Judges: Rovner
Filed: Jul. 25, 2018
Latest Update: Mar. 03, 2020
Summary: In the United States Court of Appeals For the Seventh Circuit _ No. 17 1883 PLANNED PARENTHOOD OF INDIANA AND KENTUCKY, INC., Plaintiff Appellee, v. COMMISSIONER OF THE INDIANA STATE DEPARTMENT OF HEALTH, et al., Defendants Appellants. _ Appeal from the United States District Court for the Southern District of Indiana, Indianapolis Division. No. 1:16 cv 01807 — Tanya Walton Pratt, Judge. _ ARGUED NOVEMBER 6, 2017 — DECIDED JULY 25, 2018 _ Before BAUER, KANNE, and ROVNER, Ci
Summary: In the United States Court of Appeals For the Seventh Circuit _ No. 17 1883 PLANNED PARENTHOOD OF INDIANA AND KENTUCKY, INC., Plaintiff Appellee, v. COMMISSIONER OF THE INDIANA STATE DEPARTMENT OF HEALTH, et al., Defendants Appellants. _ Appeal from the United States District Court for the Southern District of Indiana, Indianapolis Division. No. 1:16 cv 01807 — Tanya Walton Pratt, Judge. _ ARGUED NOVEMBER 6, 2017 — DECIDED JULY 25, 2018 _ Before BAUER, KANNE, and ROVNER, Cir..
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In the
United States Court of Appeals
For the Seventh Circuit
____________________ȱ
No.ȱ17Ȭ1883ȱ
PLANNEDȱPARENTHOODȱOFȱINDIANAȱȱ
ANDȱKENTUCKY,ȱINC.,ȱ
PlaintiffȬAppellee,ȱ
v.ȱ
COMMISSIONERȱOFȱTHEȱINDIANAȱSTATEȱȱ
DEPARTMENTȱOFȱHEALTH,ȱetȱal.,ȱ
DefendantsȬAppellants.ȱ
____________________ȱ
AppealȱfromȱtheȱUnitedȱStatesȱDistrictȱCourtȱforȱtheȱ
SouthernȱDistrictȱofȱIndiana,ȱIndianapolisȱDivision.ȱ
No.ȱ1:16ȬcvȬ01807ȱ—ȱTanyaȱWaltonȱPratt,ȱJudge.ȱ
____________________ȱ
ARGUEDȱNOVEMBERȱ6,ȱ2017ȱ—ȱDECIDEDȱJULYȱ25,ȱ2018ȱ
____________________ȱ
BeforeȱBAUER,ȱKANNE,ȱandȱROVNER,ȱCircuitȱJudges.ȱ
ROVNER,ȱCircuitȱJudge.ȱSinceȱ1995,ȱtheȱStateȱofȱIndianaȱhasȱ
requiredȱthat,ȱatȱleastȱeighteenȱhoursȱbeforeȱaȱwomanȱhasȱanȱ
abortion,ȱ sheȱ mustȱ beȱ givenȱ informationȱ providedȱ byȱ theȱ
Stateȱ about,ȱ amongȱ otherȱ things,ȱ theȱ procedure,ȱ factsȱ aboutȱ
theȱ fetusȱ andȱ itsȱ development,ȱ andȱ alternativesȱ toȱ abortion.ȱ
ThatȱinformationȱisȱmeantȱtoȱadvanceȱtheȱState’sȱassertedȱinȬ
2ȱ No.ȱ17Ȭ1883ȱ
terestȱinȱpromotingȱfetalȱlife.ȱInȱotherȱwords,ȱtheȱStateȱhopesȱ
thatȱ womenȱ whoȱ readȱ thatȱ informationȱ andȱ considerȱ itȱ willȱ
optȱnotȱtoȱhaveȱanȱabortion,ȱandȱwill,ȱinstead,ȱchooseȱtoȱcarȬ
ryȱ theȱ pregnancyȱ toȱ term.ȱ Afterȱ sheȱ hasȱ receivedȱ theȱ manȬ
datedȱ information,ȱ aȱ womanȱ mustȱ waitȱ atȱ leastȱ eighteenȱ
hoursȱ beforeȱ havingȱ anȱ abortion,ȱ thus,ȱ theȱ Stateȱ hopes,ȱ sheȱ
willȱ useȱ theȱ timeȱ toȱ reflectȱ uponȱ herȱ choiceȱ andȱ chooseȱ toȱ
continueȱherȱpregnancy.ȱTheȱStateȱalsoȱrequiresȱthatȱaȱwomȬ
anȱ haveȱ anȱ ultrasoundȱ andȱ hearȱ theȱ fetalȱ heartbeatȱ priorȱ toȱ
anȱabortionȱalthoughȱsheȱmayȱdeclineȱtheȱopportunityȱtoȱdoȱ
oneȱorȱboth,ȱasȱ75%ȱofȱwomenȱgenerallyȱdo.1ȱȱ
Priorȱ toȱ Julyȱ 1,ȱ 2016,ȱ womenȱ could,ȱ andȱ generallyȱ did,ȱ
haveȱtheȱultrasoundȱonȱtheȱsameȱdayȱofȱtheȱprocedure.ȱThisȱ
was,ȱ inȱ largeȱ part,ȱ becauseȱ almostȱ allȱ abortionsȱ inȱ Indianaȱ
occurȱ atȱ oneȱ ofȱ fourȱ Plannedȱ Parenthoodȱ ofȱ Indianaȱ andȱ
Kentuckyȱ(PPINK)ȱhealthȱcenters,ȱandȱonlyȱthoseȱfewȱPPINKȱ
facilitiesȱ thatȱ offerȱ abortionȱ servicesȱ (mostȱ doȱ not)ȱ hadȱ theȱ
ultrasoundȱ equipmentȱ onȱ site.ȱ Theȱ Indianaȱ Houseȱ Enrolledȱ
Actȱ 1337ȱ (HEAȱ 1337),ȱ however,ȱ amendedȱ Indianaȱ lawȱ andȱ
nowȱrequiresȱwomenȱtoȱundergoȱanȱultrasoundȱprocedureȱatȱ
leastȱ eighteenȱ hoursȱ priorȱ toȱ theȱ abortion.ȱ Becauseȱ ofȱ theȱ
structureȱandȱlocationȱofȱabortionȱservicesȱinȱIndianaȱandȱtheȱ
populationȱ ofȱ womenȱ seekingȱ abortions,ȱ thisȱ change—
movingȱ theȱ ultrasoundȱ fromȱ theȱ dayȱ ofȱ theȱ abortionȱ proceȬ
dureȱtoȱatȱleastȱeighteenȱhoursȱbefore—asȱweȱwillȱexplore,ȱisȱ
significant.ȱȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
1ȱPriorȱtoȱ2011,ȱtheȱlawȱrequiredȱthatȱpriorȱtoȱanȱabortionȱtheȱwomanȱbeȱ
shownȱanȱultrasoundȱ“uponȱtheȱwoman’sȱrequest.”ȱP.L.ȱ193Ȭ2011,ȱSec.ȱ9.ȱ
Inȱ2011ȱtheȱlegislatureȱamendedȱtheȱstatuteȱtoȱrequireȱthatȱtheȱwomanȱbeȱ
shownȱ theȱ ultrasoundȱ unlessȱ sheȱ certifiedȱ inȱ writingȱ thatȱ sheȱ didȱ notȱ
wantȱto.ȱȱ
No.ȱ17Ȭ1883ȱ 3
PPINKȱfiledȱsuitȱagainstȱtheȱCommissionerȱofȱtheȱIndianaȱ
Stateȱ Departmentȱ ofȱ Healthȱ andȱ theȱ prosecutorsȱ ofȱ Marionȱ
County,ȱ Lakeȱ County,ȱ Monroeȱ County,ȱ andȱ Tippecanoeȱ
Countyȱ (collectively,ȱ“theȱState”),ȱallȱ inȱ theirȱ officialȱ capaciȬ
ties.2ȱPPINKȱclaimedȱthatȱHEAȱ1337ȱunconstitutionallyȱburȬ
densȱ aȱ woman’sȱ rightȱ toȱ chooseȱ toȱ haveȱ anȱ abortion,ȱ andȱ itȱ
soughtȱpreliminaryȱreliefȱenjoiningȱtheȱprovisionȱduringȱtheȱ
pendencyȱofȱtheȱlitigation.ȱTheȱdistrictȱcourtȱgrantedȱtheȱpreȬ
liminaryȱ injunction.ȱ Weȱ agreeȱ withȱ theȱ wellȬreasonedȱ conȬ
clusionsȱofȱtheȱdistrictȱcourtȱopinion,ȱfromȱwhichȱweȱborrowȱ
heavily.ȱ
I.ȱ
A.ȱ Backgroundȱinformationȱ
1.ȱ Theȱnewȱlawȱ
Indianaȱ Codeȱ §ȱ 16Ȭ34Ȭ2Ȭ1.1ȱ mandatesȱ thatȱ atȱ leastȱ eightȬ
eenȱ hoursȱpriorȱ toȱ theȱabortionȱ procedure,ȱtheȱ patientȱmustȱ
beȱprovidedȱwithȱtheȱ followingȱinformationȱ(amongȱothers)ȱ
bothȱorallyȱandȱinȱwriting:ȱ“thatȱhumanȱphysicalȱlifeȱbeginsȱ
whenȱ aȱ humanȱ ovumȱ isȱ fertilizedȱ byȱ aȱ humanȱ sperm;”ȱ theȱ
probableȱgestationalȱageȱofȱtheȱfetusȱatȱtheȱtimeȱtheȱabortionȱ
isȱtoȱbeȱperformed,ȱincludingȱaȱpictureȱofȱtheȱfetusȱatȱcertainȱ
gestationalȱages,ȱandȱotherȱinformationȱaboutȱtheȱfetusȱatȱitsȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
2ȱCourtsȱhaveȱlongȱdeclaredȱthatȱabortionȱprovidersȱhaveȱstandingȱtoȱsueȱ
toȱ enjoinȱ lawsȱ thatȱ restrictȱ abortion.ȱ Plannedȱ Parenthoodȱ ofȱ Wisc.,ȱ Inc.ȱ v.ȱ
Schimel,ȱ806ȱF.3dȱ908,ȱ910ȱ(7thȱCir.ȱ2015).ȱ“Theseȱcasesȱemphasizeȱnotȱtheȱ
harmȱ toȱ theȱ abortionȱ clinicȱ ofȱ makingȱ abortionsȱ veryȱ difficultȱ toȱ obtainȱ
legally,ȱ thoughȱ thatȱ mightȱ beȱ anȱ alternativeȱ groundȱ forȱ recognizingȱ aȱ
clinic’sȱ standing,ȱ butȱ ratherȱ theȱ confidentialȱ natureȱ ofȱ theȱ physicianȬ
patientȱrelationshipȱandȱtheȱdifficultyȱforȱpatientsȱofȱdirectlyȱvindicatingȱ
theirȱ rightsȱ withoutȱ compromisingȱ theirȱ privacy.”ȱ Id.ȱ (internalȱ citationsȱ
omitted).ȱȱ
4ȱ No.ȱ17Ȭ1883ȱ
currentȱ stageȱ ofȱ development;ȱ noticeȱ thatȱ theȱ fetusȱ canȱ feelȱ
painȱatȱorȱbeforeȱtwentyȱweeks;ȱinformationȱaboutȱtheȱrisksȱ
ofȱ abortionȱ andȱ ofȱ carryingȱ theȱ fetusȱ toȱ term,ȱ andȱ inforȬ
mationȱregardingȱalternativesȱtoȱabortionȱandȱotherȱsupportȱ
servicesȱavailable.ȱInd.ȱCodeȱ §ȱ16Ȭ34Ȭ2Ȭ1.1(a)(1)Ȭ(2).ȱAȱwomȬ
anȱ seekingȱ anȱ abortionȱ mustȱ alsoȱ receiveȱ aȱ colorȱ copyȱ ofȱ aȱ
brochure,ȱauthoredȱandȱdistributedȱbyȱtheȱIndianaȱStateȱDeȬ
partmentȱ ofȱ Health,ȱ thatȱ containsȱ allȱ ofȱ thisȱ sameȱ inforȬ
mation.ȱ Theȱ Stateȱ controlsȱ everyȱ aspectȱ ofȱ theȱ informationȱ
conveyedȱtoȱpatientsȱviaȱthisȱbrochure—fromȱtheȱdrawings,ȱ
toȱ theȱ color,ȱ informationȱ aboutȱ development,ȱ andȱ wordingȱ
ofȱtheȱrisksȱofȱtheȱprocedures.ȱNeitherȱtheȱ brochureȱnorȱtheȱ
informedȬconsentȱ informationȱ hasȱ beenȱ challengedȱ inȱ thisȱ
litigation.ȱȱ
Priorȱtoȱtheȱenactmentȱofȱtheȱchallengedȱlaw,ȱIndianaȱreȬ
quiredȱthatȱ“[b]eforeȱanȱabortionȱisȱperformed,ȱtheȱproviderȱ
shallȱperform,ȱandȱtheȱpregnantȱwomanȱshallȱview,ȱtheȱfetalȱ
ultrasoundȱ imagingȱ andȱ hearȱ theȱ auscultationȱ ofȱ theȱ fetalȱ
heartȱtoneȱifȱtheȱfetalȱheartȱtoneȱisȱaudible,”ȱunlessȱtheȱpregȬ
nantȱ womanȱ certifiedȱ inȱ writing,ȱ onȱ aȱ formȱ draftedȱ byȱ theȱ
Indianaȱ Stateȱ Departmentȱ ofȱ Health,ȱ thatȱ sheȱ declinedȱ toȱ
viewȱ theȱ ultrasoundȱ orȱ hearȱ theȱ fetalȱ heartȱ tone.ȱ Ind.ȱ Codeȱ
§ȱ16Ȭ34Ȭ2Ȭ1.1(b)ȱ(2011).ȱInȱotherȱwords,ȱtheȱproviderȱmustȱofȬ
ferȱ theȱ ultrasound,ȱ butȱ aȱ womanȱ mayȱ affirmativelyȱ decline.ȱ
Priorȱ toȱ 2011ȱ theȱ providerȱ didȱ notȱ haveȱ toȱ offerȱ theȱ ultraȬ
sound,ȱbutȱonlyȱhadȱtoȱprovideȱoneȱifȱspecificallyȱrequestedȱ
byȱtheȱwoman.ȱP.L.ȱ193Ȭ2011,ȱSec.ȱ9.ȱInȱfiscalȱyearȱ2016,ȱonlyȱ
approximatelyȱ 25%ȱ ofȱ womenȱ seekingȱ abortionȱ servicesȱ
choseȱ toȱ viewȱ theirȱ ultrasoundȱ imagesȱ andȱ onlyȱ approxiȬ
matelyȱ 7%ȱ choseȱ toȱ listenȱ toȱ theȱ fetalȱ heartȱ tone.ȱ Mostȱ imȬ
portantlyȱ forȱ thisȱ litigation,ȱ beforeȱ 2016,ȱ theȱ statuteȱ didȱ notȱ
mandateȱ whenȱ theȱ ultrasoundȱ mustȱ occur,ȱ otherȱ thanȱ priorȱ
No.ȱ17Ȭ1883ȱ 5
toȱ theȱ abortion.ȱ Asȱ aȱ practicalȱ matter,ȱ however,ȱ theȱ ultraȬ
soundȱ proceduresȱ wereȱ performedȱ justȱ beforeȱ theȱ abortion.ȱ
Ultrasoundȱ equipmentȱ isȱ expensiveȱ andȱ scarce.ȱ Notȱ allȱ
PPINKȱ locationsȱ haveȱ it,ȱ but,ȱ atȱ theȱ timeȱ theȱ newȱ lawȱ wasȱ
enacted,ȱ theȱ fourȱ locationsȱ thatȱ performȱ abortionsȱ hadȱ theȱ
equipment.ȱ Althoughȱ patientsȱ canȱ receiveȱ theirȱ informedȬ
consentȱ consultationsȱ atȱ anyȱ oneȱ ofȱ theȱ seventeenȱ PPINKȱ
healthȱ centersȱ throughoutȱ Indiana,ȱ abortionsȱ areȱ performedȱ
onlyȱatȱfourȱlocationsȱthroughoutȱIndianaȱ(surgicalȱabortionsȱ
areȱ availableȱ onlyȱ atȱ threeȱ locations).ȱ Therefore,ȱ toȱ preventȱ
womenȱ fromȱ havingȱ toȱ travelȱ farȱ distancesȱ eighteenȱ hoursȱ
apart,ȱprovidersȱperformedȱtheȱultrasoundȱonȱtheȱdayȱofȱtheȱ
abortionȱ procedureȱ atȱ oneȱ ofȱ theȱ fourȱ facilitiesȱ thatȱ hadȱ ulȬ
trasoundȱandȱperformedȱabortions.ȱȱ
Theȱ newȱ statute,ȱ however,ȱ preventsȱ thisȱ practice.ȱ Itȱ reȬ
quiresȱtheȱfollowing:ȱ
Atȱleastȱeighteenȱ(18)ȱhoursȱbeforeȱanȱabortionȱ
isȱ performedȱ andȱ atȱ theȱ sameȱ timeȱ thatȱ theȱ
pregnantȱ womanȱ receivesȱ theȱ informationȱ reȬ
quiredȱ byȱ subdivisionȱ (1),ȱ theȱ providerȱ shallȱ
perform,ȱ andȱ theȱ pregnantȱ womanȱ shallȱ view,ȱ
theȱfetalȱultrasoundȱimagingȱandȱhearȱtheȱausȬ
cultationȱofȱtheȱfetalȱheartȱtoneȱifȱtheȱfetalȱheartȱ
toneȱisȱaudibleȱunlessȱtheȱpregnantȱwomanȱcerȬ
tifiesȱ inȱ writing,ȱ onȱ aȱ formȱ developedȱ byȱ theȱ
stateȱ department,ȱ beforeȱ theȱ abortionȱ isȱ perȬ
formed,ȱthatȱtheȱpregnantȱwoman:ȱ
(A)ȱdoesȱnotȱwantȱtoȱviewȱtheȱfetalȱultrasoundȱ
imaging;ȱandȱ
6ȱ No.ȱ17Ȭ1883ȱ
(B)ȱ doesȱ notȱ wantȱ toȱ listenȱ toȱ theȱ auscultationȱ
ofȱ theȱ fetalȱ heartȱ toneȱ ifȱ theȱ fetalȱ heartȱ toneȱ isȱ
audible.ȱ
Ind.ȱ Codeȱ Ann.ȱ §ȱ 16Ȭ34Ȭ2Ȭ1.1(a)(5).ȱ PPINKȱ arguesȱ thatȱ thisȱ
requirementȱ undulyȱ burdensȱ aȱ woman’sȱ rightȱ toȱ anȱ aborȬ
tion.ȱBecauseȱPPINK’sȱargumentȱisȱbasedȱonȱtheȱfactualȱconȬ
text,ȱitȱisȱcriticalȱfirstȱtoȱunderstandȱhowȱPPINKȱhealthȱcenȬ
tersȱoperateȱandȱwhereȱtheyȱareȱlocated.ȱȱ
2.ȱ PPINKȱfacilitiesȱ
Atȱtheȱtimeȱtheȱlawȱsuitȱbegan,ȱPPINKȱoperatedȱtwentyȬ
threeȱhealthȱcentersȱinȱIndiana.ȱDueȱtoȱfinancialȱconstraints,ȱ
thatȱ numberȱ hasȱ sinceȱ dwindledȱ toȱ seventeen.ȱ Onlyȱ fourȱ ofȱ
theȱcentersȱofferȱabortionȱservices—Bloomington,ȱIndianapoȬ
lis,ȱMerrillvilleȱandȱLafayette—theȱlatterȱofȱwhichȱoffersȱonlyȱ
nonȬsurgicalȱabortionsȱusingȱmedication.ȱOfȱtheȱcentersȱthatȱ
offerȱabortionȱservices,ȱtheȱtimesȱtheseȱservicesȱareȱavailableȱ
areȱ exceptionallyȱ limited.ȱ Inȱ Indianapolis,ȱ abortionȱ servicesȱ
areȱonlyȱavailableȱthreeȱdaysȱperȱweek;ȱinȱMerrillville,ȱaȱdayȱ
andȱaȱhalfȱperȱweek;ȱandȱinȱBloomingtonȱandȱLafayette,ȱonlyȱ
oneȱdayȱaȱweek.ȱR.ȱ24Ȭ1ȱatȱ6.ȱPPINKȱwillȱperformȱaȱsurgicalȱ
abortionȱonlyȱuntilȱthirteenȱweeksȱandȱsixȱdaysȱafterȱtheȱfirstȱ
dayȱofȱaȱwoman’sȱlastȱmenstrualȱperiod.ȱItȱwillȱprovideȱmedȬ
icationȱ abortionsȱ onlyȱ untilȱ sixtyȬthreeȱ daysȱ afterȱ theȱ firstȱ
dayȱ ofȱ aȱ woman’sȱ lastȱ menstrualȱ period.ȱ Womenȱ whoȱ areȱ
pushingȱ upȱ againstȱ theȱ timeȱ deadlineȱ mayȱ notȱ beȱ ableȱ toȱ
waitȱ untilȱ aȱ providerȱ isȱ availableȱ atȱ theȱ facilityȱ closestȱ toȱ
them,ȱbutȱmayȱneedȱtoȱtravelȱtoȱaȱmoreȱdistantȱfacilityȱwhereȱ
aȱ timelyȱ appointmentȱ canȱ beȱ made.ȱ Theȱ thirteenȱ PPINKȱ
healthȱcentersȱthatȱdoȱnotȱprovideȱabortionȱservicesȱprovideȱ
wellȬwomenȱexaminations,ȱscreeningȱforȱcancerȱandȱsexuallyȱ
No.ȱ17Ȭ1883ȱ 7
transmittedȱdiseases,ȱtreatmentȱforȱsexuallyȱtransmittedȱdisȬ
easesȱandȱotherȱpreventativeȱhealthȱcare.ȱ
Thereȱ areȱ noȱ clinicsȱ inȱ Indianaȱ thatȱ performȱ abortionsȱ
pastȱtheseȱdates.ȱTheȱonlyȱprovidersȱofȱabortionȱservicesȱafȬ
terȱ theseȱ datesȱ areȱ hospitalsȱ andȱ surgicalȱ centersȱ (allȱ ofȱ
