Planned Parenthood of WI v. Van Hollen, No. 13-2726 (7th Cir. 2013)

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Justia Opinion Summary

In 2013, the Governor of Wisconsin signed into law a statute that prohibits a doctor, under threat of heavy penalties, from performing an abortion unless he has admitting privileges at a hospital no more than 30 miles from the clinic in which the abortion is performed. Wis. Stat. 253.095(2). Planned Parenthood and others challenged the law under 42 U.S.C. 1983. The district court entered a preliminary injunction against enforcement of the law. The Seventh Circuit affirmed. The court noted that the seven doctors affected by the law had applied for, but after five months, had not been granted, admitting privileges; that all Wisconsin abortion clinics already have transfer agreements with local hospitals to facilitate transfer of clinic patients to the hospital emergency room. A hospital emergency room is obliged to admit and to treat a patient requiring emergency care even if the patient is uninsured, 42 U.S.C. 1395dd(b)(1). Had enforcement of the law, with its one-weekend deadline for compliance, not been stayed, two of the state’s four abortion clinics would have had to shut down and a third clinic would have lost the services of half its doctors.

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In the United States Court of Appeals For the Seventh Circuit ____________________  No. 13 2726  PLANNED PARENTHOOD OF WISCONSIN, INC., et al.,  Plaintiffs Appellees,  v.  J.B. VAN HOLLEN, Attorney General of Wisconsin, et al.,  Defendants Appellants.  ____________________  Appeal from the United States District Court for the  Western District of Wisconsin.  No. 3:13 cv 00465 wmc   William M. Conley, Chief Judge.  ____________________  ARGUED DECEMBER 3, 2013   DECIDED DECEMBER 20, 2013  ____________________  Before POSNER, MANION, and HAMILTON, Circuit Judges.  POSNER, Circuit Judge. On July 5 of this year, the Governor  of  Wisconsin  signed  into  law  a  statute  that  the  Wisconsin  legislature had passed the previous month. So far as relates  to this appeal, the statute prohibits a doctor, under threat of  heavy penalties if he defies the prohibition, from performing  an  abortion  (and  in  Wisconsin  only  doctors  are  allowed  to  perform  abortions,  Wis.  Stat.  § 940.15(5))  unless  he  has  ad mitting  privileges  at  a  hospital  no  more  than  30  miles  from  2  No. 13 2726  the  clinic  in  which  the  abortion  is  performed.  Wis.  Stat.  § 253.095(2).  A  doctor  granted  admitting  privileges  by  a  hospital  be comes  a member  of the hospital s staff  and is authorized  to  admit patients to that hospital and to treat them there; that is  the meaning of  admitting privileges.  Of course any doctor  (in  fact  any  person)  can  bring  a  patient  to  an  emergency  room  to  be  treated  by  the  doctors  employed  there  (these  days called  hospitalists ), and all Wisconsin abortion clinics  already  have  transfer  agreements  with  local  hospitals  to  streamline  the  process.  A  hospital  that  has  an  emergency  room  is  obliged  to  admit  and  to  treat  a  patient  requiring  emergency  care  even  if  the  patient  is  uninsured.  42  U.S.C.  § 1395dd(b)(1).  Planned Parenthood of Wisconsin and Milwaukee Wom en s Medical Services (also known as Affiliated Medical Ser vices) the only entities that operate abortion clinics in Wis consin filed  suit  (joined  by  two  physicians  affiliated  with  these  clinics,  whom  we ll  largely  ignore  in  an  effort  to  sim plify  our  opinion)  challenging  the  constitutionality  of  the  new  statute  under  42  U.S.C.  § 1983,  which  provides  a  tort  remedy for violations of federal law by state employees. The  suit  was  filed  promptly  on  July  5  and  simultaneously  with  the filing the plaintiffs moved in the district court for a tem porary  restraining  order.  The  court  granted  the  motion  on  July  8  and  later  converted  it  to  a  preliminary  injunction  against  enforcement  of  the  statute  pending  a  trial  on  the  merits. The sparse evidentiary record ends on August 2, the  day  the  preliminary  injunction  was  granted.  The  defend ants the Attorney General of Wisconsin and other state of ficials  involved  in  enforcing  the  statute  (we  refer  to  the  de No. 13 2726  3  fendants  collectively  as  the  state ) have  appealed.  28  U.S.C. § 1292(a)(1).  Discovery  is  continuing  in  the  district  court,  but  the  judge  has  stayed  the  trial  (originally  set  for  November  25)  pending  resolution  of  this  appeal.  The  stay  had  been  re quested  by  the  defendants,  and  in  granting  it  the  judge  ex plained that  (1) the stay will not prejudice plaintiffs; and (2)  a  stay  may  simplify  or  clarify  the  issues  in  question  and  streamline  the  case  for  trial.  Except  for  the  lingering  uncer tainty  (which  will  not  be  eliminated  until  this  matter  is  re solved through final appeal), plaintiffs are not prejudiced by  the  stay  now  that  an  injunction  is  in  place.  As  plaintiffs  acknowledge,  additional  time  may  allow  them  to  develop  the record as to their ability to obtain admitting privileges at  local hospitals. Furthermore, the Seventh Circuit s review of  the  preliminary  injunction  order  will  likely  provide  guid ance to this court and the parties on the law and its applica tion to the facts here. If anything, it would be inefficient for  this court to address the merits of plaintiffs  claims until ob taining  this  guidance  from  the  Seventh  Circuit   (citations  omitted).  All we decide today is whether the district judge was jus tified  in  entering  the  preliminary  injunction.  Evidence  pre sented at trial may critically alter the facts found by the dis trict judge on the basis of the incomplete record compiled in  the first month of the suit, and recited by us.  Although signed into law on July 5, a Friday, the statute  required compliance the possession of admitting privileges  at a hospital within a 30 mile radius of the clinic at which a  doctor  performs  abortions by  July  8,  the  following  Mon day. So there was only the weekend between the governor s  4  No. 13 2726  signing  the  bill  and  the  deadline  for  an  abortion  doctor  to  obtain  those  privileges.  There  was  no  way  the  deadline  could have been met even if the two days hadn t been week end days. It is unquestioned that it takes a minimum of two  or three months to obtain admitting privileges (often a hos pital s  credentials  committee,  which  decides  whether  to  grant  admitting  privileges,  meets  only  once  a  month),  and  often  it  takes  considerably  longer.  Moreover,  hospitals  are  permitted rather than required to grant such privileges.  All  seven  doctors  in  Wisconsin  who  perform  abortions  but as of July 8 did not have visiting privileges at a hospital  within a 30 mile radius of their clinic applied for such privi leges  forthwith.  But  as  of  the  date  of  oral  argument  of  this  appeal five  months  after  the  law  would  have  taken  effect  had it not been for the temporary restraining order the ap plication of one of the doctors had been denied and none of  the other applications had been granted. Had enforcement of  the  statute  not  been  stayed,  two  of  the  state s  four  abortion  clinics one  in  Appleton  and  one  in  Milwaukee would  have  had  to  shut  down  because  none  of  their  doctors  had  admitting  privileges  at  a  hospital  within  the  prescribed  30 mile radius of the clinics, and a third clinic would have lost  the  services  of  half  its  doctors.  The  impossibility  of  compli ance with the statute even by doctors fully qualified for ad mitting privileges is a compelling reason for the preliminary  injunction,  albeit  a  reason  that  diminishes  with  time.  There  would be no quarrel with a one year deadline for obtaining  admitting  privileges  as  distinct  from  a  one weekend  dead line,  and  if  so  that  might  seem  to  argue  for  a  one year  (or  even somewhat shorter) duration for the preliminary injunc tion.  But  there  should  be  no  problem  in  getting  the  case  to  trial and judgment well before July 8, 2014. The plaintiffs are  No. 13 2726  5  ready to go to trial. The defendants contemplate very limited  discovery.  Furthermore  there  are  more  reasons  for  the  pre liminary injunction than just the impossibility of compliance  with the statute within the deadline set by the statute.  The stated rationale of the Wisconsin law is to protect the  health  of  women  who  have  abortions.  Most  abortions in  Wisconsin  97  percent are  performed  in  clinics  rather  than  in hospitals, and proponents of the law argue that if a wom an requires hospitalization because of complications from an  abortion  she  will  get  better  continuity  of  care  if  the  doctor  who  performed  the  abortion  has  admitting  privileges  at  a  nearby hospital. The plaintiffs disagree. They argue that the  statute would do nothing to improve women s health that  its  only  effect  would  be  to  reduce  abortions  by  requiring  abortion  doctors  to  jump  through  a  new  hoop:  acquiring  admitting  privileges  at  a  hospital  within  30  miles  of  their  clinic.  No  documentation  of  medical  need  for  such  a  re quirement was presented to the Wisconsin legislature when  the bill that became the law was introduced on June 4 of this  year. The legislative deliberations largely ignored the provi sion  concerning  admitting  privileges,  focusing  instead  on  another provision a requirement not challenged in this suit  that a woman  seeking  an abortion  obtain an ultrasound ex amination of her uterus first (if she hadn t done so already),  which might induce her to change her mind about having an  abortion. Wis. Stat. § 253.10(3)(c)(1)(gm).  No  other  procedure  performed  outside  a  hospital,  even  one as invasive as a surgical abortion (such as a colonoscopy,  or  various  arthroscopic  or  laparoscopic  procedures),  and  even  if  performed  when  the  patient  is  under  general  anes thesia, and even though more than a quarter of all surgery in  6  No. 13 2726  the United States is now performed outside of hospitals, Ka ren  A.  Cullen  et  al.,  Ambulatory  Surgery  in  the  United  States:  2006,   Centers  for  Disease  Control  and  Prevention:  Na tional  Health  Statistics  Reports  No.  11,  Sept.  4,  2009,  p.  5,  www.cdc.gov/nchs/data/nhsr/nhsr011.pdf  (visited  Dec.  19,  2013, as were the other websites cited in this opinion), is re quired  by  Wisconsin  law  to  be  performed  by  doctors  who  have admitting  privileges at hospitals within a specified, or  indeed  any,  radius  of  the  clinic  at  which  the  procedure  is  performed.  