Wnco. Wlole Wononè Heol/l, sII o. nf 8.
Tho nmbuInfory surgIcnI confor rovIsIon wns sof fo go Info offocf on
Sofombor l, 20l4, whIch fho dIsfrIcf courf found wouId cnuso ovon moro
cIosuros, IonvIng onIy sovon or oIghf IIconsod rovIdors. 1J. nf l0ll.
Tho dIsfrIcf courf found fhnf fho McAIIon cIInIc cIosod ns n rosuIf of fho
ndmIffIng rIvIIogos roquIromonf. 1J. nf 8. SInco fhnf fImo, fho womon who
wouId hnvo ofhorwIso boon sorvod by fho McAIIon cIInIc hnd fo Iook
oIsowhoro for fho rocoduro. As sfnfod In hIs frInI docInrnfIon, r. Crossmnn
IdonfIfIod moro fhnn l,000 womon from fho VnIIoy who soughf nborfIons
bofwoon ovombor 20l3 nnd ArII 20l4, nnd frnvoIod fo nonrby cIfIos whoro
cIInIcs romnInod oon. urIng fhnf orIod, nroxImnfoIy 50 of fhoso
womon frnvoIod fo Corus ChrIsfI, 25 frnvoIod fo Housfon, l5 orconf fo
Snn AnfonIo, nnd l0 fo n IocnfIon ovon fnrfhor from fho VnIIoy.
In AIIo// 11, roIyIng on Coee,, wo hoId fhnf hnvIng fo frnvoI l50 mIIos
from fho !Io Crnndo VnIIoy fo Corus ChrIsfI Is nof nn unduo burdon. AIIo//
11, ?48 I.3d nf 598. Indood, Coee, ormIffod ovon gronfor frnvoI dIsfnncos, ns
26

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If uhoId n 24-hour wnIfIng orIod fhnf doubIod drIvIng fImos, IncronsIng fho
drIvo for somo womon from fhroo hours fo sIx hours.
22
See iJ.
WhIIo fho cIInIc In Corus ChrIsfI romnInod oon nffor fho ndmIffIng
rIvIIogos roquIromonf wonf Info offocf, If curronfIy doos nof comIy wIfh fho
nmbuInfory surgIcnI confor rovIsIon. Tho dIsfrIcf courf found fhnf onco fho
rovIsIon fnkos offocf, fho cIInIc nonrosf fo fho !Io Crnndo VnIIoy wIII bo In
Snn AnfonIo, bofwoon 230 nnd 250 mIIos nwny. Thoroforo, wo musf
doformIno whofhor fho Sfnfo Is IIkoIy fo rovnII on Ifs nrgumonf fhnf fhIs
IncromonfnI Incronso of l00 mIIos In dIsfnnco doos nof consfIfufo nn unduo
burdon.
Af frInI, IInInfIffs hnd fho burdon of showIng fhnf fho nddIfIonnI frnvoI
dIsfnnco fo Snn AnfonIo consfIfufod nn unduo burdon. As nofod nbovo, fho
rocord IndIcnfos fhnf 50 of fho moro fhnn l,000 womon In r. Crossmnn`s
sfudy who rosIdod In fho !Io Crnndo VnIIoy nnd woro sookIng nborfIons
frnvoIod fo Snn AnfonIo nnd Housfon (whIch Is ovon fnrfhor fhnn Snn
AnfonIo) ovon whon fho Corus ChrIsfI cIInIc wns sfIII In oornfIon. IInInfIffs
nIso hnd fho burdon, whIch fhoy fnIIod fo moof, of showIng fhnf cIInIcs In Snn
AnfonIo nnd ofhor nonrby cIfIos wouId bo unnbIo fo mnnngo fho nddIfIonnI
domnnd for nborfIons cnusod by cIosuros. Indood, womon from McAIIon hnvo
boon frnvoIIng oufsIdo fhoIr cIfy for nonrIy n yonr nnd IInInfIffs mndo no
showIng fhnf cIInIcs In Snn AnfonIo (or nny ofhor cIfy) hnvo boon doIugod.
ConsIdorIng fhnf Coee, uhoId frnvoI fImos of sIx hours (Incronsos of fhroo
hours) nnd fhnf womon In fho !Io Crnndo VnIIoy frnvoIIng fo Snn AnfonIo
hnvo Ioss fofnI frnvoI fImo fhnn womon nffocfod by fho IonnsyIvnnIn Inw In
22
If Is nIso Imorfnnf fo nofo fhnf Toxns hns n 24-hour wnIfIng orIod, whIch
IInInfIffs do nof chnIIongo horo, buf womon who musf frnvoI moro fhnn l00 mIIos fo n cIInIc
nro oxomf. Tox. HonIfh & Snfofy Codo l?l.0l2(n)(4).
2?