whichȱhappenȱtoȱbeȱlocatedȱinȱIndianapolis)ȱandȱthoseȱfaciliȬ
tiesȱgenerallyȱonlyȱprovideȱabortionsȱthatȱareȱmedicallyȱindiȬ
catedȱ becauseȱ ofȱ aȱ fetalȱ anomalyȱ orȱ aȱ threatȱ toȱ aȱ woman’sȱ
health,ȱ andȱ theseȱ areȱ quiteȱ rare.ȱ Outȱ ofȱ theȱ 7,957ȱ abortionsȱ
performedȱ inȱ Indianaȱ inȱ 2015ȱ (theȱ yearȱ beforeȱ enactmentȱ ofȱ
theȱnewȱlaw),ȱonlyȱ27ȱoccurredȱinȱaȱhospitalȱorȱsurgicalȱcenȬ
ter.ȱ Onlyȱ eighteenȱ occurredȱ afterȱ thirteenȱ weeks.ȱ Indianaȱ
Stateȱ Department,ȱ Terminatedȱ Pregnancyȱ Report—2015,ȱ atȱ
pp.ȱ 7,ȱ 17,ȱ 18ȱ (releasedȱ Juneȱ 30,ȱ 2016).ȱ Availableȱ atȱ
https://www.in.gov/isdh/files/2015%20TP%20Report.pdfȱ
[LastȱvisitedȱJuneȱ19,ȱ2018].ȱ
PPINKȱ hasȱ attemptedȱ toȱ expandȱ itsȱ healthȱ servicesȱ
throughoutȱ Indiana,ȱ butȱ itȱ operatesȱ onlyȱ seventeenȱ centersȱ
spreadȱacrossȱaȱlargeȱstateȱandȱonlyȱfourȱthatȱprovideȱaborȬ
tions.ȱ Thisȱ meansȱ thatȱ someȱ womenȱ mustȱ travelȱ greatȱ disȬ
tancesȱtoȱobtainȱanȱ abortion.ȱForȱexample,ȱ Indiana’sȱsecondȱ
largestȱcity,ȱFortȱWayne,ȱhadȱaȱPPINKȱhealthȱcenterȱuntilȱJuȬ
lyȱ 9,ȱ 2018,ȱ butȱ itȱ didȱ notȱ provideȱ abortionȱ services.ȱ Nowȱ itȱ
hasȱ none.3ȱ Theȱ closestȱ centerȱ providingȱ suchȱ servicesȱ isȱ 115ȱ
milesȱ awayȱ inȱ Lafayetteȱ (aȱ moreȱ thanȱ twoȱ hourȱ drive).4ȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
3ȱPPINKȱanticipatesȱreopeningȱanotherȱclinicȱinȱFortȱWayneȱalthoughȱitȱ
doesȱ notȱ haveȱ aȱ timeframeȱ forȱ doingȱ so.ȱ Seeȱ Appellateȱ Recordȱ atȱ 51,ȱ
PPINKȱCitationȱofȱAdditionalȱAuthority,ȱ7/12/18.ȱ
4ȱ Accordingȱ toȱ Googleȱ Maps,ȱ theȱ distanceȱ fromȱ Fortȱ Wayneȱ toȱ theȱ adȬ
dressȱofȱtheȱPPINKȱclinicsȱisȱasȱfollows:ȱ
8ȱ No.ȱ17Ȭ1883ȱ
Thereȱ areȱ alsoȱ noȱ outȬofȬstateȱ abortionȱ clinicsȱ thatȱ areȱ closeȱ
toȱFortȱWayne.ȱȱ
Priorȱ toȱ theȱ enactmentȱ ofȱ theȱ challengedȱ law,ȱ womenȱ
seekingȱ abortionsȱ couldȱ haveȱ theirȱ stateȬmandatedȱ inȬ
formedȬconsentȱ sessionȱ atȱ anyȱ oneȱ ofȱ theȱ seventeenȱ centersȱ
acrossȱ theȱ state.ȱ Atȱ thisȱ appointment,ȱ whichȱ usuallyȱ onlyȱ
lastedȱ aboutȱ fifteenȱ minutes,ȱ healthȱ careȱ providersȱ alsoȱ calȬ
culatedȱtheȱgestationalȱageȱofȱtheȱfetusȱbasedȱonȱtheȱlengthȱofȱ
timeȱfromȱtheȱfirstȱdayȱofȱtheȱlastȱmenstrualȱperiod.ȱToȱmakeȱ
itȱ moreȱ convenientȱ forȱ patients,ȱ PPINKȱ allowedȱ parentsȱ toȱ
bringȱ childrenȱ toȱ theseȱ appointments.ȱ Womenȱ couldȱ thenȱ
haveȱ anȱ ultrasound,ȱ asȱ requiredȱ byȱ thenȬexistingȱ stateȱ law,ȱ
onȱ theȱ dayȱ ofȱ theȱ procedureȱ atȱ theȱ healthȱ centerȱ providingȱ
theȱabortion.ȱPPINKȱwouldȱuseȱthatȱultrasoundȱinformationȱ
toȱverifyȱthatȱtheȱpregnancyȱwasȱintrauterineȱ(andȱnotȱectopȬ
ic)ȱ andȱ toȱ verifyȱ theȱ gestationalȱ ageȱ toȱ insureȱ thatȱ theȱ aborȬ
tionsȱareȱbeingȱperformedȱwithinȱtheȱrequiredȱlimits.ȱAnȱulȬ
trasoundȱisȱnotȱmedicallyȱnecessaryȱpriorȱtoȱanȱabortion,ȱbutȱ
theȱ stateȱ requirementȱ toȱ performȱ anȱ ultrasoundȱ isȱ notȱ chalȬ
lengedȱ inȱ thisȱ case,ȱ justȱ theȱ timingȱ ofȱ it.ȱ Allowingȱ theȱ inȬ
formedȱconsentȱtoȱbeȱperformedȱatȱanyȱofȱtheȱPPINKȱcentersȱ
madeȱ itȱ practicalȱ forȱ womenȱ whoȱ liveȱ aȱ longȱ distanceȱ fromȱ
theȱ fewȱ centersȱ thatȱ offerȱ abortionȱ services,ȱ byȱ eliminatingȱ
theȱneedȱforȱmultipleȱvisits.ȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
Merrillville:ȱȱ 124ȱmilesȱȱ
Lafayette:ȱ ȱ 115ȱmilesȱ
Indianapolis:ȱ 122ȱmilesȱ
Bloomington:ȱ 203ȱmilesȱ
R.ȱ24Ȭ1ȱatȱ3.ȱ
No.ȱ17Ȭ1883ȱ 9
Onceȱtheȱnewȱlawȱwasȱenacted,ȱrequiringȱ thatȱtheȱultraȬ
soundȱ takeȱ placeȱ atȱ leastȱ eighteenȱ hoursȱ priorȱ toȱ theȱ aborȬ
tion,ȱ theȱ barriersȱ forȱ manyȱ womenȱ increasedȱ significantly.ȱ
Becauseȱultrasoundȱmachinesȱwereȱonlyȱavailableȱatȱtheȱfourȱ
PPINKȱ centersȱ thatȱ provideȱ abortionȱ services,ȱ womenȱ whoȱ
livedȱ aȱ significantȱ distanceȱ fromȱ oneȱ ofȱ thoseȱ centersȱ wereȱ
facedȱ withȱ twoȱ lengthyȱ tripsȱ toȱ oneȱ ofȱ thoseȱ facilitiesȱ orȱ anȱ
overnightȱstayȱnearby.ȱPPINKȱattemptedȱtoȱeaseȱthatȱburdenȱ
byȱ purchasingȱ oneȱ additionalȱ ultrasoundȱ machineȱ forȱ oneȱ
healthȱ centerȱ thatȱ doesȱ notȱ offerȱ abortionȱ services,ȱ andȱ
trainedȱ aȱ staffȱ memberȱ toȱ useȱ ultrasoundȱ equipmentȱ atȱ anȬ
other.ȱThoseȱexpendituresȱexactedȱaȱheavyȱtollȱonȱtheȱfinancȬ
esȱ ofȱ theȱ organization,ȱ andȱ stillȱ didȱ notȱ easeȱ muchȱ ofȱ theȱ
burden.ȱ Theȱ ultrasoundȱ machinesȱ PPINKȱ usesȱ costȱ approxȬ
imatelyȱ$25,000ȱandȱmustȱbeȱoperatedȱbyȱtrainedȱtechnicians.ȱ
Nationalȱ Plannedȱ Parenthoodȱ policies,ȱ whichȱ areȱ designedȱ
toȱ alignȱ withȱ generallyȱ acceptedȱ medicalȱ standards,ȱ requireȱ
thatȱanȱultrasoundȱimageȱbeȱinterpretedȱbyȱaȱphysicianȱorȱanȱ
advancedȱ practiceȱ nurse.ȱ Theȱ nurseȬpractitionersȱ atȱ PPINKȱ
doȱnotȱhaveȱtheȱrequisiteȱtrainingȱandȱPPINKȱassertsȱthatȱitȱ
canȱ affordȱ neitherȱ theȱ costȱ norȱ timeȱ toȱ enrollȱ nursesȱ inȱ theȱ
fourȬweekȱtrainingȱprogram.ȱ
3.ȱ Populationȱservedȱ
Theȱ majorityȱ ofȱ womenȱ whoȱ seekȱ abortionȱ servicesȱ atȱ
PPINKȱ(andȱforȱthatȱmatter,ȱtheȱrestȱofȱtheȱnation)ȱareȱpoor.ȱ
Theȱ tableȱ belowȱ demonstratesȱ theȱ incomeȱ levelȱ ofȱ patientsȱ
relativeȱtoȱtheȱfederalȱpovertyȱlineȱ(FPL).ȱ5ȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
5ȱ Povertyȱ expertsȱ generallyȱ useȱ 200%ȱ ofȱ theȱ federalȱ povertyȱ lineȱ asȱ anȱ
approximationȱofȱtheȱincomeȱnecessaryȱtoȱsurviveȱonȱone’sȱown.ȱR.ȱ24Ȭ2ȱ
10ȱ No.ȱ17Ȭ1883ȱ
Incomeȱ %ȱ ofȱ paȬ
Unknownȱ 22%ȱ
0Ȭ100%ȱ 37%ȱ
101Ȭ150%ȱ 11%ȱ
151Ȭ200%ȱ 8%ȱ
201Ȭ250%ȱ 5%ȱ
251+%ȱ 16%ȱ
R.ȱ 24Ȭ1ȱ atȱ 14.ȱ Theseȱ womenȱ oftenȱ haveȱ precariousȱ employȬ
mentȱsituationsȱandȱgenerallyȱareȱnotȱpaidȱforȱdaysȱtheyȱdoȱ
notȱwork.ȱManyȱofȱthemȱalreadyȱhaveȱoneȱorȱmoreȱchildren.ȱ
Inȱ 2016,ȱ 33.73ȱ percentȱ ofȱ PPINKȱ patientsȱ reportedȱ thatȱ theyȱ
hadȱchildrenȱlivingȱwithȱthem.ȱR.ȱ24Ȭ1ȱatȱ4–5.ȱ
4.ȱ Theȱdistrictȱcourt’sȱdecisionȱ
Theȱ districtȱ courtȱ carefullyȱ weighedȱ theȱ burdensȱ identiȬ
fiedȱ byȱ PPINKȱ againstȱ theȱ benefitsȱ theȱ Stateȱ hopedȱ wouldȱ
accrueȱtoȱitsȱcitizens—theȱprotectionȱofȱbothȱfetalȱlifeȱandȱtheȱ
mentalȱhealthȱofȱwomen.ȱItȱconcludedȱthat:ȱ
Theȱ newȱ ultrasoundȱ lawȱ createsȱ significantȱ fiȬ
nancialȱ andȱ otherȱ burdensȱ onȱ PPINKȱ andȱ itsȱ
patients,ȱparticularlyȱonȱlowȬincomeȱwomenȱinȱ
Indianaȱ whoȱ faceȱ lengthyȱ travelȱ toȱ oneȱ ofȱ
PPINK’sȱ nowȱ onlyȱ sixȱ healthȱ centersȱ thatȱ canȱ
offerȱ anȱ informedȬconsentȱ appointment.ȱ Theseȱ
burdensȱ areȱ clearlyȱ undueȱ whenȱ weighedȱ
againstȱ theȱ almostȱ completeȱ lackȱ ofȱ evidenceȱ
thatȱtheȱlawȱfurthersȱtheȱState’sȱassertedȱjustifiȬ
cationsȱ ofȱ promotingȱ fetalȱ lifeȱ andȱ women’sȱ
mentalȱhealthȱoutcomes.ȱTheȱevidenceȱpresentȬ
edȱ byȱ theȱ Stateȱ showsȱ thatȱ viewingȱ anȱ ultraȬ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
atȱ4.ȱManyȱexpertsȱdescribeȱthoseȱatȱorȱbelowȱ100%ȱofȱtheȱfederalȱpovertyȱ
lineȱasȱ“poor”ȱandȱthoseȱbetweenȱ100%ȱandȱ200%ȱasȱ“lowȱincome.”ȱId.ȱȱ
No.ȱ17Ȭ1883ȱ 11
soundȱ imageȱ hasȱ onlyȱ aȱ “veryȱ small”ȱ impactȱ
onȱ anȱ incrementallyȱ smallȱ numberȱ ofȱ women.ȱ
Andȱ thereȱ isȱ almostȱ noȱ evidenceȱ thatȱ thisȱ imȬ
pactȱ isȱ increasedȱ ifȱ theȱ ultrasoundȱ isȱ viewedȱ
theȱdayȱbeforeȱtheȱabortionȱratherȱthanȱtheȱdayȱ
ofȱtheȱabortion.ȱMoreover,ȱtheȱlawȱdoesȱnotȱreȬ
quireȱ womenȱ toȱ viewȱ theȱ ultrasoundȱ imagineȱ
[sic]ȱatȱall,ȱandȱseventyȬfiveȱpercentȱofȱPPINK’sȱ
patientsȱ chooseȱ notȱ to.ȱ Forȱ theseȱ women,ȱ theȱ
newȱultrasoundȱ[law]ȱhasȱnoȱimpactȱwhatsoevȬ
er.ȱGivenȱtheȱlackȱofȱevidenceȱthatȱtheȱnewȱulȬ
trasoundȱ lawȱ hasȱ theȱ benefitsȱ assertedȱ byȱ theȱ
State,ȱ theȱ lawȱ likelyȱ createsȱ anȱ undueȱ burdenȱ
onȱwomen’sȱconstitutionalȱrights.ȱ
Plannedȱ Parenthoodȱ ofȱ Ind.ȱ &ȱ Ky.,ȱ Inc.ȱ v.ȱ Commȇr,ȱ Ind.ȱ Stateȱ
DepȇtȱofȱHealth,ȱ273ȱF.ȱSupp.ȱ3dȱ1013,ȱ1043ȱ(S.D.ȱInd.ȱ2017).ȱȱ
B.ȱ Theȱlegalȱstandardȱ
Weȱ reviewȱ theȱ districtȱ court’sȱ grantȱ ofȱ aȱ preliminaryȱ inȬ
junctionȱinȱthisȱcaseȱforȱanȱabuseȱofȱdiscretion,ȱreviewingȱleȬ
galȱ issuesȱdeȱnovo,ȱfactualȱfindingsȱforȱclearȱ error,ȱandȱgivȬ
ingȱdeferenceȱtoȱtheȱdistrictȱcourt’sȱweighingȱofȱtheȱevidenceȱ
andȱbalancingȱofȱtheȱequities.ȱWhitakerȱByȱWhitakerȱv.ȱKenoshaȱ
UnifiedȱSch.ȱDist.ȱNo.ȱ1ȱBd.ȱofȱEduc.,ȱ858ȱF.3dȱ1034,ȱ1044ȱ(7thȱ
Cir.ȱ2017).ȱ
Toȱobtainȱaȱpreliminaryȱinjunction,ȱPPINKȱmustȱestablishȱ
thatȱ itȱ hasȱ someȱ likelihoodȱ ofȱ successȱ onȱ theȱ merits;ȱ thatȱ itȱ
hasȱ noȱ adequateȱ remedyȱ atȱ law;ȱ thatȱ withoutȱ reliefȱ itȱ willȱ
sufferȱ irreparableȱ harm.ȱ Cityȱ ofȱ Chicagoȱ v.ȱ Sessions,ȱ 888ȱ F.3dȱ
272,ȱ282ȱ(7thȱCir.ȱ2018).ȱIfȱthatȱburdenȱisȱmet,ȱtheȱcourtȱmustȱ
weighȱtheȱharmȱthatȱtheȱplaintiffȱwillȱsufferȱabsentȱanȱinjuncȬ
12ȱ No.ȱ17Ȭ1883ȱ
tionȱ againstȱ theȱ harmȱ toȱ theȱ defendantȱ fromȱ anȱ injunction,ȱ
andȱconsiderȱwhetherȱanȱinjunctionȱisȱinȱtheȱpublicȱinterest.ȱ
Id.ȱ Ourȱ courtȱ employsȱ aȱ slidingȱ scaleȱ approach,ȱ “Theȱ moreȱ
likelyȱtheȱplaintiffȱisȱtoȱwin,ȱtheȱlessȱheavilyȱneedȱtheȱbalanceȱ
ofȱharmsȱweighȱinȱhisȱfavor;ȱtheȱlessȱlikelyȱheȱisȱtoȱwin,ȱtheȱ
moreȱ needȱ itȱ weighȱ inȱ hisȱ favor.”ȱ Valenciaȱ v.ȱ Cityȱ ofȱ SpringȬ
field,ȱ883ȱF.3dȱ959,ȱ966ȱ(7thȱCir.ȱ2018)ȱ(internalȱcitationsȱomitȬ
ted).ȱȱ
Theȱ districtȱ courtȱ correctlyȱ notedȱ thatȱ theȱ needȱ forȱ andȱ
proprietyȱ ofȱ aȱ preliminaryȱ injunctionȱ ofȱ thisȱ lawȱ wouldȱ deȬ
pendȱ mostlyȱ onȱ theȱ likelihoodȱ ofȱ successȱ onȱ theȱ merits.ȱ Itȱ
thereforeȱfocusedȱmostȱofȱitsȱattention,ȱasȱdoȱwe,ȱonȱthatȱfacȬ
tor.ȱȱ
II.ȱ
A.ȱ Theȱ testȱ articulatedȱ inȱ Caseyȱ andȱ Wholeȱ Women’sȱ
Healthȱ
Theȱbasicȱpremiseȱfromȱwhichȱweȱmustȱbeginȱourȱreviewȱ
ofȱ theȱ districtȱ courtȱ opinionȱ isȱ thatȱ theȱ Supremeȱ Courtȱ hasȱ
recognizedȱandȱaffirmedȱ“theȱrightȱofȱtheȱwomanȱtoȱchooseȱ
toȱhaveȱanȱabortionȱbeforeȱviabilityȱandȱtoȱobtainȱitȱwithoutȱ
undueȱ interferenceȱ fromȱ theȱ Stateȱ …ȱ [without]ȱ theȱ imposiȬ
tionȱ ofȱ aȱ substantialȱ obstacleȱ toȱ theȱ woman’sȱ effectiveȱ rightȱ
toȱelectȱtheȱprocedure.”ȱPlannedȱParenthoodȱofȱSe.ȱPenn.ȱv.ȱCaȬ
sey,ȱ 505ȱ U.S.ȱ 833,ȱ 846ȱ (1992).ȱ Butȱ yet,ȱ “[t]heȱ factȱ thatȱ aȱ lawȱ
whichȱ servesȱ aȱ validȱ purpose,ȱ oneȱ notȱ designedȱ toȱ strikeȱ atȱ
theȱ rightȱ itself,ȱ hasȱ theȱ incidentalȱ effectȱ ofȱ makingȱ itȱ moreȱ
difficultȱorȱmoreȱexpensiveȱtoȱprocureȱanȱabortionȱcannotȱbeȱ
enoughȱtoȱ invalidateȱit.”ȱId.ȱatȱ874.ȱHowȱthen,ȱdoȱweȱdeterȬ
mineȱ whetherȱ aȱ law’sȱ effectsȱ areȱ incidentalȱ orȱ unconstituȬ
tionallyȱlimiting?ȱTheȱCaseyȱcourtȱsetȱforthȱanȱundueȱburdenȱ
No.ȱ17Ȭ1883ȱ 13
testȱ whichȱ declaredȱ thatȱ aȱ stateȱ mayȱ notȱ establishȱ aȱ regulaȬ
tionȱ thatȱ “hasȱ theȱ purposeȱ orȱ effectȱ ofȱ placingȱ aȱ substantialȱ
obstacleȱ inȱ theȱ pathȱ ofȱ aȱ womanȱ seekingȱ anȱ abortionȱ ofȱ aȱ
nonȬviableȱfetus.”ȱId.ȱatȱ877.ȱAsȱtheȱCaseyȱcourtȱexplained,ȱ
Aȱstatuteȱwithȱ[anȱimproper]ȱpurposeȱisȱinvalidȱ
becauseȱ theȱ meansȱ chosenȱ byȱ theȱ Stateȱ toȱ furȬ
therȱtheȱinterestȱinȱpotentialȱlifeȱmustȱbeȱcalcuȬ
latedȱ toȱ informȱ theȱ woman’sȱ freeȱ choice,ȱ notȱ
hinderȱ it.ȱ Andȱ aȱ statuteȱ which,ȱ whileȱ furtherȬ
ingȱ theȱ interestȱ inȱ potentialȱ lifeȱ orȱ someȱ otherȱ
validȱ stateȱ interest,ȱ hasȱ theȱ effectȱ ofȱ placingȱ aȱ
substantialȱ obstacleȱ inȱ theȱ pathȱ ofȱ aȱ woman’sȱ
choiceȱ cannotȱ beȱ consideredȱ aȱ permissibleȱ
meansȱofȱservingȱitsȱlegitimateȱends.ȱ
Id.ȱ Recently,ȱ theȱ Supremeȱ Courtȱ reiteratedȱ thisȱ testȱ notingȱ
thatȱCaseyȱheldȱthatȱaȱlawȱisȱunconstitutionalȱifȱitȱimposesȱanȱ
“undueȱburden”ȱonȱaȱwomanȇsȱ abilityȱ toȱchooseȱ toȱ haveȱ anȱ
abortion,ȱmeaningȱthatȱitȱ“hasȱtheȱpurposeȱorȱeffectȱofȱplacȬ
ingȱaȱsubstantialȱobstacleȱinȱtheȱpathȱofȱaȱwomanȱseekingȱanȱ
abortionȱofȱaȱnonviableȱfetus.”ȱWholeȱWomanȇsȱHealthȱv.ȱHelȬ
lerstedt,ȱ136ȱS.ȱCt.ȱ2292,ȱ2324ȱ(2016),ȱ(citingȱCasey,ȱ505ȱU.S.ȱatȱ
877).ȱȱ
Importantly,ȱbothȱWholeȱWomen’sȱHealthȱandȱCaseyȱstressȱ
thatȱtheȱundueȱburdenȱtestȱisȱcontextȱspecific.ȱId.ȱatȱ2306;ȱCaȬ
sey,ȱ505ȱU.S.ȱatȱ885.ȱAnȱabortionȱstatuteȱvalidȱasȱtoȱoneȱsetȱofȱ
factsȱandȱexternalȱcircumstancesȱcanȱbeȱinvalidȱasȱtoȱanother.ȱ
WholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱatȱ2306.ȱȱ
