the court this case is about respect for the court's precedent just four years ago the court held in whole women's health that the texas admitting privileges law imposed an undue burden on women seeking abortion louisiana law at issue here acts six hundred and twenty is identical to the texas law and was expressly modeled on it after trial the district court ruled an accident unconstitutional finding n material differences between this case and whole women's health on burdens it found that x six hundred and twenty would leave louisiana with just one clinic and one doctor providing abortions at the same disregarded nearly all of its factual findings nd the th circuit accepted legal arguments that this court rejected four years ago nothing however has changed that would justify such a legal about face in fact even more medical organizations have joined the a m a and a colleague to say that admitting privileges imposed barriers to abortion with no benefit to patients and that this impact is not state dependent finally the state's th hour objection to rd party standing runs up against still more binding precedent the court squarely held incredibly boring that such  objections are wave a ball and the state deliberately and strategically waived the issue in the district court and even if the state could get past waiver denying standing here would contradict decades of this court's preceden numerous areas of the law in short petitioners have rd party standing especially because x six hundred and twenty restricts abortion by regulating them rather than their patients who do have done anything different if the rd party standing had been timely way your honor we certainly could have submitted additional evidence in the court but we believe that the evidence that is a ready there is sufficient to find rd party standing this court has squarely found rd party standing in at least four abortion cases that arm point as well as a number of other cases such as meyer kreg perry and the courts cases have been consistent in saying that who is directly regulated by a law has rd party standing would you agree with the general proposition that the parties should not be able to sue ostensibly to protect the rights of other people if there is a real conflict of interest between the party who is suing and those whose rights the party claims to be attempting to defend no your honor not if that party is directly regulated by the law in question and in fact th has allowed rd party standing in cases where the state argued that the rd parties were protected by the law and in a sense protected from the plane to leave that's amazing you think that if the point of actually has interests that are directly contrary to those of those individuals on whose behalf the plaintiff is claiming to sue never the less than plaintiff can have standing if the plaintiff is directly regulated by the law this court has allowed an attorney to bring rd party claims against a statute that kept attorneys fees in favor of clients well that's amazing what's i mean i suppose that i know you think that the admitting privileges requirement serves no safety purpose but suppose that the regulation that was being challenged was one that a lot of people might think really did serve a safety purpose let's say we're in a state where  ysicians assistants can perform abortions and an abortion clinic wants to challenge the training requirements for physicians assistants it just thinks those are too onerous and there's no justification for them  now if they're wrong about that it implicates the interests of the women who may want to get an abortion but you would say the clinic nevertheless can sue on behalf of those women this court has squarely held in many cases that a pla directly regulated by the law can sue and those cases make sense for at least two reasons your honor st because a plaintive should not be subject to severe penalties under an unconstitutional rule and nd if the plaintiff is the one directly regulated than specifically found that this law would serve no benefit and in fact would harm the health of women in louisiana you know your argument is using the merits to defeat it to support standing that was the issue in credit for says born in the law there was a state law in oklahoma and the state claimed that it was designed to protect young men from buying beer in order to make sure that they were safe and didn't get into traffic accident s is this i'm just wondering are these doctors in any different position the potential plaintiffs who feel burdened by this no your honor and in fact the state has not pointed to a single thing that would have been different if one woman had been joined in this lawsuit to the contrary the issues that the state says are the key issues in this case whether this law serves health and safety benefits and how difficult it is for physicians to obtain privileges are issues that the physicians are particularly well suited to litigate and again this is the logical point is you have standing on behalf of those women who feel burdened yes the extent that the women may not have brought a suit that's irrelevant to the fact that there are some those burdens who could have would have if situation is had permitted them to that's absolutely right here i can't why shouldn't they be the ones to bring suit your honor this is a law that restricts abortion by regulating the physicians rather than their patients and so it's appropriate for them to be the plaintiffs year again the  constitutional right it is she was not a constitutional right of abortion clinics is that it's a right of women that's correct your honor but in order for women to access their right to abortion they need to be able to access those services or do you think a party can have rd part can be rd party standing if there is no hindrance whatsoever to the bringing of suit by the people whose rights are at stake this court has allowed rd party standing in cases where the law directly regulates the plaintiff without a showing of hindrance for instance and craig was born there was clearly no hindrance but i would also say that the court doesn't need to reach these issues here because the state strategically and deliberately waived rd party standing but i think that's highly debatable that they waived