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Coee,, fho Sfnfo hns n sfrong IIkoIIhood of succoss on Ifs nonI of fho
InjuncfIons of bofh roquIromonfs ns nIIod fo fho McAIIon cIInIc.
23

+1
As fo fho II Inso cIInIc, wo grnnf, In nrf, nnd dony, In nrf, fho Sfnfo`s
mofIon fo sfny fho dIsfrIcf courf`s InjuncfIon of fho nmbuInfory surgIcnI confor
rovIsIon. Tho dIsfrIcf courf found fhnf fho hysIcnI Innf roquIromonfs of
fho nmbuInfory surgIcnI confor rovIsIon wouId forco fho II Inso cIInIc fo
cIoso. As n rosuIf, womon In II Inso wIII bo sIgnIfIcnnfIy fnrfhor from fho
nonrosf In-sfnfo nmbuInfory surgIcnI confor fhnn womon In fho !Io Crnndo
VnIIoy. Tho dIsfnnco from II Inso fo Snn AnfonIo, for oxnmIo, Is gronfor
fhnn 500 mIIos. Tho IIghfh CIrcuIf hns hoId fhnf no frnvoI dIsfnnco wIfhIn
fho sfnfo Is foo fnr. See Iorgo Wonenè Heol/l Org. t. Sclofer, l8 I.3d 526,
533 (8fh CIr. l994). Wo hnvo nof so hoId. Our cIrcuIf hns nof IdonfIfIod
whofhor fhoro Is n fIIng oInf wIfhIn fho vnsf Sfnfo of Toxns, buf nf fhIs
onrIy sfngo, wo nro hosIfnnf fo oxfond Coee, fo such n Inrgo dIsfnnco. Bu/ eee
AIIo// 11, ?48 I.3d nf 598 (Coee, counsoIs ngnInsf sfrIkIng down n sfnfufo
soIoIy bocnuso womon mny hnvo fo frnvoI Iong dIsfnncos fo obfnIn
nborfIons.).
If Is fruo fhnf nroxImnfoIy hnIf of fho womon from II Inso sookIng
nborfIons frnvoI fo Snnfn Torosn, ow MoxIco, whIch Is In fho snmo
mofrooIIfnn nron ns II Inso nnd jusf ncross fho sfnfo IIno. osIfo fho
obvIous rncfIcnI ImIIcnfIons of fho ow MoxIco cIInIc`s roxImIfy fo II Inso,
our cIrcuIf`s rocodonf suggosfs fhnf our focus musf romnIn on cIInIcs wIfhIn
Toxns whon doformInIng whofhor frnvoI fImos cronfo nn unduo burdon. See
Joc/eon Wonenè Heol/l Org., ?60 I.3d nf 45?58 (onjoInIng n MIssIssII
23
In IIghf of AIIo// 11, fho concurrIng nnd dIssonfIng oInIon doos nof oxInIn how
fho IncromonfnI Incronso of nroxImnfoIy l00 mIIos bofwoon Corus ChrIsfI nnd Snn
AnfonIo consfIfufos nn unduo burdon.
28

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Inw on fho grounds fhnf If wouId shuf down fho onIy nborfIon cIInIc In fho
sfnfo). AIfhough fho sIfunfIon In Toxns Is mnrkodIy dIfforonf from fhnf In
MIssIssII, fho oInIon In Joc/eon confnIns brond Inngungo fhnf nonrs fo
go boyond fho fncfs rosonfod In fhnf cnso. See iJ. nf 45? (ConsIsfonf wIfh
Goinee, wo hoId fhnf fho roor formuInfIon of fho unduo burdon nnnIysIs
focusos soIoIy on fho offocfs wIfhIn fho roguInfIng sfnfohoro, MIssIssII.).
Tho nnoI mnjorIfy snw IfsoIf ns roquIro|d] . . . fo conducf fho unduo burdon
InquIry by IookIng onIy nf fho nbIIIfy of MIssIssII womon fo oxorcIso fhoIr
rIghf wIfhIn MIssIssII`s bordors. 1J. CIvon fho nnoI`s roIInnco on Goinee,
fho nnoI mny hnvo monnf fo nIy Ifs IImIfnfIon onIy fo sfnfos whoro nII fho
nborfIon cIInIcs wouId cIoso. Howovor, wo nro roIucfnnf fo consfruo fho
nnoI`s brond Inngungo so nnrrowIy In fhIs omorgoncy sfny rocoodIng.
Iocnuso of fho Iong dIsfnnco bofwoon II Inso nnd fho nonrosf In-sfnfo
nborfIon cIInIc, ns woII ns fho doubf fhnf Joc/eon cnsfs on whofhor wo mny
Iook fo ouf-of-sfnfo cIInIcs, fho Sfnfo hns nof shown n sfrong IIkoIIhood of
succoss on fho morIfs of fho chnIIongo fo fho hysIcnI Innf roquIromonfs of
fho nmbuInfory surgIcnI confor rovIsIon ns nIIod fo II Inso. Thus, fho
dIsfrIcf courf`s InjuncfIon of fho hysIcnI Innf roquIromonfs of fho
nmbuInfory surgIcnI rovIsIon wIII romnIn In forco for II Inso.
Wo do, howovor, sfny fho InjuncfIon ns fo fho oornfIonnI roquIromonfs
of fho nmbuInfory surgIcnI confor rovIsIon bocnuso fho dIsfrIcf courf mndo
no fIndIngs nbouf whofhor fho II Inso cIInIc wouId bo nbIo fo comIy wIfh
fhoso roquIromonfs. Tho dIsfrIcf courf`s concIusIon fhnf fho nmbuInfory
surgIcnI confor rovIsIon Imosod nn unduo burdon rosfod soIoIy on fho
dIsfrIcf courf`s fIndIngs rognrdIng fho hysIcnI Innf roquIromonfs. In vIow of
H.I. 2`s sovornbIIIfy rovIsIon, ns woII ns fho sImIInr rovIsIon In fho
roguInfIons, 25 Tox. AdmIn. Codo l39.9, fho dIsfrIcf courf orrod by fnIIIng fo
29