TheȱStateȱarguesȱthatȱtheȱtestȱforȱweighingȱabortionȱreguȬ
lationsȱ differsȱ dependingȱ onȱ theȱ purposeȱ ofȱ theȱ statuteȱ andȱ
thatȱCaseyȱandȱWholeȱWomen’sȱHealthȱestablishȱdifferentȱtestsȱ
14ȱ No.ȱ17Ȭ1883ȱ
dependingȱonȱtheȱnatureȱofȱtheȱregulation.ȱTheȱStateȱclaimsȱ
thatȱ underȱ Casey,ȱ anȱ informedȬconsentȱ andȱ waitingȱ periodȱ
lawȱ willȱ onlyȱ beȱ invalidatedȱ ifȱ theȱ regulationsȱ “imposeȱ aȱ
‘substantialȱobstacleȱinȱtheȱpathȱofȱaȱwomanȱseekingȱanȱaborȬ
tion.’”ȱAppellant’sȱBriefȱatȱ26ȱ(citingȱ Casey,ȱ505ȱU.S.ȱatȱ877).ȱ
Thisȱ standard,ȱ itȱ argues,ȱ isȱ somehowȱ differentȱ thanȱ theȱ unȬ
dueȱ burdenȱ testȱ ofȱ Wholeȱ Women’sȱ Healthȱ which,ȱ theȱ Stateȱ
says,ȱisȱonlyȱappropriatelyȱappliedȱtoȱregulationsȱthatȱostenȬ
siblyȱpromoteȱwomen’sȱphysicalȱhealth.ȱAppellant’sȱBriefȱatȱ
17.ȱTheȱStateȱclaimsȱthatȱtheȱbalancingȱtestȱisȱnotȱappropriateȱ
hereȱ because,ȱ unlikeȱ inȱ Wholeȱ Women’sȱ Health,ȱ theȱ parties’ȱ
statedȱ interestsȱ areȱ fundamentallyȱ opposed—theȱ plaintiffs’ȱ
goalȱisȱtoȱhelpȱwomenȱcarryȱoutȱtheirȱdecisionsȱtoȱterminateȱ
aȱpregnancyȱandȱtheȱState’sȱgoalȱisȱtoȱpersuadeȱaȱwomanȱtoȱ
reconsiderȱthatȱdecision.ȱRegulationsȱthatȱaddressȱinformedȬ
consentȱandȱwaitingȱperiods,ȱtheȱStateȱargues,ȱareȱsubjectȱonȬ
lyȱ toȱ “demonstrationȱ thatȱ theyȱ willȱ causeȱ aȱ significantȱ deȬ
clineȱ inȱ abortionsȱ unrelatedȱ toȱ theȱ persuasiveȱ impact.”ȱ ApȬ
pellant’sȱBriefȱatȱ22.ȱ
Theȱ Stateȱ isȱ incorrectȱ thatȱ theȱ standardȱ forȱ evaluatingȱ
abortionȱregulationsȱdiffersȱdependingȱonȱtheȱState’sȱassertȬ
edȱ interestȱ orȱ thatȱ thereȱ areȱ evenȱ twoȱ differentȱ tests—theȱ
undueȱ burdenȱ testȱ ofȱ Wholeȱ Women’sȱ Healthȱ andȱ aȱ lessȬ
exactingȱ “substantialȱ obstacle”ȱ testȱ (asȱ theȱ Stateȱ argues)ȱ deȬ
rivedȱfromȱCasey.ȱToȱtheȱcontrary,ȱCaseyȱdescribedȱtheȱundueȱ
burdenȱ testȱ asȱ “aȱ standardȱoneȱ ofȱ generalȱ application,”ȱ andȱ
equatedȱtheȱ“substantialȱobstacle”ȱwithȱ“undueȱburden”ȱnotȬ
ingȱ thatȱ “[a]ȱ findingȱ ofȱ anȱ undueȱ burdenȱ isȱ shorthandȱ forȱ theȱ
conclusionȱthatȱaȱstateȱregulationȱhasȱtheȱpurposeȱorȱeffectȱofȱ
placingȱaȱsubstantialȱobstacleȱinȱtheȱpathȱofȱaȱwomanȱseekingȱ
anȱabortionȱofȱaȱnonȬviableȱfetus.”ȱCasey,ȱ505ȱU.S.ȱatȱ876–77ȱ
(emphasisȱ ours).ȱ Inȱ fact,ȱ inȱ Casey’sȱ seminalȱ iterationȱ ofȱ theȱ
No.ȱ17Ȭ1883ȱ 15
undueȱburdenȱtest,ȱtheȱCourtȱappliedȱitȱtoȱallȱofȱtheȱregulaȬ
tionsȱ atȱ issueȱ inȱ thatȱ case,ȱ includingȱ thoseȱ thatȱ theȱ stateȱ
claimedȱ affectedȱ women’sȱ healthȱ (recordȱ keepingȱ andȱ reȬ
porting),ȱ butȱ alsoȱ toȱ spousalȱ notificationȱ andȱ parentalȱ inȬ
volvement,ȱwhichȱtheȱstateȱassertedȱwereȱrelatedȱtoȱitsȱinterȬ
estȱ inȱ potentialȱ life.ȱ Id.ȱ atȱ 887–99.ȱ Inȱ otherȱ words,ȱ theȱ Caseyȱ
CourtȱappliedȱtheȱsameȱundueȱburdenȱtestȱtoȱallȱofȱtheȱreguȬ
lationsȱatȱissueȱinȱthatȱcaseȱwithoutȱregardȱtoȱtheȱstate’sȱasȬ
sertedȱ interest.ȱ Inȱ fact,ȱ Caseyȱ madeȱ clearȱ thatȱ “aȱ statuteȱ
which,ȱwhileȱfurtheringȱtheȱinterestȱinȱpotentialȱlife,ȱorȱsomeȱ
otherȱvalidȱstateȱinterest,ȱhasȱtheȱeffectȱofȱplacingȱaȱsubstantialȱ
obstacleȱ inȱ theȱ pathȱ ofȱ aȱ woman’sȱ choiceȱ cannotȱ beȱ considȬ
eredȱaȱpermissibleȱmeansȱofȱservingȱitsȱlegitimateȱends.”ȱId.ȱ
atȱ877ȱ(emphasisȱadded).ȱȱ
Norȱ isȱ thereȱ anythingȱ inȱ theȱ Court’sȱ decisionȱ inȱ Wholeȱ
Women’sȱHealthȱtoȱsuggestȱthatȱitȱappliedȱaȱdifferentȱstandardȱ
thanȱtheȱundueȱburdenȱtestȱarticulatedȱinȱCasey.ȱRather,ȱtheȱ
Wholeȱ Women’sȱ Healthȱ Courtȱ clearlyȱ statesȱ toȱ theȱ contrary.ȱ
Whenȱdiscussingȱ“undueȱburden”ȱitȱstartsȱwithȱtheȱsentence,ȱ
“Weȱ beginȱ withȱ theȱ standard,ȱ asȱ describedȱ inȱ Casey”ȱ andȱ
thenȱ goesȱ onȱ toȱ noteȱ howȱ itȱ willȱ applyȱ thatȱ standard:ȱ “Theȱ
ruleȱannouncedȱinȱCaseyȱ[]ȱrequiresȱthatȱcourtsȱconsiderȱtheȱ
burdensȱaȱlawȱimposesȱonȱabortionȱaccessȱtogetherȱwithȱtheȱ
benefitsȱthoseȱlawsȱconfer.”ȱWholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱ
atȱ2309.ȱAndȱinȱfact,ȱinȱannouncingȱthisȱrule,ȱtheȱCourtȱcitedȱ
specificallyȱ toȱ theȱ balancingȱ theȱ Caseyȱ courtȱ didȱ forȱ proviȬ
sionsȱ notȱ justifiedȱ byȱ aȱ concernȱ forȱ women’sȱ health—thoseȱ
relatedȱ toȱspousalȱnotificationȱ andȱparentalȱconsent.ȱId.ȱ (citȬ
ingȱCasey,ȱ505ȱU.S.ȱatȱ887–98,ȱ899–901).ȱȱ
NotȱonlyȱdoesȱWholeȱWomen’sȱHealthȱconfirmȱthatȱcourtsȱ
mustȱ applyȱ theȱ undueȱ burdenȱ balancingȱ testȱ ofȱ Caseyȱ toȱ allȱ
16ȱ No.ȱ17Ȭ1883ȱ
abortionȱ regulations,ȱ itȱ alsoȱ dictatesȱ howȱ thatȱ testȱ oughtȱ toȱ
beȱ applied.ȱ Citingȱ Casey,ȱ theȱ Wholeȱ Women’sȱ Healthȱ Courtȱ
emphasizedȱ thatȱ theȱ undueȱ burdenȱ testȱ requiresȱ courtsȱ toȱ
“retain[]ȱanȱindependentȱconstitutionalȱdutyȱtoȱreviewȱfactuȬ
alȱ findingsȱ whereȱ constitutionalȱ rightsȱ areȱ atȱ stake.”ȱ Wholeȱ
Women’sȱ Health,ȱ 136ȱ S.ȱ Ct.ȱ atȱ 2310.ȱ Inȱ otherȱ words,ȱ aȱ courtȱ
cannotȱmerelyȱdependȱonȱlegislativeȱstatementsȱandȱfindingsȱ
inȱ evaluatingȱ theȱ constitutionalityȱ ofȱ lawsȱ regulatingȱ aborȬ
tion.ȱId.ȱTheȱproperȱstandardȱisȱforȱcourtsȱtoȱconsiderȱtheȱevȬ
idenceȱinȱtheȱrecord—including,ȱexpertȱevidence.ȱId.ȱAnd,ȱasȱ
weȱdiscussȱnext,ȱthisȱisȱpreciselyȱwhatȱtheȱdistrictȱcourtȱdidȱ
below.ȱȱ
B.ȱ Theȱevidenceȱofȱburdensȱandȱbenefitsȱ
1.ȱ Burdensȱ
NotingȱtheȱSupremeȱCourt’sȱmandateȱtoȱconsiderȱtheȱevȬ
idenceȱ inȱ theȱ recordȱ andȱ thenȱ weighȱ theȱ assertedȱ benefitsȱ
againstȱ theȱ burdens,ȱ theȱ districtȱ courtȱ didȱ justȱ that;ȱ itȱ madeȱ
findingsȱ andȱ evaluatedȱ theȱ persuasivenessȱ ofȱ theȱ evidenceȱ
regardingȱtheȱburdensȱandȱbenefitsȱcreatedȱbyȱtheȱnewȱultraȬ
soundȱ law.ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ 1021ȱ (citingȱ Wholeȱ Women’sȱ
Health,ȱ 136ȱ S.ȱ Ct.ȱ atȱ 2310).ȱ Beginningȱ withȱ theȱ burdens,ȱ theȱ
districtȱ courtȱ consideredȱ theȱ burdensȱ asȱ presentedȱ byȱ
PPINK,ȱfocusingȱfirstȱonȱtheȱproperȱpopulationȱtoȱconsider,ȱ
andȱ thenȱ consideringȱ howȱ theȱ newȱ regulationsȱ impactȱ fiȬ
nances,ȱemployment,ȱchildȱcare,ȱandȱtheȱsafetyȱofȱwomenȱinȱ
abusiveȱrelationships.ȱȱ
Asȱtheȱdistrictȱcourtȱnoted,ȱ“[t]heȱproperȱfocusȱofȱconstiȬ
tutionalȱ inquiryȱ isȱ theȱ groupȱ forȱ whomȱ theȱ lawȱ isȱ aȱ reȬ
striction,ȱnotȱtheȱgroupȱforȱwhomȱtheȱlawȱisȱirrelevant.”ȱId.ȱatȱ
1021ȱ(citingȱCasey,ȱ505ȱU.S.ȱatȱ894).ȱInȱthisȱcase,ȱasȱtheȱdistrictȱ
No.ȱ17Ȭ1883ȱ 17
courtȱ correctlyȱ determined,ȱ theȱ newȱ ultrasoundȱ lawȱ isȱ aȱ reȬ
strictionȱ primarilyȱ forȱ womenȱ forȱ whomȱ anȱ additionalȱ
lengthyȱ tripȱ toȱ aȱ PPINKȱ healthȱ centerȱ forȱ theirȱ informedȬ
consentȱ appointmentȱ actsȱ asȱ anȱ impedimentȱ toȱ theirȱ accessȱ
toȱabortionȱservices.ȱTheȱdistrictȱcourtȱfoundȱspecificallyȱthatȱ
thisȱgroupȱconsistedȱofȱlowȱincomeȱwomenȱwhoȱdoȱnotȱliveȱ
nearȱ oneȱ ofȱ PPINK’sȱ sixȱ healthȱ centersȱ whereȱ ultrasoundsȱ
areȱavailable.ȱWeȱagreeȱwithȱtheȱdistrictȱcourtȱonȱthisȱpoint,ȱ
butȱ alsoȱ noteȱ thatȱ theȱ concernsȱ aboutȱ confidentialityȱ inȱ emȬ
ploymentȱ situationsȱ andȱ abusiveȱ spousesȱ thatȱ weȱ addressȱ
furtherȱbelow,ȱcanȱcreateȱimpedimentsȱthatȱspanȱincomeȱlevȬ
els.ȱNevertheless,ȱourȱanalysis,ȱlikeȱtheȱdistrictȱcourt’s,ȱdoesȱ
notȱrelyȱuponȱthisȱlargerȱgroup.ȱȱ
Allȱofȱtheȱburdenȱinȱthisȱcaseȱoriginatesȱfromȱtheȱlengthyȱ
travelȱthatȱisȱrequiredȱofȱsomeȱwomenȱwhoȱhaveȱtoȱtravelȱfarȱ
distancesȱ forȱ anȱ ultrasoundȱ appointmentȱ atȱ leastȱ eighteenȱ
hoursȱpriorȱtoȱanȱabortion.ȱRecallȱthatȱbeforeȱtheȱenactmentȱ
ofȱ theȱ newȱ ultrasoundȱ regulation,ȱ allȱ womenȱ seekingȱ anȱ
abortionȱ hadȱ toȱ travelȱ someȱ distanceȱ toȱ theȱ nearestȱ PPINKȱ
facilityȱ atȱ leastȱ eighteenȱ hoursȱ priorȱ toȱ anȱ abortionȱ inȱ orderȱ
toȱ participateȱ inȱ anȱ informedȬconsentȱ informationȱ session.ȱ
Becauseȱ theȱ lawȱ didȱ notȱ requireȱ thatȱ womenȱ haveȱ anȱ ultraȬ
soundȱ untilȱ justȱ beforeȱ theȱ abortionȱ procedure,ȱ however,ȱ
theyȱ couldȱ participateȱ inȱ thatȱ informedȬconsentȱ meetingȱ atȱ
anyȱ ofȱ theȱ twentyȬthreeȱ PPINKȱ facilitiesȱ spreadȱ throughoutȱ
Indiana.6ȱ Now,ȱ however,ȱ theyȱ mustȱ travelȱ onȱ theȱ dayȱ priorȱ
toȱtheȱabortion,ȱtoȱoneȱofȱsixȱPPINKȱfacilitiesȱthatȱhasȱultraȬ
soundȱequipment.ȱAsȱweȱnotedȱabove,ȱthisȱmeansȱthatȱsomeȱ
womenȱmustȱtravelȱgreatȱdistancesȱtwiceȱinȱorderȱtoȱreceiveȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
6ȱDueȱtoȱbudgetȱproblemsȱthereȱareȱnowȱonlyȱseventeenȱPPINKȱfacilitiesȱ
inȱIndiana.ȱȱ
18ȱ No.ȱ17Ȭ1883ȱ
anȱ abortion.ȱ Forȱ example,ȱ womenȱ inȱ theȱ secondȱ largestȱ cityȱ
inȱIndiana,ȱFortȱWayne,ȱmustȱnowȱtravelȱapproximatelyȱ400ȱ
milesȱoverȱtwoȱdaysȱtoȱobtainȱanȱabortion,ȱasȱtheȱclosestȱulȬ
trasoundȱmachineȱisȱ87ȱmilesȱawayȱinȱMishawakaȱ(174ȱmilesȱ
roundȱtrip)ȱandȱtheȱnearestȱabortionȬprovidingȱhealthȱcenterȱ
isȱ115ȱmilesȱawayȱinȱLafayetteȱ(230ȱmilesȱroundȱtrip).ȱR.ȱ24Ȭ1ȱ
atȱ 3,ȱ 13–14.ȱ Previously,ȱ whenȱ Fortȱ Wayneȱ stillȱ hadȱ itsȱ nonȬ
abortionȬprovidingȱ healthȱ clinic,ȱ womenȱ inȱ Fortȱ Wayneȱ
couldȱ haveȱ theirȱ fifteenȬminuteȬlongȱ informedȬconsentȱ apȬ
pointmentȱrightȱatȱtheȱPPINKȱhealthȱcenterȱinȱFortȱWayne.ȱ
Althoughȱ theȱtravelȱ distanceȱisȱtheȱoriginȱofȱtheȱburden,ȱ
theȱdistrictȱcourtȱfoundȱthatȱtheȱstrainȱofȱtheȱlawȱextendsȱintoȱ
theȱrealmȱofȱfinances,ȱemployment,ȱchildȱcare,ȱandȱdomesticȱ
safety.ȱ Theȱ districtȱ courtȱ consideredȱ theȱ testimonyȱ ofȱ
PPINK’sȱ expertȱ inȱ genderȱ studies,ȱ poverty,ȱ andȱ lowȬwageȱ
laborȱmarkets,ȱDr.ȱJaneȱCollins,ȱwhoȱexplainedȱtheȱimpactȱofȱ
theȱnewȱlawȱonȱtheseȱinterconnectedȱstressorsȱandȱonȱtheȱalȬ
readyȱ precariousȱ financialȱ livesȱ ofȱ poorȱ womenȱ seekingȱ anȱ
abortion.ȱ R.ȱ 24Ȭ2.ȱ Sheȱ analyzedȱ theȱ familyȱ budgetsȱ ofȱ lowȬ
incomeȱwomenȱandȱassessedȱhowȱtheȱadditionalȱcostsȱassoȬ
ciatedȱ withȱ theȱ newȱ ultrasoundȱ lawȱ wouldȱ impactȱ theseȱ
womenȱ andȱ theirȱ families.ȱ Herȱ testimonyȱ confirmedȱ whatȱ
commonȱ senseȱ suggests.ȱ Manyȱ lowȬincomeȱ womenȱ doȱ notȱ
haveȱ employmentȱ thatȱ paysȱ themȱ whenȱ theyȱ missȱ aȱ dayȱ ofȱ
workȱ orȱ theyȱ mayȱ haveȱ precariousȱ jobȱ situationsȱ inȱ whichȱ
theyȱcouldȱbeȱfiredȱforȱexcessiveȱabsences.ȱAȱsecondȱlengthyȱ
tripȱforȱanȱ ultrasoundȱappointmentȱlikelyȱrequiresȱaȱsecondȱ
missedȱdayȱofȱwork.ȱAndȱwomenȱwithȱyoungȱchildrenȱwhoȱ
couldȱ previouslyȱ bringȱ themȱ alongȱ toȱ anȱ informedȬconsentȱ
sessionȱ mustȱ leaveȱ themȱ behindȱ forȱ theȱ ultrasound,ȱ asȱ
PPINK’sȱ policiesȱ prohibitȱ childrenȱ fromȱ beingȱ presentȱ durȬ
ingȱ anȱ ultrasound.ȱ (Andȱ asȱ weȱ discussȱ below,ȱ bothȱ safetyȱ
No.ȱ17Ȭ1883ȱ 19
andȱ commonȱ senseȱ supportȱ suchȱ aȱ policy).ȱ Theȱ newȱ ultraȬ
soundȱ lawȱ thereforeȱ requiresȱ womenȱ toȱ arrangeȱ childȱ careȱ
forȱanȱadditionalȱday.ȱ
Dr.ȱ Collinsȱ calculatedȱ thatȱ theȱ additionalȱ costȱ posedȱ byȱ
theȱnewȱultrasoundȱlawȱforȱaȱwomanȱlivingȱinȱFortȱ Wayne,ȱ
Indianaȱ whoȱ hasȱ children,ȱ noȱ car,ȱ andȱ wouldȱ loseȱ aȱ day’sȱ
wagesȱ wouldȱ beȱ betweenȱ $219ȱ toȱ $247.ȱ R.ȱ 24Ȭ2ȱ atȱ 18.ȱ Manyȱ
lowȬincomeȱfamiliesȱhaveȱaȱdiscretionaryȱmonthlyȱbudgetȱofȱ
approximatelyȱ$40.ȱId.ȱTheȱadditionalȱexpensesȱofȱoverȱ$200ȱ
constituteȱ roughlyȱ 25%ȱ ofȱ theirȱ entireȱ monthlyȱ budget.ȱ Id.ȱ
Theseȱ expensesȱ areȱ aboveȱ andȱ beyondȱ theȱ costȱ ofȱ theȱ aborȬ
tionȱitselfȱwhichȱwas,ȱatȱtheȱtimeȱofȱtheȱhearing,ȱ$410ȱforȱtheȱ
abortionȱandȱ$100ȱforȱtheȱultrasound.ȱR.ȱ24Ȭ1ȱatȱ8;ȱR.ȱ35Ȭ5ȱatȱ
35.ȱ Dr.ȱ Collinsȱ explainedȱ thatȱ toȱ coverȱ theȱ costsȱ associatedȱ
withȱabortions,ȱmanyȱwomenȱ(aboutȱoneȱthird)ȱwillȱdelayȱorȱ
stopȱpayingȱbasicȱbillsȱinȱorderȱtoȱaffordȱanȱabortion.ȱR.ȱ24Ȭ2ȱ
atȱ21.ȱUpȱtoȱ50%ȱofȱwomenȱborrowȱmoneyȱfromȱfamilyȱandȱ
friends.ȱ R.24Ȭ1ȱ atȱ 20.ȱ Theȱ districtȱ courtȱ concludedȱ that,ȱ “forȱ
manyȱ womenȱ facedȱ withȱ theȱ alreadyȱ highȱ costsȱ ofȱ anȱ aborȬ
tionȱ andȱ aȱ lackȱ ofȱ meansȱ toȱ affordȱ them,ȱ theȱ additionalȱ exȬ
pensesȱ ofȱ lengthyȱ travel,ȱ lostȱ wages,ȱ andȱ childȱ careȱ createdȱ
byȱtheȱnewȱultrasoundȱlawȱcreateȱaȱsignificantȱburden.”ȱ273ȱ
F.ȱSupp.ȱ3dȱatȱ1028.ȱȱ
Theȱ costȱ ofȱ theȱ ultrasoundȱ ruleȱ isȱ measuredȱ notȱ onlyȱ inȱ
dollarsȱbutȱinȱtimeȱandȱaccessȱasȱwell.ȱSurgicalȱabortionsȱareȱ
availableȱ atȱ PPINKȱ healthȱ centersȱ untilȱ thirteenȱ weeksȱ andȱ