That  is  true  even  for  gynecological  procedures  such as  diagnostic  dilation and  curettage (removal  of tissue  from  the  inside  of  the  uterus),  hysteroscopy  (endoscopy  of  the uterus), and surgical completion of miscarriage (surgical  removal  of  fetal  tissue  remaining  in  the  uterus  after  a  mis carriage,  which  is  to  say  a  spontaneous  abortion),  that  are  medically similar to and as dangerous as abortion or so at  least  the  plaintiffs  argue,  without  contradiction  by  the  de fendants.  These  procedures,  often  performed  by  the  same  doctors who perform abortions, appear to be virtually indis tinguishable from abortion from a medical standpoint.  An issue of equal protection of the laws is lurking in this  case.  For  the  state  seems  indifferent  to  complications  from  non hospital  procedures  other  than  surgical  abortion  (espe cially  other  gynecological  procedures),  even  when  they  are  more likely to produce complications. The rate of complica tions resulting in hospitalization from colonoscopies, for ex ample, appears to be three to six times the rate of complica tions  from  abortions.  Compare  Cynthia  W.  Ko  et  al.,  Seri ous Complications Within 30 Days of Screening and Surveil lance Colonoscopy Are Uncommon,  8 Clinical Gastroenterol ogy & Hepatology 166, 171 72 (2010), with two studies cited in  an amicus curiae brief filed by the American College of Ob No. 13 2726  7  stetricians  and  Gynecologists,  Tracy  A.  Weitz  et  al.,  Safety  of  Aspiration  Abortion  Performed  by  Nurse  Practitioners,  Certified Nurse Midwives, and Physician Assistants Under a  California  Legal  Waiver,   103  Am.  J.  Public  Health  454,  457 58  (2013),  and  Kelly  Cleland  et  al.,  Significant  Adverse  Events and Outcomes After Medical Abortions,  121 Obstet rics & Gynecology 166, 169 (2013). Wisconsin s annual report  on  abortions  suggests  a  higher  incidence  of  complications  but it is unclear whether they all require hospitalization and  it still is lower than the reported incidence of complications  from  colonoscopies.  Wisconsin  Department  of  Health  Ser vices,  Reported  Induced  Abortions  in  Wisconsin,  2012   (Aug  2013),  www.dhs.wisconsin.gov/publications/p4/ p45360 12.pdf. It is possible that because of widespread dis approval of abortion, abortions and their complications may  be underreported some women who experience such com plications and are hospitalized may tell the hospital staff that  the complications are from a miscarriage. But as yet there is  no evidence in the record of such undercounting. The state s  own report on abortions, just cited, lists (at table 9 of the re port)  only  11  complications  out  of  the  6,692  abortions  of  Wisconsin residents reported in 2012 a rate of less than 1.6  tenths of 1 percent (1 per 608 abortions). And the report does  not indicate how many of the complications involved hospi talization  or  whether  6,692  was  an  undercount  of  the  num ber of abortions.  We  asked  the  state s  lawyer  at  oral  argument  what  evi dence he anticipated producing at the trial on the merits. He  did not mention evidence of alleged undercounting of abor tions, but only that the state was looking for women in Wis consin who had experienced complications from an abortion  to testify. He did not mention any medical or statistical evi 8  No. 13 2726  dence.  This may explain why the trial,  originally  scheduled  for November 25, only four and a half months after the suit  was filed, was expected to last only a couple of days. And it  is why we think it most unlikely that the trial can t be com pleted well before the one year anniversary of the date of the  statute s enactment.  The  district  judge  said  in  a  footnote  in  his  opinion  that  while he would  await trial on the issue,  ¦ the complete ab sence of an admitting privileges requirement for clinical [i.e.,  outpatient] procedures including for those with greater risk  is  certainly  evidence  that  Wisconsin  Legislature s  only  pur pose  in  its  enactment  was  to  restrict  the  availability  of  safe,  legal abortion in this State, particularly given the lack of any  demonstrable medical benefit for its requirement either pre sented  to  the  Legislature  or  [to]  this  court   (emphasis  in  original).  A  fuller  enumeration  of  considerations  based  on  purpose  would  include  the  two day  deadline  for  obtaining  admitting  privileges,  the  apparent  absence  of  any  medical  benefit  from  requiring  doctors  who  perform  abortions  to  have  such  privileges  at  a  nearby  or  even  any  hospital,  the  differential  treatment  of  abortion  vis à vis  medical  proce dures that are at least as dangerous as abortions and proba bly more so, and finally the strange private civil remedy for  violations: The father or grandparent of the  aborted unborn  child  is entitled to obtain damages, including for emotional  and psychological distress, if the abortion was performed by  a  doctor  who  violated  the  admitting privileges  provision.  Wis. Stat. § 253.095(4)(a). Yet if the law is aimed only at pro tecting the mother s health, a violation of the law could harm  the fetus s father or grandparent only if the mother were in jured as a result of her abortion doctor s lacking the required  admitting privileges. But no proof of such injury is required  No. 13 2726  9  to entitle the father or grandparent to damages if he proves a  violation and resulting emotional or psychological injury to  himself.  However, the purpose of the statute is not at issue in this  appeal.  In  urging  affirmance  the  plaintiffs  reserve  the  issue  for  trial,  arguing  to  us  only  that  the  law  discourages  abor tions  without  medical  justification  and  imposes  an  undue  burden on women. And the state on its side does not defend  the statute  as protecting fetal  life but only  as protecting the  health of women who have abortions.  Wisconsin s  statute  is  not  unique.  Six  states  have  laws  nearly  identical  to  Wisconsin s:  Ala.  Code  § 26 23E 4;  Miss.  Code. § 41 75 1(f); Mo. Stat. § 188.080; N.D. Cent. Code § 14 02.1 04(1);  Tenn.  Code  § 39 15 202(h);  Tex.  Health  &  Safety  Code  § 171.0031(a)(1).  Five  more  have  similar  though  less  stringent  requirements  relating  to  admitting  privileges  for  abortion  doctors:  Ariz.  Rev.  Stat.  § 36 449.03(C)(3);  Fla.  Stat.  § 390.012(3)(c)(1);  Ind.  Code  § 16 34 2 4.5;  Kan.  Stat.  § 65 4a09(d)(3);  Utah  Admin.  Code  R432 600 13(2)(a).  The  plain tiffs argue that such laws, which are advocated by the right  to  life  movement,  are  intended  to  hamstring  abortion.  The  defendants deny this. We needn t take sides. Discovering the  intent behind a statute is difficult at best because of the col lective character of a legislature, and may be impossible with  regard to the admitting privileges statutes. Some Wisconsin  legislators doubtless voted for the statute in the hope that it  would  reduce  the  abortion  rate,  but  others  may  have  voted  for  it  because  they  considered  it  a  first  step  toward  making  invasive outpatient procedures in general safer.  As now appears (the trial may cast the facts in a different  light), the statute, whatever the intent behind it (if there is a  10  No. 13 2726  single intent), seems bound  to have  a  substantial impact  on  the  practical  availability  of  abortion  in  Wisconsin,  and  not  only  because  of  the  unreasonably  tight  implementation  deadline. Virtually all abortions in Wisconsin are performed  at the plaintiffs  four clinics; no other clinics in the state per form  abortions  and  hospitals  perform  only  a  small  fraction  of the state s abortions; and a significant fraction of the clin ics   doctors  don t  have  admitting  privileges  at  hospitals  within 30 mile radii of their clinics.  What is more, because few doctors in Wisconsin perform  abortions, those who do often work at more than one clinic,  so  that  the  statute  would  require  them  to  obtain  admitting  privileges  at  multiple  hospitals.  And  whether  any  of  the  hospitals  would  give  these  doctors  admitting  privileges  is  unknown. It is true that federal law prohibits hospitals that  receive  federal  funding,  including  Catholic  hospitals,  from  denying  admitting  privileges  merely  because  a  doctor  per forms  abortions.  42  U.S.C.  § 300a 7(c)(1)(B)  (the  Church  Amendments ).  Yet  Wisconsin  State  Senator  Mary  Lazich,  one  of  the  authors  of  the  admitting privileges  law,  was  seemingly unaware of the Church Amendments, as were in deed officials of the largest Catholic hospitals in Wisconsin,  which  before  they  were  informed  of  the  amendments  were  emphatic  that  their  religious  beliefs  would  preclude  their  granting admitting privileges to doctors who perform abor tions.  Akbar  Ahmed,  Abortion  Ruling  Mired  in  Confu sion,   Milwaukee  Journal  Sentinel,  July  27,  2013,  p.  A1,  www.jsonline.com/news/statepolitics/court file shows confusion over wisconsin abortion regulation law b9961373z1 217196251.html#ixzz2mcyeJ5ba.  In  the  words  of  the  chief  medical  officer  of  one  such  hospital,  Wheaton  Franciscan  Healthcare  is  a  ministry  of  the  Catholic  church.  No. 13 2726  11  ¦ For that reason, if it s known to us that a doctor performs  abortions and that doctor applies for privileges at one of our  hospitals, our hospital board would not grant privileges.  Id.  So not only would allowing the new law to go into effect  on  July  8  have  wreaked  havoc  with  the  provision  of  abor tions in Wisconsin because of the months it would have tak en  for  the  doctors  who  perform  abortions  to  obtain  admit ting privileges within the prescribed radii of their clinics; in  addition  their  requests  for  such  privileges  would  have  en countered  resistance  at  Catholic  hospitals and  perhaps  at  other  hospitals  as  well,  given  the  widespread  hostility  to  abortion and the lack of any likely benefit to a hospital from  granting such privileges to an abortion doctor.  The  criteria  for  granting  admitting  privileges  are  multi ple, various, and unweighted. They include how frequently  the physician uses the hospital (that is, the number of patient  admissions), the quantity of services provided to the patient  at the hospital, the revenue generated by the physician s pa tient  admissions,  and  the  physician s  membership  in  a  par ticular practice group or academic faculty ( closed staff  ar rangements).  Barry  R.  Furrow  et  al.,  Health Law  § 14 15,  pp.  707 08  (2d  ed.  2000);  Elizabeth  A.  Weeks,  The  New  Eco nomic Credentialing: Protecting Hospitals from Competition  by Medical Staff Members,  36 J. Health L. 247, 249 52 (2003).  