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consIdor whofhor fho hysIcnI Innf roquIromonfs couId bo sovorod from fho
oornfIonnI roquIromonfs, nIIowIng fho oornfIonnI roquIromonfs fo fnko
offocf. See AIIo// 1, ?34 I.3d nf 4l5.
24
As n rosuIf, If doos nof nonr fhnf
fho dIsfrIcf courf`s InjuncfIon of fho oornfIonnI roquIromonfs wns suorfod
by nny ovIdonco. Wo fhoroforo sfny fho dIsfrIcf courf`s InjuncfIon of fho
oornfIonnI roquIromonfs.
(1
Tho dIsfrIcf courf nIso onjoInod fho nmbuInfory surgIcnI confor
rovIsIon ns nIIod fo modIcnfIon nborfIons. To fho oxfonf fho dIsfrIcf courf
concIudod fhnf fho nmbuInfory surgIcnI confor rovIsIon hnd nn Imroor
uroso ns nIIod fo modIcnfIon nborfIon, wo hnvo nIrondy rojocfod fhnf
nrgumonf for fho ronsons sfnfod nbovo. To fho oxfonf fhnf fho dIsfrIcf courf
doformInod fhnf fho rovIsIon`s offocf ns nIIod fo modIcnfIon nborfIon wns
unconsfIfufIonnI, fho rocord ovIdonco doos nof suorf fhnf concIusIon. In
conducfIng Ifs own bnInncIng nnnIysIs, fho dIsfrIcf courf sfnfod fhnf nny
modIcnI jusfIfIcnfIon for fho roquIromonf Is nf Ifs nbsoIufo wonkosf In
comnrIson wIfh fho honvy burdon If Imosos. Wlole Wononè Heol/l, sII
o. nf l8. Howovor, ns dIscussod, our cIrcuIf doos nof Incorornfo n bnInncIng
nnnIysIs Info fho unduo burdon InquIry. See AIIo// 11, ?48 I.3d nf 594 (cIfIng
Ci/, of CleIurne t. CleIurne Liting C/r., 4?3 !.S. 432, 440 (l985)). Tho
dIsfrIcf courf rovIdod no suorf for Ifs concIusIon ofhor fhnn Ifs Imroor
bnInncIng. Tho dIsfrIcf courf dId nof cIfo fo rocord ovIdonco or mnko nny
fIndIngs fo suorf Ifs concIusIon fhnf fho nmbuInfory surgIcnI confor
24
Indood, fho dIsfrIcf dId nof nonr fo nddross fho consfIfufIonnIIfy of fho
ImIomonfIng roguInfIons. To fho oxfonf fhnf If InvnIIdnfod fho roguInfIons euI eilen/io, Ifs
fnIIuro fo consIdor fho sovornbIIIfy rovIsIon In fho roguInfIons wns orror.

30

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rovIsIon Imosos nn unduo burdon ns nIIod fo modIcnfIon nborfIons.
25