sixȱ daysȱ afterȱ theȱ lastȱ menstrualȱ period.ȱ Inȱ fiscalȱ yearȱ 2016,ȱ
approximatelyȱ 22%ȱ ofȱ allȱ abortionsȱ andȱ moreȱ thanȱ 34%ȱ ofȱ
surgicalȱ abortionsȱ performedȱ atȱ PPINKȱ tookȱ placeȱ inȱ theȱ
threeȱweeksȱbeforeȱtheȱdeadline.ȱR.ȱ24Ȭ1ȱatȱ7–8.ȱWomenȱoftenȱ
pushȱupȱagainstȱtheȱdeadlineȱbecauseȱtheyȱareȱgatheringȱtheȱ
20ȱ No.ȱ17Ȭ1883ȱ
necessaryȱfunds,ȱmakingȱlogisticalȱarrangementsȱorȱbecauseȱ
theyȱ failedȱ toȱ promptlyȱ recognizeȱ theȱ signsȱ ofȱ pregnancy.ȱ
R.ȱ24Ȭ1ȱatȱ7–8.ȱ(Mostȱwomenȱcannotȱknowȱtheyȱareȱpregnantȱ
untilȱ atȱ leastȱ 4ȱ weeksȱ followingȱ theirȱ lastȱ menstrualȱ period,ȱ
thusȱreducingȱtheȱtimeȱtheyȱhaveȱtoȱdiscoverȱtheȱpregnancy,ȱ
exploreȱtheirȱoptionsȱandȱdiscussȱthemȱwithȱaȱpartner,ȱfamiȬ
lyȱorȱdoctor,ȱarrangeȱforȱmissedȱworkȱandȱchildȱcare,ȱandȱseȬ
cureȱ twoȱ appointments—toȱ onlyȱ nineȱ weeks,ȱ 6ȱ daysȱ forȱ aȱ
surgicalȱ abortionȱ andȱ thirtyȬfiveȱ days,ȱ forȱ aȱ medicalȱ aborȬ
tion).ȱ
Beforeȱtheȱnewȱultrasoundȱlaw,ȱPPINKȱcouldȱusuallyȱacȬ
commodateȱ womenȱ imminentlyȱ facingȱ theȱ deadlineȱ byȱ
schedulingȱanȱ informedȬconsentȱ appointmentȱatȱ theȱ nearestȱ
PPINKȱhealthȱcenterȱandȱthen,ȱtheȱnextȱday,ȱsheȱcouldȱtravelȱ
theȱfurtherȱdistance,ȱifȱnecessary,ȱtoȱaȱPPINKȱfacilityȱthatȱofȬ
feredȱ abortionȱ services.ȱ Afterȱtheȱenactmentȱ ofȱtheȱnewȱlawȱ
(andȱ beforeȱ theȱ districtȱ courtȱ issuedȱ aȱ preliminaryȱ injuncȬ
tion),ȱ theȱ PPINKȱ healthȱ centersȱ withȱ ultrasoundȱ machinesȱ
becameȱ soȱ overwhelmedȱ withȱ appointmentsȱ thatȱ PPINKȱ
couldȱ notȱ adequatelyȱ respondȱ toȱ womenȱ whoȱ contactedȱ
PPINKȱ nearȱ theȱ endȱ ofȱ theȱ allowableȱ timeȱ period.ȱ Asȱ aȱ reȬ
sult,ȱ PPINKȱ hadȱ toȱ doubleȱ bookȱ appointmentsȱ causingȱ furȬ
therȱ delaysȱ forȱ womenȱ andȱ longerȱ waitȱ timesȱ forȱ womenȱ
whoȱ wereȱ alreadyȱ missingȱ workȱ timeȱ andȱ needingȱ toȱ arȬ
rangeȱ childȱ care.ȱ Evenȱ withȱ overscheduling,ȱ appointmentȱ
availabilityȱ grewȱ scarceȱ andȱ womenȱ hadȱ toȱ waitȱ longerȱ toȱ
haveȱ anȱ abortion.ȱ Thisȱ precludedȱ theȱ optionȱ ofȱ medicationȱ
abortionsȱforȱsomeȱwomenȱandȱanyȱabortionȱchoicesȱforȱothȬ
ers.ȱ Abortionȱ appointmentsȱ wereȱ alreadyȱ scarceȱ inȱ Indianaȱ
givenȱ thatȱ physiciansȱ areȱ onlyȱ availableȱ atȱ theȱ fourȱ healthȱ
centersȱ offeringȱ abortionsȱ atȱ limitedȱ times:ȱ Indianapolisȱ (3ȱ
days/week);ȱ Bloomingtonȱ (1ȱ day/week);ȱ Merrillvilleȱ (1.5ȱ
No.ȱ17Ȭ1883ȱ 21
days/week);ȱ andȱ Lafayetteȱ (1ȱ dayȱ perȱ week).ȱ R.ȱ 24Ȭ1ȱ atȱ 6.ȱ
Withȱ suchȱ limitedȱ availability,ȱ delaysȱ inȱ gettingȱ anȱ ultraȬ
soundȱ appointmentȱ mightȱ meanȱ havingȱ toȱ waitȱ anȱ entireȱ
weekȱ longerȱ beforeȱ aȱ physicianȱ isȱ availableȱ atȱ theȱ closestȱ
PPINKȱcenter,ȱorȱtravellingȱtoȱtheȱhealthȱcenterȱwhereȱaȱphyȬ
sicianȱisȱonȱduty.ȱMoreover,ȱtheȱnewȱlawȱcausesȱotherȱprobȬ
lemsȱ relatedȱ toȱ delay.ȱ Althoughȱ theȱ informedȬconsentȱ proȬ
cessȱ onlyȱ tookȱ approximatelyȱ fifteenȱ minutesȱ before,ȱ afterȱ
theȱ enactmentȱ ofȱ theȱ newȱ law,ȱ theȱ processȱ tookȱ asȱ longȱ asȱ
seventyȬfiveȱ minutes.ȱ Thisȱ addedȱ toȱ theȱ costȱ ofȱ childȱ care,ȱ
missedȱ workȱ time,ȱ andȱ madeȱ itȱ harderȱ toȱ hideȱ visitsȱ fromȱ
abusiveȱpartners.ȱ
Theȱdistrictȱcourtȱcreditedȱtheȱevidenceȱthatȱtheȱdemandsȱ
onȱ theȱ PPINKȱ staffȱ tryingȱ toȱ accommodateȱ soȱ manyȱ addiȬ
tionalȱ ultrasoundȱ appointmentsȱ duringȱ theȱ periodȱ ofȱ timeȱ
theȱ lawȱ wasȱ enforcedȱ wereȱ unsustainable.ȱ Theȱ additionalȱ
quantityȱofȱappointmentsȱrequiredȱstaffȱtoȱstayȱlateȱandȱtookȱ
awayȱ resourcesȱ fromȱ theȱ manyȱ nonȬabortionȱ servicesȱ thatȱ
PPINKȱ providesȱ suchȱ asȱ cancerȱ screening,ȱ wellȬwomenȱ
healthȱscreening,ȱfamilyȱplanning,ȱandȱpreventativeȱservices.ȱ
Accordingȱ toȱ PPINK’sȱ CEO,ȱ requiringȱ staffȱ toȱ workȱ atȱ thisȱ
paceȱ andȱ levelȱ ofȱ intensityȱ isȱ notȱ workableȱ overȱ theȱ longȱ
term,ȱandȱultimatelyȱleadsȱtoȱhighȱstaffȱturnover,ȱexacerbatȬ
ingȱtheȱproblemȱfurther.ȱR.ȱ24Ȭ1ȱatȱ11.ȱ
Finally,ȱ theȱ districtȱ courtȱ foundȱ thatȱ theȱ newȱ regulationȱ
hasȱ anȱ impactȱ onȱ victimsȱ ofȱ domesticȱ violence.ȱ Theȱ districtȱ
courtȱ notedȱ thatȱ oneȱ nationalȱ studyȱ showedȱ thatȱ 13.8%ȱ ofȱ
womenȱ whoȱ hadȱ anȱ abortionȱ hadȱ beenȱ inȱ anȱ abusiveȱ relaȬ
tionshipȱwithinȱaȱyearȱbeforeȱtheȱabortion.ȱ273ȱF.ȱSupp.ȱ3dȱatȱ
1026.ȱInsteadȱofȱstealingȱawayȱforȱaȱfifteenȬminuteȱinformedȬ
consentȱ sessionȱ atȱ aȱ nearbyȱ PPINKȱ healthȱ center,ȱ abusedȱ
22ȱ No.ȱ17Ȭ1883ȱ
womenȱ tryingȱ toȱ keepȱ theirȱ choiceȱ confidentialȱ haveȱ toȱ arȬ
rangeȱtoȱbeȱawayȱforȱallȱorȱmostȱofȱtwoȱdays.ȱȱ
Theȱdistrictȱcourtȱalsoȱconsideredȱtheȱanecdotalȱevidenceȱ
submittedȱbyȱPPINKȱ aboutȱ nineȱwomenȱ whoȱ couldȱ notȱ obȬ
tainȱanȱabortionȱdueȱtoȱtheȱburdensȱimposedȱbyȱtheȱnewȱulȬ
trasoundȱlaw.ȱTheȱcourtȱconsideredȱtheȱfollowingȱnarrativesȱ
collectedȱbyȱPPINKȱfromȱwomenȱwhoȱdescribedȱtheirȱexpeȬ
riencesȱasȱfollows:ȱ
•ȱTheȱnearestȱPPINKȱhealthȱcenterȱtoȱaȱwomanȱ
seekingȱ anȱ abortionȱ wasȱ overȱ anȱ hourȱ away,ȱ
andȱ dueȱ toȱ theȱ factȱ thatȱ sheȱ hasȱ twoȱ youngȱ
childrenȱandȱdifficultyȱwithȱtransportation,ȱsheȱ
wasȱ unableȱ toȱ scheduleȱ theȱ twoȱ lengthyȱ tripsȱ
duringȱtheȱthirteenȱweek,ȱsixȱdayȱtimeframeȱinȱ
whichȱanȱabortionȱisȱavailable.ȱ
•ȱAȱwomanȱfromȱtheȱFortȱWayneȱareaȱdidȱnotȱ
scheduleȱ anȱ abortionȱ becauseȱ ofȱ theȱ twoȱ
lengthyȱtripsȱnecessary.ȱSheȱwasȱelevenȱweeks,ȱ
fourȱ daysȱ pregnantȱ whenȱ sheȱ contactedȱ
PPINK,ȱ butȱ couldȱ notȱ missȱ workȱ twiceȱ withinȱ
theȱshortȱtimeframeȱremaining.ȱ
•ȱAȱwomanȱwhoȱpreviouslyȱhadȱanȱabortionȱatȱ
PPINKȱ calledȱ toȱ scheduleȱ another,ȱ butȱ ultiȬ
matelyȱ saidȱ sheȱ couldȱ notȱ scheduleȱ oneȱ afterȱ
sheȱwasȱinformedȱsheȱwouldȱhaveȱtoȱmakeȱtwoȱ
tripsȱ toȱ theȱ PPINKȱ healthȱ centerȱ inȱ BloomingȬ
ton,ȱIndiana.ȱ
•ȱAȱwomanȱlivingȱinȱaȱshelterȱwithȱtwoȱyoungȱ
childrenȱ decidedȱ notȱ toȱ scheduleȱ anȱ abortionȱ
appointmentȱbecauseȱofȱtheȱtransportationȱandȱ
No.ȱ17Ȭ1883ȱ 23
childcareȱ difficultiesȱ twoȱ appointmentsȱ wouldȱ
cause.ȱ
•ȱAȱwomanȱwhoȱrecentlyȱstartedȱaȱnewȱjobȱafȬ
terȱ aȱ yearȱ ofȱ unemploymentȱ statedȱ thatȱ sheȱ
couldȱ notȱ driveȱ theȱ threeȬhourȱ roundtripȱ toȱ aȱ
PPINKȱhealthȱcenterȱonȱtwoȱseparateȱoccasionsȱ
dueȱtoȱtheȱcombinationȱofȱwork,ȱchildcare,ȱandȱ
transportationȱ expenses,ȱ inȱ additionȱ toȱ herȱ
concernsȱ regardingȱ theȱ confidentialityȱ ofȱ theȱ
abortion.ȱ
•ȱ Aȱ womanȱ whoȱ didȱ notȱ learnȱ sheȱ wasȱ pregȬ
nantȱ forȱ tenȱ weeksȱ facedȱ aȱ longȱ delayȱ beforeȱ
sheȱ couldȱ haveȱ herȱ informedȬconsentȱ appointȬ
mentȱ thatȱ requiredȱ travelȱ toȱ aȱ PPINKȱ healthȱ
center,ȱandȱbyȱtheȱtimeȱofȱherȱappointmentȱsheȱ
wasȱoneȱdayȱbeyondȱtheȱdeadlineȱforȱanȱaborȬ
tion.ȱ
•ȱ Aȱ womanȱ fromȱ Fortȱ Wayneȱ whoȱ hadȱ aȱ preȬ
viousȱabortionȱatȱPPINKȱcalledȱtoȱscheduleȱanȬ
other,ȱ butȱ onceȱ sheȱ wasȱ informedȱ thatȱ sheȱ
wouldȱ haveȱ toȱ makeȱ twoȱ lengthyȱ tripsȱ toȱ aȱ
PPINKȱhealthȱcenter,ȱsheȱsaidȱsheȱcouldȱnotȱafȬ
fordȱtoȱdoȱsoȱandȱdidȱnotȱscheduleȱanȱabortion.ȱ
•ȱ Aȱ womanȱ livingȱ anȱ hourȱ northȱ ofȱ Fortȱ
Wayneȱ whoȱ hasȱ specialȱ needsȱ childrenȱ deȬ
clinedȱ toȱ scheduleȱ anȱ abortionȱ afterȱ learningȱ
thatȱsheȱwouldȱhaveȱtoȱmakeȱtwoȱlengthyȱtripsȱ
forȱ eachȱ appointment,ȱ asȱ sheȱ couldȱ notȱ affordȱ
toȱ beȱ awayȱ fromȱ herȱ childrenȱ forȱ thatȱ longȱ onȱ
twoȱoccasions.ȱ
24ȱ No.ȱ17Ȭ1883ȱ
•ȱ Aȱ womanȱ fromȱ Fortȱ Wayneȱ whoȱ wasȱ apȬ
proachingȱtheȱdeadlineȱtoȱhaveȱanȱabortionȱdeȬ
clinedȱ toȱ scheduleȱ anȱ appointmentȱ dueȱ toȱ theȱ
requiredȱ travelȱ andȱ riskȱ ofȱ missingȱ theȱ deadȬ
lineȱ byȱ theȱ timeȱ sheȱ couldȱ scheduleȱ bothȱ apȬ
pointments.ȱ
273ȱF.ȱSupp.ȱ3dȱatȱ1029–30ȱ(citingȱR.ȱ24–1ȱatȱ16–17;ȱR.ȱ38–1ȱatȱ
1–2).ȱȱ
Beforeȱ theȱ districtȱ court,ȱ andȱ againȱ onȱ appeal,ȱ theȱ Stateȱ
arguedȱthatȱPPINK’sȱexamplesȱwereȱunreliableȱasȱtheyȱwereȱ
passedȱonȱtoȱaȱPPINKȱstaffȱmemberȱandȱthenȱtoȱtheȱ declarȬ
antȱ withoutȱ PPINKȱ takingȱ anyȱ actionȱ toȱ verifyȱ theȱ inforȬ
mation.ȱTheȱdistrictȱcourtȱconsideredȱtheȱreliabilityȱissueȱbut,ȱ
notingȱ thatȱ aȱ courtȱ couldȱ baseȱ aȱ preliminaryȱ injunctionȱ onȱ
lessȱ formalȱ proceduresȱ andȱ lessȱ extensiveȱ evidenceȱ thanȱ aȱ
trialȱonȱtheȱmeritsȱ(citingȱDexiaȱCreditȱLocalȱv.ȱRogan,ȱ602ȱF.3dȱ
879,ȱ885ȱ(7thȱCir.ȱ2010)),ȱtheȱdistrictȱcourtȱfoundȱtheȱevidenceȱ
toȱbeȱsufficientlyȱreliableȱforȱtheȱpurposeȱatȱhand.ȱTheȱcourtȱ
reasonedȱ thatȱ theȱ reportsȱ reflectedȱ aȱ plausible,ȱ ifȱ notȱ likely,ȱ
consequenceȱofȱtheȱnewȱultrasoundȱlaw.ȱMoreover,ȱtheȱcourtȱ
recognizedȱthat,ȱasȱweȱexploreȱmoreȱfullyȱbelow,ȱtheȱState’sȱ
“onlyȱevidenceȱthatȱtheȱlawȱfurthersȱitsȱinterestȱinȱpromotingȱ
fetalȱ lifeȱ isȱ fromȱ aȱ womanȱ whoseȱ testimonyȱ wasȱ admittedȱ
intoȱevidenceȱthroughȱtheȱdeclarationȱofȱherȱphysician.”ȱ273ȱ
F.ȱSupp.ȱ3dȱatȱ1030ȱ(emphasisȱinȱoriginal).ȱInȱaȱgoodȬforȬtheȬ
gooseȬandȬganderȱway,ȱtheȱdistrictȱcourtȱpointedȱoutȱthatȱif,ȱ
forȱpurposesȱofȱtheȱpreliminaryȱinjunction,ȱtheȱcourtȱignoredȱ
allȱevidenceȱnotȱdirectlyȱfromȱitsȱsource,ȱ“theȱStateȱwouldȱbeȱ
leftȱ withoutȱ anyȱ evidenceȱ directlyȱ supportingȱ itsȱ position.”ȱ
Id.ȱ Theȱ districtȱ court’sȱ comparisonȱ wasȱ aptȱ andȱ itsȱ concluȬ
No.ȱ17Ȭ1883ȱ 25
sionsȱ reasonable.ȱ Weȱ cannotȱ sayȱ thatȱ thisȱ wasȱ anȱ abuseȱ ofȱ
discretionȱtoȱconsiderȱtheȱanecdotalȱevidenceȱonȱbothȱsides.ȱ
Theȱ Stateȱ arguedȱ thatȱ PPINKȱ couldȱ mitigateȱ theseȱ burȬ
densȱ byȱ makingȱ differentȱ medicalȱ andȱ businessȱ decisions,ȱ
primarilyȱ byȱ outfittingȱ allȱ ofȱ itsȱ healthȱ centersȱ withȱ lessȱ exȬ
pensiveȱ ultrasoundȱ equipmentȱ andȱ byȱ puttingȱ moreȱ reȬ
sourcesȱtowardȱabortionȱservices.7ȱPPINK’sȱdirectorȱofȱaborȬ
tionȱservicesȱexplainedȱthatȱtheȱ$25,000ȱmachineȱthatȱPPINKȱ
ordinarilyȱ purchasesȱ comesȱ withȱ anȱ extendedȱ warranty,ȱ inȬ
cludesȱ plannedȱ maintenance,ȱ replacementȱ parts,ȱ softwareȱ
updates,ȱsupport,ȱandȱaȱguaranteedȱ24Ȭhourȱresponseȱtimeȱifȱ
thereȱ areȱ anyȱ problemsȱ withȱ theȱ machine.ȱ R.ȱ 38Ȭ1ȱ atȱ 3–4.ȱ Itȱ
alsoȱintegratesȱwithȱPPINK’sȱelectronicȱrecordȱsystemȱwhichȱ
isȱ criticalȱ whenȱ theȱ ultrasoundȱ andȱ abortionȱ appointmentȱ
occurȱ atȱ differentȱ healthȱ centers.ȱ Id.ȱ atȱ 4.ȱ And,ȱ asȱ PPINKȱ
pointsȱ out,ȱ evenȱ ifȱ itȱ couldȱ affordȱ toȱ buyȱ theȱ machines,ȱ itȱ
wouldȱ stillȱ beȱ limitedȱ byȱ spaceȱ andȱ personnel.ȱ Theȱ districtȱ
courtȱ rejectedȱ theȱ State’sȱ mitigationȱ argument,ȱ notingȱ thatȱ
theȱ “undueȱ burdenȱ inquiryȱ doesȱ notȱ contemplateȱ reȬ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
7ȱ Beforeȱ theȱ districtȱ court,ȱ theȱ Stateȱ alsoȱ arguedȱ thatȱ PPINKȱ shouldȱ acȬ
ceptȱultrasoundsȱresultsȱfromȱotherȱproviders,ȱbutȱhasȱdroppedȱthatȱarȬ
gumentȱ onȱ appeal.ȱ Theȱ Stateȱ lawȱ requiresȱ thatȱ theȱ sameȱ providerȱ whoȱ
performsȱtheȱultrasoundȱalsoȱengageȱtheȱpatientȱinȱtheȱinformedȬconsentȱ
process.ȱTheȱrequiredȱinformedȬconsentȱprocessȱisȱveryȱspecificȱandȱdeȬ
tailedȱ andȱ requiresȱ thatȱ theȱ personȱ providingȱ theȱ informationȱ provideȱ
someȱ informationȱ thatȱ onlyȱ theȱ abortionȱ providerȱ mightȱ have,ȱ suchȱ asȱ
theȱnameȱofȱtheȱphysicianȱperformingȱtheȱabortion,ȱtheȱphysician’sȱmediȬ
calȱlicenseȱnumber,ȱandȱtheȱemergencyȱphoneȱnumberȱwhereȱtheȱphysiȬ
cianȱcanȱbeȱreachedȱtwentyȬfourȱhoursȱaȱday,ȱsevenȱdaysȱaȱweek.ȱInd.ȱSt.ȱ
16Ȭ34Ȭ2.1.1(a)(4).ȱTheȱdistrictȱcourtȱfoundȱthat,ȱgivenȱtheseȱrequirements,ȱ
itȱ seemsȱ unlikelyȱ thatȱ anȱ outsideȱ providerȱ couldȱ complyȱ withȱ theȱ inȬ
formedȬconsentȱprocedureȱasȱdictatedȱbyȱtheȱstatute.ȱWeȱagree.ȱȱ
26ȱ No.ȱ17Ȭ1883ȱ
examiningȱ everyȱ preȬexistingȱ policyȱ orȱ practiceȱ ofȱ abortionȱ
providersȱ toȱ seeȱ ifȱ theyȱ couldȱ furtherȱ mitigateȱ burdensȱ imȬ
posedȱ byȱ aȱ newȱ abortionȱ regulation.”ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ
1023.ȱ Inȱ general,ȱ courtsȱ doȱ notȱ micromanageȱ anȱ entity’sȱ
businessȱ decisions.ȱ Seeȱ Rileyȱ v.ȱ Elkhartȱ Cmty.ȱ Sch.,ȱ 829ȱ F.3dȱ
886,ȱ895ȱ(7thȱCir.ȱ2016)ȱ(notingȱthat,ȱinȱtheȱTitleȱVIIȱcontext,ȱ
courtsȱ doȱ notȱ “secondȬguess[]ȱ employers’ȱ businessȱ judgȬ
ments”).ȱProvidedȱPPINKȱsetȱforthȱaȱreasonableȱexplanationȱ
forȱpurchasingȱtheseȱparticularȱultrasoundȱmachines—andȱitȱ