The absence of definite standards for the granting of admit ting privileges makes it difficult not only to predict who will  be granted such privileges at what hospitals and when, but  also to prove an improper motive for denial. Akbar Ahmed,  Hospitals  Can t  Deny  Privileges,   Milwaukee  Journal  Senti nel,  Aug.  7,  2013,  p.  A1,  www.jsonline.com/news/ statepolitics/wisconsin attorney general says hospitals cant 12  No. 13 2726  deny admitting privileges to abortion doctors b997046 218608951.html, points out for example that according to the  Senior  Counsel  of  the  National  Women s  Law  Center,  in  other  states  that  have  recently  passed  privileges  require ments for abortion providers, religiously affiliated hospitals  have  denied  the  doctors   applications  by  citing  their  failure  to meet other standards, such as admitting a certain number  of patients per year. In Mississippi, a Baptist hospital did not  provide doctors at an abortion clinic with an application for  privileges  because  none  of  its  staff  would  write  letters  in  support of the doctors, according to a court affidavit provid ed  by  the  clinic s  attorneys  at  the  Center  for  Reproductive  Rights.   Pretext aside, a common and lawful criterion for granting  admitting  privileges  (though  it  has  been  criticized  by  the  American  Medical  Association,  see  AMA,  Opinion  4.07 Staff  Privileges,   www.ama assn.org/ama/pub/physician resources/medical ethics/code medical ethics/ opinion407.page) is the number of patient admissions a doc tor  can  be  expected  to  produce  for  the  hospital the  more  the  better,  as  that  means  more  utilization  of  hospital  em ployees and resources and hence more fees for the hospital.  But  the  number  of  patient  admissions  by  doctors  who  per form abortions is likely to be negligible because there appear  to  be  so  few  complications  from  abortions  and  only  a  frac tion of those require hospitalization probably a very small  fraction. An even smaller fraction will still be near the hospi tal  at  which  the  doctor  has  admitting  privileges  when  the  complication  arises.  The  state  does  not  dispute  the  district  court s finding that  up to half of the complications will not  present themselves until after the patient is home.   No. 13 2726  13  But what is certain  and also  not  disputed  by the  state  is  that  banning  abortions  by  doctors  who  cannot  obtain  the  requisite admitting privileges within the span of a weekend  is bound to impede access to abortions. It would have creat ed (had it not been for judicial intervention) a hiatus of un known  duration  (but  duration  measured  in  months  rather  than in weeks or days) in which a critical number of the few  doctors  who  perform  abortions  in  Wisconsin  would  have  been  forbidden  to  do  so,  under  threat  of  heavy  penalties  if  they disobeyed.  There  cannot  have  been  a  felt  sense  of  urgency  on  the  state s  part  for  making  the  law  effective  too  abruptly  to  al low  compliance  with  it.  It  has  been  40  years  since  Roe  v.  Wade,  410  U.S.  113  (1973),  was  decided,  legalizing  (most)  abortion throughout the United States, and it could not have  taken  the  State  of  Wisconsin  all  this  time  to  discover  the  supposed  hazards  of  abortions  performed  by  doctors  who  do  not  have  admitting  privileges  at  a  nearby  hospital.  The  state can without harm to its legitimate interests wait a few  months more to implement its new law, should it prevail in  this litigation.  One reason it can wait is that its expressed concern about  the  hazards  resulting  from  abortions  performed  by  doctors  who don t have admitting privileges at a nearby hospital has  intersected a movement in the hospital industry (an industry  in  ferment,  as  everyone  now  knows)  to  restrict  admitting  privileges on economic grounds. See Weeks, supra, at 248 49,  252 53 ( for example, hospitals may refuse to grant initial or  continuing  staff  privileges  to  physicians  who  own  or  have  other financial interests in competing healthcare entities, re fer patients to competing entities, have staff privileges at any  14  No. 13 2726  other area hospitals, or fail to admit some specified percent age  of  their  patients  to  the  hospital );  Peter  J.  Hammer  &  William  M.  Sage,  Antitrust,  Health  Care  Quality,  and  the  Courts,  102 Colum. L. Rev. 545, 567 68 and n. 58 (2002). The  trend  in  the  hospital  industry  is  for  the  hospital  to  require  the treating physician to hand over his patient who requires  hospitalization  to  physicians  employed  by  the  hospital,  ra ther than allowing the treating physician to continue partici pating in the patient s treatment in the hospital. Wisconsin is  trying to buck that trend but only with regard to abortions,  though there is no evidence that the complications to which  abortion  can  give  rise  require  greater  physician  continuity  than  other  outpatient  procedures.  And  there  is  no  evidence  that  women  who  have  complications  from  an  abortion  re cover more quickly or more completely or with less pain or  discomfort if their physician has admitting privileges at the  hospital  to  which  the  patient  is  taken  for  treatment  of  the  complications.  The state devotes most of its briefing in this court not to  the merits but instead to arguing that the plaintiffs cannot be  allowed  to  maintain  this  suit  because  their  rights  have  not  been violated. The state does not deny that they may be in jured  by  the  statute.  But  it  argues  that  no  rights  of  theirs  have  been  violated  but  only  rights  of  their  patients,  if  it  is  true (which of course the defendants deny) that the statute is  a  gratuitous  interference  with  a  woman s  right  to  an  abor tion.  Yet the cases are legion that allow an abortion provider,  such  as  Planned  Parenthood  of  Wisconsin  or  Milwaukee  Women s  Medical  Services,  to  sue  to  enjoin  as  violations  of  federal  law  (hence  litigable  under  42  U.S.C.  § 1983)  state  No. 13 2726  15  laws  that  restrict  abortion.  See,  e.g.,  Isaacson  v.  Horne,  716  F.3d 1213, 1221 (9th Cir. 2013) ( recognizing the confidential  nature of the physician patient relationship and the difficul ty  for  patients  of  directly  vindicating  their  rights  without  compromising  their  privacy,  the  Supreme  Court  has  enter tained both broad facial challenges and pre enforcement as applied  challenges  to  abortion  laws  brought  by  physicians  on  behalf  of  their  patients );  Richard  H.  Fallon,  Jr.,  As Applied  and  Facial  Challenges  and  Third Party  Standing,   113 Harv. L. Rev. 1321, 1359 61 (2000). The reason for allow ing such third party standing in the present case is different  from  but  analogous  to  the  reason  that  persuaded  the  Su preme  Court,  beginning  with  Roe  v.  Wade,  to  waive  the  mootness defense to a suit by a pregnant woman challenging  a state law restricting abortion. The suit could not be litigat ed  to  judgment  before  she  gave  birth;  and  so  if  mootness  were allowed as a defense, restrictions on abortion could not  effectively be challenged by the persons whose rights the re strictions  infringe.  That  was  a  practical  bar  to  insisting  on  first party standing. The bar in this case is the extraordinary  heterogeneity of the class likely to be affected by the statute.  If  two  of  the  four  abortion  clinics  in  the  state  close  and  a  third shrinks by half, some women wanting an abortion may  experience  delay  in  obtaining,  or  even  be  unable  to  obtain,  an abortion yet not realize that the new law is likely to have  been  the  cause.  Those  women  are  unlikely  to  sue.  Other  women may be able to find an abortion doctor who has ad mitting  privileges  at  a  nearby  hospital,  yet  incur  costs  and  delay  because  the  law  has  reduced  the  number  of  abortion  doctors  and  hence  access.  The  heterogeneity  of  the  class  is  likely to preclude class action treatment; and while one or a  16  No. 13 2726  handful of women might sue, the entire statute would be un likely to be enjoined on the basis of such a suit.  The  principal  objection  to  third party  standing  is  that  it  wrests  control  of  the  lawsuit  from  the  person  or  persons  primarily concerned in it. See, e.g., MainStreet Organization of  Realtors v. Calumet City, 505 F.3d 742, 746 (7th Cir. 2007); 13A  Charles  A.  Wright,  Arthur  R.  Miller  &  Edward  H.  Cooper,  Federal  Practice  &  Procedure  § 3531.9.3,  pp.  720 26  (3d  ed.  2008).  For  an  extreme  example,  imagine  that  if  A  broke  his  contract  with  B,  a  stranger  to  both  of  them  could  sue  A  for  breach of contract, leaving B out in the cold. But that is not a  problem in a case such as this. Wisconsin women who have  or  want  to  have  an  abortion  are  not  seeking  damages  from  the state, and so are not losing control over their legal rights  as  a  result  of  litigation  by  clinics  and  doctors.  They  are  (or  would be, if they were plaintiffs) seeking the same thing the  clinics  are seeking  (with greater  resources): invalidating  the  statute.  Anyway there is an alternative ground for standing, un related  to  third party  standing,  in  this  case.  The  Supreme  Court  held  in  Doe  v.  Bolton,  410  U.S.  179,  188  (1973)  (the  companion  case  to  Roe  v.  Wade),  that  doctors  (two  of  the  plaintiffs in this case are doctors) have first party standing to  challenge  laws  limiting  abortion  when,  as  in  Doe  v.  Bolton  and the present case as well, see Wis. Stat. §§ 253.095(3), (4),  penalties for violation of the laws are visited on the doctors.  See also Planned Parenthood of Southeastern Pennsylvania v. Ca sey,  505  U.S.  833,  903 04,  909  (1992);  Planned  Parenthood  of  Central  Missouri  v.  Danforth,  428  U.S.  52,  62  (1976);  Karlin  v.  Foust,  188  F.3d  446,  456  n.  5  (7th  Cir.  1999);  Planned  Parenthood  of  Wisconsin  v.  Doyle,  162  F.3d  463,  465  (7th  Cir.  No. 13 2726  17  1998);  13A  Wright,  Miller  &  Cooper,  supra,  pp.  748 50.  The  state  argues  that  none  of  these  precedents  governs  because  none  of  them  grapple[d]  with  whether  [42  U.S.C.]  § 1983  creates  a  cause  of  action  for  abortion  providers  or  clinics  to  assert  the  rights  of  their  patients.   But  nearly  all  the  cited  cases  in  which  doctors  and  abortion  clinics  were  found  to  have  had  standing  had  been  filed  pursuant  to  section  1983,  and the justiciability of such cases is not in question.  