Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_15-cv-01022/USCOURTS-azd-2_15-cv-01022-0/pdf.json

Nature of Suit Code: 950
Nature of Suit: Constitutionality of State Statutes
Cause of Action: 28:2201 Injunction

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IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA

 

 At issue are Motions to Dismiss filed by Defendants Mark Brnovich, Cara Christ, 

M.D., Patricia E. McSorley, Richard T. Perry, James Gillard, Jodi A. Bain, Marc D. 

Berg, Donna Brister, R. Screven Farmer, Gary R. Figge, Robert E. Fromm, Paul S. 

Gerding, Lois Krahn, Edward G. Paul, and Wanda J. Salter. (Docs. 40, 41, 44, 46.) 

Plaintiffs Planned Parenthood Arizona, Inc., Desert Star Family Planning, LLC, Eric 

Reuss, Paul A. Isaacson, and DeShawn Taylor, have also filed a Motion for Leave to 

Amend the Complaint (Doc. 81), which Defendants oppose. The motions are fully 

briefed, and will be addressed jointly as follows. 

I. Background 

 A. Arizona Informed Consent Law

 Arizona law requires that an abortion shall not be performed or induced without 

the voluntary and informed consent of the woman seeking the procedure, certified in 

writing. Ariz. Rev. Stat. § 36-2153(A)(4). With exception to instances involving a 

medical emergency, consent is voluntary and informed only if, at least twenty-four hours 

Planned Parenthood Arizona, Inc., et al., 

 

Plaintiffs, 

vs. 

Mark Brnovich, et al., 

Defendants. 

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No. CV-15-01022-PHX-SPL

ORDER 

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before an abortion, the woman has been informed orally and in person, individually and 

in private, of two categories of information. Ariz. Rev. Stat. § 36-2153(A)(1)-(3).1 

 First, the woman must be informed by the physician who is to perform the 

abortion, or the referring physician, of: 

(a) The name of the physician who will perform the abortion. 

(b) The nature of the proposed procedure or treatment. 

(c) The immediate and long-term medical risks associated with the 

procedure that a reasonable patient would consider material to the 

decision of whether or not to undergo the abortion. 

(d) Alternatives to the procedure or treatment that a reasonable 

patient would consider material to the decision of whether or not to 

undergo the abortion. 

(e) The probable gestational age of the unborn child at the time the 

abortion is to be performed. 

(f) The probable anatomical and physiological characteristics of the unborn child at the time the abortion is to be performed. 

(g) The medical risks associated with carrying the child to term. 

Ariz. Rev. Stat. § 36-2153(A)(1). 

 Second, the woman must be informed by the physician who is to perform the 

abortion, a qualified physician, physician assistant, nurse, psychologist, or licensed 

behavioral health professional delegated with authority by the physician, that: 

(a) Medical assistance benefits may be available for prenatal care, 

childbirth and neonatal care. 

(b) The father of the unborn child is liable to assist in the support of the child, even if he has offered to pay for the abortion. In the case of rape or incest, this information may be omitted. 

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 Voluntary and informed consent requires satisfaction of these two requirements, contained at Ariz. Rev. Stat. § 36-2153(A)(1) and (2), and satisfaction of the additional 

requirements contained in Title 36, Chapter 20, Article 1 of the Arizona Revised Statutes. 

See Ariz. Rev. Stat. § 36-2156 (consent to an abortion is informed if, within 24-hours 

before the abortion is to be performed or induced, the woman is given an opportunity to view the active ultrasound image and hear the fetal heartbeat); § 36-2158 (consent to an 

abortion is informed if the woman has certain received information where a lethal and 

non-lethal fetal condition has been diagnosed). 

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(c) Public and private agencies and services are available to assist 

the woman during her pregnancy and after the birth of her child if 

she chooses not to have an abortion, whether she chooses to keep the child or place the child for adoption. 

(d) It is unlawful for any person to coerce a woman to undergo an abortion. 

(e) The woman is free to withhold or withdraw her consent to the 

abortion at any time without affecting her right to future care or treatment and without the loss of any state or federally funded 

benefits to which she might otherwise be entitled. 

(f) The department of health services maintains a website that 

describes the unborn child and lists the agencies that offer alternatives to abortion. 

(g) The woman has a right to review the website and that a printed 

copy of the materials on the website will be provided to her free of 

charge if she chooses to review these materials. 

Ariz. Rev. Stat. § 36-2153(A)(2).2

 The Arizona Department of Health Services 

(“ADHS”) must establish and “annually update a website that includes a link to a 

printable version of all materials listed [in the informed consent statute] on the website.” 

Ariz. Rev. Stat. § 36-2153(C). 

 In 2015, the Arizona legislature passed Senate Bill 1318, a set of statutory 

amendments regulating abortion that was signed in to law by the Governor on March 30, 

2015. Ariz. Legis. Serv. Ch. 87 (S.B. 1318) (2015). The requirements for obtaining a 

patient’s informed consent was amended to include that a woman must also be informed 

that: 

(h) It may be possible to reverse the effects of a medication abortion 

if the woman changes her mind but that time is of the essence. 

