Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca8-04-03379/USCOURTS-ca8-04-03379-0/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 

---

*

Pursuant to Federal Rule of Appellate Procedure 43(c)(2), Alberto Gonzales

is automatically substituted for his predecessor, John Ashcroft, as appellant.

United States Court of Appeals

FOR THE EIGHTH CIRCUIT

___________

No. 04-3379 

___________

LeRoy Carhart, M.D., on behalf of *

themselves and the patients they serve; *

William G. Fitzhugh, M.D., on behalf of *

themselves and the patients they serve; *

William H. Knorr, M.D., on behalf of *

themselves and the patients they serve; *

Jill L. Vibhakar, M.D., on behalf of *

themselves and the patients they serve, *

*

Appellees, *

* Appeal from the United States

v. * District Court for the

* District of Nebraska.

Alberto Gonzales, in his official * 

capacity as Attorney General of the *

United States, and his employees, *

agents, and successors in office,* *

* 

Appellant, *

*

and *

*

Susan Frietsche; David S. Cohen; *

Stacey I. Young, *

*

Interested Parties. *

Appellate Case: 04-3379 Page: 1 Date Filed: 07/08/2005 Entry ID: 1925457
**An official caption containing a complete list of parties is on file and

available for inspection in the Office of the Clerk of Court, United States Court of

Appeals for the Eighth Circuit.

1

The Honorable Richard G. Kopf, Chief Judge, United States District Court for

the District of Nebraska.

-2-

*

-------------------------------- *

*

Margie Riley, et al.,** *

*

Amici on Behalf of Appellee. *

___________

Submitted: April 14, 2005

 Filed: July 8, 2005

___________

Before LOKEN, Chief Judge, FAGG, and BYE, Circuit Judges.

___________

BYE, Circuit Judge.

This case presents a challenge to the federal Partial-Birth Abortion Ban Act of

2003, Pub. L. No. 108-105, 117 Stat. 1201 (codified at 18 U.S.C. § 1531). The day

the President signed the Act into law, plaintiffs filed suit in the United States District

Court for the District of Nebraska seeking an injunction against enforcement of the

Act. After a trial, the district court1

 held the Act unconstitutional on several grounds.

The government appeals. We affirm the judgment of the district court.

Appellate Case: 04-3379 Page: 2 Date Filed: 07/08/2005 Entry ID: 1925457
-3-

I

A

In 2000, the Supreme Court handed down its decision in Stenberg v. Carhart,

530 U.S. 914 (2000), which found Nebraska’s partial-birth abortion ban

unconstitutional for two separate reasons. First, the Court determined the law was

unconstitutional because it did not contain an exception to preserve the health of the

mother. Second, the Court determined the law was worded so broadly it covered the

vast majority of late-term abortions and thus imposed an undue burden on the right

to abortion itself.

In the eight years before the Court’s decision in Stenberg, at least thirty states

passed laws banning partial-birth abortions. See id. at 983 (Thomas, J., dissenting).

In 1996 and 1997, Congress enacted prohibitions on partial-birth abortions, however,

President Clinton vetoed them. Id. at 994 n.11 (Thomas, J., dissenting). In 2003,

Congress enacted, and President George W. Bush signed, the Partial-Birth Abortion

Ban Act of 2003. The Act exposes “[a]ny physician who, in or affecting interstate

or foreign commerce, knowingly performs a partial-birth abortion and thereby kills

a human fetus” to up to two years of imprisonment. 18 U.S.C. § 1531(a). The Act

goes on to define a “partial-birth abortion” as an abortion in which the person

performing the abortion:

(A) deliberately and intentionally vaginally delivers a living fetus until,

in the case of a head first presentation, the entire fetal head is outside the

body of the mother, or, in the case of a breech presentation, any part of

the fetal trunk past the navel is outside the body of the mother, for the

purpose of performing an overt act that the person knows will kill the

partially delivered living fetus; and

(B) performs the overt act, other than completion of delivery, that kills

the partially delivered living fetus . . . .

Id. § 1531(b)(1).

Appellate Case: 04-3379 Page: 3 Date Filed: 07/08/2005 Entry ID: 1925457
-4-

The Act contains an exception allowing the performance of “a partial-birth

abortion that is necessary to save the life of the mother.” Id. § 1531(a). The Act does

not, however, contain an exception for the preservation of the health of the mother.

Presumably recognizing that the Act is similar (though not identical) to the

Nebraska law found unconstitutional in Stenberg, Congress made several findings

and declarations in the Act. Congress “f[ound] and declare[d]” that “under wellsettled Supreme Court jurisprudence, the United States Congress is not bound to

accept the same factual findings that the Supreme Court was bound to accept in

Stenberg.” Partial-Birth Abortion Ban Act of 2003 § 2(8), 117 Stat. at 1202.

Congress concluded that a “moral, medical, and ethical consensus exists that the

practice of performing a partial-birth abortion . . . is a gruesome and inhumane

procedure that is never medically necessary and should be prohibited.” § 2(1), 117

Stat. at 1201. In addition to determining there is “substantial evidence” that partialbirth abortions are never medically necessary, Congress also concluded partial-birth

abortions “pose[] serious risks to the health of the mother undergoing the procedure.”