Apart from the issue of standing just discussed, the legal  principles  applicable  to  our  consideration  of  the  appeal  are  not in contention between the parties. The task of the district  court asked to grant a preliminary injunction is  to estimate  the likelihood that the plaintiff will prevail in a full trial and  which of the parties is likely to be harmed more by a ruling,  granting or denying a preliminary injunction, in favor of the  other party, and combine these findings in the manner sug gested in such cases as Abbott Laboratories v. Mead Johnson &  Co.,  971  F.2d  6,  12  (7th  Cir.  1992):  the  more  likely  it  is  the  plaintiff  will  succeed  on  the  merits,  the  less  the  balance  of  irreparable harms need weigh towards its side; the less like ly it  is  the  plaintiff  will succeed, the  more the balance  need  weigh  towards  its  side.   Kraft  Foods  Group  Brands  LLC  v.  Cracker  Barrel  Old  Country  Store,  Inc.,  735  F.3d  735,  740  (7th  Cir.  2013); see  also  NLRB  v.  Electro Voice, Inc.,  83  F.3d  1559,  1568 (7th Cir. 1996); Grocery Outlet Inc. v. Albertson s Inc., 497  F.3d  949,  951  (9th  Cir.  2007)  (per  curiam);  O  Centro  Espirita  Beneficiente Uniao Do Vegetal v. Ashcroft, 389 F.3d 973, 1028 29  (10th Cir. 2004) (en banc) (per curiam), affirmed, 546 U.S. 418  (2006);  Novartis  Consumer  Health,  Inc.  v.  Johnson  &  Johnson Merck  Consumer  Pharmaceuticals  Co.,  290  F.3d  578,  597  (3d  Cir. 2002). This formulation is a variant of, though consistent  with, the Supreme Court s recent formulations of the stand 18  No. 13 2726  ard,  in  such  cases  as  Winter  v.  National  Resources  Defense  Council, Inc., 555 U.S. 7, 20 (2008):  A plaintiff seeking a pre liminary injunction must establish that he is likely to succeed  on  the  merits,  that  he  is  likely  to  suffer  irreparable  harm  in  the absence of preliminary relief, that the balance of equities  tips in his favor, and that an injunction is in the public inter est.   Because of the uncertainty involved in balancing the con siderations that bear on the decision whether to grant a pre liminary  injunction an  uncertainty  amplified  by  the  una voidable haste with which the district judge must strike the  balance we  appellate  judges  review  his  decision  deferen tially.  The state concedes that its only  interest  pertinent  to  this  case  is  in  the  health  of  women who  obtain  abortions.  But  it  has  neither  presented  evidence  of  a  health  benefit  (beyond  an inconclusive affidavit by one doctor concerning one abor tion  patient  in  another  state,  as  we ll  see),  or  rebutted  the  plaintiffs  evidence that the statute if upheld will harm abor tion providers and their clients and potential clients.  And  it  is  beyond  dispute  that  the  plaintiffs  face  greater  harm irreparable by the entry of a final judgment in their fa vor  than  the  irreparable  harm  that  the  state  faces  if  the  im plementation of its statute is delayed. For if forced to comply  with  the  statute,  only  later  to  be  vindicated  when  a  final  judgment  is  entered,  the  plaintiffs  will  incur  in  the  interim  the  disruption  of  the  services  that  the  abortion  clinics  pro vide.  With  the  closure  of  two  and  a  half  of  the  state s  four  abortion clinics if their doctors fail to obtain admitting privi leges, including one clinic responsible for half the abortions  performed  in  the  state,  their  doctors   practices  will  be  shut  No. 13 2726  19  down completely unless and until the doctors obtain visiting  privileges  at  nearby  hospitals.  Patients  will  be  subjected  to  weeks  of  delay  because  of  the  sudden  shortage  of  eligible  doctors and delay in obtaining an abortion can result in the  progression  of  a  pregnancy  to  a  stage  at  which  an  abortion  would be less safe, and eventually illegal.  Some  patients  will  be  unable  to  afford  the  longer  trips  they ll  have  to  make  to  obtain  an  abortion  when  the  clinics  near  them  shut  down 60  percent  of  the  clinics   patients  have incomes below the federal poverty line. One of the clin ics that will close is Planned Parenthood s clinic in Appleton,  which, as shown in the accompanying map, is in the approx imate  center of the state.  The remaining  abortion clinics are  in  Madison  or  Milwaukee,  about  100  miles  south  of  Apple ton.  A  woman  who  lives  north  of  Appleton  who  wants  an  abortion may (unless she lives close to the Minnesota border  with  Wisconsin  and  not  far  from  an  abortion  clinic  in  that  state) have to travel up to an additional 100 miles each way  to obtain it. And that is really 400 miles a nontrivial burden  on  the  financially  strapped  and  others  who  have  difficulty  traveling long distances to obtain an abortion, such as those  who already have children. For Wisconsin law requires two  trips to the abortion clinic (the first for counseling and an ul trasound)  with  at  least  twenty four  hours  between  them.  Wis. Stat. § 253.10(3)(c). When one abortion regulation com pounds the effects of another, the aggregate effects on abor tion rights must be considered.  20  No. 13 2726    The  state  has  made  no  attempt  to  show  an  offsetting  harm from a delay of a few months in the implementation of  its  new  law  (should  it  be  upheld  after  a  trial).  States  that  have passed  similar laws have allowed much longer imple mentation  time  than  a  weekend for  example,  Mississippi  has  allowed  76  days,  Alabama  114  days,  Texas  103,  and  North Dakota 128. See 2012 Miss. Gen. Laws 331 (H.B. 1390),  enjoined, Jackson Women s Health Org. v. Currier, 940 F. Supp.  2d  416,  424  (S.D.  Miss.  2013); 2013  Ala.  Legis.  Serv.  2013 79  (H.B. 57), enjoined, Planned Parenthood Southeast, Inc. v. Bent ley,  No.  2:13cv405 MHT,  2013  WL  3287109,  at  *8  (M.D.  Ala.  June 28, 2013); 2013 Tex. Sess. Law Serv. 2nd Called Sess. Ch.  No. 13 2726  21  1  (H.B.  2),  permanent  injunction  stayed  pending  appeal,  Planned Parenthood of Greater Texas Surgical Health Services v.  Abbott, 734 F.3d 406 (5th Cir. 2013); 2013 North Dakota Laws  Ch. 118 (S.B. 2305), enjoined, MKB Management Corp. v. Bur dick, No. 1:13 cv 071, 2013 WL 3779740, at *2 (D.N.D. July 22,  2013).  Is  there  such  urgency  to  implementing  the  law,  because  Wisconsin  is  rife  with  serious  complications  from  abortion  and requiring admitting privileges to hospitals within short  distances  of  abortion  clinics  is  essential  to  preventing  such  complications?  As  noted  earlier,  the  state  has  presented  no  evidence of either reason for the weekend deadline. Compli cations of abortion are estimated to occur in only one out of  111  physician performed  aspiration  abortions  (the  most  common  type  of  surgical  abortion);  and  96  percent  of  com plications are  minor.  Weitz et al., supra, p. 457; cf. Cleland  et  al.,  supra.  The  official  Wisconsin  figure,  cited  earlier,  is  much  lower:  one  complication  per  608  abortions.  Few  com plications require hospitalization; studies cited earlier found  that  only  1  in  1,915  aspiration  abortions  (0.05%)  and  1  in  1,732  medical  abortions  (0.06%)  result  in  complications  re quiring hospitalization. Weitz et al., supra, p. 459; Cleland et  al., supra, p. 169 table 2.  What  fraction  of  these  hospitalizations  go  awry  because  the doctor who performed the abortion did not have admit ting privileges at the hospital to which the woman was taken  is another unknown in a case in which thus far the state has  been chary in the presentation of evidence. True, one doctor,  who said he s been treating complications from abortions for  29 years, furnished the defendants with an affidavit describ ing a case in which, he opines, a woman with a complication  22  No. 13 2726  from an abortion might have avoided a hysterectomy had her  abortion  doctor,  who  did  not  have  admitting  privileges,  re mained in closer touch with her. That is the only evidence in  the  record  that  any  woman  whose  abortion  results  in  com plications  has  ever,  anywhere  in  the  United  States,  been  made  worse  off  by  being  handed  over   by  her  abortion  doctor to a gynecologist employed by the hospital to which  she s taken. One (doubtful) case in 29 years is not impressive  evidence  of  the  medical  benefits  of  the  Wisconsin  statute.  And we note that as a protection for Wisconsin women who  have  abortions,  abortion  clinics uniquely,  it  appears,  among  outpatient  providers  of  medical  services  in  Wiscon sin are required to adopt the transfer protocols, mentioned  earlier, which are intended to assure prompt hospitalization  of any abortion patient who experiences complications seri ous  enough  to  require  hospitalization.  See  Wis.  Admin.  Code Med. § 11.04(g).  The defendants argue that obtaining admitting privileges  operates as a kind of Good Housekeeping Seal of Approval  of a physician. But that benefit does not require that the hos pital  in  which  he  obtains  the  privileges  be  within  a  30 mile  radius of the clinic. Cf. Women s Health Center of West County,  Inc.  v.  Webster,  871  F.2d  1377,  1378 81  (8th  Cir.  1989)  (up holding  an  admitting  privileges  requirement  with  no  geo graphic  restriction).  Several  abortion  doctors  in  Wisconsin  who  lack  admitting  privileges  at  hospitals  within  30  miles  have them at hospitals beyond that radius. Yet they are not  excused by the statute from having to obtain the same privi leges from a hospital within 30 miles.  Furthermore,  nothing in the statute requires an abortion  doctor  who  has  admitting  privileges  to  care  for  a  patient  No. 13 2726  23  who has complications from an abortion. He doesn t have to  accompany her to the hospital, treat her there, visit her, call  her,  or  indeed  do  anything  that  a  doctor  employed  by  the  hospital might not do for the patient.  Also  the  statute  does  not  distinguish  between  surgical  and medical abortions. The latter term refers to an abortion  induced by a pill given to the patient by her doctor: she takes  one  pill  in  the  clinic,  goes  home,  and  takes  a  second  pill  a  few days later to complete the procedure. (The first pill ends  the  fetus s  life,  the  second  induces  the  uterus  to  expel  the  remains.)  Her  home  may  be  far  from  any  hospital  within  a  30 mile  radius  of  her  doctor s  clinic,  but  close  to  a  hospital  outside that radius. If she calls an ambulance, the paramed ics are likely to take her to the nearest hospital a hospital at  which  her  doctor  is  unlikely  to  have  admitting  privileges.  Likewise  in  the  case  of  surgical  abortions  when  complica tions occur not at the clinic, during or immediately after the  abortion, but after the patient has returned home: because of  distance  she may  no longer have ready access  to  the hospi tals  near  the  clinic  at  which  the  abortion  was  performed,  even though she may live near a hospital at which the doctor  who performed her abortion does not have admitting privi leges.  