that they certainly didn't raise it in the district court but whether they they affirmatively waived it is quite debatable your honor at j a forty five the state explicitly conceded rd party standing and urged the district court to reach the undue burden cl saying that it had a keen interest in removing any cloud upon the validity of its law that this case was the proper vehicle for doing so it's a hard it's a highly debatable interpretation of that passage which i've read numerous times what the state was saying was that the while the template if a temporary restraining order was issued the lawsuits should continue to go forward and they said there wouldn't be an impediment to a lawsuit going forward because the doctors would have standing and what i think they may have been saying in that is sense is that they would have standing under the law that was applicable at that time when we could debate what was actually said i think it's quite a stretch of the record for you to say there was an affirmative waiver  five there was a deliberate waiver and the court and the state did it strategically because it was attempting to take advantage of favorable th circuit precedent at the time because the th circuit had just a pelt the texas admitting privileges law again the state specifically urged the district court to decide the undue burden claim saying that this case was the proper proper vehicle for resolving the constitutional issues and that any delay wouldn't serve judicial efficiency it wasn't in the district or in the court of appea fact it would be profoundly unfair to allow the state to raise the objection for the st time five years into this litigation after it urged the district court to decide the under burden claim and then pursue the undue burden claim through multiple rounds of appeals it didn't even raise the issue in this case came before the court in two thousand and sixteen on the stay the st time that it raised an objection was when it filed its cross petition for cert and again it j a forty five it deliberately and strategically waived believe at least four of them squarely allowed standing in precisely the circumstances if we didn't in this case it would require either directly or indirectly overruling eight cases of this court that's correct and in fact in dan forth in akron the same type of law was that issue it was the law that the state claimed was designed to protect the health and safety aware of women but the court allowed the physicians to bring the claim and to show that in fact the law didn't further health and safety and how many of those cases the court discussed the issue of conflict of interest the court in danforth specifically said that the plaintiffs had standing it wasn't discussed in terms of the words conflict your honor but again the same types of arguments were in front of the court because  dear that's correct your honor in the court allowed the saloon keeper to bring the rd party standing claim again in triplicate the court allowed an attorney to challenge a law designed to cap attorney's fees and in carry the court allowed a mail order contraceptive company to challenge a law that was designed to limit the prescription of contraceptives to pharmacists again claiming that that was about protecting the health and safety of people so the court has allowed rd party standing in many cases that are squarely  differences between this case i know i know but in if the issue this statutes are on the books in other states and if the issues are raised there is the same inquiry required in each case you have to have the district court examined the availability of medically unnecessary and its burdens were undue that holdings should clearly apply to louisiana's identical law and certainly the court's reasoning is a political in the easy and now the burdens of a lot may vary but a law that has no benefits and doesn't serve any valid state interest is much more likely to impose an undue burden if the state passed admitting privileges wall therefore and suppose the state had ten clinics and two doctors for each corner but all twenty doctors could easily get the admitting privileges so that there'd be no effect on the clinics no effect on the doctors who perform abortions and therefore no effect on the women who obtain abortions would a law be constitutional in that state that law may still be unconstitutional if it's restricting access because of the thirty mile limit your honor but that's very different from the situation here where the district i'm sorry interrupt if it didn't though put aside the thirty mile assume all the doctors who currently perform abortions can obtain admitting privileges could you say that the law still imposes a don't do burden even if there were no effect that law would have no benefit your honor and it may pose a much harder question in this case but in this case the district court after a trial explicitly found that the burdens of this law would be severe and it would leave only one physician to honor so he had that he didn't have it would be counter to his own interests for him to make a super effort to get admitting privileges would because he'd be defeating his own claim brought this lawsuit to protect the rights of his patients and the district court found that he was competent in qualified in that he made good faith efforts all right so if all right we can argue about whether he has a conflict of interest or not he previously had admitting privileges at a hospital in the shreveport area did he not yes rather susser of christa's shumpert yes your honor he testified that he didn't apply for admitting privileges there because it's a catholic correct that's correct your honor all right don't number three performs abortions does he not yes the number three has admitting privileges there he has admitting privileges that require for fifty admissions per year which he's ill able to satisfy because he has an obstetrics practice and that's why he was the only physician with privileges the state's own credentialing expert in this case conceded that outpatient positions like these who never intend to treat patients in the hospital will not be able to get privileges and the hospital bylaws included many criteria that these physicians could never satisfy him better number two explained