§§ 2(13), 2(14), 117 Stat. at 1203-04.

After a trial, the district court found the Act unconstitutional on two separate

grounds. First, the district court concluded Congress’s finding regarding a medical

consensus was unreasonable and thus the Act was unconstitutional due to its lack of

health exception. Second, the district court concluded the Act covered the most

common late-term abortion procedure and thus imposed an undue burden on the right

to an abortion.

B

The procedures in question in this case are used during late-term abortions and

we therefore must, for context, present some basic information regarding these

procedures. There are three primary methods of late-term abortions: medical

induction; dilation and evacuation (D&E); and dilation and extraction (D&X). In a

Appellate Case: 04-3379 Page: 4 Date Filed: 07/08/2005 Entry ID: 1925457
-5-

medical induction, formerly the most common method of second-trimester abortion,

a physician uses medication to induce premature labor. Stenberg, 530 U.S. at 924.

In a D&E, now the most common procedure, the physician causes dilation of the

woman’s cervix and then “the physician reaches into the woman’s uterus with an

instrument, grasps an extremity of the fetus, and pulls.” Women’s Med. Prof’l Corp.

v. Taft, 353 F.3d 436, 439 (6th Cir. 2003). “When the fetus lodges in the cervix, the

traction between the grasping instrument and the cervix causes dismemberment and

eventual death, although death may occur prior to dismemberment.” Id. This process

is repeated until the entire fetus has been removed.

D&X and a process called intact D&E are what are “now widely known as

partial birth abortion.” Id. In these procedures, the fetus is removed “intact” in a

single pass. If the fetus presents head first, the physician collapses the skull of the

fetus and then removes the “intact” fetus. Stenberg, 530 U.S. at 927. This is what is

known as an intact D&E. If the fetus presents feet first, the physician “pulls the fetal

body through the cervix, collapses the skull, and extracts the fetus through the

cervix.” Id. This is the D&X procedure. “Despite the technical differences” between

an intact D&E and a D&X, they are “sufficiently similar for us to use the terms

interchangeably.” Id. at 928.

II

As a preliminary matter, although the plaintiffs purported to bring a facial

challenge to the Act, the district court expressed confusion over whether its judgment

declared the Act facially unconstitutional or unconstitutional as applied to the

plaintiffs. See Carhart v. Ashcroft, 331 F. Supp. 2d 805, 1042-47 (D. Neb. 2004)

(stating the district court “do[es] not know” if its ruling was facial or as applied and

leaving “that for others to determine”). This is a question of law and we therefore

review it de novo. See, e.g., United States v. Jeffries, 405 F.3d 682, 684 (8th Cir.

2005). The traditional standard for evaluating a facial challenge was set forth in

Appellate Case: 04-3379 Page: 5 Date Filed: 07/08/2005 Entry ID: 1925457
-6-

United States v. Salerno, 481 U.S. 739 (1987). In Salerno, the Supreme Court

explained that a “facial challenge to a legislative Act is, of course, the most difficult

challenge to mount successfully, since the challenger must establish that no set of

circumstances exists under which the Act would be valid.” Id. at 745. In Stenberg,

however, the Supreme Court struck down Nebraska’s partial-birth abortion ban as

facially unconstitutional without applying the Salerno standard. In fact, the approach

taken in Stenberg was fundamentally inconsistent with Salerno’s “no set of

circumstances” test in that it regarded rarity of the need for a particular procedure as

“not highly relevant.” Stenberg, 530 U.S. at 934. The Salerno test is also

inconsistent with the general undue burden analysis for abortion statutes set forth in

Planned Parenthood v. Casey, 505 U.S. 833 (1992). This has led the vast majority of

circuit courts to apply these abortion-specific standards in place of Salerno. See

Planned Parenthood of N. New England v. Heed, 390 F.3d 53, 57-59 (1st Cir. 2004)

(collecting cases), cert. granted sub nom. Ayotte v. Planned Parenthood, 125 S. Ct.

2294 (May 23, 2005); Richmond Med. Ctr. for Women v. Hicks, 409 F.3d 619, 627-

28 (4th Cir. 2005) (same). We have previously declined to apply the “no set of

circumstances” test in the context of facial challenges to abortion restrictions in

Planned Parenthood, Sioux Falls Clinic v. Miller, 63 F.3d 1452, 1458 (8th Cir. 1995),

where we explained we would “follow what the Supreme Court actually did—rather

than what it failed to say” and thus applied Casey’s undue burden test. We will again

follow what the Supreme Court “actually did” and apply the test from Stenberg rather

than the one from Salerno. We therefore join every circuit that has addressed the

question. See Hicks, 409 F.3d at 628; Planned Parenthood of Idaho, Inc. v. Wasden,

376 F.3d 908, 921 n.10 (9th Cir. 2004); Planned Parenthood of the Rocky Mountains

Servs., Corp. v. Owens, 287 F.3d 910, 919 (10th Cir. 2002). Thus, if the Act fails the

Stenberg test, it must be held facially unconstitutional.