Indood, nf ornI nrgumonf, IInInfIffs couId nof IdonfIfy nny fIndIngs In fho
dIsfrIcf courf`s oInIon suorfIng fho concIusIon fhnf fho nmbuInfory
surgIcnI confor rovIsIon Imosod nn unduo burdon ns nIIod fo modIcnfIon
nborfIon. Thus, fho Sfnfo hns shown n subsfnnfInI IIkoIIhood of succoss on
fho morIfs of fho dIsfrIcf courf`s InjuncfIon of fho nmbuInfory surgIcnI confor
rovIsIon ns nIIod fo modIcnfIon nborfIons.
2!1
As In AIIo// 1, fho Sfnfo hns mndo n sfrong showIng of IIkoIIhood of
succoss on fho morIfs of Ifs nonI ns fo nII of fho dIsfrIcf courf`s InjuncfIons
oxcof for fho InjuncfIon of fho hysIcnI Innf roquIromonfs of fho nmbuInfory
surgIcnI confor rovIsIon ns nIIod fo fho cIInIc In II Inso. !ognrdIng fho
ofhor fhroo fncfors wo musf woIgh In doformInIng whofhor fo grnnf n mofIon
fo sfny ondIng nonI, fho Sfnfo hns nIso mof Ifs burdon. Whon n sfnfufo Is
onjoInod, fho Sfnfo nocossnrIIy suffors fho IrronrnbIo hnrm of donyIng fho
ubIIc Inforosf In fho onforcomonf of Ifs Inws. AIIo// 1, ?34 I.3d nf 4l9
(cIfIng Mor,lonJ t. King, l33 S. Cf. l, 3 (20l2); Aeu Mo/or Velicle BJ. t.
Orrin W. Iox Co., 434 !.S. l345, l35l (l9??)). Tho ubIIc Inforosf Is dIrocfIy
nIIgnod wIfh fho Sfnfo`s Inforosf. A/en, 556 !.S. nf 435. To fho oxfonf fho
Sfnfo`s Inforosf Is nf sfnko, so Is fho ubIIc`s. AIIo// 1, ?34 I.3d nf 4l9. Wo
rocognIzo fhnf IInInfIffs hnvo nIso mndo n sfrong showIng fhnf fhoIr Inforosfs
wIII bo Injurod by n grnnf of fho sfny. Howovor, gIvon fhnf fho fIrsf fwo
fncfors nro fho mosf crIfIcnI, A/en, 556 !.S. nf 434, nnd fho Sfnfo hns mndo n
sfrong showIng rognrdIng onch, n sfny Is nrorInfo. Wo hnvo nddrossod
onIy fho Issuos nocossnry fo ruIo on fho mofIon for n sfny ondIng nonI, nnd
25
In AIIo// 11, wo nofod fhnf modIcnfIon nborfIons hnvo hIghor comIIcnfIon rnfos
fhnn surgIcnI nborfIons. AIIo// 11, ?48 I.3d nf 602.
3l

Case: l4-50928 Document: 005l279l273 Page: 3l Date Filed: l0/02/20l4
%! #$ %&
l4-50928

our doformInnfIons nro for fhnf uroso nnd do nof bInd fho morIfs nnoI.
See, e.g., AIIo// 1, ?34 I.3d nf 4l9.
IT IS O!I!I fhnf AoIInnfs` oosod mofIon for sfny ondIng
nonI Is C!ATI, In nrf, nnd III, In nrf, nnd fhnf fho dIsfrIcf
courf`s InjuncfIon ordors nro STAYI unfII fho fInnI dIsosIfIon of fhIs
nonI, In nccordnnco wIfh fhIs oInIon.
32

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STIIHI A. HICCISO, CIrcuIf Judgo, concurrIng In nrf nnd dIssonfIng
In nrf:
I foo wouId dony fho Sfnfo`s mofIon for n Ilon/e/ sfny of fho dIsfrIcf
courf judgmonf onforod on Augusf 29, 20l4, ondIng nonI. I ngroo wIfh n
sfny of fho dIsfrIcf courf`s fncInI InvnIIdnfIon of fho ndmIffIng-rIvIIogos
roquIromonf bocnuso fho InInfIffs dId nof roquosf fhnf roIIof. See Joc/eon
Wonenè Heol/l Org. t. Currier, ?60 I.3d 448, 458 (5fh CIr. 20l4). Socond, I
ngroo wIfh n sfny fo nIIow onforcomonf of fho oornfIonnI roquIromonfs of fho
nmbuInfory surgIcnI confor (ASC) rovIsIon bocnuso fho dIsfrIcf courf onIy
ovnIunfod fho burdons Imosod by fho rovIsIon`s hysIcnI Innf
roquIromonfs. AIyIng H.I. 2`s sovornbIIIfy rovIsIon, howovor, I wouId nof
sfny fho dIsfrIcf courf`s fncInI InvnIIdnfIon of fho hysIcnI Innf roquIromonfs.
IInnIIy, I wouId nnrrow fho sfny so fhnf If doos nof ronch fho ndmIssIon-
rIvIIogos roquIromonf ns nIIod fo fho McAIIon nnd II Inso cIInIcs, whIch
fho dIsfrIcf courf found wouId rosuIf In cIosuro of nII cIInIcs wosf nnd soufh of
Snn AnfonIo.
l