why you didn't apply to this hospital he said in part because it's not a place where i would feel comfortable to do so he did your honor doe too focused his efforts on hospitals where he thought he had the best chance of obtaining privileges he'd had privileges at ellis you and wasn't even able to get privileges there at the district court mention any of  these yes your honor the district court's opinion was very careful and it's to see its decision and finding that these positions would not be able to get privileges was based on at least four points one the fact that they applied and attempted to get privileges at fifteen hospitals over one and a half years to get the state's key credentialing expert conceded that physicians who never intend to treat patients in the hospital will not get privileges doctor number six conceded that a physician who provides only medication and counseling would never be able to get privileges in addition the district courts burdens findings were supported supported by what happened when this law actually took effect for a brief time in tw abortion access in louisiana was devastated and of course the finding of every district court that has held a trial on a similar law has been that these laws will restrict access to abortion and here the district court found that this law would leave louisiana with just one clinic and one state to serve about ten thousand dollars people per year and that would mean that hundreds of thousands of women would now live more than one hundred and fifty miles from the closest provider and the burdens were actually more correct there's been much talk about his statement or findings by the district court that he was a superseding close to the act because he on his own will not practice in that in hope if this law goes into effect because he would be the only doctor but putting that aside he also testified i'm sorry the hope manager testified that he only does a limited number of abortions and with out the other doctor that clinic would have to close that's absolutely right your honor the district court found that without doe one the primary provider a hope hope would not be a viable going concern so regardless of doe three is testimony hope would have to close because don't three was providing fewer than thirty percent of the abortion services that clinic the primary provider was unable to get privileges and hope would close meaning that women living in northern louisiana would now have to travel hundreds of additional miles for a law that has no benefit in order to access abortion services there is no dispute here about the one that's cracked the other side that finding it says it's right now till three whether or not he would quit or not the clinic would have to close because he wouldn't have a deal one correct so at least with respect to that with respect to do six that's a medical doctor only who hasn't been in a hospital for over ten years so it seems implausible given that every single hospital mentioned by the district court in that area  has requirements of in patient receiving patients by the doctor and he can't fulfill that under any circumstance that's crocked cannot cannot follow up on the chief justices earlier question in mind as well are you saying privileges laws are always unconstitutional such so we don't have to look at the facts in state by state or are you saying that i actually do look at the facts state by state and in some states admitting privileges undue burden could admitting privileges law of this kind ever have a valid purpose in your view no your honor the medical consensus against these laws is clear so your view is that they're all unconstitutional in any state regardless of the facts they certainly serve no valid state interest and in fact the district court here found that this law was a solution for a problem that didn't exist and would actually jeopardize the health and safety of people in this big different if  if they did something as limited as for example you have to be admitted somewhere because some being admitted somewhere does further credentialing benefits but this was you have to be admitted within thirty miles some of these doctors were admitted further away but they still were credentialed by someone correct that's correct your honor if credentialing were the true goal of this law the thirty mile limit would make no sense and one of the practical real world impacts if the slower to take effect is that women in the baton rouge area would now have to travel three hundred and twenty miles back and forth to new orleans to see the same exact position that they previously could have seen on that riles from the north and from the  three hundred and twenty miles in your honor from shreveport to new orleans and from baton rouge back and forth because of the true trip to la it's three hundred and twenty miles and again they would be making that trip to see the same exact position who had been previously providing services in baton rouge and that has no benefit to women's health it will only hurt their health which is that zach lee with the district court found here you haven't mentioned thirty mile from clinic when that's exactly right your honor that's what this court recognized in homans health and one of the reasons why i concluded the law is medically unnecessary because the hot the complication rate is extremely small to begin with but when complications do occur it's almost always after the woman has left the clinic and the standard of care at that point is for her to go to the hospital closest to her home and of course about forty percent of abortions in louisiana are medication abortions and any complication from those abortions will often always happen when the patient is that home which again is what this court recognized in home is hell and that is one of the reasons why the a m a and cogged are clear that these laws have no medical benefits whatsoever and only impose barriers to abortion and that is true in every state regardless of the state circumstances these laws will always put barriers to abortion while serving no health and safety benefits and in fact the district court here found that abortion in louisiana in the years before the law was extremely safe with a very low rate of complications that hope had an