The cases that deal with abortion related statutes sought  to be justified on medical grounds require not only evidence  (here lacking as we have seen) that the medical grounds are  legitimate  but  also  that  the  statute  not  impose  an  undue  burden  on women seeking abortions. Planned Parenthood of  Southeastern Pennsylvania v. Casey, supra, 505 U.S. at 874, 877,  900 01  (plurality  opinion);  Stenberg  v.  Carhart,  530  U.S.  914,  930, 938 (2000); cf. Mazurek v. Armstrong, 520 U.S. 968, 972 73  24  No. 13 2726  (1997)  (per  curiam).  The  feebler  the  medical  grounds,  the  likelier the burden, even if slight, to be  undue  in the sense  of  disproportionate  or  gratuitous.  It  is  not  a  matter  of  the  number of women likely to be affected.  [A]n undue burden  is a shorthand for the conclusion that a state regulation has  the purpose or effect of placing a substantial obstacle in the  path of a woman seeking an abortion of a nonviable fetus.   Planned  Parenthood  of  Southeastern  Pennsylvania  v.  Casey,  su pra, 505 U.S. at 877 (plurality opinion). In this case the medi cal  grounds  thus  far  presented  ( thus  far   being  an  im portant qualification given the procedural setting a prelim inary injunction proceeding) are feeble, yet the burden great  because  of  the  state s  refusal  to  have  permitted  abortion  providers a reasonable time within which to comply.  And so the district judge s grant of the injunction must be  upheld.  But  given  the  technical  character  of  the  evidence  likely  to  figure  in  the  trial both  evidence  strictly  medical  and  evidence  statistical  in  character  concerning  the  conse quences both for the safety of abortions and the availability  of abortion in Wisconsin the district judge may want to re consider appointing a neutral medical expert to testify at the  trial, as authorized by Fed. R. Evid. 706, despite the parties   earlier objections.  Given the passions that swirl  about abor tion rights and their limitations there is a danger that  party  experts  will  have  strong  biases,  clouding  their  judgment.  They will still be allowed to testify if they survive a Daubert  challenge,  but  a court appointed  expert  may  help  the  judge  to  resolve  the  clash  of  the  warring  party  experts.  And  the  judge may be able to procure a genuine neutral expert simp ly by directing the party experts to confer and agree on two  or  three  qualified  neutrals  among  whom  the  judge  can  choose  with  confidence  in  their  competence  and  neutrality.  No. 13 2726  25  If either side s party experts stonewall in the negotiations for  the  compilation  of  the  neutral  list,  the  judge  can  take  disci plinary action; we doubt that will be necessary.  We  emphasize  in  conclusion  that  the  trial  on  the  merits  may cast the facts we have recited, based as they are on the  record  (by  no  means  slim,  however,  though  entirely  docu mentary) of the preliminary injunction proceeding, in a dif ferent light. That record all we have requires that the dis trict  judge s  grant  of  the  preliminary  injunction  be,  and  it  hereby is,  AFFIRMED.  26 No. 13-2726 MANION, Circuit Judge, concurring in part and in the judgment. I agree with the court that the temporary restraining order and the subsequent preliminary injunction were appropriate. The Wisconsin law at issue requires abortion doctors to obtain admitting privileges at a hospital no more than 30 miles from the clinic in which the abortion is performed. 2013 Wis. Act 37, § 1 (codified at Wis. Stat. § 253.095(2)). As I explain below, the legislature had a rational basis to enact the law. However, the law was signed by the governor on a Friday and took effect the following Monday. The law s immediate effective date made it impossible for the doctors employed at the various clinics providing abortion services to seek and obtain admitting privileges at a nearby hospital. The injunctive relief has now been in place for nearly half a year, so abortion doctors have had plenty of time to secure admitting privileges. However, in this appeal, Wisconsin has only argued that the original entry of the injunction was error, so whether the injunction remains appropriate will be decided on remand. I also agree with the court about third-party standing. There is no need for the parties to dwell on this issue. As the court notes, at this juncture, the Seventh Circuit s review of the preliminary injunction order will likely provide guidance to the court and the parties on the law and its application to the facts here. Maj. Op. at 3. The court has expressed rather extensive guidance for the district court on remand. At this point, I hope to offer some of my own observations on the legitimate interests that are furthered by the requirements of Wisconsin Act 37 and the nature of the No. 13-2726 27 burdens that the requirements may impose on access to abortion. The Two-Part Test for Laws Regulating the Provision of Abortions Where it has a rational basis to act, and it does not impose an undue burden, the State may regulate the provision of abortions. Gonzales v. Carhart, 550 U.S. 124, 158 (2007). Thus, legislation regulating abortions must past muster under rational basis review and must not have the practical effect of imposing an undue burden on the ability of women to obtain abortions. See Karlin v. Foust, 188 F.3d 446, 481 (7th Cir. 1999); Planned Parenthood of Greater Tex. Surgical Health Servs. v. Abbott, 734 F.3d 406, 411 (5th Cir. 2013), application to vacate stay of injunction denied, 134 S. Ct. 506 (Nov. 19, 2013). Step 1: Rational Basis At the first step, we must presume that the admittingprivileges requirement is constitutional, and uphold it so long as the requirement is rationally related to Wisconsin s legitimate interests. See St. John s United Church of Christ v. City of Chicago, 502 F.3d 616, 637 38 (7th Cir. 2007) (quoting City of Cleburne, Tex. v. Cleburne Living Ctr., 473 U.S. 432, 440 (1985)). Wisconsin asserts that its admitting-privileges requirement furthers its legitimate interests in protecting the health of mothers and in maintaining the professional standards applicable to abortion doctors. Carhart, 550 U.S. at 157; Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 846 (1992). The question, then, is whether Wisconsin s adoption of the admitting-privileges requirement is rationally related to these interests. Under rational basis review, the plaintiff has the 28 No. 13-2726 burden of proving the government s action irrational, and [t]he government may defend the rationality of its action on any ground it can muster, not just the one articulated at the time of decision. RJB Props., Inc. v. Bd. of Educ. of Chicago, 468 F.3d 1005, 1010 (7th Cir. 2006) (quoting Smith v. City of Chicago, 457 F.3d 643, 652 (7th Cir. 2006)). The court suggests that Wisconsin must come forward with medical evidence that the admitting-privileges requirement furthers the State s legitimate interests. Maj. Op. at 23. But, under rational basis review, Wisconsin s legislative choice may be based on rational speculation unsupported by evidence or empirical data. F.C.C. v. Beach Commc ns, Inc., 508 U.S. 307, 315 (1993). States have broad latitude to regulate abortion doctors, even if an objective assessment might suggest that the regulation is not medically necessary. Mazurek v. Armstrong, 520 U.S. 968, 973 (1997) (quotation marks and emphasis omitted). Thus, the Supreme Court has rejected as misguided arguments that an abortion law is unconstitutional because the medical evidence contradicts the claim that the law has any medical basis. Id.; see also Greenville Women s Clinic v. Bryant, 222 F.3d 157, 169 (4th Cir. 2000) ( [T]here is no requirement that a state refrain from regulating abortion facilities until a public-health problem manifests itself. In Danforth, for example, the [Supreme] Court upheld health measures that may be helpful and can be useful. (quoting Planned Parenthood of Cent. Mo. v. Danforth, 428 U.S. 52, 80 81 (1976))). In sum, Wisconsin need offer only a conceivable state of facts that could provide a rational basis for requiring abortion physicians to have hospital admission privileges. Abbott, 734 F.3d at 411 (quoting F.C.C., 508 U.S. at 313). No. 13-2726 29 The Medical Professions Support for Admitting Privileges In 2003, the American College of Surgeons issued a statement on patient-safety principles that reflected a consensus in the surgical community on a set of 10 core principles that states should examine when moving to regulate office-based procedures. 1 These principles were based on a document that was unanimously agreed to by medical associations of every stripe, including the American Medical Association and the American College of Obstetricians and Gynecologists. Core Principle #4 provides that [p]hysicians performing office-based surgery must have admitting privileges at a nearby hospital, a transfer agreement with another physician who has admitting privileges at a nearby hospital, or maintain an emergency transfer agreement with a nearby hospital. Unsurprisingly, the National Abortion Federation has specifically recommended that [i]n the case of emergency, the doctor should be able to admit patients to a nearby hospital (no more than 20 minutes away). National Abortion Federation, Having an Abortion? Your Guide to Good Care (2000) (pamphlet), available at http://web.archive.org/web/20000619200916/http:// www.prochoice.org/pregnant/goodcare.htm (internet archive of NAF website on June 19, 2000) (hereinafter, NAF Guide to Good Care ). This should be sufficient to establish that Wiscon- 1 See American College of Surgeons, Statement on Patient Safety Principles for Office-based Surgery Utilizing Moderate Sedation/Analgesia, Deep Sedation/Analgesia, or General Anesthesia, Bulletin of the American College of Surgeons, Vol. 89, No. 4 (Apr. 2004), available at http://www.facs.org/ fellows_info/statements/st-46.html (last visited on Dec. 12, 2013, as were the other websites cited in this opinion). 