has,ȱindeed,ȱdoneȱso—theȱdistrictȱcourtȱwasȱentitledȱtoȱdeferȱ
toȱ PPINK’sȱ justifiableȱ businessȱ decisionsȱ andȱ considerȱ theȱ
burdensȱofȱtheȱnewȱultrasoundȱlawȱwithinȱtheȱcontextȱofȱtheȱ
realityȱ thatȱ existsȱ forȱ bothȱ PPINKȱ inȱ operatingȱ itsȱ businessȱ
andȱ forȱ theȱ patientsȱ itȱ serves.ȱ Weȱ agreeȱ withȱ theȱ districtȱ
court’sȱ assessmentȱ andȱ itsȱ deferenceȱ toȱ PPINK’sȱ reasonableȱ
businessȱdecisions.ȱInȱaddition,ȱweȱnoteȱthatȱitȱalsoȱwouldȱbeȱ
reasonableȱ forȱ PPINKȱ toȱ makeȱ decisionsȱ aboutȱ itsȱ medicalȱ
equipmentȱneedsȱbasedȱnotȱonlyȱonȱeconomicȱconcerns,ȱbutȱ
alsoȱonȱitsȱabilityȱtoȱprovideȱtheȱbestȱmedicalȱcareȱforȱitsȱpaȬ
tients,ȱtoȱattractȱcertainȱmedicalȱprofessionals,ȱforȱtheȱsafetyȱ
ofȱ itsȱ technicians,ȱ toȱ preventȱ malpracticeȱ claims,ȱ orȱ forȱ anyȱ
numberȱofȱotherȱlegitimateȱreasons.ȱȱ
TheȱsameȱcanȱbeȱsaidȱofȱPPINK’sȱstaffingȱdecisions.ȱTheȱ
Stateȱ thoughtȱ thatȱ PPINKȱ alsoȱ couldȱ mitigateȱ burdensȱ byȱ
trainingȱ nurseȱ practitionersȱ toȱ interpretȱ ultrasounds.ȱ Thisȱ
training,ȱhoweverȱisȱbothȱexpensiveȱandȱrequiresȱfourȱweeksȱ
awayȱfromȱclinicalȱwork.ȱPPINKȱrationallyȱcouldȱdetermineȱ
thatȱitȱwasȱnotȱtheȱbestȱallocationȱofȱitsȱresources.ȱTheȱStateȱ
arguesȱthatȱtheȱrightȱtoȱanȱabortionȱdoesȱnotȱinsulateȱPPINKȱ
fromȱ makingȱ difficultȱ decisionsȱ aboutȱ theȱ allocationȱ ofȱ reȬ
sources.ȱThatȱmayȱbeȱtrue,ȱbutȱneitherȱisȱitȱappropriateȱforȱanȱ
opposingȱpartyȱorȱaȱcourtȱtoȱdictateȱtheȱbestȱuseȱofȱresourcesȱ
No.ȱ17Ȭ1883ȱ 27
forȱ aȱ business,ȱ providedȱ itsȱ choicesȱ areȱ withinȱ theȱ rangeȱ ofȱ
reasonableness—butȱ particularlyȱ inȱ theȱ caseȱ ofȱ aȱ nonȬprofitȱ
agencyȱwithȱlimitedȱfundingȱseekingȱtoȱprovideȱtheȱmostȱefȬ
ficientȱhealthȱcareȱservicesȱtoȱaȱmostlyȱpoorȱpopulation.ȱȱ
Theȱ districtȱ courtȱ creditedȱ theȱ attestationȱ byȱ PPINK’sȱ
presidentȱ andȱ CEOȱ thatȱ PPINKȱ wasȱ unableȱ toȱ supplyȱ eachȱ
centerȱwithȱtheȱequipmentȱandȱstaffȱitȱneededȱtoȱprovideȱulȬ
trasounds.ȱ Inȱ responseȱ toȱ theȱ newȱ law,ȱ PPINKȱ didȱ buyȱ oneȱ
newȱ ultrasoundȱ machineȱ forȱ oneȱ ofȱ itsȱ nonȬabortionȬ
providingȱ healthȱ centersȱ andȱ trainedȱ aȱ staffȱ memberȱ toȱ useȱ
ultrasoundȱequipmentȱatȱanother,ȱindicatingȱitsȱcommitmentȱ
toȱprovidingȱasȱmuchȱserviceȱasȱitȱcouldȱdespiteȱtheȱburdensȱ
ofȱ theȱ newȱ law.ȱ Theȱ State’sȱ argumentȱ aboutȱ PPINKȱ merelyȱ
needingȱtoȱshiftȱresourcesȱtoȱaffordȱtheȱultrasoundȱmachinesȱ
isȱ bothȱ oddȱ andȱ unworkable.ȱ Onlyȱ 7%ȱ ofȱ PPINK’sȱ patientsȱ
receiveȱabortionȱservices,ȱsoȱinȱtheoryȱPPINKȱcouldȱshiftȱreȬ
sourcesȱforȱtheȱ93%ȱofȱitsȱotherȱservicesȱtoȱabortionȱservices.ȱ
Itȱ seemsȱ illogicalȱ forȱ aȱ stateȱ withȱ anȱ assertedȱ interestedȱ inȱ
protectingȱfetalȱlifeȱtoȱbeȱencouragingȱPPINKȱtoȱshiftȱallȱofȱitsȱ
resourcesȱfromȱotherȱhealthcare,ȱsuchȱasȱpregnancyȱprevenȬ
tionȱandȱcancerȱscreening,ȱtoȱabortionȱservices.ȱItȱisȱunworkȬ
ableȱ because,ȱ asȱ weȱ noted,ȱ neitherȱ theȱ Stateȱ norȱ theȱ courtsȱ
hasȱ theȱ authorityȱ toȱ rewriteȱ PPINK’sȱ missionȱ andȱ dictateȱ
howȱitȱmustȱallocateȱitsȱlimitedȱresources.ȱPPINKȱoperatesȱinȱ
aȱ worldȱ whereȱ limitedȱ healthȱ careȱ dollarsȱ forȱ mostlyȱ poorȱ
womenȱmustȱbeȱallocatedȱinȱanȱefficientȱway,ȱandȱ inȱ aȱwayȱ
thatȱprovidesȱtheȱgreatestȱcareȱforȱtheȱgreatestȱneeds.ȱȱ
Theȱfactȱthatȱcourtsȱareȱboundȱbyȱtheȱrealityȱinȱwhichȱtheȱ
lawsȱ operateȱ isȱ reflectedȱ inȱ otherȱ abortionȱ cases.ȱ Inȱ Wholeȱ
Women’sȱ Health,ȱ theȱ Courtȱ foundȱ thatȱ theȱ requirementȱ thatȱ
allȱabortionȱfacilitiesȱmeetȱtheȱstandardsȱforȱambulatoryȱsurȬ
28ȱ No.ȱ17Ȭ1883ȱ
gicalȱcentersȱwouldȱreduceȱtheȱnumberȱofȱabortionȱfacilitiesȱ
inȱ Texasȱ fromȱ fortyȱ toȱ sevenȱ andȱ thusȱ unconstitutionallyȱ
burdenȱ theȱ rightȱ toȱ anȱ abortion.ȱ Wholeȱ Women’sȱ Health,ȱ 136ȱ
S.ȱCt.ȱ atȱ 2301,ȱ 2318.ȱ Theȱ Courtȱ lookedȱ atȱ theȱ costȱ aȱ facilityȱ
wouldȱ haveȱ toȱ incurȱ toȱ meetȱ theȱ requirements—$1–$3ȱ milȬ
lion—andȱassumedȱthatȱtheȱfacilitiesȱwouldȱcloseȱratherȱthanȱ
beȱ ableȱ toȱ meetȱ theȱ requirements,ȱ despiteȱ theȱ factȱ thatȱ eachȱ
facilityȱcould,ȱinȱanȱalternateȱuniverseȱwhereȱresourcesȱwereȱ
unlimited,ȱsimplyȱmakeȱtheȱchanges.ȱId.ȱatȱ2318.ȱȱ
Similarly,ȱinȱSchimel,ȱthisȱcourtȱlookedȱatȱtheȱburdenȱimȬ
posedȱ byȱ theȱ proposedȱ abortionȱ lawȱ requiringȱ physiciansȱ
whoȱ provideȱ abortionȱ servicesȱ toȱ haveȱ admittingȱ privilegesȱ
atȱ aȱ hospitalȱ withinȱ thirtyȱ milesȱ ofȱ theȱ abortionȱ clinic.ȱ
PlannedȱParenthoodȱofȱWisc.,ȱInc.ȱv.ȱSchimel,ȱ806ȱF.3dȱ908,ȱ918ȱ
(7thȱCir.ȱ2015).ȱInȱgrantingȱanȱinjunction,ȱweȱrecognizedȱthatȱ
theȱdelaysȱcausedȱbyȱtheȱnewȱlawȱmightȱcauseȱsomeȱwomenȱ
toȱloseȱtheȱchanceȱtoȱhaveȱanȱabortionȱwithinȱtheȱtimeȱperiodȱ
thatȱ Plannedȱ Parenthoodȱ allowed.ȱ Noȱ oneȱ inȱ thatȱ caseȱ sugȬ
gestedȱ thatȱ Plannedȱ Parenthoodȱ provideȱ laterȱ termȱ aborȬ
tions.ȱId.ȱInsteadȱthisȱcourtȱspentȱmostȱofȱtheȱopinionȱexamȬ
iningȱ theȱ realityȱ ofȱ whatȱ anȱ emergentȱ situationȱ mightȱ lookȱ
likeȱinȱtheȱabortionȱcontextȱandȱhowȱaȱpatientȱinȱsuchȱaȱsituaȬ
tionȱ mightȱ receiveȱ care.ȱ Id.ȱ atȱ 912–16.ȱ Courtsȱ mustȱ considerȱ
theȱimpactȱofȱtheȱnewȱultrasoundȱlawȱbasedȱonȱtheȱrealityȱofȱ
theȱabortionȱproviderȱandȱitsȱpatients,ȱnotȱasȱitȱcouldȱifȱproȬ
vidersȱandȱpatientsȱhadȱunlimitedȱresources.ȱȱ
Theȱ State’sȱ argumentsȱ aboutȱ mitigatingȱ childȱ careȱ burȬ
densȱsimilarlyȱmissȱtheȱmark.ȱTheȱStateȱsuggestsȱthatȱwomenȱ
simplyȱcouldȱbringȱalongȱtheirȱchildrenȱtoȱtheȱultrasound—
mostȱ ofȱ whichȱ areȱ performedȱ transvaginallyȱ atȱ theseȱ earlyȱ
stages.ȱ Seeȱ R.ȱ 35Ȭ5ȱ atȱ 27.ȱ Butȱ Plannedȱ Parenthood’sȱ policyȱ
No.ȱ17Ȭ1883ȱ 29
prohibitsȱ childrenȱ atȱ ultrasoundȱ appointments,ȱ andȱ withȱ
goodȱreason.ȱOneȱwondersȱatȱwhatȱageȱaȱchildȱcouldȱapproȬ
priatelyȱsitȱthroughȱsuchȱaȱprocedure?ȱAȱwomanȱundergoingȱ
aȱtransvaginalȱultrasoundȱmustȱlieȱstillȱwhileȱtheȱtransducerȱ
isȱ insertedȱ intoȱ herȱ vaginaȱ andȱ usedȱ toȱ viewȱ theȱ fetusȱ andȱ
herȱ organs.ȱ Seeȱ https://www.healthline.com/health/transvagȱ
inalȬultrasound.ȱSheȱ wouldȱhaveȱnoȱwayȱ toȱsootheȱ aȱ cryingȱ
babyȱorȱmonitorȱaȱtoddlerȱrunningȱthroughȱtheȱexamȱroom.ȱ
Neitherȱ theȱ personȱ performingȱ theȱ ultrasoundȱ norȱ theȱ paȬ
tientȱ isȱ inȱ aȱ positionȱ toȱ monitorȱ theȱ safetyȱ ofȱ theȱ childȱ inȱ aȱ
medicalȱ examinationȱ room,ȱ andȱ PPINKȱ submittedȱ evidenceȱ
ofȱitsȱconcernsȱaboutȱtheȱ“seriousȱriskȱofȱdistraction”ȱforȱtheȱ
doctorȱ performingȱ theȱ procedure.ȱ R.ȱ 35Ȭ5ȱ atȱ 26.ȱ Norȱ wouldȱ
mostȱwomenȱwishȱtoȱundergoȱsuchȱaȱprocedureȱwithȱaȱpreȬ
teenȱ sonȱ orȱ daughterȱ inȱ theȱ room,ȱ evenȱ with,ȱ asȱ theȱ Stateȱ
suggests,ȱaȱsheetȱdrapedȱoverȱherȱlegs.ȱLikeȱallȱwomen,ȱpoorȱ
womenȱdeserveȱaȱlevelȱofȱdignityȱandȱchoiceȱaboutȱtheȱconȬ
fidentialityȱofȱtheirȱhealthcare.ȱMoreover,ȱthisȱisȱaȱperplexingȱ
argumentȱ fromȱ aȱ Stateȱ thatȱ wantsȱ womenȱ toȱ seriouslyȱ “reȬ
flectȱuponȱcompellingȱevidenceȱofȱfetalȱhumanity,”ȱandȱformȱ
aȱ bondȱ withȱ theȱ fetusȱ “whileȱ viewingȱ thisȱ live,ȱ movingȱ imȬ
ageȱofȱtheirȱbaby,ȱwithȱarmsȱandȱlegs.”ȱAppellant’sȱBriefȱatȱ2,ȱ
4.ȱ Itȱ seemsȱ likelyȱ thatȱ havingȱ childrenȱ inȱ theȱ roomȱ wouldȱ
significantlyȱdecreaseȱtheȱabilityȱforȱseriousȱreflectionȱinȱtheȱ
bulkȱofȱsituations.ȱȱ
2.ȱ Benefitsȱ
Balancedȱ againstȱ theseȱ substantialȱ burdens,ȱ theȱ districtȱ
courtȱ consideredȱ theȱ intendedȱ benefitsȱ ofȱ theȱ newȱ law.ȱ Asȱ
weȱjustȱnoted,ȱtheȱStateȱwishesȱtoȱ“encourageȱwomenȱtoȱreȬ
flectȱ uponȱ compellingȱ evidenceȱ ofȱ fetalȱ humanity,”ȱ andȱ toȱ
persuadeȱ aȱ womanȱ toȱ reconsiderȱ herȱ decisionȱ toȱ haveȱ anȱ
30ȱ No.ȱ17Ȭ1883ȱ
abortion.ȱ Appellant’sȱ Briefȱ atȱ 2,ȱ 18,ȱ 20,ȱ 23.ȱ Theȱ Stateȱ arguesȱ
thatȱultrasoundsȱhaveȱaȱuniqueȱimpactȱonȱaȱpregnantȱwomȬ
anȱbecauseȱtheyȱallowȱherȱtoȱseeȱherȱownȱfetusȱratherȱthanȱaȱ
photographȱ orȱ illustrationȱ ofȱ aȱ genericȱ fetus,ȱ andȱ this,ȱ theȱ
Stateȱhopes,ȱhelpsȱ“createȱaȱbondȱthatȱleadsȱthemȱtoȱcontinueȱ
theirȱpregnancy.”ȱAppellant’sȱBriefȱatȱ4.ȱȱ
Theȱ newȱ ultrasoundȱ lawȱ encouragesȱ womenȱ toȱ carryȱ
pregnanciesȱ toȱ termȱ inȱ twoȱ ways,ȱ theȱ Stateȱ argues.ȱ First,ȱ itȱ
givesȱthemȱinformationȱaboutȱtheirȱparticularȱfetusȱand,ȱsecȬ
ond,ȱ itȱ givesȱ themȱ timeȱtoȱreflectȱuponȱ thatȱinformationȱ beȬ
foreȱ theyȱ makeȱ theirȱ finalȱ decision.ȱ Accordingȱ toȱ theȱ State,ȱ
“Aȱ womanȱ offeredȱ theȱ chanceȱ toȱ viewȱ anȱ ultrasoundȱ 18ȱ
hoursȱbeforeȱanȱabortionȱmayȱwellȱhaveȱaȱdifferentȱmindsetȱ
thanȱ aȱ womanȱ whoȱ hasȱ alreadyȱ madeȱ aȱ finalȱ decisionȱ andȱ
presentsȱ herselfȱ atȱ theȱ clinicȱ toȱ carryȱ itȱ out.”ȱ Appellant’sȱ
Briefȱatȱ25.ȱToȱsupportȱitsȱclaimȱthatȱultrasoundsȱmatter,ȱtheȱ
Stateȱ introducedȱ aȱ studyȱ demonstratingȱ thatȱ forȱ theȱ 7%ȱ ofȱ
womenȱwhoȱseekȱabortionsȱandȱhaveȱmediumȱtoȱlowȱ“deciȬ
sionȱcertainty,”ȱ(presumablyȱmeaningȱthatȱtheyȱareȱnotȱveryȱ
certainȱaboutȱtheirȱchoice),ȱthoseȱwhoȱviewedȱanȱultrasoundȱ
imageȱhadȱaȱ95.2%ȱrateȱofȱproceedingȱwithȱanȱabortionȱcomȬ
paredȱtoȱ97.5%ȱrateȱforȱwomenȱwithȱhighȱdecisionȱcertaintyȱ
whoȱ viewedȱ anȱ ultrasound.ȱ Maryȱ Gatterȱ et.ȱ al.ȱ Relationshipȱ
Betweenȱ Ultrasoundȱ Viewingȱ andȱ Proceedingȱ toȱ Abortion,ȱ 123ȱ
Obstetricsȱ &ȱ Gynecologyȱ 81,ȱ 83ȱ (2014).ȱ Thisȱ evidence,ȱ howȬ
ever,ȱisȱfocusedȱonȱtheȱbenefitsȱofȱanȱultrasoundȱandȱnotȱtheȱ
benefitsȱofȱanȱultrasoundȱeighteenȱhoursȱbeforeȱanȱabortion.ȱ
TheȱState’sȱstrongestȱevidenceȱthatȱtheȱeighteenȬhourȱreȬ
quirementȱ providesȱ someȱ benefit,ȱ however,ȱ cameȱ fromȱ theȱ
testimonyȱofȱDr.ȱChristinaȱFrancis,ȱaȱboardȬcertifiedȱobstetriȬ
cianȬgynecologistȱ whoȱ testifiedȱ thatȱ sheȱ hadȱ aȱ patientȱ whoȱ
No.ȱ17Ȭ1883ȱ 31
wouldȱhaveȱbenefittedȱfromȱtheȱnewȱlaw.ȱTheȱpatientȱhadȱaȱ
medicationȱ abortionȱ atȱ PPINKȱ inȱ Indianapolisȱ andȱ underȬ
wentȱ theȱ requiredȱ ultrasoundȱ thatȱ day,ȱ asȱ requiredȱ byȱ theȱ
lawȱatȱtheȱtime.ȱSheȱtoldȱDr.ȱFrancis,ȱthatȱsheȱregrettedȱhavȬ
ingȱtheȱabortionȱȱ
andȱ feelsȱ thatȱ anȱ ultrasoundȱ waitingȱ periodȱ
wouldȱ haveȱ givenȱ herȱ moreȱ timeȱ toȱ considerȱ
herȱ decisionȱ andȱ changeȱ herȱ mind.ȱ …ȱ Sheȱ unȬ
derwentȱtheȱultrasoundȱonȱtheȱdayȱofȱherȱaborȬ
tion,ȱ immediatelyȱ priorȱ toȱ receivingȱ theȱ mediȬ
cation.ȱ Sheȱ choseȱ notȱ toȱ viewȱ theȱ ultrasoundȱ
imageȱbecauseȱsheȱfeltȱthatȱifȱsheȱsawȱanȱimageȱ
ofȱ herȱ babyȱ itȱ wouldȱ causeȱ herȱ toȱ changeȱ herȱ
mind.ȱ Sheȱ toldȱ [Dr.ȱ Francis]ȱ thatȱ sheȱ didȱ notȱ
wantȱtoȱbeȱpersuadedȱnotȱtoȱabortȱbecauseȱsheȱ
wasȱalreadyȱatȱtheȱclinic,ȱhadȱpaidȱforȱtheȱaborȬ
tion,ȱandȱfeltȱpressuredȱbyȱthoseȱcircumstancesȱ
toȱ goȱ throughȱ withȱ it.ȱ [She]ȱ toldȱ [Dr.ȱ Francis]ȱ
thatȱhadȱsheȱundergoneȱtheȱultrasoundȱtheȱdayȱ
beforeȱ theȱ abortion,ȱ sheȱ likelyȱ wouldȱ haveȱ
viewedȱ theȱ imageȱ andȱ sheȱ doesȱ notȱ thinkȱ sheȱ
wouldȱhaveȱcomeȱbackȱtheȱnextȱdayȱtoȱproceedȱ
withȱtheȱmedicationȱabortion.ȱ
R.ȱ35Ȭ1ȱatȱ5.ȱThisȱisȱtheȱState’sȱstrongestȱevidenceȱbecauseȱitȱisȱ
theȱonlyȱevidenceȱthatȱtheȱeighteenȬhourȱwaitingȱperiodȱmatȬ
tersȱ forȱ womenȱ seekingȱ abortions,ȱ asȱ opposedȱ toȱ theȱ ultraȬ
soundȱitself.ȱȱ
TheȱStateȱalsoȱarguedȱthatȱvoluntaryȱwaitingȱperiodsȱareȱ
commonȱ forȱ otherȱ proceduresȱ whereȱ physiciansȱ giveȱ paȬ
tientsȱtheȱopportunityȱtoȱweighȱtheȱcostsȱandȱbenefitsȱofȱvarȬ
iousȱ optionsȱ andȱ thinkȱ ofȱ additionalȱ questionsȱ orȱ concerns.ȱ
32ȱ No.ȱ17Ȭ1883ȱ
Asȱevidence,ȱtheȱstateȱpresentedȱtheȱdeclarationȱtestimonyȱofȱ
Dr.ȱ Francis,ȱ whoȱ explainedȱ herȱ preferenceȱ toȱ “giveȱ patientsȱ
timeȱtoȱreflectȱonȱtheȱinformationȱtheyȱhaveȱreceived,ȱweighȱ
theȱpossibleȱrisksȱandȱbenefitsȱofȱtheȱprocedure,ȱdiscussȱtheȱ
procedureȱwithȱlovedȱones,ȱandȱaskȱquestionsȱofȱtheȱdoctor.”ȱ
R.ȱ35Ȭ1ȱatȱ2–3.ȱSheȱstatedȱthatȱforȱ“lifeȱaltering”ȱprocedures,ȱ
sheȱ providesȱ informedȬconsentȱ informationȱ oneȱ toȱ fourȱ
weeksȱpriorȱtoȱtheȱprocedure.ȱR.ȱ35Ȭ1ȱatȱ3.ȱTheȱStateȱdidȱnotȱ
argueȱ thatȱ aȱ waitingȱ periodȱ isȱ mandatoryȱ forȱ anyȱ ofȱ theseȱ
procedures.ȱȱ
Finally,ȱtheȱStateȱarguesȱthatȱtheȱultrasoundȱlawȱadvancȬ
esȱ importantȱ stateȱ interestsȱ inȱ theȱ psychologicalȱ healthȱ ofȱ