excellent safety record and that it's physicians who are competent and qualified to provide abortion services and again it concluded that there is no basis to distinguish this case from home and health and instead the burdens of this law would be even more severe than the texas law that this court struck down in homans health the name under which june medical bills businesses correct yes your honor was just medicals license suspended for regulatory violations it was briefly your honor in two thousand and ten and the court heard testimony about that and rejected the state's allegations after listening to the clinics administrator and looking at the evidence in the record it concluded that hope has an excellent safety record and that its physicians are qualified and competent thank you counsel thank you mr chief justice and may it please the court the th circuit correctly held that the plaintiffs in this case failed to carry their burden their heavy burden of proof that is required to facially invalidate a state law louisiana's decision require abortion providers to have admitting privileges was justified by abundant evidence of life threatening health and safety violations malpractise noncompliance with professional licensing rules legislative testimony from post abortive women testimony from doctors who took care of abortion providers abandon patients the substantive due process claim that plaintiffs assert on their patients behalf hinged upon their assertion that they would not be able to get privileges but they can and they did their claims also fail for an independent reason so when they do not meet the modern rigorous rule for rd party standing so instead they invite this court to exempt them from the rule this court should decline to make abortion providers unique among federal plaintiffs and reaffirm that even abortion providers must comply with the same rules as all the other litigants doctors and health care providers and health care facilities are heavily regulated for ethics reasons and for consumer protection and in this context the conflict between the plaintiffs and individuals that the law seeks to protect should defeat the close relationship problem of rd party standing apart from that conflict the record shows that they do not have a close relationship with their patients and individual women have litigated abortion cases on their own for decades i'd like to st address why this case is different from heller stat and then address standing and waiver the state presented abundant evidence of how this case is different the law is different the facts are different the regulatory structure is different and the record is different and all of those things dictated a different result so the th circuit focused on one of the things that the pick up circuit focused on was credentialing the record in this case demonstrates that there is no credential that is performed by these facilities they alleged that they had robust policies but they don't read them and they don't follow them  regulation is consistent with the regulation that we have in our office surgery regulations and our amatory surgery regulations so it is consistent with our regulatory structure we also had evidence in the record of women who did require a miscarriage as i understand it these two procedures very much alike similar regulations about thirty miles and meeting privileges applicable to family miscarriage under the amateur surgery center regs yes under the office practice regs which do not regulate abortion clinics a doctor who doesn't have a residency in the proper scope of care the office practice regulations are not as tightly regulated as amatory surgery centers which are facility licensing these are separate licensing constructs facilities are licensed by the louisiana department of health as are inventory surgery centers and both require all the medical staff to have admitting privileges to the requirement under a ses says geographically close and it is interpreted under the regs as the same way so we don't interpret it differently we're applying them consistently  m reading those regulations the same do you agree that the benefits under the law is going to be the same in every case regardless of which state we're talking i mean i understand the idea that the impact might be different in different places but as far as the benefits of the law it's going to be the same in each state is no i don't think the benefit i mean i think that the state can certainly show greater benefits depending on what their regulatory structure is and what the facts are on the ground in that state i think we absolutely could show that we that it serves a greater benefit in our situation for example we've demonstrated that the doctors don't do credentialing that the l s b amee testimony from the executive director from doctor and the record laws that require credentialling to be done by the state with respect to these doctors correct they have to get a license and they have to have certain competencies to get the license and also the license is suspended if they're committed if they're convicted of a criminal act you're making it sound like there is no state licensing of these doctors they're licensed they aren't regulated in my are they  ensure that each of these doctrines was skilled in the procedures that they were performing no in fact three hired a radiologist and an ophthalmologist to perform abortions at one point in time so they clearly were not but you want revising what they were doing that's what he testified to that is not within the scope of care and our record clearly demonstrates that you should have a residency and you should have training in the area in which you are performing surgical procedure so it would not comply even with our office practice regs for a doctor to a radiologist to perform abortions that would not was my willing to surgical procedure or was he doing medical abortion he was performing surgical abortions to the best of my knowledge there's no indication that he wasn't i believe that the testimony is that he was performing all there he wasn't restricting as practice there's not a lot of testimony in the record about what those doctors were doing other than he hired them but to your question talking about them we're talking about these