As fo fho fIrsf sfny fncfor, fho dIsfrIcf courf found, nffor frInI wIfh
wIfnoss crodIbIIIfy doformInnfIons, fhnf nn unduo burdon oxIsfod bocnuso
Toxns hnd ovor forfy nborfIon cIInIcs rIor fo fho onncfmonf of H.I. 2, nnd
l
I do nof boIIovo fhnf fho Sfnfo hns shown n sfrong IIkoIIhood of succoss on fho morIfs of Ifs
nrgumonf fhnf fhIs ns-nIIod chnIIongo Is bnrrod by ros judIcnfn. ThIs courf In AIIo// 11 dIsnvowod
roIyIng on nny now fncfunI dovoIomonfs fhnf woro nof In fho rocord boforo fho dIsfrIcf courf durIng
fho bonch frInI In AIIo//. See PlonneJ Poren/looJ of Greo/er Tex. Surgicol Heol/l Serte. t. AIIo//
(AIIo// 11), ?48 I.3d 584, 599 n.l4 (5fh CIr. 20l4). SIgnIfIcnnfIy, AIIo// 11 nnfIcInfod fhnf
hysIcInns, IIko fhoso In McAIIon nnd II Inso, wouId gnIn ndmIffIng rIvIIogos. See iJ. nf 598-99 &
n.l3; eee oleo PlonneJ Poren/looJ of Wie., 1nc. t. Von Hollen, ?38 I.3d ?86, 80? (?fh CIr. 20l3)
(MnnIon, J., concurrIng) (Tho nofIon fhnf nborfIon docfors wIII bo unnbIo fo obfnIn ndmIffIng
rIvIIogos Is n fIcfIon.). Indood, ns AIIo// 11 ncknowIodgod, |I]nfor ns-nIIod chnIIongos cnn nIwnys
donI wIfh subsoquonf, concrofo consfIfufIonnI Issuos. 1J. nf 589; eee oleo Joc/eon Wonenè Heol/l
Org., ?60 I.3d nf 450-5l (ovnIunfIng fho Imncf of H.I. l390 nffor fho InInfIff`s docfors woro
concIusIvoIy donIod ndmIffIng rIvIIogos). ow fhnf fho hysIcInns` nIIcnfIons hnvo boon donIod,
fho nvnIInbIIIfy of nborfIon sorvIcos for womon IIvIng nonr fho McAIIon nnd II Inso cIInIcs hns
concrofoIy chnngod. See !osfnfomonf (Socond) of Judgmonfs 24, cmf. (f) (Whoro Imorfnnf humnn
vnIuos . . . nro nf sfnko, ovon n sIIghf chnngo of cIrcumsfnncos mny nfford n suffIcIonf bnsIs for
concIudIng n socond ncfIon mny bo broughf.).
33

%% #$ %&
l4-50928
fhnf nffor fho ASC rovIsIon fnkos offocf, onIy sovon or oIghf cIInIcs wIII
romnIn, rorosonfIng moro fhnn nn 80 roducfIon In cIInIcs sfnfowIdo In
nonrIy fourfoon monfhs, wIfh n l00 roducfIon In cIInIcs wosf nnd soufh of
Snn AnfonIo. See O/poloIi t. Ioe/er, l90 I.3d 33?, 35? (5fh CIr. l999) (A
monsuro fhnf hns fho offocf of forcIng nII or n subsfnnfInI orfIon of n sfnfo`s
nborfIon rovIdors fo sfo offorIng such rocoduros cronfos n subsfnnfInI
obsfncIo fo n womnn`s rIghf fo hnvo n ro-vInbIIIfy nborfIon, fhus consfIfufIng
nn unduo burdon undor Coee,.), toco/eJ on o/ler grounJe on rel`g en Ionc,
244 I.3d 405 (5fh CIr. 200l); cf. oleo Mocure/ t. Arne/rong, 520 !.S. 968,
9?2 (l99?) (fIndIng no unduo burdon whon no womnn sookIng nn nborfIon
wouId bo roquIrod by fho now Inw fo frnvoI fo n dIfforonf fncIIIfy fhnn wns
rovIousIy nvnIInbIo); PlonneJ Poren/looJ of Se. Po. t. Coee,, 505 !.S. 833,
869 (l992) (|I]f fnIIs fo us fo gIvo somo ronI subsfnnco fo fho womnn`s IIborfy
fo doformIno whofhor fo cnrry hor rognnncy fo fuII form.). Tho dIsfrIcf
courf furfhor found fhnf fhoro wns no crodIbIo ovIdonco of modIcnI or honIfh
bonofIf nssocInfod wIfh fho ASC roquIromonf In fho nborfIon confoxf. Af fhIs
omorgoncy sfny oInf, fho Sfnfo doos nof chnIIongo ns cIonr orror oIfhor sof of
fncfunI fIndIngs.
2
WoIghIng Inck of modIcnI bonofIf ngnInsf fho sIgnIfIcnnf
roducfIon In cIInIc nccoss, fho dIsfrIcf courf found fho burdon fo bo unduo.
2
Tho mnjorIfy oInIon IIsfs fho foIIowIng nddIfIonnI fIndIngs mndo by fho dIsfrIcf courf,
whIch nro onfIfIod fo doforonco, eee AnJereon t. Beeeener, 4?0 !.S. 564, 5?3-?4 (l985); A.A.A.C.P. t.
IorJice, 252 I.3d 36l, 365 (5fh CIr. 200l): (l) fho consfrucfIon cosfs of brIngIng oxIsfIng cIInIcs Info
comIInnco wIfh ASC sfnndnrds wIII undIsufodIy nronch l mIIIIon doIInrs nnd wIII mosf IIkoIy
oxcood l.5 mIIIIon doIInrs; (2) for oxIsfIng cIInIcs fhnf cnnnof comIy duo fo hysIcnI snco
IImIfnfIons, |f]ho cosf of ncquIrIng Innd nnd consfrucfIng n now comIInnf cIInIc wIII IIkoIy oxcood
fhroo mIIIIon doIInrs; (3) If bofh chnIIongod H.I. 2 rovIsIons nro onforcod, womon`s frnvoI dIsfnncos
fo cIInIcs wIII sIgnIfIcnnfIy Incronso: l.3 mIIIIon womon of roroducfIvo ngo In Toxns wIII IIvo moro
fhnn l00 mIIos from n cIInIc, 900,000 womon wIII IIvo moro fhnn l50 mIIos from n cIInIc, ?50,000
womon wIII IIvo moro fhnn 200 mIIos from n cIInIc, nnd somo womon wIII IIvo ns fnr ns 500 mIIos from
n cIInIc; (4) fho burdons of Incronsod frnvoI combIno wIfh rncfIcnI concorns IncIudo|Ing] Inck of
nvnIInbIIIfy of chIId cnro, unroIInbIIIfy of frnnsorfnfIon, unnvnIInbIIIfy of noInfmonfs nf nborfIon
fncIIIfIos, unnvnIInbIIIfy of fImo off from work, ImmIgrnfIon sfnfus nnd . . . ovorfy IovoI, |nnd] fho
fImo nnd oxonso InvoIvod In frnvoIIng Iong dIsfnncos; nnd (5) fho romnInIng sovon or oIghf cIInIcs
wIII unIIkoIy hnvo fho cnncIfy fo orform 60,000-?2,000 nborfIons or yonr In Toxns.
34