womenȱ consideringȱ abortion.ȱ Forȱ thisȱ propositionȱ itȱ reliedȱ
onȱaȱcontroversialȱandȱmuchȱmalignedȱ(seeȱbelow)ȱstudyȱbyȱ
PriscillaȱK.ȱColemanȱwhichȱconcludedȱthatȱ“quiteȱconsistentȬ
lyȱ …ȱ abortionȱ isȱ associatedȱ withȱ moderateȱ toȱ highlyȱ inȬ
creasedȱ risksȱ ofȱ psychologicalȱ problemsȱ subsequentȱ toȱ theȱ
procedure.”ȱ Priscillaȱ K.ȱ Coleman,ȱ Abortionȱ andȱ Mentalȱ
Health:ȱ Quantitativeȱ Synthesisȱ andȱ Analysisȱ ofȱ Researchȱ
Published,ȱ1995Ȭ2009,ȱ199ȱBritishȱJournalȱofȱPsychiatry,ȱ180–
86ȱ(2011).ȱMoreover,ȱtheȱStateȱargued,ȱtheȱearlierȱultrasoundȱ
ensuresȱ thatȱ aȱ womanȱ doesȱ notȱ becomeȱ psychologicallyȱ
committedȱtoȱhavingȱanȱabortionȱonlyȱtoȱarriveȱforȱtheȱproȬ
cedureȱandȱlearnȱthatȱsheȱhasȱwaitedȱtooȱlong.ȱ
Theȱ districtȱ courtȱ unequivocallyȱ acceptedȱ theȱ State’sȱ asȬ
sertedȱ interestsȱ asȱ legitimate.ȱ Indeed,ȱ Caseyȱ instructsȱ thatȱ
“theȱ Stateȱ hasȱ aȱ legitimateȱ interestȱ inȱ promotingȱ theȱ lifeȱ orȱ
potentialȱlifeȱofȱtheȱunborn.”ȱCasey,ȱ505ȱU.S.ȱatȱ870.ȱAnd,ȱofȱ
course,ȱ noȱ oneȱ wouldȱ argueȱ thatȱ protectingȱ maternalȱ psyȬ
chologicalȱhealthȱisȱnotȱaȱlegitimateȱstateȱinterest.ȱȱ
No.ȱ17Ȭ1883ȱ 33
3.ȱ Weighingȱȱ
AfterȱthisȱthoroughȱcompilationȱofȱtheȱburdensȱandȱbeneȬ
fits,ȱtheȱdistrictȱcourtȱturnedȱitsȱattentionȱtoȱresolvingȱtheȱulȬ
timateȱ question—whether,ȱ afterȱ consideringȱ theȱ burdenȱ theȱ
lawȱ imposesȱ onȱ abortionȱ access,ȱ togetherȱ withȱ theȱ benefitsȱ
thoseȱlawsȱconfer,ȱtheȱnewȱultrasoundȱlawȱhasȱ“theȱeffectȱofȱ
placingȱ aȱ substantialȱ obstacleȱ inȱ theȱ pathȱ ofȱ aȱ woman’sȱ
choice”ȱtoȱhaveȱanȱabortion.ȱWholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱ
atȱ 2309ȱ (citingȱ Casey,ȱ 505ȱ U.S.ȱ atȱ 877).ȱ Butȱ beforeȱ theȱ courtȱ
couldȱweighȱtheȱbenefitsȱandȱburdens,ȱitȱhadȱtoȱanswerȱtwoȱ
baselineȱ questions:ȱ first,ȱ whatȱ groupȱ ofȱ womenȱ shouldȱ theȱ
courtȱ considerȱ whenȱ weighingȱ theȱ burdensȱ imposed,ȱ andȱ
second,ȱonȱwhatȱaspectȱofȱtheȱlawȱshouldȱtheȱcourtȱfocusȱitsȱ
benefitȱandȱburdenȱweighingȱanalysis—inȱotherȱwords,ȱwhatȱ
isȱtheȱrelevantȱquestionȱpresentedȱbyȱthisȱcase.ȱTheȱCourtȱinȱ
WholeȱWomen’sȱHealthȱmadeȱtheȱanswerȱtoȱtheȱfirstȱquestionȱ
clearȱ byȱ explainingȱ thatȱ aȱ courtȱ mustȱ lookȱ specificallyȱ atȱ
“thoseȱ womenȱ forȱ whomȱ theȱ provisionȱ isȱ anȱ actualȱ ratherȱ
thanȱ anȱ irrelevantȱ restriction.”ȱ Id.ȱ (citingȱ Casey,ȱ 505ȱ U.S.ȱ atȱ
895).ȱInȱthisȱcase,ȱtheȱdistrictȱcourtȱdeterminedȱthatȱtheȱreleȬ
vantȱgroupȱconsistedȱofȱlowȬincomeȱwomenȱwhoȱliveȱaȱsigȬ
nificantȱ distanceȱ fromȱ oneȱ ofȱ theȱ sixȱ PPINKȱ healthȱ centersȱ
offeringȱinformedȬconsentȱappointments.ȱȱ
Asȱ forȱ theȱ questionȱ ofȱ whichȱ benefitsȱ andȱ burdensȱ theȱ
courtȱ mustȱ weigh,ȱ theȱ districtȱ courtȱ emphasizedȱ thatȱ theȱ
questionȱitȱwasȱrequiredȱtoȱconsiderȱwasȱ“whetherȱtheȱultraȬ
soundȱ lawȱ providesȱ theȱ assertedȱ benefitsȱ asȱ comparedȱ toȱ theȱ
priorȱlaw.”ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1031ȱ(emphasisȱinȱoriginal)ȱ(citȬ
ingȱWholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱatȱ2311).ȱInȱotherȱwords,ȱ
theȱonlyȱrelevantȱburdensȱandȱbenefitsȱtoȱconsiderȱasȱaȱcourtȱ
weighsȱoneȱagainstȱtheȱotherȱareȱtheȱburdensȱimposedȱbyȱtheȱ
34ȱ No.ȱ17Ȭ1883ȱ
requirementȱtoȱ haveȱ anȱ ultrasoundȱatȱ leastȱ eighteenȱhoursȱbeȬ
foreȱanȱabortion,ȱandȱtheȱbenefitsȱofȱhavingȱtheȱultrasoundȱatȱ
leastȱ eighteenȱ hoursȱ beforeȱ theȱ procedureȱ (notȱ theȱ burdensȱ orȱ
benefitsȱ ofȱ theȱ ultrasoundȱ itself).ȱ PPINKȱ didȱ notȱ challengeȱ
theȱ requirementȱ thatȱ aȱ patientȱ undergoȱ anȱ ultrasoundȱ atȱ
someȱ pointȱ priorȱ toȱ theȱ abortion.ȱ Norȱ wasȱ itȱ challengedȱ
whenȱ itȱ wasȱ enacted.ȱ Seeȱ Appellant’sȱ Briefȱ atȱ 4.ȱ Thereforeȱ
theȱbenefitsȱofȱhavingȱanȱultrasoundȱatȱsomeȱtimeȱpriorȱtoȱanȱ
abortionȱ (withoutȱ regardȱ toȱ theȱ “eighteenȱ hourȱ prior”ȱ reȬ
quirement)ȱareȱirrelevant.ȱItȱisȱtheȱburdenȱofȱtravellingȱtwiceȱ
whichȱbecomesȱtheȱobstacleȱtoȱaccess.ȱ
Havingȱ determinedȱ theȱ properȱ focusȱ ofȱ theȱ inquiry,ȱ theȱ
districtȱ courtȱ couldȱ turnȱ toȱ itsȱ ultimateȱ taskȱ ofȱ determiningȱ
whetherȱ theȱ burdensȱ ofȱ theȱ law’sȱ requirementsȱ wereȱ “disȬ
proportionate,ȱ inȱ theirȱ effectȱ onȱ theȱ rightȱ toȱ anȱ abortion”ȱ
comparedȱtoȱtheȱbenefitsȱthatȱtheȱrestrictionsȱareȱbelievedȱtoȱ
confer.”ȱ Schimel,ȱ 806ȱ F.3dȱ atȱ 919.ȱ Toȱ determineȱ whetherȱ aȱ
burdenȱisȱundue,ȱtheȱcourtȱmustȱ“weighȱtheȱburdensȱagainstȱ
theȱ state’sȱ justification,ȱ askingȱ whetherȱ andȱ toȱ whatȱ extentȱ
theȱchallengedȱregulationȱactuallyȱadvancesȱtheȱstate’sȱinterȬ
ests.ȱ Ifȱ aȱ burdenȱ significantlyȱ exceedsȱ whatȱ isȱ necessaryȱ toȱ
advanceȱtheȱstate’sȱinterests,ȱitȱisȱ‘undue,’”ȱandȱthusȱunconȬ
stitutional.ȱSchimel,ȱ806ȱF.3dȱatȱ919.ȱȱ
Theȱ districtȱ courtȱ foundȱ thatȱ theȱ burdensȱ wereȱ signifiȬ
cant:ȱ additionalȱ travelȱ expenses,ȱ childcareȱ costs,ȱ lossȱ ofȱ enȬ
tireȱ days’ȱ wages,ȱ riskȱ ofȱ losingȱ jobs,ȱ andȱ potentialȱ dangerȱ
fromȱanȱabusiveȱpartner.ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1037.ȱIncreasedȱ
travelȱ distance,ȱ theȱ Wholeȱ Women’sȱ Healthȱ Courtȱ instructed,ȱ
constitutesȱ aȱ concreteȱ hardshipȱ thatȱ canȱ ultimatelyȱ contribȬ
uteȱ toȱ theȱ burdenȱ beingȱ undue.ȱ Wholeȱ Womanȇsȱ Health,ȱ 136ȱ
S.ȱCt.ȱ atȱ 2313.ȱ Seeȱ alsoȱ Schimel,ȱ 806ȱ F.3dȱ atȱ 919ȱ (notingȱ thatȱ
No.ȱ17Ȭ1883ȱ 35
theȱ90Ȭmile,ȱoneȬwayȱtripȱfromȱMilwaukeeȱtoȱChicagoȱmightȱ
notȱcauseȱaȱsignificantȱburdenȱtoȱaȱpersonȱwhoȱcanȱaffordȱaȱ
carȱorȱtrainȱticket,ȱbutȱwasȱindeedȱanȱundueȱburdenȱforȱtheȱ
largeȱ percentȱ ofȱ womenȱ seekingȱ abortionsȱ whoȱ liveȱ belowȱ
andȱ farȱ belowȱ theȱ povertyȱ line).ȱ Theseȱ areȱ justȱ theȱ typesȱ ofȱ
burdens,ȱ theȱ districtȱ courtȱ concluded,ȱ thatȱ preventȱ womenȱ
fromȱexercisingȱtheirȱrightȱtoȱhaveȱanȱabortion.ȱ
Theȱ funnelingȱ ofȱ allȱ informedȬconsentȱ appointmentsȱ toȱ
theȱ sixȱ PPINKȱ healthȱ centersȱ withȱ ultrasoundȱ equipmentȱ
imposedȱ otherȱ burdens.ȱ Itȱ requiredȱ PPINKȱ toȱ doubleȬbookȱ
appointmentsȱ whichȱ increasedȱ waitȱ timesȱ forȱ appointmentsȱ
andȱ elongatedȱ theȱ durationȱ ofȱ thoseȱ appointments.ȱ Theseȱ
wereȱ theȱ kindsȱ ofȱ incrementalȱ burdensȱ thatȱ theȱ Supremeȱ
Courtȱ consideredȱ inȱ Wholeȱ Women’sȱ Healthȱ asȱ well,ȱ whenȱ itȱ
notedȱ thatȱ “[t]hoseȱ closuresȱ meantȱ fewerȱ doctors,ȱ longerȱ
waitingȱtimes,ȱandȱincreasedȱcrowding,”ȱandȱthatȱthoseȱburȬ
dens,ȱ alongȱ withȱ increasedȱ drivingȱ distancesȱ wereȱ theȱ typeȱ
ofȱ incrementalȱ burdens,ȱ which,ȱ whenȱ takenȱ togetherȱ adeȬ
quatelyȱsupportȱanȱ“undueȱburden”ȱconclusion.ȱWholeȱWomȬ
anȇsȱHealth,ȱ136ȱS.ȱCt.ȱatȱ2313.ȱȱ
Onȱ theȱ otherȱ sideȱ ofȱ theȱ scale,ȱ theȱ districtȱ courtȱ foundȱ
thatȱtheȱState’sȱmanyȱargumentsȱregardingȱtheȱbenefitsȱofȱtheȱ
ultrasoundȱmissedȱtheȱmarkȱbyȱaddressingȱtheȱutilityȱofȱtheȱ
ultrasoundȱ itselfȱ asȱ opposedȱ toȱ theȱ periodȱ ofȱ reflection.ȱ Butȱ
evenȱ consideringȱ theȱ meritsȱ ofȱ thatȱ dataȱ submittedȱ byȱ theȱ
State,ȱtheȱdistrictȱcourtȱnotedȱthatȱtheȱultrasoundȱeffectȱstudyȱ
reliedȱ uponȱ byȱ theȱ Stateȱ describedȱ theȱ potentialȱ impactȱ ofȱ
viewingȱanȱultrasoundȱtoȱhaveȱaȱ“veryȱsmall”ȱeffectȱonȱaȱpoȬ
tentialȱpoolȱofȱonlyȱaboutȱ7%ȱofȱwomenȱseekingȱabortions—
thoseȱ whoȱ hadȱ lowȱ orȱ mediumȱ decisionȱ certainty,ȱ andȱ noȱ
impactȱ onȱ womenȱ withȱ highȱ decisionȱ certainty—thoseȱ whoȱ
36ȱ No.ȱ17Ȭ1883ȱ
makeȱ upȱ 93%ȱ ofȱ womenȱ seekingȱ abortions.ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ
atȱ1032–33ȱ(citingȱGatter,ȱObstetricsȱ&ȱGynecology,ȱVol.ȱ123ȱ
atȱ83).ȱAndȱ althoughȱtheȱstudyȱ statesȱ thatȱ womenȱ withȱlowȱ
decisionȱ certaintyȱ whoȱ viewedȱ anȱ ultrasoundȱ imageȱ hadȱ aȱ
95.2%ȱ rateȱ ofȱ proceedingȱ withȱ anȱ abortionȱ comparedȱ toȱ
97.5%ȱ rateȱ forȱ womenȱ withȱ highȱ decisionȱ certaintyȱ whoȱ
viewedȱ anȱ ultrasound,ȱ (Gatter,ȱ Obstetricsȱ &ȱ Gynecology,ȱ
Vol.ȱ 123ȱ atȱ 83)ȱ theȱ Stateȱ doesȱ notȱ tellȱ usȱ howȱ manyȱ womenȱ
withȱ lowȱ decisionȱ certaintyȱ changedȱ theirȱ mindsȱ evenȱ withȬ
outȱ seeingȱ anȱ ultrasoundȱ image.ȱForȱ theȱ ultrasoundȱtoȱhaveȱ
anyȱ impact,ȱ theȱ womenȱ mustȱ actuallyȱ viewȱ theȱ ultrasound,ȱ
andȱonlyȱapproximatelyȱ25%ȱofȱPPINKȱpatientsȱchoseȱtoȱdoȱ
soȱ (Weȱ doȱ notȱ knowȱ whetherȱ thatȱ numberȱ differsȱ betweenȱ
lowȱ andȱ highȱ decisionȬcertaintyȱ patientsȱ becauseȱ theȱ Stateȱ
presentedȱ noȱ evidenceȱ onȱ thatȱ point.).ȱ Thisȱ meansȱ thatȱ ifȱ
thereȱ isȱ anyȱ chanceȱ thatȱ thisȱ “veryȱ small”ȱ impactȱ willȱ sucȬ
ceedȱ itȱ willȱ doȱ soȱ onlyȱ forȱ theȱ poolȱ ofȱ womenȱ consistingȱ ofȱ
theȱ7%ȱofȱabortionȱseekersȱwithȱlowȱorȱmediumȱdecisionȱcerȬ
taintyȱandȱ onlyȱonȱwhateverȱpercentageȱofȱthatȱ7%ȱwhoȱacȬ
tuallyȱ chooseȱ toȱ alsoȱ viewȱ theȱ ultrasound,ȱ butȱ likelyȱ onlyȱ
25%ȱ ofȱ thatȱ 7%ȱ orȱ 1.75%.ȱ Norȱ canȱ weȱ tellȱ ifȱ theseȱ lowȱ deciȬ
sionȬcertaintyȱpatientsȱmightȱhaveȱchangedȱtheirȱmindsȱevenȱ
withoutȱtheȱultrasound.ȱInȱgeneral,ȱtheȱstudyȱthatȱbothȱparȬ
tiesȱ citeȱ ofȱ overȱ 15,000ȱ womenȱ seekingȱ abortionsȱ atȱ aȱ
PlannedȱParenthoodȱinȱLosȱAngelesȱdemonstratedȱthatȱmostȱ
visitsȱendȱinȱabortion—98.8%.ȱGatter,ȱObstetricsȱ&ȱGynecolȬ
ogy,ȱ Vol.ȱ 123ȱ atȱ 82.ȱ Forȱ theȱ wholeȱ populationȱ ofȱ womenȱ inȱ
thatȱ studyȱ whoȱ viewedȱ anȱ ultrasound,ȱ 98.4%ȱ hadȱ anȱ aborȬ
tion.ȱ Id.ȱ Itȱ seemsȱ fromȱ theȱ studyȱ thatȱ increasingȱ gestationalȱ
ageȱofȱtheȱfetusȱ(somethingȱthatȱcanȱbeȱdeterminedȱwithoutȱ
ultrasound),ȱhadȱmoreȱtoȱdoȱwithȱtheȱdecisionȱnotȱtoȱproceedȱ
toȱ abortionȱ thanȱ viewingȱ ofȱ anȱ ultrasound.ȱ Id.ȱ Theȱ districtȱ
No.ȱ17Ȭ1883ȱ 37
courtȱ concludedȱ thatȱ ifȱ viewingȱ theȱ ultrasoundȱ hasȱ littleȱ toȱ
noȱ impact,ȱ thenȱ “[i]tȱ isȱ simplyȱ notȱ aȱ reasonableȱ assumpȬ
tionȱ…ȱ thatȱ furtherȱ timeȱ toȱ deliberateȱ onȱ anȱ imageȱ thatȱ hasȱ
nearlyȱ noȱ impactȱ atȱ theȱ time,ȱ wouldȱ createȱ aȱ meaningfullyȱ
strongerȱ impactȱ afterȱ eighteenȱ hours.”ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ
1034.ȱȱ
Weȱ agreeȱ withȱ theȱ Stateȱ thatȱ itȱ isȱ entitledȱ toȱ tryȱ toȱ perȬ
suadeȱ womenȱ notȱ toȱ haveȱ anȱ abortionȱ evenȱ ifȱ theȱ impactȱ isȱ
minimal.ȱNevertheless,ȱinȱweighingȱtheȱbenefitȱofȱtheȱparticȬ
ularȱmeasureȱatȱissue,ȱaȱcourtȱmayȱconsiderȱtheȱminimalȱpuȬ
tativeȱeffectsȱofȱtheȱState’sȱaction.ȱTheȱmoreȱfeebleȱtheȱstate’sȱ
assertedȱinterest,ȱ“theȱlikelierȱtheȱburden,ȱevenȱifȱslight,ȱtoȱbeȱ
‘undue’ȱ inȱ theȱ senseȱ ofȱ disproportionateȱ orȱ gratuitous.”ȱ
Plannedȱ Parenthoodȱ ofȱ Wisconsin,ȱ Inc.ȱ v.ȱ Vanȱ Hollen,ȱ 738ȱ F.3dȱ
786,ȱ798ȱ(7thȱCir.ȱ2013).ȱȱ
Moreȱ importantly,ȱevenȱifȱtheȱultrasoundȱdoesȱinfluenceȱ
aȱveryȱsmallȱpercentageȱofȱwomenȱtoȱalterȱtheirȱdecision,ȱallȱ
ofȱthatȱisȱirrelevant,ȱbecause,ȱasȱtheȱdistrictȱcourtȱexplained,ȱ
“[e]videnceȱ thatȱ someȱ women’sȱ decisionsȱ asȱ toȱ whetherȱ toȱ
haveȱanȱabortionȱareȱimpactedȱbyȱviewingȱtheȱultrasoundȱisȱ
notȱevidenceȱthatȱdoingȱsoȱatȱleastȱeighteenȱhoursȱbeforeȱtheȱ
abortion,ȱratherȱthanȱonȱtheȱdayȱofȱtheȱabortion,ȱhasȱanyȱadȬ
ditionalȱpersuasiveȱimpact.”ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1032.ȱ
Theȱ State’sȱ argumentȱ thatȱ theȱ additionalȱ eighteenȱ hoursȱ
givesȱwomenȱtimeȱforȱdeeperȱreflectionȱandȱtoȱabsorbȱinforȬ
mation,ȱ actuallyȱ doesȱ addressȱ theȱ questionȱ atȱ issueȱ inȱ theȱ
case,ȱ butȱ itsȱ argumentȱ isȱ unsupportedȱ byȱ anythingȱ otherȱ
thanȱDr.ȱFrancis’ȱoneȱanecdote.ȱMoreover,ȱoneȱcouldȱjustȱasȱ
easilyȱinferȱthatȱtheȱimpactȱofȱviewingȱtheȱultrasoundȱimage,ȱ
forȱ someȱ women,ȱ dissipatesȱ overȱ theȱ eighteenȱ hoursȱ beforeȱ
theȱ abortion.ȱ Theȱ Stateȱ asksȱ usȱ toȱ inferȱ thatȱ someȱ womenȱ
38ȱ No.ȱ17Ȭ1883ȱ
whoȱ chooseȱ notȱ toȱ viewȱ theȱ ultrasoundȱ doȱ soȱ becauseȱ theyȱ
areȱunderȱaȱtimeȱpressureȱandȱbecauseȱtheyȱhaveȱarrivedȱatȱ
theȱ healthȱ centerȱ havingȱ alreadyȱ madeȱ upȱ theirȱ minds,ȱ butȱ
theȱ Stateȱ offersȱ noȱ evidenceȱ forȱ this.ȱ Recallȱ thatȱ evenȱ underȱ
theȱoldȱlaw,ȱwomenȱwhoȱarrivedȱatȱtheȱhealthȱcenterȱonȱtheȱ
dayȱ ofȱ theirȱ abortionȱ hadȱ alreadyȱ receivedȱ copiousȱ inforȬ
mationȱ fromȱ theȱ Stateȱ designedȱ toȱ alterȱ theirȱ decisionȱ toȱ