Appellate Case: 04-3379 Page: 6 Date Filed: 07/08/2005 Entry ID: 1925457
2

Amici have argued Stenberg does not apply for several reasons. To the extent

their arguments suggest we disregard or overrule Supreme Court precedent, such a

course of action is beyond our power. One amicus suggests Stenberg does not control

because that case was decided under the Fourteenth Amendment, which, of course,

does not apply to the federal government. While Stenberg was indeed a Fourteenth

Amendment case, the Due Process Clause of the Fifth Amendment is textually

identical to the Due Process Clause of the Fourteenth Amendment, and both proscribe

virtually identical governmental conduct. See, e.g., Malloy v. Hogan, 378 U.S. 1, 8

(1964). If anything, the Fifth Amendment’s Due Process Clause has a broader reach

in that it has been interpreted to apply the principles of the Fourteenth Amendment’s

Equal Protection Clause to the federal government. See, e.g., Adarand Constructors,

Inc. v. Pena, 515 U.S. 200, 253 n.8 (1995); Bolling v. Sharpe, 347 U.S. 497 (1954).

-7-

III

We begin our analysis with the Supreme Court’s decision in Stenberg.

2

 That

case has engendered some disagreement as to the proper standard for evaluating the

necessity of a health exception. The proper reading of Stenberg is a question of law

and therefore is reviewed de novo. See, e.g., Jeffries, 405 F.3d at 684. The

government argues Stenberg merely examined the specific factual record before the

Court, and thus a health exception is only required when a banned procedure is

actually “necessary, in appropriate medical judgment, for the preservation of the

health of the mother.” Stenberg, 530 U.S. at 930 (internal quotations omitted).

Plaintiffs, in contrast, contend that “where substantial medical authority supports the

proposition that banning a particular abortion procedure could endanger women’s

health, Casey requires the statute to include a health exception when the procedure

is ‘“necessary, in appropriate medical judgment, for the preservation of the life or

health of the mother.”’” Stenberg, 530 U.S. at 938 (quoting Casey, 505 U.S. at 879

(quoting Roe v. Wade, 410 U.S. 113, 165 (1973))).

The government argues that Stenberg embodies a lenient standard, and further

urges that congressional factfinding must be afforded deference under Turner

Appellate Case: 04-3379 Page: 7 Date Filed: 07/08/2005 Entry ID: 1925457
-8-

Broadcasting v. FCC, 512 U.S. 622 (1994) (Turner I), and Turner Broadcasting v.

FCC, 520 U.S. 180 (1997) (Turner II). The government contends that because (in its

opinion) Congress is afforded deference in factfinding as a general proposition, the

district court’s adoption of the “substantial medical authority” standard amounts to

an implicit overruling of the Turner line of cases. According to the government, the

“substantial medical authority” standard “must [therefore] be understood as[,] at

most[,] a rule of decision in the absence of congressional findings, not as a basis for

disregarding such findings.” Br. of Appellant at 33. The government’s argument,

however, fundamentally misconstrues the threshold issue, for our task lies not in

identifying who gets to decide, but rather in identifying the precise question that must

be answered.

The other end of the spectrum on potential readings of Stenberg is exemplified

by a recent decision in which the Fourth Circuit addressed Stenberg’s health

exception requirement standard in a case involving a state partial-birth abortion

statute. Hicks, 409 F.3d at 625-26. The Fourth Circuit held that Stenberg

“established the health exception requirement as a per se constitutional rule.” Id. at

625. The court explained that “[t]his rule is based on substantial medical authority

(from a broad array of sources) recognized by the Supreme Court, and this body of

medical authority does not have to be reproduced in every subsequent challenge to

a ‘partial birth abortion’ statute lacking a health exception,” and therefore all statutes

regulating partial-birth abortion must contain a health exception. Id. Several district

courts have, at least implicitly, taken this position as well. See, e.g., Reproductive

Health Servs. of Planned Parenthood v. Nixon, 325 F. Supp. 2d 991, 994-95 (W.D.

Mo. 2004); WomenCare of Southfield, P.C. v. Granholm, 143 F. Supp. 2d 849, 855

(E.D. Mich. 2001); Summit Med. Assocs. v. Siegelman, 130 F. Supp. 2d 1307, 1314

(M.D. Ala. 2001); Daniel v. Underwood, 102 F. Supp. 2d 680, 684 (S.D. W.Va.

2000).

Appellate Case: 04-3379 Page: 8 Date Filed: 07/08/2005 Entry ID: 1925457
-9-

We agree with the Fourth Circuit that Stenberg establishes a per se

constitutional rule in that the constitutional requirement of a health exception applies

to all abortion statutes, without regard to precisely how the statute regulates abortion.