30 No. 13-2726 sin s admitting-privileges requirement is reasonably designed to promote the state s legitimate interest in women s health. And, as the court recognizes, Wisconsin is one of twelve states adopting such a requirement. Maj. Op. at 9. The Benefits of Admitting Privileges in an Emergency Situation Further, the parties agree that at least a small number of abortions result in complications that require hospitalization.2 Wisconsin offers doctors declarations establishing that the admitting-privileges requirement expedites the admission process and avoids mis-communications between the patient and the hospital in situations where swift treatment is critical. See J.A. 149 50, ¶¶ 12 19 (Decl. of Dr. James Anderson); 175 76, ¶ 14 (Decl. of Dr. Matthew Lee); 184, ¶ 9 (Decl. of Dr. Linn); 237 38, ¶¶ 6 12 (Decl. of Dr. David C. Merrill); 332 33, ¶¶ 25 31 (Decl. of Dr. John Thorp); see also Darrell J. Solet, MD, et al., Lost in Translation: Challenges and Opportunities to Physician-to-Physician Communication During Patient Handoffs, 80 Academic Medicine 1094, 1097 (Dec. 2005) (observing, in the 2 The exact percentage is in dispute, but at least .3% of abortions result in complications requiring hospitalization. In Wisconsin, this amounts to a woman requiring hospitalization as a result of an abortion or attempted abortion every 16 days. As the court recognizes, however, this percentage is likely artificially low due to under-reporting. Maj. Op. at 7. When a woman is admitted to a hospital without a request for admission from an abortion doctor, the social stigmas associated with abortion will likely cause her to report her complications as arising from a miscarriage or other mishap rather than a botched abortion. See also Abbott, 734 F.3d at 412 (quoting Dr. John Thorp regarding the unique nature of an elective pregnancy termination and its likely under-reported morbidity and mortality ); J.A. 183, ¶ 6 & n.1 (Decl. of Dr. Linn). No. 13-2726 31 context of patient transfers, that poor communication in medical practice turns out to be one of the most common causes of error ). After all, the abortion doctor is better acquainted with his patient s medical history and is in a better position to quickly diagnose complications resulting from the procedure. See J.A. 238, ¶ 12 (Decl. of Dr. Merrill); 332, ¶ 25 (Decl. of Dr. Thorp). Additionally, the admitting-privileges requirement ensures that a physician will have the authority to admit his patient into a hospital whose resources and facilities are familiar to him ¦ . Women s Health Ctr. of W. Cnty., Inc. v. Webster, 871 F.2d 1377, 1381 (8th Cir. 1989) (quotation marks omitted). The Oversight Function of the Admitting-Privileges Requirement Moreover, [t]he requirement that physicians performing abortions must have hospital admitting privileges helps to ensure that credentialing of physicians beyond initial licensing and periodic license renewal occurs. 3 Abbott, 734 F.3d at 411. Thus, Wisconsin s admitting-privileges requirement adds an extra layer of protection for all of the patients of abortion 3 The court expresses doubts about this justification because Wisconsin requires that the hospital be within 30 miles of the clinic at which the doctor performs the abortions. Under rational basis review, however, the [selected means] need not be the most narrowly tailored means available to achieve the desired end. Zehner v. Trigg, 133 F.3d 459, 463 (7th Cir. 1997); see also American College of Surgeons, supra note 1 ( Physicians performing office-based surgery must have admitting privileges at a nearby hospital, a transfer agreement with another physician who has admitting privileges at a nearby hospital, or maintain an emergency transfer agreement with a nearby hospital. ) (emphasis added); NAF Guide to Good Care (recommending admitting privileges at a hospital no more than 20 minutes away ). 32 No. 13-2726 doctors. Indeed, every circuit to address the issue has held that admitting-privileges requirements further states legitimate interests. Abbott, 734 F.3d at 412 ( We have little difficulty in concluding that, with regard to the district court s rational basis determination, the State has made a strong showing that it is likely to prevail on the merits. ); Greenville Women s Clinic v. Comm r, S.C. Dep t of Health & Envtl. Control, 317 F.3d 357, 363 (4th Cir. 2002) ( These requirements of having admitting privileges at local hospitals and referral arrangements with local experts are so obviously beneficial to patients. ); Webster, 871 F.2d at 1381 (Missouri s admitting-privileges requirement furthers important state health objectives. ). Admitting Privileges and Other Outpatient Surgeries The court emphasizes the fact that Wisconsin has not imposed an admitting-privileges requirement on doctors who perform outpatient procedures other than abortion. But the plaintiffs bear the burden of proof and have offered no evidence that doctors in those other fields have a lack of admitting privileges as do abortion doctors which would necessitate a legislative response. Moreover, there is no mandate that state legislatures uniformly regulate medical procedures or regulate medical procedures with higher or even the highest incidents of complications. States may select one phase of one field and apply a remedy there, neglecting the others. Williamson v. Lee Optical of Okla. Inc., 348 U.S. 483, 489 (1955). Finally, Wisconsin had a perfectly good reason for addressing abortion first namely, the Gosnell scandal. No. 13-2726 33 The Dr. Kermit Gosnell Scandal There has been no high-profile exposure of substandard care by doctors who perform outpatient procedures other than abortion. However, just a few weeks prior to the enactment of Wisconsin s admitting-privileges requirement, there was a shocking revelation of terrible conditions and procedures at an abortion clinic that received nationwide attention. On May 13, 2013, a Philadelphia abortion doctor, Dr. Kermit Gosnell, was convicted of three counts of first-degree murder for the death of three infants delivered alive but subsequently killed at his clinic. The record in this appeal contains articles extensively discussing the egregious health care practices at Dr. Gosnell s clinic leading up to his conviction. These include bloody floors and unlicensed employees conducting gynecological examinations and administering painkillers, resulting in the death of a patient. See J.A. 154 (Joann Loviglio, Abortion Doctor Suspended After Philadelphia Raid: Deplorable Conditions Reported At Kermit Gosnell s Office, The Huffington Post, Feb. 23, 2010, http:// www.huffingtonpost.com/2010/02/23/abortion-doctorsuspended_n_473963.html). In addition, media reports circulated that, among other things, Dr. Gosnell physically assaulted and performed a forced abortion on a minor and left fetal remains in a woman s uterus causing her excruciating pain.4 Although these details were first publicized after Dr. Gosnell s arrest in 2011, the case did not garner national 4 Jessica Hopper, Alleged Victim Calls Philadelphia Abortion Doc Kermit Gosnell a Monster , ABC News, Jan. 25, 2011, http://abcnews.go.com/US/allegedvictim-calls-philadelphia-abortion-doctor-kermit-gosnell/story? id=12731387&singlePage=true 34 No. 13-2726 attention until his trial in March 2013. Unsurprisingly, the case provoked shock and outrage, prompting a heightened concern for the health of women seeking abortions. In addition to Dr. Gosnell s case, Wisconsin identifies numerous other examples of egregious and substandard care by abortion providers and clinics. See Appendix to the Concurrence; J.A. 154 56. On June 4, 2013, Wisconsin Act 37, which contained the admitting-privileges requirement at issue in this appeal and also contained an ultrasound requirement, was introduced in the Wisconsin Senate. On June 12, the Act passed in the Senate. On June 13, the Act passed in the Assembly, where it was returned to the Senate and presented to the governor for his signature on July 3. On July 5, the Act was signed into law by the governor. This timeline demonstrates that Wisconsin legislators promptly responded to their constituents concerns. Wisconsin Act 37 was a response to the dangers (graphically illustrated by Dr. Gosnell s case) to women s health and the right to freely exercise their choice. The Interaction Between the Act s Admitting-Privileges and Ultrasound Requirements In addition, the admitting-privileges requirement furthers the Act s ultrasound requirement. See Wis. Stat. § 253.10(3)(c). Performing an ultrasound allows an abortion doctor to get a clear picture of the woman s pregnancy including the gestational age and size of the unborn child, whether there are twins, whether the heart is beating,5 and the orientation of the 5 Detecting a heartbeat enables the abortion doctor to determine whether (continued...) No. 13-2726 35 unborn child within the uterus which allows the doctor to anticipate any likely complications. The law requires that, absent an emergency, the woman receive an ultrasound at the clinic or elsewhere. Accordingly, regardless of where the ultrasound is performed, important and easily determinable facts about the pregnancy are available to the abortion doctor. Additionally, the ultrasound must be explained to the woman so that she can exercise her right to choose while fully informed.6 These benefits conferred by the ultrasound require 5 (...continued) the unborn child is still alive a serious concern in light of the prevalence of miscarriages. See National Institute of Health, National Library of Medicine, Miscarriage, http://www.nlm.nih.gov/medlineplus/ency/article/ 001488.htm ( Among women who know they are pregnant, the miscarriage rate is about 15-20%. ). Determining whether there is a beating heart is a crucial component to ensuring that a woman receives quality care. For example, if more than seven weeks have passed since the last menstrual cycle ( LMC ), and there is no fetal heartbeat, then the unborn child is almost certainly naturally deceased although a pregnancy test will continue to generate a positive result. In that situation, the woman must be fully informed about whether an abortion is still necessary because statesubsidized private health insurance and Medicaid which in most cases do not cover an abortion will generally cover the procedure for removing the remains. See Wis. Stat. Ann. § 632.8985 (prohibiting coverage of abortions by health plans offered through health benefit exchanges); Wis. Stat. Ann. § 20.927 (prohibiting state or municipal subsidies for the performance of abortions). 6 Wisconsin may also hope that a woman who sees the ultrasound picture of her unborn child and hears the heart beating will choose to carry the unborn child to term. But because the ultrasound requirement is not challenged in this case, Wisconsin does not assert its legitimate interest in (continued...) 36 No. 13-2726 ment are secured by the oversight function of the admittingprivileges requirement. Specifically, hospitals extending admitting privileges are given a role in ensuring that the new requirements for the protection of women s health and choice are observed by abortion doctors to prevent a substandard abortion care crisis in Wisconsin. Additionally, many abortion-seeking patients face uniquely challenging circumstances not faced by other surgery patients. Many are young and vulnerable. Some may be pressured by angry, disappointed parents or by a putative father shirking responsibility. And, as the court remarks, there is wide-spread social disapproval of abortion. Maj. Op. at 7. So the woman is likely seeking absolute privacy and has had little or no external consultation or advice. A legislature could rationally speculate that a surgical procedure commonly undergone by young and vulnerable patients under the influence of either direct or social pressures is in greater need of regulation. In summary, [t]he State may regulate the abortion procedure to the extent that the regulation reasonably relates to the preservation and protection of maternal health. City of Akron v. Akron Ctr. for Reprod. Health, 462 U.S. 416, 430 31 (1983) (quoting Roe v. Wade, 410 U.S. 113, 163 (1973)). That is what Wisconsin has done in this case, and its decision to do so by means of an admitting-privileges requirement is certainly rational. 