abort,ȱ andȱ hadȱ plentyȱ ofȱ time—atȱ leastȱ eighteenȱ hours—toȱ
digestȱ andȱ considerȱ theirȱ optionsȱ whileȱ notȱ underȱ anȱ acuteȱ
timeȱpressure.ȱȱ
Theȱ onlyȱ relevantȱ evidenceȱ theȱ Stateȱ submittedȱ toȱ supȬ
portȱ theȱ propositionȱ thatȱ theȱ eighteenȬhourȱ requirementȱ inȬ
creasesȱ aȱ woman’sȱ abilityȱ toȱ reflectȱ moreȱ seriouslyȱ onȱ herȱ
decisionȱcameȱfromȱtheȱtestimonyȱofȱDr.ȱFrancisȱwhoȱstatedȱ
thatȱoneȱpatientȱreportedȱtoȱherȱthatȱsheȱmightȱhaveȱoptedȱtoȱ
viewȱ theȱ ultrasoundȱ andȱ thenȱ mightȱ haveȱ continuedȱ herȱ
pregnancyȱhadȱsheȱbeenȱgivenȱtheȱoptionȱtoȱviewȱtheȱultraȬ
soundȱeighteenȱhoursȱbeforeȱherȱprocedure,ȱasȱopposedȱtoȱatȱ
theȱ timeȱ ofȱ theȱ procedure.ȱ Theȱ districtȱ courtȱ notedȱ thatȱ thisȱ
wasȱ indeedȱ someȱ evidenceȱ thatȱ womenȱ mayȱ changeȱ theirȱ
mindsȱifȱtheyȱhaveȱmoreȱtimeȱtoȱreflectȱonȱtheȱdecision,ȱbutȱitȱ
alsoȱfoundȱthisȱsingularȱexampleȱtoȱbeȱexceedinglyȱspeculaȬ
tive.ȱ “Sheȱ canȱ onlyȱsayȱ thatȱsheȱ‘likely’ȱwouldȱhaveȱviewedȱ
theȱ ultrasound,ȱ ifȱ itȱ wasȱ offeredȱ aȱ dayȱ earlier”ȱ (whichȱ curȬ
rentlyȱonlyȱaboutȱ25%ȱofȱwomenȱdo),ȱandȱ“sheȱ‘likely’ȱwouldȱ
notȱhaveȱreturnedȱforȱanȱabortionȱtheȱnextȱday.”ȱ273ȱF.ȱSupp.ȱ
3dȱ atȱ 1035.ȱ Theȱ districtȱ court,ȱ whenȱ weighingȱ howȱ muchȱ
weightȱ toȱ giveȱ thisȱ evidence,ȱ concludedȱ thatȱ thisȱ wasȱ “farȱ
fromȱ compellingȱ evidenceȱ thatȱ theȱ newȱ ultrasoundȱ lawȱ
wouldȱ haveȱ theȱ impactȱdesiredȱbyȱtheȱ State,ȱandȱasȱsuch,ȱ itȱ
mustȱbeȱgivenȱdiminishedȱweightȱinȱtheȱbalancingȱprocess.”ȱ
No.ȱ17Ȭ1883ȱ 39
Id.ȱ Weȱ seeȱ noȱ reasonȱ toȱ disruptȱ theȱ districtȱ court’sȱ vastȱ disȬ
cretionȱinȱweighingȱthisȱevidence.ȱ
Dr.ȱFrancis’ȱotherȱ testimony—thatȱsomeȱofȱherȱ pregnantȱ
patientsȱhaveȱtoldȱherȱthatȱ“viewingȱanȱultrasoundȱimageȱofȱ
theirȱ babyȱ causedȱ themȱ toȱ decideȱ notȱ toȱ haveȱ anȱ abortion”ȱ
(R.ȱ35Ȭ1ȱatȱ4)—doesȱnotȱaddȱanythingȱtoȱtheȱconsiderationȱofȱ
whetherȱ viewingȱ theȱ ultrasoundȱ eighteenȱ hoursȱ priorȱ toȱ theȱ
abortionȱaltersȱtheȱcalculusȱinȱanyȱway.ȱ
Theȱ State’sȱ argumentȱ thatȱ doctorsȱ commonlyȱ useȱ inȬ
formedȬconsentȱwaitingȱperiodsȱtoȱgiveȱpatientsȱtimeȱtoȱconȬ
siderȱ importantȱ medicalȱ decisionsȱ doesȱ comeȱ closerȱ toȱ theȱ
relevantȱquestionȱinȱtheȱcase—theȱbenefitȱofȱaȱwaitingȱperiodȱ
betweenȱacquisitionȱofȱknowledgeȱandȱaȱmedicalȱprocedureȱ
itself.ȱDr.ȱFrancisȱtestifiedȱaboutȱtheȱimportanceȱofȱgivingȱpaȬ
tientsȱ timeȱ toȱ reflect,ȱ weighȱ risksȱ andȱ benefits,ȱ andȱ thinkȱ ofȱ
questions.ȱSeeȱR.ȱ35Ȭ1ȱatȱ3.ȱTheȱdistrictȱcourtȱnoted,ȱhowever,ȱ
thatȱ Dr.ȱ Francisȱ doesȱ notȱ provideȱ abortionȱ servicesȱ andȱ
thereforeȱ couldȱ notȱ attestȱ toȱ theȱ utilityȱ ofȱ aȱ waitingȱ periodȱ
afterȱ anȱ informedȬconsentȱ processȱ precedingȱ anȱ abortion.ȱ
Theȱ districtȱ courtȱ insteadȱ gaveȱ moreȱ weightȱ toȱ PPINK’sȱ arȬ
gumentȱ thatȱ abortionȱ proceduresȱ areȱ differentȱ thanȱ otherȱ
proceduresȱ whereȱ doctorsȱ giveȱ informationȱ longȱ beforeȱ aȱ
procedure,ȱ becauseȱ unlikeȱ inȱ theȱ contextȱ whereȱ aȱ doctorȱ isȱ
providingȱaȱpreviouslyȱunknownȱdiagnosisȱtoȱaȱpatientȱandȱ
thenȱ detailingȱ variousȱ options,ȱ aȱ womanȱ visitingȱ PPINKȱ toȱ
haveȱ anȱ abortionȱ knowsȱ herȱ diagnosisȱ (sheȱ isȱ pregnant),ȱ asȱ
wellȱ asȱ herȱ options—sheȱ mayȱ continueȱ theȱ pregnancyȱ orȱ
haveȱ anȱ abortion.ȱ Moreover,ȱ theȱ lawȱ alreadyȱ requiresȱ thatȱ
sheȱbeȱinformedȱofȱherȱoptionsȱandȱwaitȱeighteenȱhoursȱuntilȱ
theȱ procedure.ȱ Theȱ onlyȱ issueȱ isȱ whetherȱ havingȱ theȱ ultraȬ
soundȱ eighteenȱ hoursȱ beforeȱ altersȱ theȱ calculus.ȱ Finally,ȱ
40ȱ No.ȱ17Ȭ1883ȱ
thereȱ isȱ aȱ qualitativeȱ differenceȱ betweenȱ aȱ stateȬmandatedȱ
waitingȱ period,ȱ whichȱ theȱ Stateȱ requiresȱ onlyȱ forȱ abortions,ȱ
andȱotherȱoptionalȱwaitingȱperiods,ȱforȱallȱotherȱprocedures,ȱ
whereȱaȱdoctorȱandȱherȱpatientȱmayȱdecideȱtogetherȱwhetherȱ
timeȱ forȱ reflectionȱ wouldȱ beȱ optimalȱ orȱ whether,ȱ forȱ examȬ
ple,ȱwaitingȱwouldȱcauseȱtheȱpatientȱanxiety,ȱinconvenience,ȱ
orȱdeterȱherȱfromȱhavingȱtheȱdesiredȱprocedureȱatȱall.ȱ
Moreover,ȱasȱtheȱdistrictȱcourtȱdiscussed,ȱthereȱareȱmanyȱ
officeȱproceduresȱthatȱgynecologistsȱmightȱperformȱimmediȬ
atelyȱafterȱdiscussingȱtheȱprocedureȱandȱaskingȱforȱconsent,ȱ
suchȱasȱcolposcopiesȱandȱLEEPȱprocedures.ȱ273ȱF.ȱSupp.ȱ3dȱ
atȱ 1034.ȱ Andȱ thereȱ areȱ manyȱ timesȱ thatȱ doctorsȱ mightȱ needȱ
toȱ performȱ anȱ emergentȱ procedureȱ immediatelyȱ afterȱ
providingȱ informedȱ consent,ȱ orȱ timesȱ inȱ whichȱ patientsȱ
mightȱ optȱ forȱ immediacyȱ evenȱ inȱ aȱ nonȬemergentȱ situationȱ
forȱ theȱ sakeȱ ofȱ convenienceȱ orȱ becauseȱ theyȱ areȱ certainȱ ofȱ
theirȱ decision.ȱ Unlikeȱ forȱ aȱ hysterectomyȱ orȱ tubalȱ ligation,ȱ
waitingȱaȱfewȱweeksȱforȱanȱabortionȱisȱnotȱanȱoptionȱbecauseȱ
abortionsȱareȱnotȱavailableȱatȱPPINKȱafterȱ13ȱweeksȱandȱsixȱ
daysȱpostȱlastȱmenstrualȱperiod,ȱandȱtheȱmostȱvigilantȱwomȬ
anȱwillȱnotȱknowȱsheȱisȱpregnantȱuntilȱaboutȱfourȱweeksȱafȬ
terȱherȱlastȱmenstrualȱperiod.ȱInȱshort,ȱabortionsȱareȱfarȱmoreȱ
timeȱsensitiveȱthanȱmostȱotherȱelectiveȱprocedures.ȱ
Ultimately,ȱtheȱdistrictȱcourt’sȱconclusionȱthatȱtheȱnewȱulȬ
trasoundȱlawȱposedȱ anȱundueȱburdenȱwasȱsolidifiedȱbyȱtheȱ
factȱthatȱtheȱStateȱhadȱalmostȱnoȱevidenceȱthatȱtheȱadditionalȱ
timeȱtoȱreflectȱadvancedȱitsȱinterests.ȱAlmostȱallȱofȱtheȱState’sȱ
evidenceȱ onȱ theȱ benefitsȱ ofȱ theȱ newȱ eighteenȬhourȱ ultraȬ
soundȱ lawȱ focusedȱ onȱ theȱ benefitsȱ womenȱ mightȱ receiveȱ
fromȱhavingȱanȱultrasound,ȱandȱnotȱtheȱbenefitsȱfromȱhavingȱ
toȱwaitȱeighteenȱhoursȱafterȱhavingȱanȱultrasoundȱtoȱobtainȱ
No.ȱ17Ȭ1883ȱ 41
theȱ procedure.ȱ Theȱ districtȱ courtȱ notedȱ thisȱ andȱ thereforeȱ
dismissedȱmuchȱofȱthisȱevidenceȱasȱirrelevantȱtoȱtheȱdiscusȬ
sionȱ atȱ hand.ȱ Butȱ beforeȱ theȱ districtȱ courtȱ didȱ so,ȱ itȱ wentȱ
aboveȱ andȱ beyondȱ itsȱ dutyȱ andȱ thoroughlyȱ evaluatedȱ theȱ
meritsȱofȱtheȱevidenceȱnevertheless.ȱForȱexample,ȱtheȱdistrictȱ
courtȱrejectedȱtheȱState’sȱevidenceȱregardingȱwomen’sȱmenȬ
talȱhealthȱnotingȱthatȱtheȱscienceȱbehindȱDr.ȱColeman’sȱstudȬ
ies,ȱdescribedȱabove,ȱhadȱbeenȱnearlyȱuniformlyȱrejectedȱbyȱ
otherȱexpertsȱinȱtheȱfield.ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1036.ȱTheȱdistrictȱ
courtȱchoseȱtoȱcreditȱinsteadȱtwoȱmentalȱhealthȱorganizationsȱ
thatȱconductedȱaȱcomprehensiveȱreviewȱofȱstudiesȱonȱmentalȱ
healthȱ andȱ abortionȱ andȱ concludedȱ thatȱ “onȱ theȱ bestȱ eviȬ
denceȱavailableȱ…ȱ[t]heȱratesȱofȱmentalȱhealthȱproblemsȱforȱ
womenȱ withȱ unwantedȱ pregnancyȱ wereȱ theȱ sameȱ whetherȱ
theyȱhadȱanȱabortionȱorȱgaveȱbirth.”ȱR.ȱ38Ȭ3ȱatȱ3.ȱAȱtaskȱforceȱ
ofȱ theȱ Americanȱ Psychologicalȱ Associationȱ similarlyȱ reȬ
viewedȱstudiesȱandȱconcludedȱthat,ȱ“theȱmostȱmethodologiȬ
callyȱsoundȱresearchȱindicatesȱthatȱamongȱwomenȱwhoȱhaveȱ
aȱsingle,ȱlegal,ȱfirstȱtrimesterȱabortionȱofȱanȱunplannedȱpregȬ
nancyȱforȱnonȬtherapeuticȱreasons,ȱtheȱrelativeȱrisksȱofȱmenȬ
talȱ healthȱ problemsȱ areȱ notȱ greaterȱ thanȱ theȱ risksȱ amongȱ
womenȱ whoȱ deliverȱ anȱ unplannedȱ pregnancy.”ȱ Id.ȱ atȱ 2–3.ȱ
Thatȱ reportȱ specificallyȱ criticizesȱ Dr.ȱ Coleman’sȱ 2002ȱ reportȱ
asȱbeingȱ“characterizedȱbyȱaȱnumberȱofȱmethodologicalȱlimiȬ
tationsȱthatȱmakeȱitȱdifficultȱtoȱinterpretȱtheȱresults.”ȱId.ȱatȱ4.ȱ
Theȱ districtȱ court,ȱ usingȱ itsȱ substantialȱ discretionȱ weighedȱ
theȱ competingȱ evidenceȱ andȱ determinedȱ thatȱ PPINK’sȱ eviȬ
denceȱ wasȱ “significantlyȱ moreȱ persuasiveȱ onȱ thisȱ issue,ȱ esȬ
peciallyȱ givenȱ thatȱ Dr.ȱ Coleman’sȱ studiesȱ areȱ theȱ subjectȱ ofȱ
significantȱ criticism.”ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ 1036.ȱ Thisȱ typeȱ ofȱ
evidenceȱ weighingȱ isȱ wellȱ withinȱ theȱ districtȱ court’sȱ provȬ
42ȱ No.ȱ17Ȭ1883ȱ
ince,ȱ andȱ weȱ seeȱ noȱ reasonȱ toȱ disturbȱ itsȱ thoroughlyȱ reaȬ
sonedȱfindings.ȱ
Moreȱimportantly,ȱtheȱcourtȱbelowȱnoted,ȱDr.ȱColeman’sȱ
studyȱ failedȱ toȱ addressȱ theȱ relevantȱ question:ȱ whetherȱ havȬ
ingȱanȱultrasoundȱeighteenȱhoursȱbeforeȱanȱabortionȱleadsȱtoȱ
moreȱfavorableȱpsychologicalȱoutcomes.ȱId.ȱAnd,ȱasȱweȱhaveȱ
discussedȱextensively,ȱthisȱwasȱtheȱultimateȱquestionȱthatȱtheȱ
districtȱcourtȱhadȱtoȱaddress.ȱ
Theȱdistrictȱcourtȱconsideredȱallȱ ofȱtheȱfollowingȱtogethȬ
er:ȱtheȱfactȱthatȱoverȱaȱthirdȱofȱsurgicalȱabortionsȱoccurȱwithȬ
inȱ threeȱ weeksȱ ofȱ PPINK’sȱ deadlineȱ forȱ performingȱ aborȬ
tions;ȱtheȱdifficultyȱofȱmakingȱtwoȱlengthyȱtripsȱinȱquickȱsucȬ
cession;ȱ theȱ overȬbookingȱ ofȱ informedȬconsentȱ appointȬ
ments;ȱandȱtheȱfactȱthatȱphysiciansȱonlyȱprovidedȱabortionsȱ
onȱlimitedȱdaysȱinȱeachȱhealthȱcenter.ȱAddingȱtheseȱburdensȱ
together,ȱ theȱ districtȱ courtȱ concluded,ȱ “itȱ wouldȱ beȱ surprisȬ
ingȱ ifȱ theȱ newȱ ultrasoundȱ lawȱ didȱ notȱ preventȱ aȱ significantȱ
numberȱofȱlowȱincomeȱwomenȱfromȱobtainingȱanȱabortion.”ȱ
273ȱF.ȱSupp.ȱ 3dȱatȱ1038.ȱ Andȱindeedȱ theȱevidenceȱprovidedȱ
byȱ PPINKȱ fromȱ nineȱ womenȱ whoȱ were,ȱ inȱ fact,ȱ severelyȱ
burdenedȱ andȱ impededȱ inȱ theirȱ attemptsȱ atȱ obtainingȱ anȱ
abortionȱinȱtheȱshortȱtimeȱthatȱtheȱlawȱwasȱinȱeffect,ȱconfirmsȱ
thisȱprediction.ȱ
Theȱ districtȱ courtȱ didȱ notȱ errȱ byȱ concludingȱ thatȱ theȱ ulȬ
trasoundȱ lawȱ “imposesȱ significantȱ burdensȱ againstȱ aȱ nearȱ
absenceȱofȱevidenceȱthatȱtheȱlawȱpromotesȱeitherȱofȱtheȱbeneȬ
fitsȱ assertedȱ byȱ theȱ State.”ȱ Id.ȱ atȱ 1039.ȱ Seeȱ Wholeȱ Women’sȱ
Health,ȱ136ȱS.ȱCt.ȱatȱ2318ȱ(strikingȱdownȱtheȱchallengedȱaborȬ
tionȱrestrictionsȱbecauseȱtheȱlawȱ“providesȱfew,ȱifȱany,ȱhealthȱ
benefitsȱ forȱ women”ȱ andȱ “posesȱ aȱ substantialȱ obstacleȱ toȱ
womenȱseekingȱabortions.”).ȱ“AȱstatuteȱthatȱcurtailsȱtheȱconȬ
No.ȱ17Ȭ1883ȱ 43
stitutionalȱ rightȱ toȱ anȱ abortionȱ …ȱ cannotȱ surviveȱ challengeȱ
withoutȱevidenceȱthatȱtheȱcurtailmentȱisȱjustifiableȱbyȱreferȬ
enceȱ toȱ theȱ benefitsȱ conferredȱ byȱ theȱ statute.”ȱ Schimel,ȱ 806ȱ
F.3dȱatȱ921.ȱȱ
TheȱStateȱwouldȱlikeȱtoȱsimplifyȱtheȱcourt’sȱcomplexȱburȬ
denȱ andȱbenefitȱ weighingȱtoȱ aȱmoreȱcookieȱcutterȱ approachȱ
andȱ haveȱ usȱ concludeȱ thatȱ Caseyȱ pavedȱ theȱ wayȱ forȱ anȱ alȬ
mostȱperȱseȱapprovalȱofȱallȱreasonableȱwaitingȱperiods.ȱApȬ
pellant’sȱBriefȱatȱ20–22,ȱ38.ȱTheȱSupremeȱCourtȱinȱCaseyȱupȬ
heldȱ aȱ twentyȬfourȱ hour,ȱ informedȬconsentȱ waitingȱ periodȱ
despiteȱtheȱfactȱpatientsȱwouldȱneedȱtoȱmakeȱtwoȱsometimesȱ
lengthyȱtripsȱinȱorderȱtoȱobtainȱanȱabortion.ȱCasey,ȱ505ȱU.S.ȱatȱ
885–87.ȱ Andȱ weȱ followedȱ suitȱ inȱ Aȱ Womanȇsȱ ChoiceȬE.ȱ Sideȱ
WomenȇsȱClinicȱv.ȱNewman,ȱ305ȱF.3dȱ684,ȱ691ȱ(7thȱCir.ȱ2002),ȱ
upholdingȱ Indiana’sȱ eighteenȬhourȱ waitingȱ periodȱ afterȱ anȱ
inȬpersonȱinformedȬconsentȱmeeting.ȱButȱoneȱofȱtheȱprimaryȱ
lessonsȱofȱWholeȱWomen’sȱHealthȱisȱthatȱtheȱburdenȱandȱbeneȬ
fitȱweighingȱisȱcontextȬspecific.ȱInȱWholeȱWomen’sȱHealth,ȱtheȱ
courtȱ basedȱ itsȱ conclusionsȱ aboutȱ undueȱ burdenȱ onȱ theȱ
280,000ȱsquareȱmilesȱofȱTexasȱterritory,ȱtheȱnumberȱofȱaborȬ
tionȬofferingȱfacilitiesȱthatȱcouldȱoperateȱafterȱtheȱenactmentȱ
ofȱtheȱcontestedȱlaw,ȱtheȱnumberȱofȱpatientsȱeachȱremainingȱ
facilityȱ wouldȱ haveȱ toȱ accommodateȱ (1,200ȱ perȱ month),ȱ theȱ
distanceȱ womenȱ wouldȱ haveȱ toȱ travelȱ toȱ getȱ toȱ aȱ clinicȱ andȱ
theȱ populationȱ numbersȱ forȱ womenȱ whoȱ wouldȱ haveȱ toȱ
travelȱ thisȱ far,ȱ theȱ rateȱ ofȱ deathsȱ andȱ complicationsȱ fromȱ
abortionsȱ inȱ Texas,ȱ andȱ theȱ costȱ toȱ clinicsȱ ofȱ comingȱ intoȱ
complianceȱ withȱ theȱ newȱ regulation.ȱ Wholeȱ Women’sȱ Health,ȱ
136ȱS.ȱCt.ȱatȱ2301–03.ȱTheȱCourtȱspentȱmuchȱtimeȱdiscussingȱ
theȱimportanceȱofȱtheseȱfactsȱinȱassessingȱtheȱconstitutionaliȬ
tyȱofȱtheȱcontestedȱlaw,ȱnotingȱthatȱaȱstatuteȱvalidȱasȱtoȱoneȱ
44ȱ No.ȱ17Ȭ1883ȱ
setȱ ofȱ factsȱ mayȱ beȱ invalidȱ asȱ toȱ another.ȱ Id.ȱ atȱ 2306ȱ (citingȱ
Nashville,ȱC.ȱ&ȱSt.ȱL.R.ȱCo.ȱv.ȱWalters,ȱ294ȱU.S.ȱ405,ȱ415ȱ(1935)).ȱȱ
Theȱ Courtȱ inȱ Caseyȱ notedȱ thatȱ “inȱ theoryȱ atȱ least,ȱ theȱ
waitingȱ periodȱ isȱ aȱ reasonableȱ measureȱ toȱ implementȱ theȱ
State’sȱ interestȱ inȱ protectingȱ theȱ lifeȱ ofȱ theȱ unborn,”ȱ andȱ
wentȱonȱtoȱanalyzeȱwhethersuchȱaȱ“waitingȱperiodȱisȱnoneȬ