%( #$ %&
l4-50928
Tho mnjorIfy oInIon dIsngroos, concIudIng osocInIIy fhnf fho dIsfrIcf
courf orrod whon If bnInncod fho offIcncy of fho nmbuInfory surgIcnI confor
rovIsIon ngnInsf fho burdons fho rovIsIon Imosod. Ior my nrf, I do nof
rond AIIo// 11 fo rocIudo consIdornfIon of fho roInfIonshI bofwoon fho
sovorIfy of fho obsfncIo Imosod nnd fho woIghf of fho Sfnfo`s Inforosf In
doformInIng If fho burdon Is unduo. AIfhough I ngroo wIfh fho mnjorIfy
oInIon fhnf AIIo// 11 rojocfod fho dIsfrIcf courf`s nssossmonf of omIrIcnI
dnfn ns nrf of Ifs ro/ionol-Ioeie nnnIysIs, eee ?48 I.3d nf 594, AIIo// 11 dId
nof oxrossIy dIscInIm such nn InquIry for urosos of fho unJue-IurJen
rong, eee iJ. nf 590 (roforrIng fo Coee,è unduo burdon Ioloncing fosf
(omhnsIs nddod)). In AIIo// 11In confrnsf fo fho dIsfrIcf courf`s fncfunI
fIndIngs In fhIs cnsoour courf concIudod fhnf fhoro hnd boon no showIng
whnfsoovor fhnf on, womnn |wouId] Inck ronsonnbIo nccoss fo n cIInIc wIfhIn
Toxns. 1J. nf 598. In IIghf of fho mInImnI or non-oxIsfonf burdon found on
fhnf rocord, fho courf In AIIo// 11 dId nof nood fo conducf nn In-dofh
nnnIysIs of fho Sfnfo`s Inforosf ns nrf of Ifs unduo-burdon rovIow. Ofhor
courfs` crIfIcIsm of AIIo// 11 on fhIs ground Is fhoroforo Inoxncf. See PlonneJ
Poren/looJ Aric., 1nc. t. HunIle, ?53 I.3d 905, 9l4 (9fh CIr. 20l4); PlonneJ
Poren/looJ Se., 1nc. t. S/ronge, o. 2:l3cv405-MHT, 20l4 W! 3809403, nf
*?-8 (M.. AIn. Aug. 4, 20l4).
ConsIsfonf wIfh fhIs nnnIysIs, fho dIsfrIcf courf consIdorod fho woIghf
of fho Sfnfo`s Inforosf In Ifs unduo-burdon rovIow. See Bornee t. Mieeieeippi,
992 I.2d l335, l338 (5fh CIr. l993) (As Iong ns Coee, romnIns nufhorIfnfIvo,
fho consfIfufIonnIIfy of nn nborfIon roguInfIon fhus furns on nn oxnmInnfIon
of fho Imorfnnco of fho sfnfo`s Inforosf In fho roguInfIon nnd fho sovorIfy of
fho burdon fhnf roguInfIon Imosod on fho womnn`s rIghf fo sook nn
nborfIon.); eee oleo Coee,, 505 !.S. nf 8?8 (Inneceeeor, honIfh roguInfIons
35
%) #$ %&
l4-50928
fhnf hnvo fho uroso or offocf of rosonfIng n subsfnnfInI obsfncIo fo n
womnn sookIng nn nborfIon Imoso nn unduo burdon on fho rIghf. (omhnsIs
nddod)). In doIng so, fho dIsfrIcf courf ndhorod fo ronsonIng fhnf roconcIIos,
rnfhor fhnn dIvIdos, cIrcuIf nufhorIfy nIyIng Coee,è unduo-burdon fosf.
See, e.g., HunIle, ?53 I.3d nf 9l2 (|W]o comnro fho oxfonf of fho burdon n
Inw Imosos on n womnn`s rIghf fo nborfIon wIfh fho sfrongfh of fho sfnfo`s
jusfIfIcnfIon of fho Inw. Tho moro subsfnnfInI fho burdon, fho sfrongor fho
sfnfo`s jusfIfIcnfIon for fho Inw musf bo fo snfIsfy fho unduo burdon fosf.);
Von Hollen, ?38 I.3d nf ?98 (Tho foobIor fho modIcnI grounds, fho IIkoIIor
fho burdon, ovon If sIIghf, fo bo 'unduo` In fho sonso of dIsroorfIonnfo or
grnfuIfous.); eee oleo !OII!T A. !II!A!, AIII!!ATI J!ICIA! OIIIOS 235
(l9?4) (|C]omofIng vnIuos . . . musf somohow bo broughf fogofhor so fhnf ns
much ns ossIbIo of fho good In onch cnn bo rofocfod nnd rosorvod.).
I nIso do nof soo n sfrong IIkoIIhood of IognI orror roInfod fo fho dIsfrIcf
courf`s domogrnhIc cnIcuInfIons orfnInIng fo Imncf on womon, roIovnnf
bofh fo Ifs fncInI InvnIIdnfIon of fho ASC rovIsIon, ns woII ns fo our sfny
fncfors. IIrsf, fho dIsfrIcf courf rocognIzod fhnf fhoro nro 5.4 mIIIIon womon
of roroducfIvo ngo In Toxns. oxf, fho dIsfrIcf courf found fhnf If fho ASC
rovIsIon goos Info offocf, 900,000 womon wIII IIvo moro fhnn l50 mIIos from
nn nborfIon cIInIc; ?50,000 womon wIII IIvo moro fhnn 200 mIIos from n cIInIc;
nnd somo womon wIII IIvo ns fnr ns 500 mIIos or moro from n cIInIc.
Iurfhormoro, fho dIsfrIcf courf oxIIcIfIy consIdorod fho fInnncInI nnd ofhor
rncfIcnI obsfncIos fhnf Inforncf wIfh nnd comound fho burdons Imosod by
fho Inw, bofh In If Ifs dIscornmonf of n subsfnnfInI obsfncIo nnd nIso In Ifs
nssossmonf of Imncf on womon.
3
IInnIIy, fho dIsfrIcf courf nIso found fhnf
3
Indood, fho Sfnfo forfhrIghfIy ncknowIodgod durIng ornI nrgumonf fhnf fho ronI-worId
confoxf In whIch womon`s docIsIons nro mndo nnd oornfo doos fncfor Info fho unduo-burdon
36