6 (...continued) fetal life here. See Carhart, 550 U.S. at 145 (recognizing that the government has a legitimate and substantial interest in preserving and promoting fetal life pre-viability). No. 13-2726 37 Step 2: Undue Burden The court also suggests that the admitting-privileges requirement imposes significant burdens on women s ability to obtain abortions. At this second step, we must determine whether the [admitting privileges requirement has] the practical effect of imposing an undue burden on women s abortion rights. Karlin, 188 F.3d at 481. We cannot find the requirement unconstitutional unless the plaintiffs can show that the requirement will have the likely effect of preventing a significant number of women for whom the regulation is relevant from obtaining abortions. Id. In this case, because the requirement applies to all abortion doctors in the state, it affects all Wisconsin women who may seek abortions.7 See Abbott, 734 F.3d at 414. Therefore, the question is whether the requirement prevents a significant number of women from obtaining abortions. At this step too, the plaintiffs have the burden of proof. See Karlin, 188 F.3d at 485; Bryant, 222 F.3d at 171. In suggesting that Wisconsin s admitting-privileges requirement imposes an undue burden, the court emphasizes that it will temporarily force two abortion clinics to stop providing abortions and another clinic to cut the number of doctors by half, which could cause delays for women seeking abortions. Of course, this effect will only last until the doctors at these clinics obtain admitting privileges in accordance with 7 Thus, the district court erred because it limited its review to women living in the areas near the clinics that may be closed. 38 No. 13-2726 the law.8 Regardless, more than 70% of women in Wisconsin who seek abortions live in the southern counties near Milwaukee and Madison, where clinics will continue operating. See J.A. 292. Thus, to the extent the remaining clinics are unable to quickly adjust for the decreased supply of legally qualified abortion doctors, most Wisconsin women seeking abortions can travel to clinics in Illinois. Indeed, women living in the northern part of Wisconsin can seek abortions in Minnesota. For example, both Minneapolis and Duluth have abortion clinics.9 Thus, the admitting-privileges requirement itself will likely not prevent any woman from obtaining an abortion if she wishes to do so. See Bryant, 222 F.3d at 163, 170 72 (holding that increased costs, delays in the ability to obtain abortions, decreased availability of abortion clinics, [and] increased distances to travel to clinics do not constitute an undue burden). Any delays are merely the incidental effects of 8 The undue burden analysis is not concerned with any burden the law may place on abortion doctors, except insofar as the law burdens women s ability to obtain abortions. Any burden on women will vanish once abortion doctors obtain admitting privileges. 9 The district court thought that the availability of abortions in cities near the Wisconsin border was irrelevant. Although the Wisconsin law does not affect doctors performing abortions in Minnesota, the availability of nearbut-out-of-state abortions at least speaks to whether the admittingprivileges requirement has the practical effect of preventing a significant number of women from obtaining abortions. In our economy, crossing state lines to obtain services at a nearby urban center is common. Thus, state lines are unlikely to affect a woman s decision about where to get an abortion and the availability of abortion at out-of-state clinics should be considered in the undue burden analysis. No. 13-2726 39 abortion doctors obligation to come into compliance with the admitting-privileges requirement. The fact that the requirement has the incidental effect of making it more difficult or more expensive to procure an abortion cannot be enough to invalidate it. Casey, 505 U.S. at 874. And here, we are affirming the district court s decision to give abortion doctors a reasonable amount of time to obtain admitting privileges.10 The court is also concerned by the fact that (because of Wisconsin s 24-hour waiting law) some Wisconsin women live around 100 miles from the closest abortion clinic namely, those living in north-eastern Wisconsin and consequently, will have to traverse that distance four times to obtain abortions (if they cannot afford to spend the night at a local hotel).11 10 Now that some months have passed, Wisconsin abortion doctors have had sufficient time to come into compliance with the admitting-privileges requirement. The court suggests that disapproval for abortion may interfere with abortion doctors abilities to obtain admitting privileges at sectarian hospitals. Maj. Op. at 10 11. However, Lutheran and Jewish hospitals in Milwaukee allow abortions. J.A. 185, ¶ 13 (Decl. of Dr. James G. Linn). Furthermore, [w]hile Catholic hospitals do not permit abortions to be performed at their facilities, they do allow abortion providers staff membership. Id. ( I know for a fact that Catholic hospitals in Milwaukee have or have had abortion providers on their medical staffs. ). Although federal law prohibits sectarian hospitals from discriminating against abortion doctors when awarding admitting privileges, it seems reasonable that in light of Catholic social teaching Catholic hospitals would wish to grant admitting privileges to abortion doctors so that women injured by abortions would have better access to the compassionate medical care needed in that delicate circumstance. 11 The number of women who seek abortions living in the areas near the (continued...) 40 No. 13-2726 The court suggests that the time and costs of that travel will prevent a significant number of Wisconsin women from obtaining abortions. But the costs of traveling up to 100 miles on four different occasions pale in comparison to the cost of an abortion. The costs of travel are undoubtedly inconvenient, but an inconvenience even a severe inconvenience is not an undue burden. Karlin, 188 F.3d at 481; see also Casey, 505 U.S. at 874 ( The fact that a law which serves a valid purpose, one not designed to strike at the right itself, has the incidental effect of making it more difficult or more expensive to procure an abortion cannot be enough to invalidate it. ); Bryant, 222 F.3d at 163, 170 72. Moreover, in reversing a district court s decision to preliminarily enjoin Texas s admitting-privileges requirement, the Fifth Circuit recently held that [a]n increase in travel distance of less than 150 miles for some women is not an undue burden on abortion rights. Abbott, 734 F.3d at 415. Texas also imposes a 24-hour waiting requirement (which applies to any woman who lives within 100 miles of the clinic). See Tex. Health & Safety Code § 171.012(a)(4). Thus, under Abbott, Texas women could face an increase in travel distance of almost 400 miles. If an increase in travel distance of almost 400 miles is not an undue burden, it is difficult to see how a total travel distance of 11 (...continued) closed clinics is apparently very small compared to those living near the clinics that will continue to operate. Thus, the admitting-privileges requirement likely only will compel a few rural women to drive longer distances. So it is far from clear that a significant number of women will be prevented from obtaining abortions. No. 13-2726 41 about 400 miles could be. See also Bryant, 222 F.3d at 170 71 (finding that admitting-privileges requirement imposed no undue burden where, inter alia, an abortion clinic was still operating some 70 miles away ); Women s Med. Prof l Corp. v. Baird, 438 F.3d 595, 605 (6th Cir. 2006) (concluding, in an asapplied challenge to abortion regulation, that an increase in travel distance of 45 to 55 miles is not an undue burden). In summary, the plaintiffs have not demonstrated that the [admitting-privileges requirement] would be unconstitutional in a large fraction of relevant cases. Carhart, 550 U.S. at 167-68. The other circuits to address this issue have reached the same conclusion. See Abbott, 734 F.3d at 416, 419; Bryant, 222 F.3d at 159, 173. Conclusion The decision to have an abortion is, for many women, the most difficult decision they will ever make. Lizz Winstead, Abortion Is a Medical Procedure, The Huffington Post, Nov. 11, 2012, http://www.huffingtonpost.com/lizz-winstead/abortionis-a-medical-procedure_b_2064176.html. Therefore, when a woman enters an abortion clinic, she has a right to expect excellent care from a qualified doctor. One key component of quality care is the use of an ultrasound, which furnishes the abortion doctor with important and easily determinable facts about the pregnancy related to the woman s health and exercise of her free choice. For example, an ultrasound allows a determination of whether there is a fetal heartbeat, the gestational age and size of the unborn child, and whether there 42 No. 13-2726 are twins.12 An ultrasound is also material to the costs of the procedure inasmuch as it may reveal that an abortion is no longer necessary (if the unborn child is no longer alive) and because clinics base the cost of the abortion procedure on the unborn child s gestational age. The admitting-privileges requirement has an indisputable benefit when emergency care is needed. If serious complications arise, then the woman should be able to call her clinic and speak with the doctor who treated her. If that physician has admitting privileges, he or she can direct the woman to the hospital and meet her there, or at least contact the hospital and notify the proper admitting personnel to describe the possible causes of the woman s symptoms. Then, upon arrival at the hospital, the woman would be able to receive immediate care. And, if necessary, the hospital s doctor could contact the abortion doctor to confidentially obtain further details. Indeed, by requiring abortion doctors to commit to continued care, the admitting-privileges requirement prevents a situation where a hospital doctor is not fully aware of medical concerns because the patient does not wish to disclose that she had an abortion. Relatedly, the ability to obtain any followup care from same doctor furthers a patient s interest in privacy a significant concern given the social stigma associated with abortion. Moreover, the admitting-privileges requirement furthers the state s interest in preventing crises of substandard 12 If the ultrasound reveals twins, this result may cause a woman to reconsider or at least reflect on an unexpected circumstance. In either case, the ultrasound furthers her health and ability to make a fully informed decision. No. 13-2726 43 care. By entrusting hospitals with an oversight function, the requirement guards against worst-case scenarios. The notion that abortion doctors will be unable to obtain admitting privileges is a fiction. Some already have them.13 Even sectarian hospitals, apart from their legal duties, are interested in providing compassionate care to women who need it. Some hospitals may not allow elective or discretionary abortions to be performed on their premises, but even these hospitals have every reason to grant admitting privileges to abortion doctors in order to ensure that women in need receive adequate as well as compassionate medical care. At trial, testimony from a technician who routinely performs ultrasounds on pregnant women those who anticipate and look forward to having a baby as well as those who are considering terminating an unwanted pregnancy would be beneficial. A neutral technician could explain the value an ultrasound provides for women s health in order to further illustrate the oversight benefit of the admitting-privileges requirement. 