See Heed, 390 F.3d at 59 (applying Stenberg to parental notification law). As the

Ninth Circuit recently explained: “Any abortion regulation must contain adequate

provision for a woman to terminate her pregnancy if it poses a threat to her life or her

health.” Wasden, 376 F.3d at 922. While Stenberg’s health exception rule

undoubtedly applies to all abortion statutes, such a proposition does not explain how

to evaluate whether a given restriction poses a constitutionally significant threat to

the mother’s health.

We believe the appropriate question is whether “substantial medical authority”

supports the medical necessity of the banned procedure. See Stenberg, 530 U.S. at

938; id. at 948 (O’Connor, J., concurring); see also Planned Parenthood Fed’n of Am.

v. Ashcroft, 320 F. Supp. 2d 957, 1033 (N.D. Cal. 2004); Nat’l Abortion Fed’n v.

Ashcroft, 330 F. Supp. 2d 436, 487-90 (S.D.N.Y. 2004); Carhart, 331 F. Supp. 2d at

1008. The Stenberg Court determined medical necessity (as that term was used in

Casey) does not refer to “an absolute necessity or to absolute proof.” Stenberg, 530

U.S. at 937. Rather, “appropriate medical judgment” must “embody the judicial need

to tolerate responsible differences of medical opinion.” Id. Recognition of this

principle was driven by the Court’s concern that “the division of medical opinion

about the matter at most means uncertainty, a factor that signals the presence of risk,

not its absence.” Id. Thus, when “substantial medical authority” supports the

medical necessity of a procedure in some instances, a health exception is

constitutionally required. In effect, we believe when a lack of consensus exists in the

medical community, the Constitution requires legislatures to err on the side of

protecting women’s health by including a health exception.

In dissent, both Justice Kennedy and Justice Thomas criticized the Stenberg

majority for imposing what they believed was a high burden on legislatures. Justice

Appellate Case: 04-3379 Page: 9 Date Filed: 07/08/2005 Entry ID: 1925457
-10-

Kennedy commented that by disagreeing with Nebraska, the Court was effectively

“[r]equiring Nebraska to defer to Dr. Carhart’s judgment[, which was] no different

from forbidding Nebraska from enacting a ban at all; for it is now Dr. Leroy Carhart

who sets abortion policy . . . .” Id. at 965 (Kennedy, J., dissenting). Justice Thomas

characterized the majority opinion as requiring a health exception “because there is

a ‘division of opinion among some medical experts . . . .’” Id. at 1009 (Thomas, J.,

dissenting) (quoting id. at 936-37). “In other words, unless a State can conclusively

establish that an abortion procedure is no safer than other procedures, the State cannot

regulate that procedure without including a health exception.” Id. (Thomas, J.,

dissenting).

Although the Stenberg majority did not believe the rule it announced gave

individual doctors an absolute veto over legislatures, it emphasized that a health

exception is required where “substantial medical authority” supports the medical

necessity of a procedure. Id. at 938. Such language would be rendered essentially

meaningless if we accepted the government’s reading of the case, a reading that

would conform to neither the majority’s reasoning nor to the dissenters’concerns. In

sum, we conclude Stenberg requires the inclusion of a health exception whenever

“substantial medical authority” supports the medical necessity of the prohibited

procedure. 

IV

A

Having identified the proper question, we now turn to determining how this

question should be answered. The government argues the Turner line of cases

requires courts to “‘accord substantial deference to the predictive judgments of

Congress,’” and the “sole obligation” of reviewing courts “is ‘to assure that, in

formulating its judgments, Congress has drawn reasonable inferences based on

Appellate Case: 04-3379 Page: 10 Date Filed: 07/08/2005 Entry ID: 1925457
-11-

substantial evidence.’” Turner II, 520 U.S. at 195 (quoting Turner I, 512 U.S. at 665-

66). Thus, under the government’s formulation, we would be bound by Congress’s

determination that a “moral, medical, and ethical consensus exists that the practice

of performing a partial-birth abortion” is never medically necessary, so long as this

apparent factual determination is reasonable and supported by substantial evidence.

The government’s argument is predicated on an erroneous assumption: that the

“substantial medical authority” standard is a question of fact. While questions of law

and questions of fact sometimes can be neatly separated, such questions are often

intermingled and identified as so-called mixed questions of fact and law. See, e.g.,

Ornelas v. United States, 517 U.S. 690, 696 (1996). Whether a partial-birth abortion

is medically necessary in a given instance would be a question of fact; for in any

given instance it would be either true or false that a partial-birth abortion is medically

necessary. There may be conflicting expert opinions, but only one can actually be

right in any given set of medical circumstances. In contrast, whether the record in a

particular lawsuit reflects the existence of “substantial medical authority” supporting

the medical necessity of such procedures is a question that is different in kind; it asks

only whether there is a certain quantum of evidence to support a particular answer,

not which of the divergent opinions is ultimately correct. Reviewing the record to

determine if the evidence presented suffices to support the conclusion reached by the

lower court is typically treated as a matter of law. See, e.g., Howard v. Massanari,

255 F.3d 577, 580 (8th Cir. 2001) (applying de novo review of the Social Security

Commissioner’s conclusion despite prior district court review); United States v.