doctors and their credentials and i don't and i'm sort of still at a mystery to me why if what's important to you is the credential thirty mile limit has significance because it's not just credentialing it is all of the other factors that also play into it it does provide continuity of care it does cover for  care this lawyer itself permits a doctor either have admitting privileges or to be in contract with someone who does so it's not necessary that there be continuity of care in a hospital that the only thing is the credential you said is to make sure that they have the skill level but if they're credential somewhere else they have the skill level just to set them are they did not even comply with the transfer requirement they did not comply with multiple helped and health and safety requirements in the state so part of what the credential is this article one before the district court yes all right and the district court looked at it and found explanations that were adequate for each and didn't come to the conclusions you to the legislature did i thought the standard to review for the th circuit here was whether there was a plausible basis in the record for the conclusions the district court reached the district court judge ignored all of the health and safety violations he ignored an entire category of courtesy privileges if we're talking about compliance i mean i would i would like to take us back to the point that they could and did get privileges and there in the beginning before you learn that police on this credentialing point which you've mentioned several times and of course whole women's health discussed that insisted a state can say it's doing this for purposes if the hospitals reasons for denying admitting privileges have nothing to do with the doctor's quality and that was true in whole women's health and it's true here too that there's a great deal of evidence in the record that indicates that admissions privileges rest on many things it could rest on qualifications but it could rest on the number of patients a doctor has it could rest on whether it does whether a particular hospital needs more providers it could rest too could rest on a general view that they don't want abortion providers in the hospital so given that that's true it was true in texas and it's true here it seems that whole women's health precludes you from making this credentialing argument doesn't it no i don't think that it does at all i mean in our case it was demat demonstrably different they could indeed get privileges so all of that that conjecture and the this funding the district court hospital transfer was required far less than one year or less than one for several one thousand record demonstrated is that they don't know what their qualification what their complication rates are they all testified that they don't know because women don't follow up with them or they don't follow up with women so they really don't know what their complication rates are and they did testify that they had direct transfers that resulted in women having hysterectomy you said randy emerging is it isn't right that there is evidence in the record that hope clinic has served over three thousand women annually for twenty three years so that's around seventy thousand women and that's transferred only four patients ever to a hospital and there is evidence in the record that they really don't know that that's an accurate right because they don't track the complications they really don't know what their numbers are so they  a st trimester abortion can be either medical or surgical and even if it's medical the doctor should have the qualifications to be to be able to handle the most likely complication of that procedure which is a surgical abortion so under the standard of care in louisiana even if it's a medical even if it's a medication abortion the doctor should be able to handle a surgical abortion and be qualified to do that i think the writs record is questionable about whether joe one can even do that because everybody agreed including the th circuit the doe one is barred by this new law the only law said that you have to have admitting privileges or a written transfer agreement so it's a little hard to see how this improves anything since you had to have a written transfer agreement anyway isn't that true or not which doe one did not comply with or but then i don't know why th appeals would seem to have problems with the district court agreed with the district court as to doe one but that isn't my question my question is we're not going to solve this in oral argument i mean what i've done and i'm sure the others have is i've gone through the district court findings and i have gone through the court of appeals findings and i have looked at the relevant bits of the record through my office and we'll do more of that so i think go to your weakest case i think there are others that are stronger but i'd like your opinion your opinion about what of the use dos is your strongest i want to know of your opinion in respect to which doe is your argument the strongest your argument is that the th circuit was right to overturn a fact finding and with no three a credibility finding of the district court that your argument now you have to support that and i wouldn't know in respect to which doe you feel it's the strongest support for you want well i mean i think that there's evidence in virtually all of them that they sabotage their own applications and that joe five was joe five obtained privileges in baton rouge and new orleans asked only one doctor to back him up in baton rouge and of the doctors agreed that is not difficult to satisfy to simply but they don't all agree i mean that's the i don't think but we're not going to get if you are all i want to know is a number and the reason is we have limited time and i could spend two own expert testify that it was not likely that he was going to get privileges anywhere because he only did medical procedures never sore a patient in virtually all of the hospitals if not all of them even if there wasn't like into lane even if there wasn't a minimum number of patients that had to be admitted before you got privileges you had to see a certain number of patients in the hospital per year to maintain your privileges and he couldn't