thelessȱ invalidȱ becauseȱ inȱ practiceȱ itȱ isȱ aȱ substantialȱ obstacleȱ
toȱaȱwoman’sȱchoiceȱtoȱterminateȱherȱpregnancy.”ȱCasey,ȱ505ȱ
U.S.ȱatȱ885ȱ(emphasisȱours).ȱThisȱwasȱtheȱexactȱreasoningȱweȱ
adoptedȱlater,ȱinȱlightȱofȱCasey,ȱwhereȱweȱnotedȱthatȱ“[w]hileȱ
aȱtwentyȬfourȱhourȱwaitingȱperiodȱthatȱrequiresȱtwoȱtripsȱtoȱ
anȱabortionȱproviderȱhasȱbeenȱfoundȱnotȱtoȱimposeȱanȱundueȱ
burdenȱonȱPennsylvaniaȱwomenȱbasedȱonȱtheȱcircumstancesȱ
ofȱ thatȱ stateȱ atȱ theȱ timeȱ theȱ Courtȱ decidedȱ Casey,ȱ aȱ similarȱ
provisionȱ inȱ anotherȱ state’sȱ abortionȱ statuteȱ couldȱ wellȱ beȱ
foundȱ toȱ imposeȱ anȱ undueȱ burdenȱ onȱ womenȱ inȱ thatȱ stateȱ
dependingȱonȱtheȱinterplayȱofȱfactors”—factorsȱsuchȱasȱ“theȱ
numberȱofȱphysiciansȱwhoȱperformȱabortions,ȱtheȱnumberȱofȱ
abortionȱfacilities,ȱtheȱdistancesȱwomenȱmustȱtravelȱinȱorderȱ
toȱ reachȱ anȱ abortionȱ facility,ȱ andȱ theȱ averageȱ incomeȱ ofȱ
womenȱseekingȱabortions.”ȱKarlinȱv.ȱFoust,ȱ188ȱF.3dȱ446,ȱ485ȱ
(7thȱ Cir.ȱ 1999).ȱ Theȱ languageȱ inȱ theseȱ casesȱ reflectsȱ thatȱ theȱ
factsȱandȱcontextȱruleȱtheȱdayȱwhenȱevaluatingȱwaitingȱperiȬ
ods.ȱ Thisȱ isȱ farȱ fromȱ beingȱ aȱ blanketȱ stampȱ ofȱ approvalȱ onȱ
them.ȱȱ
Analyzingȱtheȱregulationȱinȱlightȱofȱtheȱrealityȱofȱtheȱfactsȱ
inȱIndianaȱisȱpreciselyȱwhatȱtheȱdistrictȱcourtȱdidȱinȱthisȱcase.ȱ
AȱcourtȱcannotȱassessȱtheȱlawȱinȱaȱworldȱwhereȱPPINKȱhasȱ
unlimitedȱresourcesȱtoȱopenȱdozensȱofȱclinics,ȱeachȱwithȱtheȱ
abilityȱ toȱ provideȱ ultrasoundȱ andȱ abortionsȱ alongȱ withȱ unȬ
limitedȱaccessȱtoȱotherȱhealthȱcareȱneeds,ȱorȱinȱaȱworldȱwhereȱ
No.ȱ17Ȭ1883ȱ 45
allȱ womenȱ haveȱ paidȱ sickȱ days,ȱ andȱ reliableȱ childȱ careȱ andȱ
transportation.ȱTheȱcourtȱmustȱtakeȱtheȱfactsȱasȱtheyȱareȱpreȬ
sentedȱbeforeȱitȱandȱcompareȱtheȱburdensȱagainstȱtheȱweightȱ
ofȱtheȱevidenceȱofȱtheȱbenefitsȱspecificȱtoȱtheȱproposedȱlaw.ȱ
Wholeȱ Women’sȱ Health,ȱ 136ȱ S.ȱ Ct.ȱ atȱ 2310.ȱ Theȱ districtȱ courtȱ
didȱjustȱthatȱandȱconcludedȱthatȱtheȱevidenceȱofȱbenefitsȱwasȱ
exceptionallyȱ slightȱ ifȱ any,ȱ andȱ theȱ burdenȱ imposedȱ byȱ theȱ
doubleȱ travelȱ requirementȱ great.ȱ Asȱ theȱ districtȱ courtȱ conȬ
cluded,ȱ“theȱnewȱultrasoundȱlawȱcreatesȱsignificantȱfinancialȱ
andȱotherȱburdensȱonȱPPINKȱandȱitsȱpatients,ȱparticularlyȱonȱ
lowȬincomeȱ womenȱ inȱ Indianaȱ whoȱ faceȱ lengthyȱ travelȱ toȱ
oneȱofȱPPINK’sȱnowȱonlyȱsixȱhealthȱcentersȱthatȱcanȱofferȱanȱ
informedȬconsentȱ appointment.ȱ Theseȱ burdensȱ areȱ clearlyȱ
undueȱ whenȱ weighedȱ againstȱ theȱ almostȱ completeȱ lackȱ ofȱ
evidenceȱ thatȱ theȱ lawȱ furthersȱ theȱ State’sȱ assertedȱ justificaȬ
tionsȱofȱpromotingȱfetalȱlifeȱandȱwomen’sȱmentalȱhealthȱoutȬ
comes.”ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1043.ȱ
TheȱStateȱarguesȱtoȱthisȱcourtȱthatȱtheȱdistrictȱcourt’sȱfindȬ
ingsȱareȱclearlyȱerroneous.ȱWeȱcannotȱagree.ȱUnderȱtheȱclearȱ
errorȱstandardȱweȱcanȱreverseȱaȱdistrictȱcourt’sȱfactualȱfindȬ
ingsȱonlyȱifȱ“basedȱonȱtheȱentireȱrecord,ȱweȱareȱleftȱwithȱtheȱ
definiteȱandȱfirmȱconvictionȱthatȱaȱmistakeȱhasȱbeenȱcommitȬ
ted.”ȱUnitedȱStatesȱv.ȱOrillo,ȱ733ȱF.3dȱ241,ȱ244ȱ(7thȱCir.ȱ2013).ȱ
Theȱ districtȱ thoroughlyȱ addressedȱ eachȱ ofȱ theȱ burdensȱ andȱ
benefitsȱ assertedȱ byȱ theȱ partiesȱ andȱ engagedȱ inȱ aȱ painstakȬ
inglyȱthoroughȱweighing.ȱItsȱfactualȱfindingsȱwereȱnotȱclearȬ
lyȱerroneousȱandȱareȱentitledȱtoȱourȱdeference.ȱȱ
C.ȱ Theȱremainingȱpreliminaryȱinjunctionȱconsiderationsȱ
Thatȱ conclusionȱ aboutȱ theȱ likelihoodȱ ofȱ successȱ onȱ theȱ
meritsȱ doesȱ notȱ endȱ theȱ inquiry,ȱ althoughȱ itȱ certainlyȱ putsȱ
theȱheaviestȱweightȱonȱtheȱscale.ȱPPINKȱmustȱalsoȱshowȱthatȱ
46ȱ No.ȱ17Ȭ1883ȱ
itȱ isȱ likelyȱ toȱ sufferȱ irreparableȱ harmȱ inȱ theȱ absenceȱ ofȱ preȬ
liminaryȱ reliefȱ andȱ thatȱ itȱ hasȱ noȱ adequateȱ remedyȱ atȱ law.ȱ
CityȱofȱChicagoȱv.ȱSessions,ȱ888ȱF.3dȱ272,ȱ282ȱ(7thȱCir.ȱ2018).ȱ“Ifȱ
thoseȱ burdensȱ areȱ met,ȱ theȱ courtȱ mustȱ weighȱ theȱharmȱ thatȱ
theȱplaintiffȱwillȱsufferȱabsentȱanȱinjunctionȱagainstȱtheȱharmȱ
toȱ theȱ defendantȱ fromȱ anȱ injunction,ȱ andȱ considerȱ whetherȱ
anȱinjunctionȱisȱinȱtheȱpublicȱinterest.”ȱId.ȱȱ
Forȱ PPINKȱ andȱ itsȱ patientsȱ whoȱ loseȱ theȱ opportunityȱ toȱ
exerciseȱ theirȱ constitutionalȱ rightȱ toȱ anȱ abortion,ȱ theȱ irrepaȬ
rabilityȱ ofȱ theȱ harmȱ isȱ clear.ȱ Evenȱ anȱ extendedȱ delayȱ inȱ obȬ
tainingȱ anȱ abortionȱ canȱ causeȱ irreparableȱ harmȱ byȱ “reȬ
sult[ing]ȱ inȱ theȱ progressionȱ ofȱ aȱ pregnancyȱ toȱ aȱ stageȱ atȱ
whichȱ anȱ abortionȱ wouldȱ beȱ lessȱ safe,ȱ andȱ eventuallyȱ illeȬ
gal.”ȱPlannedȱParenthoodȱofȱWis.,ȱ738ȱF.3dȱatȱ796.ȱTheȱevidenceȱ
suggestsȱthatȱtheȱnewȱultrasoundȱlawȱhasȱalreadyȱpreventedȱ
someȱ womenȱ fromȱ exercisingȱ theirȱ constitutionalȱ rights.ȱ Itȱ
hasȱ causedȱ delayȱ toȱ others.ȱ Becauseȱ we,ȱ likeȱ theȱ districtȱ
court,ȱ haveȱ concludedȱ thatȱ thereȱ isȱ noȱ substantialȱ evidenceȱ
thatȱtheȱlawȱfurthersȱitsȱstatedȱinterest,ȱanyȱharmȱtoȱtheȱStateȱ
isȱminimal,ȱatȱworst.ȱAndȱtheȱStateȱcertainlyȱhasȱmyriadȱreȬ
mainingȱ methodsȱtoȱ persuadeȱwomenȱtoȱ carryȱaȱpregnancyȱ
toȱtermȱinȱorderȱtoȱpromoteȱtheȱState’sȱinterestȱinȱpromotingȱ
fetalȱlife.ȱȱ
TheȱStateȱarguesȱthatȱPPINKȱcanȱavoidȱsomeȱofȱtheȱharmȱ
byȱ expendingȱ moreȱ resourcesȱ onȱ abortionȱ services,ȱ buyingȱ
moreȱ ultrasoundȱ machines,ȱ butȱ again,ȱ theȱ courtȱ mustȱ takeȱ
theȱrecordȱasȱitȱfindsȱitȱandȱnotȱbaseȱitsȱfindingȱonȱwhatȱtheȱ
factsȱ mightȱ lookȱ likeȱ ifȱ theȱ courtȱ couldȱ deviseȱ aȱ differentȱ
businessȱ orȱ careȱ modelȱ forȱ PPINK.ȱ See,ȱ e.g.,ȱ Wholeȱ Women’sȱ
Health,ȱ136ȱS.ȱCt.ȱatȱ2318.ȱInȱanyȱcase,ȱPPINKȱpresentedȱeviȬ
denceȱthatȱitȱhasȱalreadyȱshiftedȱresourcesȱandȱtriedȱtoȱmitiȬ
No.ȱ17Ȭ1883ȱ 47
gateȱharmȱtoȱtheȱbestȱofȱitsȱability.ȱSomeȱofȱtheseȱchangesȱareȱ
unsustainableȱlongȱterm.ȱOthersȱcannotȱbeȱmadeȱatȱall.ȱȱ
Balancedȱ againstȱ theȱ harmȱ toȱ PPINKȱ patientsȱ isȱ theȱ
State’sȱ claimȱ ofȱ irreparableȱ harm.ȱ Theȱ Stateȱ facesȱ theȱ sameȱ
harmȱ anyȱ Stateȱ facesȱ whenȱ aȱ democraticallyȱ enactedȱ lawȱ isȱ
enjoined.ȱItȱalsoȱclaimsȱthatȱitȱwouldȱpreventȱitȱfromȱfurtherȬ
ingȱitsȱgoalȱofȱpromotingȱfetalȱlife.ȱThisȱweȱthink,ȱisȱaȱminiȬ
mal,ȱpotentiallyȱtemporaryȱharmȱinȱthisȱcase,ȱcomparedȱwithȱ
theȱburdensȱonȱtheȱwomenȱthatȱtheȱdistrictȱcourtȱidentified.ȱ
Thisȱisȱparticularlyȱtrueȱwhenȱweȱconsiderȱthat—evenȱcreditȬ
ingȱtheȱState’sȱassertedȱbenefitȱofȱtheȱlaw—theȱpotentialȱabilȬ
ityȱ toȱ alterȱ anyȱ woman’sȱ decisionȱ inȱ aȱ mannerȱ thatȱ protectsȱ
fetalȱlifeȱwouldȱbeȱminimal,ȱatȱbest.ȱȱ
Asȱ forȱ theȱ publicȱ interest,ȱ theȱ districtȱ courtȱ foundȱ thatȱ
upholdingȱ constitutionalȱ rightsȱ servesȱ anȱ importantȱ publicȱ
interestȱandȱweȱseeȱnoȱreasonȱtoȱaddȱtoȱorȱupsetȱthisȱfinding.ȱ
AndȱbecauseȱtheȱStateȱhadȱnotȱdemonstratedȱthatȱitsȱinterestȱ
wouldȱbeȱservedȱbyȱtheȱlaw,ȱneitherȱcouldȱtheȱpublic’sȱinterȬ
est.ȱ
III.ȱ
Theȱ Stateȱ assertsȱ thatȱ itsȱ reasonȱ forȱ thisȱ newȱ eighteenȬ
hourȱ ultrasoundȱ requirementȱ isȱ toȱ persuadeȱ womenȱ notȱ toȱ
haveȱanȱabortion.ȱThereȱisȱnoȱdoubtȱthatȱthisȱisȱaȱlegitimateȱ
positionȱ forȱ aȱ stateȱ toȱ take.ȱ Butȱ itȱ isȱ alsoȱ trueȱ thatȱ womenȱ
haveȱ theȱ rightȱ toȱ chooseȱ toȱ haveȱ anȱ abortion,ȱ albeitȱ withȱ
someȱlimitations.ȱCasey,ȱ505ȱU.S.ȱatȱ846.ȱWomen,ȱlikeȱallȱhuȬ
mans,ȱ areȱ intellectualȱ creaturesȱ withȱ theȱ abilityȱ toȱ reason,ȱ
consider,ȱponder,ȱandȱchallengeȱtheirȱownȱideasȱandȱthoseȱofȱ
others.ȱTheȱusualȱmannerȱinȱwhichȱweȱseekȱtoȱpersuadeȱisȱbyȱ
rhetoricȱ notȱ barriers.ȱ Theȱ Stateȱ certainlyȱ isȱ entitledȱ toȱ useȱ
48ȱ No.ȱ17Ȭ1883ȱ
theseȱ rhetoricalȱ toolsȱ toȱ persuadeȱ womenȱ notȱ toȱ haveȱ anȱ
abortion.ȱ Itȱ hasȱ chosenȱ toȱ doȱ soȱ byȱ requiringȱ anȱ informedȬ
consentȱ process—theȱ requiredȱ contentsȱ ofȱ whichȱ itȱ hasȱ deȬ
signedȱ andȱ mandated—andȱ anȱ ultrasoundȱ andȱ fetalȱ heartȱ
beatȱrequirement.ȱItȱalsoȱrequiresȱeveryȱwomanȱtoȱreceiveȱaȱ
brochureȱaboutȱabortion,ȱtheȱcontentsȱofȱwhichȱtheȱStateȱconȬ
trolsȱinȱtoto—fromȱhowȱitȱwillȱpresentȱtheȱimagesȱofȱfetusesȱ
toȱ theȱ decisionsȱ aboutȱ whichȱ medicalȱ risksȱ itȱ includesȱ andȱ
whichȱ itȱ omitsȱ (forȱ example,ȱ theȱ brochureȱ whichȱ aȱ womanȱ
takesȱ homeȱ andȱ isȱ supposedȱ toȱ ponderȱ forȱ eighteenȱ hours,ȱ
doesȱnotȱspeakȱofȱtheȱriskȱtoȱtheȱfetusȱfromȱdrugsȱandȱalcoȬ
holȱ thatȱ aȱ womanȱ mayȱ haveȱ consumedȱ priorȱ toȱ knowingȱ
aboutȱ anȱ unplannedȱ pregnancy).ȱ Moreover,ȱ itȱ statesȱ asȱ factȱ
thatȱ“humanȱphysicalȱlifeȱbeginsȱwhenȱaȱhumanȱovumȱisȱferȬ
tilizedȱ byȱ aȱ humanȱ sperm”—aȱ propositionȱ debatedȱ amongȱ
scientists,ȱ religiousȱ leaders,ȱ andȱ medicalȱ ethicists.ȱ Theȱ Stateȱ
hasȱvastȱpowerȱtoȱuseȱtheȱinformationȱthatȱitȱprovidesȱtoȱperȬ
suadeȱwomenȱnotȱ toȱhaveȱanȱabortion.ȱButȱtheȱrequirementȱ
thatȱwomenȱhaveȱtheȱultrasoundȱeighteenȱhoursȱpriorȱtoȱtheȱ
abortionȱ placesȱ aȱ largeȱ barrierȱ toȱ accessȱ withoutȱ anyȱ eviȬ
denceȱthatȱitȱservesȱtheȱintendedȱgoalȱofȱpersuadingȱwomenȱ
toȱcarryȱaȱpregnancyȱtoȱterm.ȱInstead,ȱitȱappearsȱthatȱitsȱonlyȱ
effectȱ isȱ toȱ placeȱ barriersȱ betweenȱ aȱ womanȱ whoȱ wishesȱ toȱ
exerciseȱ herȱ rightȱ toȱ anȱ abortionȱ andȱ herȱ abilityȱ toȱ doȱ so.ȱ
Rhetoricȱandȱpersuasionȱareȱcertainlyȱlegitimateȱmethodsȱforȱ
aȱstateȱtoȱassertȱitsȱpreference,ȱbutȱitȱcannotȱforceȱcomplianceȱ
withȱ itsȱ otherwiseȱ legitimateȱ viewsȱ byȱ erectingȱ barriersȱ toȱ
abortionȱwithoutȱevidenceȱthatȱthoseȱbarriersȱserveȱtheȱbeneȬ
fitȱtheȱstateȱintended.ȱ“UntilȱandȱunlessȱRoeȱv.ȱWadeȱisȱoverȬ
ruledȱbyȱtheȱSupremeȱCourt,ȱaȱstatuteȱlikelyȱtoȱrestrictȱaccessȱ
toȱabortionȱwithȱnoȱoffsettingȱmedicalȱbenefitȱcannotȱbeȱheldȱ
toȱ beȱ withinȱ theȱ enactingȱ state’sȱ constitutionalȱ authority.”ȱ
No.ȱ17Ȭ1883ȱ 49
Schimel,ȱ806ȱF.3dȱatȱ916.ȱInȱlightȱofȱtheȱevidenceȱofȱsubstantialȱ
burdensȱ imposedȱbyȱ theȱlawȱ andȱwithoutȱ evidenceȱ thatȱ theȱ
additionalȱ eighteenȱ hoursȱ followingȱ anȱ ultrasoundȱ hasȱ anyȱ
legitimateȱ persuasiveȱ effectȱ onȱ decisionȬmaking,ȱ theȱ lawȱ
constitutesȱ anȱ undueȱ burdenȱ onȱ thoseȱ seekingȱ anȱ abortionȱ
withoutȱanyȱknownȱbenefitsȱtoȱbalanceȱit.ȱTheȱopinionȱofȱtheȱ
districtȱcourtȱisȱAFFIRMEDȱinȱallȱrespects.ȱ
50ȱ ȱ No.ȱ17Ȭ1883ȱ
ȱ
KANNE,ȱ Circuitȱ Judge,ȱ concurringȱ inȱ theȱ judgment.ȱ Ourȱ
decisionȱ todayȱ isȱ compelledȱ byȱ longȬstandingȱ Supremeȱ
Courtȱprecedent.ȱSeeȱRoeȱv.ȱWade,ȱ410ȱU.S.ȱ113ȱ(1973);ȱPlannedȱ
ParenthoodȱofȱSe.ȱPa.ȱv.ȱCasey,ȱ505ȱU.S.ȱ833ȱ(1992).ȱ
Theȱ State’sȱ reasonȱ forȱ theȱ newȱ 18Ȭhourȱ ultrasoundȱ reȬ
quirementȱisȱtoȱpersuadeȱwomenȱnotȱtoȱhaveȱanȱabortion.ȱAsȱ
theȱ opinionȱ notes,ȱ “[t]hereȱ isȱ noȱ doubtȱ thatȱ thisȱ isȱ aȱ legitiȬ
mateȱpositionȱforȱaȱstateȱtoȱtake.”ȱMajorityȱOp.ȱatȱ47.ȱThis,ȱofȱ
course,ȱ isȱ weighedȱ againstȱ theȱ factȱ thatȱ “womenȱ haveȱ theȱ
rightȱtoȱchooseȱtoȱhaveȱanȱabortion,ȱalbeitȱwithȱsomeȱlimitaȬ
tions.”ȱId.ȱ
Inȱ thisȱ caseȱ twoȱ evidentiaryȱ factorsȱ leadȱ meȱ toȱ concludeȱ
thatȱtheȱ18Ȭhourȱrequirementȱimposesȱanȱundueȱburdenȱonȱaȱ
woman’sȱrightȱtoȱchoose,ȱwhichȱrequiresȱaffirmingȱtheȱdeciȬ
sionȱ ofȱ theȱ districtȱ court.ȱ Theȱ firstȱ factorȱ isȱ theȱ additionalȱ
travelȱnecessitatedȱbyȱtheȱavailabilityȱofȱonlyȱsixȱultrasoundȱ
imagingȱ sitesȱ locatedȱ inȱ Indianaȱ atȱ PPINKȱ healthȱ centers.
ȱ
Theȱ secondȱ factorȱ isȱ thatȱ theȱ Stateȱ offeredȱ littleȱ evidenceȱ toȱ
showȱ thatȱ anȱ 18Ȭhourȱ waitȱ followingȱ anȱ ultrasoundȱ wouldȱ
persuadeȱthoseȱseekingȱanȱabortionȱtoȱpreserveȱfetalȱlife.ȱȱ
Basedȱonȱtheȱforegoingȱfactors,ȱIȱagreeȱthat,ȱinȱtheȱcontextȱ
presentedȱ byȱ thisȱ appeal,ȱ Ind.ȱ Codeȱ §ȱ 16Ȭ34Ȭ2Ȭ1.1(a)(5)—asȱ
written—constitutesȱanȱundueȱburdenȱonȱwomenȱseekingȱanȱ
abortion.ȱ
Thisȱ concurrenceȱ extendsȱ toȱ theȱ finalȱ judgmentȱ setȱ forthȱ
byȱ myȱ esteemedȱ colleague,ȱ Judgeȱ Rovner,ȱ butȱ doesȱ notȱ enȬ
Onȱappeal,ȱtheȱStateȱdidȱnotȱpursueȱtheȱargumentȱthatȱPPINKȱshouldȱ
acceptȱultrasoundȱresultsȱfromȱtheȱmanyȱotherȱIndianaȱprovidersȱofȱulȬ
trasoundȱimagingȱthroughoutȱtheȱState.ȱSeeȱMajorityȱOp.ȱatȱ24,ȱn.6.ȱ
No.ȱ17Ȭ1883ȱ 51ȱ
dorseȱ theȱ proprietyȱ ofȱ theȱ ancillaryȱ findingsȱ ofȱ theȱ districtȱ
court.ȱ