Thompson, 285 F.3d 731, 733 (8th Cir. 2002) (reviewing the sufficiency of the

evidence de novo). We must, of course, examine the evidence, but the legal question

inherent in this inquiry is whether such record evidence constitutes “substantial

medical authority” in a given case. 

This case differs slightly from the typical case in which we review the evidence

to determine if the record is sufficient to support the lower court’s conclusion. Under

Appellate Case: 04-3379 Page: 11 Date Filed: 07/08/2005 Entry ID: 1925457
-12-

the “substantial medical authority” standard, our review of the record is effectively

limited to determining whether substantial evidence exists to support the medical

necessity of partial-birth abortions without regard to the factual conclusions drawn

from the record by the lower court (or, in this case, Congress). Thus, Stenberg

created a standard in which the ultimate factual conclusion is irrelevant. Under this

standard, we must examine the record to determine if “substantial medical authority”

supports the medical necessity of the banned procedures. If it does, then a health

exception is constitutionally required. If the need for a health exception is not

supported by “substantial medical authority,” by contrast, then the state is free to

impose the restriction without providing a health exception.

We believe an example from the Supreme Court’s First Amendment

jurisprudence is instructive here. In New York Times v. Sullivan, 376 U.S. 254

(1964), the Court held that the First Amendment “prohibits a public official from

recovering damages for a defamatory falsehood relating to his official conduct unless

he proves that the statement was made with ‘actual malice’—that is, with knowledge

that it was false or with reckless disregard of whether it was false or not.” Id. at 279-

80. To meet this burden, the public official must show actual malice by clear and

convincing evidence. See, e.g., Campbell v. Citizens for an Honest Gov’t, Inc., 255

F.3d 560, 569 (8th Cir. 2001). In Bose Corp. v. Consumers Union of the United

States, Inc., 466 U.S. 485 (1984), the Court faced the question of whether Federal

Rule of Civil Procedure 52(a), which makes facts subject only to review for clear

error, was the appropriate standard for reviewing a finding of actual malice. Id. at

487. An individual’s state of mind is a question of historical fact and would thus

normally be reviewed only for clear error. See, e.g., Hickey v. Reeder, 12 F.3d 754,

756-57 (8th Cir. 1993) (holding that state of mind is a question of fact that is

reviewed for clear error); see also Bose, 466 U.S. at 498 n.15 (noting that in Herbert

v. Lando, 441 U.S. 153, 170 (1979), the Court had referred “in passing” to actual

malice as “ultimate fact”). The Court concluded, however, that the First Amendment

requires independent appellate review. The Bose Court explained that “[j]udges, as

Appellate Case: 04-3379 Page: 12 Date Filed: 07/08/2005 Entry ID: 1925457
-13-

expositors of the Constitution, must independently decide whether the evidence in the

record is sufficient to cross the constitutional threshold.” Id. at 511. The Court

further stated that “independent inquiries of this kind are familiar under the settled

principle that in cases in which there is a claim of denial of rights under the Federal

Constitution, this Court is not bound by the conclusions of lower courts, but will

reexamine the evidentiary basis on which those conclusions are founded.” Id. at 510

(internal quotations and alterations omitted). Thus, despite the fact that an

individual’s mental state is a question of pure historical fact, a determination of

whether the record supports the finding of actual malice is a question of law. See,

e.g., Harte-Hanks Communications, Inc. v. Connaughton, 491 U.S. 657, 685 (1989);

Mercer v. City of Cedar Rapids, 308 F.3d 840, 849 (8th Cir. 2002); see also Bose,

466 U.S. at 499 (explaining the “New York Times rule emphasizes the need for an

appellate court to make an independent examination of the entire record”). The

same reasoning applies here. While judges under Bose must determine whether clear

and convincing evidence of an individual’s state of mind exists in an effort to protect

that individual’s First Amendment rights, here we must examine the record to

determine whether “substantial medical authority” supports the need for a health

exception so as to guard against the denial of another constitutional right.

As a result, the government’s argument regarding Turner deference is irrelevant

to the case at hand. Our review is based on the record and is guided, as described

below, by the legal conclusions reached by the Supreme Court in prior cases.

Therefore, we need not address the government’s assertions that federal courts must

defer to congressional factfinding.

B

Courts engage in different types of factfinding, as the facts that they find can

be either of an adjudicatory or legislative nature. See Qualley v. Clo-Tex Int’l, Inc.,

212 F.3d 1123, 1128 (8th Cir. 2000). Adjudicatory facts are those relevant only to

Appellate Case: 04-3379 Page: 13 Date Filed: 07/08/2005 Entry ID: 1925457
3

Of course, this may not be true of all abortion-related restrictions.