%* #$ %&
l4-50928
fho romnInIng sovon or oIghf nborfIon ASCs Inck suffIcIonf cnncIfy fo
nccommodnfo nII womon sookIng nborfIons In fho sfnfo. Indood, fhoso
romnInIng cIInIcs wouId hnvo fo Incronso by nf Ionsf fourfoId fho numbor of
nborfIons fhoy orform nnnunIIy. AIfogofhor, nIfhough fho dIsfrIcf courf dId
nof uso fho hrnso Inrgo frncfIon, Ifs fIndIngswhIch roInfod nof onIy fo
frnvoI dIsfnncos buf nIso fo ofhor rncfIcnI obsfncIosdomonsfrnfo fhnf
onforcomonf of fho ASC rovIsIon wIII IIkoIy nffocf n sIgnIfIcnnf numbor onJ n
Inrgo frncfIon of womon ncross fho sfnfo of Toxns. See Coee,, 505 !.S. nf 893-
95 (fncInIIy InvnIIdnfIng IonnsyIvnnIn`s sousnI-nofIfIcnfIon roquIromonf
bocnuso If wouId IIkoIy rovonf n eignificon/ nunIer of womon from
obfnInIng nn nborfIon (omhnsIs nddod)).
As fo fho romnInIng sfny fncfors, whIch ronsonnbIo mInds mny bnInnco
dIfforonfIy, nnd In fhIs cnso do, If Is nonofhoIoss undIsufod fhnf fho Sfnfo for
docndos hns nof hoId InInfIffs` cIInIcs fo ASC sfnndnrdsIndood, novor unfII
now. Insod on fho rocord osfnbIIshod nf frInI, nssossod fIrsfhnnd by fho
dIsfrIcf courf, I do nof orcoIvo fhnf Toxns hns domonsfrnfod urgoncy,
modIcnI or ofhorwIso, fo ImmodInfo onforcomonf. Affor honrIng confIIcfIng
oxorf fosfImony, fho dIsfrIcf courf found fhnf nborfIon In Toxns |Is]
oxfromoIy snfo wIfh nrfIcuInrIy Iow rnfos of sorIous comIIcnfIons, nnd
furfhor found fhnf rIsks nro nof nrocInbIy Ioworod for nfIonfs who
undorgo nborfIon nf nmbuInfory surgIcnI confors. Tho donInI of n sfny wouId
rosorvo fhIs sfnfus quo ondIng our courf`s uIfImnfo docIsIon on fho
corrocfnoss of fho dIsfrIcf courf`s ruIIng. See ConnoJi/, Iu/uree TroJing
Conn`n t. Bri/iel An. ConnoJi/, Op/ione Corp., 434 !.S. l3l6, l320
(l9??).
nnnIysIs, ovon If fho Sfnfo wIII confond fhnf fho rocord doos nof suorf fho InforIny of cIrcumsfnnco
nnd Inw fhnf fho dIsfrIcf courf hoId fo bo doformInnfIvo.
3?