13 According to the plaintiffs, Planned Parenthood s Milwaukee-Jackson clinic would be able to remain open even if the admitting-privileges requirement went into effect. Thus, at least one abortion doctor at that clinic must have admitting privileges at a nearby hospital. But Affiliated Medical Services clinic, which will allegedly close for lack of abortion doctors with admitting privileges, is only 1.3 miles away from Planned Parenthood s Milwaukee-Jackson clinic. So any claim that abortion doctors at AMS will be unable to obtain admitting privileges because of recalcitrant local hospitals is all but meritless. 44 No. 13-2726 Wisconsin s admitting-privileges requirement is rationally related to the State s legitimate interests and should not create an undue burden to Wisconsin women s right to abortion. But Wisconsin s failure to include a reasonable time for compliance merited a preliminary injunction. Therefore, I concur in part and concur in the judgment. No. 13-2726 45 Appendix to the Concurrence Dr. Soleiman Soli in Pennsylvania. See Mark Scolforo, Two Abortion Clinics Closed After Reports, The Washington Times, Mar. 10, 2011, http://www.washingtontimes.com/news/2011/ mar/10/2-abortion-clinics-closed-after-reports/ (two abortion clinics shut down when inspection revealed expired drugs, uncalibrated medical equipment, and untrained personnel; a network of abortion care providers described the clinics as women exploiters ). Dr. Andrew Rutland in California. See C. Perkes, Abortion Doctor Gives Up License Over Death, Orange County Register, Jan. 25, 2011, http://www.ocregister.com/articles/rutland285561-death-license.html (woman died where clinic was not equipped to handle emergencies and the abortion doctor failed to recognize [an allergic] reaction, adequately attempt resuscitation or promptly call 911. The doctor had previously given up his license after allegations of . . . scaring patients into unnecessary hysterectomies, botching surgeries, lying to patients, falsifying medical records, over-prescribing painkillers and having sex with a patient in his office. ). Dr. Albert Dworkin in Delaware. See Steven Ertelt, Hearing: Delaware Abortionist Helped Kermit Gosnell Avoid Law, LifeNews, Mar. 16, 2011, http://www.lifenews.com/2011/03/16/hearingdelaware-abortionist-helped-kermit-gosnell-avoid-law/ (doctor 46 No. 13-2726 complicit in Kermit Gosnell s violations has license suspended). Dr. James Pendergraft in Florida. See Steven Ertelt, Abortion Practitioner James Pendergraft Loses Florida License a Fourth Time, LifeNews, Jan. 1, 2009, http://www.lifenews.com/2009/01/01/ state-5339/ (abortion doctor s license suspended for fourth time for entrusting drug administration to unlicensed employee, previous suspensions included a botched abortion that resulted in the unborn child being shoved into the abdominal cavity and requiring that the woman receive a hysterectomy). The Gentilly Medical Clinic for Women and the Hope Medical Group for Women in Louisiana. See Steven Ertelt, Abortion Business in Louisiana Loses License for Poor Health, Safety Standards, LifeNews, Jan. 20, 2010, http://www.lifenews.com/ 2010/01/20/state-4743/ (clinic lost license for operating without trained nurse or proper drug license); P. J. Smith, Louisiana Abortion Clinic Shut Down for Ignoring Most Basic Medical Practices, LifeNews, Sep. 7, 2011, http://www.lifesitenews.com/ news/archive/ldn/2010/sep/10090707 (clinic s operations suspended for failing to observe the most basic medical practices including provid[ing] women a physical examination prior to abortions or follow[ing] necessary protocols for the administration of anesthesia and monitoring their clients vital signs ). Drs. Romeo Ferrer, George Shepard, Leroy Carhart, and Nicola Riley in Maryland. See, respectively, Steven Ertelt, No. 13-2726 47 Pro-Lifers Want Maryland Practitioner Disciplined, Killed Woman in Botched Abortion, LifeNews, June 1, 2010, http:// www.lifenews.com/2010/06/01/state-5145/ ( Board of Physician s Peer Reviewers concluded the woman s death resulted from Ferrer s failure to meet the standard of quality care in violation of state law. ); Steven Ertelt, Troubled Abortion Biz Sees Two Practitioners Lose Medical Licenses, LifeNews, Sept. 3, 2010, http://www.lifenews.com/2010/09/03/state-5416/ (transfer of patient of botched abortion in a rental car to a clinic in another state leads to the discovery, and suspension, of two doctors circumventing state law); Authorities: Woman Died from Abortion Complications, June 12, 2013, http://www.usatoday.com/story/ news/nation/2013/02/21/woman-late-term-abortion-bledtodeath/1935799/ (Dr. Carhart is under investigation for the death of Jennifer Morbelli, a 29 year-old school teacher who underwent a late-term abortion); The order is available at http://abortiondocs.org/wp-content/uploads/2013/05/ Nicola-Riley-MD-Permanent-Revocation-May-6-2013.pdf (order permanently revoking Dr. Nicola Riley s medical license Maryland after she failed to call for emergency help for a critically injured abortion patient and transported her to the hospital in the backseat of a rental car). Dr. Steven Brigham in Maryland, New Jersey, and Pennsylvania. See N.J. Targets Abortion Doctor Steven Brigham s License, Lehigh Valley Live, Sept. 9, 2010, http://www.lehighvalleylive. com/phillipsburg/index.ssf/2010/09/nj_targets_abortion_ doctor_ste.html (New Jersey seeks to take doctor s license after Maryland already took his license for risky interstate abortion scheme). 48 No. 13-2726 Dr. Rapin Osathanondh in Massachusetts. See Denise Lavoie, Doctor Gets 6 Months in Abortion Patient Death, Associated Press, Sep. 14, 2010, http://www.msnbc.msn.com/id/ 39177186/ns/us_news-crime_and_courts/t/doctor-gets-monthsabortion-patientdeath/ (doctor sentenced to six months in jail for involuntary manslaughter because he failed to monitor [abortion patient] while she was under anesthesia, delayed calling emergency services when her heart stopped, and later lied to try to cover up his actions. ). Dr. Alberto Hodari in Michigan. See Schuette Files Suit to Close Unlicensed Abortion Clinic, Office of the Attorney General, State of Michigan, Mar. 29, 2011, http://www.michigan.gov/ag/ 0,4534,7-164--253426--,00.html (Michigan Attorney General sues to close abortion clinic for failing to comply with health and safety rules applicable to surgical outpatient facilities). Drs. Salomon Epstein and Robert Hosty in New York. See Steven Ertelt, Practitioner Denies He Botched Legal Abortion That Killed Hispanic Woman, LifeNews, Mar. 1, 2010, http:// www.lifenews.com/2010/03/01/state-4858/ (New York police investigate doctor after 37-year-old patient dies in botched abortion); http://operationrescue.org/pdfs/Hosty%20 revocation.pdf (eventually, responsibility for the death Dr. Epstein was investigated for was attributed to another doctor at the clinic, Dr. Hosty, whose license was revoked in this order); Southwestern Women Options in New Mexico, see Jeremy Kryn, New 911 Call from New Mexico Abortion Clinic Exposes Pattern of Emergencies, LifeNews, Oct. 20, 2011, http:// No. 13-2726 49 www.lifesitenews.com/news/new-911-call-from-new-mexicoabortion-clinic-exposes-pattern-of-emergencies ( A recording of a 911 call . . . highlights the continuing danger [at] an Albuquerque abortion clinic . . . . The call is the eleventh emergency call [from the clinic] in less than two years . . . . it was transcribed as follows, Uh, we have a 31-year-old female who underwent an abortion today. She s continuing to bleed. We need to transfer her to the hospital, please . . . . The bleeding is persistent. It will not stop. ). Dr. Tami Lynn Holst Thorndike in North Dakota. See Denise Burke, North Dakota Abortionist Practices With Expired License, Americans United for Life, Nov. 8, 2010, http:// www.aul.org/2010/11/north-dakota-abortionist-practices-withexpired-license/ ( [A] North Dakota abortionist is being investigated for practicing with an expired license. ). Drs. Robert E. Hanson Jr., Margaret Kini, Douglas Karpen, Pedro J. Kowalyszyn, Sherwood C. Lynn Jr., Alan Molson, Robert L. Prince, H. Brook Randal, Franz Theard, and William W. West, Jr. of Whole Women Health in Texas. See Steven Ertelt, Tenth Texas Abortion Practitioner Under State Investigation, LifeNews, Aug. 24, 2011, http://www.lifenews.com/2011/08/24/ tenth-texas-abortion-practitioner-under-state-investigation/ (abortion center investigated for illegal dumping of patient records and medical waste ). 50 No. 13-2726 Dr. Thomas Walter Tucker II in Alabama and Mississippi. See Abortion Doctor Suspended for Improper Drug Storage, Orlando Sentinel, Apr. 24, 1994, http://articles.orlandosentinel. com/1994-04-24/news/9404240462_1_abortion-doctor-tucker -licensing (Dr. Tucker lost his medical license for drug-storage violations, and was subsequently found liable for $10 million in a medical malpractice case involving the death of an abortion patient. See Former Abortion Doctor Ordered to Pay $10 Million, Sun Herald, Dec. 8, 1996, 1996 WLNR 256209). Dr. Mi Yong Kim in New York and Virginia. See Operation Rescue, Troubled Virginia Abortion Clinic Puts Bleeding Botched Abortion Patient in Hospital, LifeSiteNews, Apr. 20, 2012, http:// www.lifesitenews.com/news/troubled-virginia-abortion-clinicputs-bleeding-botched-abortion-patient-in/ (patient put in hospital after abortion at clinic run by a doctor whose license had been surrendered. The surrender order available at http:// abortiondocs.org/wp-content/uploads/2012/04/Kim-VALicense-Surrender05182007.pdf.).