-14-

the particular parties involved in the case. United States v. Gould, 536 F.2d 216, 219

(8th Cir. 1976). Classic examples are “‘who did what, when, where, how and with

what motive or intent.’” Id. (quoting 2 Kenneth Davis, Administrative Law Treatise

§15.03, at 353 (1958)). In contrast, legislative facts are those that have salience

beyond the specific parties to the suit. Qualley, 212 F.3d at 1128. The medical

necessity of particular abortion procedures clearly falls into this latter category, as

such procedures are either sometimes medically necessary or they are not: the answer

to this question does not vary from place to place or party to party.3

 While lower

court conclusions drawn from the same body of evidence may vary from individual

case to individual case, appellate courts can impose uniformity within their

jurisdictions by according no deference to a lower court’s record-based conclusions.

Indeed, adopting a deferential posture in such circumstances could lead to the absurd

result where two district courts within the same circuit (perhaps even within the same

state) might examine the same body of evidence and reach different conclusions as

to the medical necessity of the partial-birth abortion procedures, but we would be

forced to affirm both because the question is a close one. See Hope Clinic v. Ryan,

195 F.3d 857, 883-84 (7th Cir. 1999) (en banc) (Posner, J., dissenting), vacated and

remanded, 530 U.S. 1271 (2000); see also Lockhart v. McCree, 476 U.S. 162, 169 n.3

(1986) (expressing doubt that “legislative facts” are reviewed deferentially because

different courts can come to different conclusions from the same evidence). As Judge

Easterbrook has cogently explained for the Seventh Circuit, the medical necessity of

partial-birth abortion “must be assessed at the level of legislative fact, rather than

adjudicative fact determined by more than 650 district judges. Only treating the

matter as one of legislative fact produces the nationally uniform approach that

Stenberg demands.” A Woman’s Choice-E. Side Women’s Clinic v. Newman, 305

F.3d 684, 688 (7th Cir. 2002). The Newman court recognized that “[f]indings based

on new evidence could produce a new understanding, and thus a different legal

outcome . . . . But if the issue is one of legislative rather than adjudicative fact, it is

Appellate Case: 04-3379 Page: 14 Date Filed: 07/08/2005 Entry ID: 1925457
-15-

unsound to say that, on records similar in nature, Wisconsin’s law could be valid . . .

and Indiana’s law invalid, just because different district judges reached different

conclusions about the inferences to be drawn from the same body of statistical work.”

Id.; see also Hope Clinic, 195 F.3d at 884 (en banc) (Posner, J., dissenting). Thus,

although the Seventh Circuit prior to Stenberg had affirmed a trial court’s decision

upholding a partial-birth abortion ban based on the trial court’s conclusion that

partial-birth abortions are never medically necessary, the Supreme Court vacated the

decision without regard to the specific facts found by that particular trial court. See

Hope Clinic, 530 U.S. at 1271. On remand, the Seventh Circuit held the state bans

unconstitutional (in agreement with the parties). See Hope Clinic v. Ryan, 249 F.3d

603, 604 (2001) (en banc) (decision on remand) (“[B]oth Illinois and Wisconsin have

conceded that their partial-birth-abortion statutes are unconstitutional under the

approach the Court adopted in Stenberg. We agree with this assessment of Stenberg’s

significance.”). While we are hesitant to read too much into the Supreme Court’s

decision to vacate and remand Hope Clinic, its decision, along with the Seventh

Circuit’s comments regarding Stenberg’s significance, is suggestive of a need to

achieve constitutional uniformity through treatment of the issue as one of legislative

fact.

In the specific context of a ban on partial-birth abortions, we join the reasoning

of the Fourth Circuit and some of the district courts that have treated Stenberg as a

per se constitutional rule. In Stenberg, the Court surveyed all of the available medical

evidence (including the formal district court record, the district court records from

other partial-birth abortion cases, amicus submissions, and some congressional

records) and determined that “substantial medical authority” supported the need for

a health exception. “[T]his body of medical authority does not have to be reproduced

in every subsequent challenge to a ‘partial birth abortion’ statute lacking a health

exception.” Hicks, 409 F.3d at 625. Neither we, nor Congress, are free to disagree

with the Supreme Court’s determination because the Court’s conclusions are final on

matters of constitutional law. See, e.g., United States v. Dickerson, 530 U.S. 428,

Appellate Case: 04-3379 Page: 15 Date Filed: 07/08/2005 Entry ID: 1925457
-16-

437 (2000) (“Congress may not legislatively supersede our decisions interpreting and

applying the Constitution.”); City of Boerne v. Flores, 521 U.S. 507, 517-21 (1997);

Stell v. Savannah-Chatham County Bd. of Educ., 333 F.2d 55, 61 (5th Cir. 1964)

(“[N]o inferior federal court may refrain from acting as required by [Brown v. Board

of Education] even if such a court should conclude that the Supreme Court erred as

to its facts or as to the law.”). And because the medical necessity of a health

exception is a question of legislative fact, subsequent litigants need not relitigate

questions the Supreme Court has already addressed. See, e.g., Hicks, 409 F.3d at

625; N.J. Citizen Action v. Edison Township, 797 F.2d 1250, 1268 (3d Cir. 1986)

(Weis, J., dissenting) (“The constitutional facts supporting a rule or doctrine must

necessarily carry precedential weight so that government will be able to predict the

validity of their regulatory actions. Thus, in large part the longevity of constitutional

facts may be attributed to the doctrine of stare decisis and the important purposes that

principle serves.”); Matthews v. Launius, 134 F. Supp. 684, 686-87 (D. Ark. 1955)

(recognizing that to succeed in a suit under Brown, a plaintiff need not reprove

Brown’s factual predicates).