%+ #$ %&
l4-50928
On fho ofhor hnnd, fho dIsfrIcf courf found fhnf If fho ASC roquIromonf
goos Info offocf InInfIffs IIkoIy wIII suffor subsfnnfInI Injury, nofnbIy fhnf
onforcomonf wouId cnuso cIInIcs fo cIoso In Corus ChrIsfI, Snn AnfonIo,
AusfIn, McAIIon, II Inso, Housfon, nnd nIIns. Tho Iongor fhoso cIInIcs
romnIn cIosod, fho Ioss IIkoIy fhoy nro fo rooon If fhIs courf nffIrms fhnf fho
Inw Is unconsfIfufIonnI. Tho dIsfrIcf courf furfhor found fhnf onIy sovon or
oIghf cIInIcs wIII romnIn oon, nnd fhnf fhoso cIInIcs nIono Inck suffIcIonf
cnncIfy. !nIoss shown fo bo cIonr orror, fhIs cIrcumsfnnco Is comnrnbIo fo
fho ono fho Sovonfh CIrcuIf obsorvod wouId subjocf nfIonfs fo wooks of
doIny bocnuso of fho suddon shorfngo of oIIgIbIo |cIInIcs]nnd doIny In
obfnInIng nn nborfIon cnn rosuIf In fho rogrossIon of n rognnncy fo n sfngo
nf whIch nn nborfIon wouId bo Ioss snfo, nnd ovonfunIIy IIIognI. See Von
Hollen, ?38 I.3d nf ?96.
AgrooIng nof fo Imoso n bInnkof sfny on dIrocf nonI, buf nof hnvIng
convIncod coIIonguos whom I rosocf ns fo fho scoo of fho sfny fhnf Is
nrorInfo, I wouId grnnf fho Sfnfo`s Indoondonf roquosf fo oxodIfo Ifs
nonI of nn undorIyIng Issuo fhnf hns comIoxIfy whIch dIvIdos courfs, ns
woII ns rofundIfy whIch dIvIdos convIcfIons dooor fhnn fho ruIos of Inw
courfs musf nIy.

38
%, #$ %&
United States Court of Appeals
FIFTH CIRCUIT
OFFICE OF THE CLERK

LYLE W. CAYCE
CLERK

TEL. 504-310-7700
600 S. MAESTRI PLACE
NEW ORLEANS, LA 70130

October 02, 2014

MEMORANDUM TO COUNSEL OR PARTIES LISTED BELOW:

No. 14-50928 Whole Woman's Health v. David Lakey
USDC No. 1:14-CV-284

Enclosed is an opinion order entered in this case.

Sincerely,

LYLE W. CAYCE, Clerk

By: _________________________
Joseph M. Armato, Deputy Clerk

Ms. Esha Bhandari
Mr. David Patrick Brown
Mr. Betre Gizaw
Ms. Beth Ellen Klusmann
Mr. Joseph Alexander Lawrence
Mr. Jonathan F. Mitchell
Mr. Michael P. Murphy
Mr. Andrew S. Oldham
Mr. William Putnicki
Ms. Jan Soifer
Ms. Stephanie Toti
Honorable Lee Yeakel

Case: l4-50928 Document: 005l279l278 Page: l Date Filed: l0/02/20l4
%& #$ %&

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