meet that requirement so you talk about him applying to only one hospital in a situation where it was guaranteed that he couldn't meet the requirements of any hospital my understanding of hospital practice today is you've got to stay alive only if somebody sees patients because if they don't see patients they're of no value to the hospital if the patients aren't admitted and there's no circumstance in which this doctor is going to admit a patient because he does know surgical procedures just to say to my i think the record shows that that they can get privileges they did get quote probably not and quote be able to obtain quote activity meeting and surgical privileges and quote now that was your expert and a basis of the out and various other things the district court filings that he didn't have to apply to all the hospitals because there was no point because your expert said he probably could not get them and it's on the basis of that kind of thing that the district court held that he was likely not to be able to practice where does the fist circuit able to say that that was clearly rome justice prior to the th circuit did a searching review of the record just as it is instructed to do by whole woman's health and the brief amount of time that i have left i would like to say just one thing about standing i think that the record is the reason why it demonstrates that these doctors should not be able to challenge a regulation that protects people that is intended to protect a class of people from a certain type of activity its health and safety regulations as a practical matter and  even yesterday this court was talking about the fact that consumers are protected by certain body of laws that's what we are doing with health and safety regulations differ from board cregg against boren and st of all had a very very briefly counsel justice ginsburg my answer to that is that the buyer in that case was much more just it was much more just a financial transaction their interests were better aligned because he was not prohibited from sassing the alcohol so it really wasn't helping to counsel gen walt mr chief justice and may please the court petitioners counsel began this morning by saying that this case is about respect for the court's precedents but she went on to acknowledge two rather remarkable propositions that flow from the logic of petitioners position and they are nowhere to be found in the court's cases to use justice alito that the plaintiffs may bring this suit even if there is a potential or actual conflict of interest with louisiana women and to use justice kavanagh that this lo unconstitutional even if all providers in louisiana already had it been in privileges or could easily get them i do think though petitioner did acknowledge what is in the court's cases which is to your question mr chief justice that the burdens may vary by state at that point facts there's no factual dispute about what the doctors did and didn't do it's about how rigorously we're going to review that fairly modest effort that's what i don't understand i think everybody also it again that's going straight to the benefits and bypassing the burns not looking st to where there's a substantial obstacle but to go straight to your question all admitting republican privileges acquirements of which i'm aware and they're fairly uncontroversial in the medical field have some distance limitation i think the benefits that they give to the most obvious is the continuity of care right because you want the dr to be able to admit them at some nearby hospital at least in some rural areas there isn't always a hospital right around the road so  here on like in hellish that reveals that sometimes it's not true that sometimes women develop complications in the clinic and in fact three who i think on this record is probably the most competent of the doe's and is the medical director at hope said that he has on occasion had a patient who develops a problem like a perforated uterus and admitted in the hospital and treated to even do three things of that as a best medical practice now granted we don't know how often it happens in just skate and i'm prepared to concede that it may not happen all that often i don't think anybody knows the real rate but the point is that it does happen and when it does it's very serious and louisiana would never happen to the kid just to take pills as well if you develop a complication home it's not it's not clear that you won't call the clinic and say to your doctor i'm having a problem in your doctor will say then go to the following hospital privileges i'll meet you there now that's not to say as a patient that's necessarily what you want but it's hard for me to believe that women in the easy and it wouldn't at least want the option question is there at least one potential woman you believe that could bring this lawsuit i assume that there are barry has not i don't stop a moment assuming we assume because it's logical ok the woman who lives three hundred there's going to be some woman who lives three hundred and thirty miles away who's going to say that's in and usually a long period of time for me to have to drive and then drive back the same day all right but putting or the next day putting that aside where is there a conflict between that woman and the doctor if that woman is going to take the position that this will all unduly burdens me what's the potential conflict she's going to come in and say you doctors could get credentialing so i really shouldn't sue you doctors haven't really made an effort so i really shouldn't sue what sane woman who's a pla is going to have a conflict with a doctor who wants to protect her rights by doing what they can to comply with the law or not but their interests are not misaligned they want to achieve the interest of for profit providers and not being regulated in particular ways the other is the interest of women in their own health and safety now i don't know how those would have played out if women had filed suit i don't know why they wanted something but to give you a couple of examples just to give you i did not clear to me that women w proficient challenge maybe to all of the current providers in louisiana you deal with this i mean i have read the briefs on the stand there are good arguments on