This is not to say, however, that because the Supreme Court concluded

“substantial medical authority” supported the need for a health exception in 2000,

legislatures are forever constitutionally barred from enacting partial-birth abortion

bans. Rather, the “substantial medical authority” test allows for the possibility that

the evidentiary support underlying the need for a health exception might be

reevaluated under appropriate circumstances. Medical technology and knowledge

is constantly advancing, and it remains theoretically possible that at some point

(either through an advance in knowledge or the development of new techniques, for

example), the procedures prohibited by the Act will be rendered obsolete. Should

that day ever come, legislatures might then be able to rely on this new evidence to

prohibit partial-birth abortions without providing a health exception. 

Appellate Case: 04-3379 Page: 16 Date Filed: 07/08/2005 Entry ID: 1925457
4

Though the government argues at length that substantial evidence supports

Congress’s conclusion, it at no point engages the analysis undertaken by all three

district courts to have addressed the constitutionality of the Act and one of the major

points raised by the Appellees: that Congress’s conclusion that a consensus has

formed against the medical necessity of the procedures was unreasonable. The

government has argued the district court adopted an erroneous reading of Stenberg

by focusing on “substantial medical authority” and a lack of consensus against the

procedures. Despite the fact that every federal court to have addressed the issue has

rejected the government’s position, the government never challenges the district

court’s conclusion that “substantial medical authority” supports the medical necessity

of the banned procedures. By virtue of the government’s failure to argue the issue in

either its opening brief or in its reply, we could consider the issue waived. See, e.g.,

Chay-Velasquez v. Ashcroft, 367 F.3d 751, 756 (8th Cir. 2004) (failure to raise issue

in opening brief constitutes waiver). However, we decline to do so and will address

the issue nonetheless.

-17-

V

Stenberg identified what some refer to as “evidentiary circumstances” upon

which the Court purportedly relied in determining whether “substantial medical

authority” supported the need for a health exception. The Stenberg Court noted (1)

the district court’s conclusion that D&X significantly obviates health risks in certain

circumstances and a highly plausible record-based explanation of why that might be

so; (2) a division of opinion among medical experts regarding the procedure; and (3)

an absence of controlled medical studies that address the safety and medical necessity

of the banned procedures. 530 U.S. at 936-37. In evaluating the government’s case,

we take Stenberg as the baseline and then determine if the government has proffered

evidence sufficient to distinguish the present situation from Stenberg’s “evidentiary

circumstances.” If the government marshals such evidence, we must then determine

whether the evidence on the other side remains “substantial medical authority.”

Because we conclude the government has not adduced evidence distinguishing this

case from Stenberg, we need not attempt to define the precise contours of

“substantial medical authority.”4

Appellate Case: 04-3379 Page: 17 Date Filed: 07/08/2005 Entry ID: 1925457
-18-

We know from Stenberg that “substantial medical authority” supports the

conclusion that the banned procedures obviate health risks in certain situations. For

example, there is “substantial medical authority” (in the form of expert testimony and

amici submissions) that these procedures reduce the risk of uterine perforation and

cervical laceration because they avoid significant instrumentation and the presence

of sharp fetal bone fragments. Stenberg, 530 U.S. at 930-34. There is also evidence

the procedure takes less time and thus reduces blood loss and prolonged exposure to

anesthesia. Id. The banned procedure may also eliminate the risk posed by retained

fetal tissue and embolism of cerebral tissue into the woman’s bloodstream. Id.

Moreover, there is evidence regarding the health advantages the banned procedures

provide when the woman has prior uterine scarring or when the fetus is nonviable due

to hydrocephaly. Id.

There is some evidence in the present record indicating each of the advantages

discussed in Stenberg are incorrect and the banned procedures are never medically

necessary. See Carhart, 331 F. Supp. 2d at 822-51. There were, however, such

assertions in Stenberg as well. See Stenberg, 530 U.S. at 933-34; id. at 964-66

(Kennedy, J., dissenting). Though the contrary evidence now comes from (some)

different doctors, the substance of this evidence does not distinguish this case from

Stenberg in any meaningful way. 

To avoid Stenberg, the government cannot simply claim Stenberg was wrongly

decided, for we are bound by the Supreme Court’s conclusions. The facts in Stenberg

were hotly contested, and simply asserting that the other side should have prevailed

accomplishes nothing. Rather, to succeed, the government must demonstrate that

relevant evidentiary circumstances (such as the presence of a newfound medical

consensus or medical studies) have in fact changed over time.