both sides indeed in the country people have very strong feelings and a lot of people morally think it's wrong and a lot of people morally think the opposite is wrong and in casey and the later cases i think personally the court is struggling with the problem of what kind of rule of law do you have in a country that contains both sorts of people not all right so therefore i take casey as given and i think eight cases where you've given standing i mean we could go back and reexamine marbury vs madison but really we have eight cases in the abortion or you we have several cases in other areas and whole women's health picks that up casey picks that up and you really want us to go back and reexamine this let's go think if you want to go back for forty years i think what we want to say is that in none of those cases has the court ever considered and signed off in the face of a potential or actual conflict of interest so yes there is an argument never been in front of the court and we don't think the court now faced with it should accept it and i know you have limited time you know i understand the point that the impact of the laws varies from state to state but why do you look at each state differently if the benefits of the law they're not going to change from state to state so i disagree mr chief justice i think the variance isn't going to be as wide as on the burden side but take credentialing for instance i think the petitioners would have to say that if you had a state that really did focus on competence and the hospitals really were vetting for competence and they can dispute whether that happens here i mean that was that this case right well i would say that competence is i think a pretty key factor in what the hospitals do and if you look at the joints record i think if you look at the joint commission standards that are in the record but my only point to the chief justice was that however we however we think about that they can vary depending on how the credentialing system works in a particular state if i could just make one last point on the merits i don't really think it's clear or standard justice alito is how rigorously are we going to review pretty modest efforts due to did not apply to a hospital where he used to have privileges and do three currently has privileges so five got privileges at toro hospital in new orleans and just needed to get a covering doctor in baton rouge those six didn't apply to toro in new orleans were due five has privileges sodo five did the thing that petitioners are here saying can't be done and it's hard to figure out what the basis for distinction is because the sites they give in their brief and it's pretty general and pretty thin to be honest but when you really trace it back it seems to be the hospital bylaws and toro as best we can tell seems to have bylaws that look like the ones that they say would keep people from getting privileges and each of those has an answer i mean they say look the ones who didn't get the  get the privileges practice in o b g y n practice and so they had women who in fact were admitted to hospitals and the ones who don't are the ones who do medical abortion you've heard that and on the other one as far as i mean go to a go to says  i i tried to get a covering doctor he said no the other covering doctors there's no point because i'm in baton rouge is that where he was i think and he said look it's a tougher climate here really tough for people who perform abortions quite different from new orleans and i was told by one that don't do it because you try to get the covering doctor or not doctor be subject to picketing da da da ok we've all seen it so we've gone through it we'll go through it more what you want to say so i i think gotos in shreveport but far more importantly i think what i'd say is this in a pre enforcement setting that sort of to beat back and forth isn't enough to carry the burden one ought to have to happen is these physicians are to have to put their applications where their mouths are and then we'll find out once they've applied to the full range of hospitals whether they really can't whether dough to really can't at christus whether do five really can't find a covering doctor in baton rouge whether n practice got privileges torro i think petitioners acknowledge that they're not explicit patient minimums they call them implicit but the kinds of requirements that they are pointing to are the sorts of things that look like they would have precluded do five and didn't your honor the lack of benefits of these laws is not state dependent the medical consensus is clear that in no state did they hurt serve health and safety benefits and in fact even the federal government a few months ago removed in admitting privileges requirement from its regulations of surgery centers nationwide finding that requirement is medically unnecessary and imposes burdens and is justice kagan asked this court rejected an alleged credentialing benefit in whol and after holding a trial the district court rejected that this law would serve a credentialing benefit in louisiana with respect to burdens the district court found that this law would be extremely burdensome or the so then the texas law in home and health and it's finding the b s physicians would not be able to get privileges is supported by at least four aspects of the record the fact that they tried to get privileges at fifteen hospitals over one and a half years under the court's supervision the fact that the state's expert conceded that outpatient positions who don't have a hospital based practice are unlikely to get privileges the fact that abortion access was thrown into chaos when this law actually took effect and the hospital bylaws themselves which included a variety of criteria that these physicians could never meet including residency armand's and finally i'd like to point out that this is not in fact a pre enforcement challenge the state has recognized that including in its state papers before this court the district court allowed the law to take effect but in joint its penalties and supervise the physicians efforts to get privileges over a year and a half again the state has previously knowledge that this is not a pre foresman challenge there are no further questions thank you counsel cases submitted