If one thing is clear from the record in this case, it is that no consensus exists

in the medical community. The record is rife with disagreement on this point, just as

Appellate Case: 04-3379 Page: 18 Date Filed: 07/08/2005 Entry ID: 1925457
5

The government argues the district court erred for various reasons in

discounting the testimony of experts. We need not address this issue because giving

full value to the government’s witnesses would in no way alter our conclusion that

no consensus has been reached by the medical community. 

6

The variations in long-term health effects noted in the study were not

statistically significant and we therefore will not address them. See Br. of Appellant

at 43 (study cannot support “meaningful conclusions” about long-term complication

rates due to small sample size).

-19-

in Stenberg. In fact, one of the government’s witnesses himself testified that no

consensus exists in the medical community and further stated that there exists a “body

of medical opinion,” including the “position[s] taken by [the] American College of

Obstetrics and Gynecologists” (ACOG) and “a responsible group of physicians,”

indicating that the procedures are indeed sometimes medically necessary. Carhart,

331 F. Supp. 2d at 1012. The lack of consensus also extends to medical

organizations. The American Medical Association believes the banned procedures

to be medically unnecessary while ACOG believes these procedures can be the most

appropriate in certain situations. Id. at 843, 997. The Supreme Court relied on the

ACOG view in particular in Stenberg. 530 U.S. at 935-36. Moreover, the

congressional findings quote “a prominent medical association’s” conclusion that

“there is no consensus among obstetricians about its use.” Partial Birth Abortion Ban

Act of 2003 § 2(14)(C), 117 Stat. at 1204 (internal quotations omitted). In short, no

medical consensus has developed to support a different outcome.5

 See, e.g., Carhart,

331 F. Supp. 2d at 1009 (concluding Congress’s determination that a consensus

against the banned procedures existed is unreasonable and not supported by

substantial evidence); Nat’l Abortion Fed’n, 330 F. Supp. 2d at 488-89 (same);

Planned Parenthood Fed’n of Am., 320 F. Supp. 2d at 1025 (same).

While the existence of disagreement among medical experts has not changed,

there has been one new study on the safety of the banned procedures. A recent study

by Dr. Stephen Chasen addressed the comparative health effects of the D&X and

D&E procedures.6

 Stephen T. Chasen et al., Dilation and evacuation at $ 20 weeks:

Appellate Case: 04-3379 Page: 19 Date Filed: 07/08/2005 Entry ID: 1925457
-20-

Comparison of operative techniques, 190 Am. J. of Obstetrics and Gynecology 1180

(2004). The study found no significant difference in blood loss, procedure time, or

short-term complication rates between the procedures. The government argues that

these conclusions reinforce Congress’s finding that the banned procedures are not

safer than other methods (while also conceding that the conclusions militate against

Congress’s finding that the banned procedures have “serious” health risks). In

drawing its conclusions, however, the government ignores the study’s methodology.

The choice of procedure in each case was not random, but was rather “based on

cervical dilation and fetal position.” Id. at 1181. Thus, the only real conclusion that

can be drawn from this new study is that D&X is not inherently more dangerous than

D&E in situations where the medical professional believes D&X to be the most

appropriate procedure. No general conclusion regarding the medical necessity of the

banned procedures in any given situation can be drawn from the study, which neither

conclusively supports the position that the banned procedures are sometimes

medically necessary, nor does it conclusively support the position that they are never

medically necessary. The Chasen study therefore detracts in no way from the

Supreme Court’s prior conclusion, as there are still no medical studies addressing the

medical necessity of the banned procedures. 

We need not belabor the point. The record in this case and the record in

Stenberg are similar in all significant respects. See Nat’l Abortion Fed’n, 330 F.

Supp. 2d at 492 (explaining that the government’s arguments “all fail to meaningfully

distinguish the evidentiary circumstances present here from those that Stenberg held

required a health exception to a ban on partial-birth abortion”). There remains no

consensus in the medical community as to the safety and medical necessity of the

banned procedures. There is a dearth of studies on the medical necessity of the

banned procedures. In the absence of new evidence which would serve to distinguish

this record from the record reviewed by the Supreme Court in Stenberg, we are bound

by the Supreme Court’s conclusion that “substantial medical authority” supports the

medical necessity of a health exception. “As a court of law, [our responsibility] is

Appellate Case: 04-3379 Page: 20 Date Filed: 07/08/2005 Entry ID: 1925457
-21-

neither to devise ways in which to circumvent the opinion of the Supreme Court nor

to indulge delay in the full implementation of the Court’s opinions. Rather, our

responsibility is to faithfully follow its opinions, because that court is, by

constitutional design, vested with the ultimate authority to interpret the Constitution.”

Richmond Med. Ctr. for Women v. Gilmore, 219 F.3d 376, 378 (4th Cir. 2000)

(Luttig, J., concurring). Because the Act does not contain a health exception

exception, it is unconstitutional. We therefore do not reach the district court’s

conclusion of the Act imposing an undue burden on a woman’s right to have an

abortion.

V

For the reasons stated above, the judgment of the district court is affirmed. 

______________________________

Appellate Case: 04-3379 Page: 21 Date Filed: 07/08/2005 Entry ID: 1925457