(i) Information on and assistance with reversing the effects of a medication abortion is available on the department of health services’ website. 

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 Ariz. Rev. Stat. § 36-2153(A) first went into effect in 2009. Ariz. Legis. Serv. Ch. 172 (H.B. 2564 § 4) (2009). Prior challenges to the constitutionality of this statute have been brought, but are not relevant to the issues before the Court. See Tucson Women’s 

Center v. Arizona Medical Board, No. CV-09-01909-PHX-DGC (D. Ariz. Mar. 8, 2010) 

(dismissed in its entirely without prejudice); Planned Parenthood Arizona, Inc. v. 

American Ass’n of Pro-Life Obstetricians & Gynecologists, 257 P.3d 181, 195 (Ariz Ct. 

App. 2011) (finding the requirement that certain information “be provided in person and by a physician” was constitutional). 

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S.B. 1318 § 4 (codified at Ariz. Rev. Stat. § 36-2153(A)(2)(h) and (i)). Further, ADHS 

must include on their website:

Information on the potential ability of qualified medical professionals to reverse a medication abortion, including information directing women where to obtain further information and assistance in locating a medical professional who can aid in the reversal of a medication abortion. 

S.B. 1318 § 4 (codified at Ariz. Rev. Stat. § 36-2153(C)(8)).

B. Plaintiffs’ Challenge to the Act 

 Plaintiffs commenced the instant action challenging the amended provisions 

codified at Ariz. Rev. Stat. § 36-2153(A)(2)(h) and (i), otherwise referred to by the 

parties and this Court as “the Act.”3

 (Doc. 1.) Plaintiffs claim that the Act violates 

physicians’ rights under the First Amendment, and the rights of patients seeking 

abortions under the Fourteenth Amendment. (Docs. 1 ¶ 57, 59; 81-1 ¶ 61, 63.) 4 Plaintiffs 

seek injunctive and declaratory relief, asking that enforcement of the Act be permanently 

enjoined, and the Act be declared unconstitutional. 

 Plaintiffs include two health care facilities and three physicians. Planned 

Parenthood Arizona, Inc. is a nonprofit corporation that provides reproductive, sexual 

health, and abortion services. It provides both surgical and medication abortions at four 

of its health centers, which are licensed by ADHS. It employs obstetricians and 

gynecologists licensed to practice medicine by the Arizona Medical Board. Planned 

Parenthood sues on behalf of itself, its patients, and its physicians. (Docs. 1 ¶ 7; 81-1 ¶ 

7.) Desert Star Family Planning, LLC, is a private physician practice that provides 

comprehensive family planning and health services, including abortion services, and is 

licensed by ADHS. It employs board-certified obstetricians and gynecologists. Desert 

Star sues on behalf of itself, its physicians, and its patients. (Docs. 1 ¶ 10; 81-1 ¶ 10.) 

Plaintiffs Eric Reuss, M.D., M.P.H., Paul A. Isaacson, M.D., and DeShawn Taylor, M.D. 

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 Plaintiffs did not challenge Ariz. Rev Stat. § 36-2153(C)(8). 

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 Because the Court addresses Plaintiffs’ request for leave to amend simultaneously with Defendants’ challenges, it cites to both the original complaint (Doc. 1) and the 

proposed amended complaint (Doc. 81-1). 

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(“Physician-Plaintiffs”), are board-certified obstetricians and gynecologists that perform 

abortions and are licensed to practice medicine in Arizona. They sue on their own behalf 

and on behalf of patients. (Docs. 1 ¶¶ 8, 9, 10; 81-1 ¶¶ 8, 9, 10.) 

 On the basis of their alleged statutory authority to enforce the Act, Plaintiffs sue 

the members of the Arizona Medical Board, the Executive Director of the Arizona 

Medical Board, the Arizona Attorney General, and the Director of ADHS.5

 (Doc. 1 ¶¶ 11-

14; 81-1 ¶¶ 11-14.) 

 Before the Act was to take effect on July 3, 2015, pursuant to the stipulation of the 

parties, the Court entered a temporary restraining order enjoining enforcement of the Act 

(Doc. 32). Also on request of the parties, the temporary restraining order was lifted and 

the Court entered an order of preliminary injunction (Doc. 107) enjoining enforcement of 

the Act pending final judgment on the merits. 

II. Present Issues in Dispute

 Defendants have each individually moved to dismiss some or all of the claims 

brought against them on the basis that they are improper parties to this action. (Docs. 40, 

41, 44, 46.) Defendants also challenge Plaintiffs’ standing. (See Docs. 87 at 5 n.2; 60 at 

31-33; 73.)6

 

 First, Defendants move to dismiss on the basis that Plaintiffs “have failed to 

properly assert any claims under 42 U.S.C. § 1983.” (Docs. 41 at 3; 44 at 3; 46 at 3.) A 

plaintiff may bring a cause of action under 42 U.S.C. § 1983 to seek redress for the 

deprivation of a right protected by the Constitution or laws of the United States caused by 

a person acting under color of state law. Crumpton v. Gates, 947 F.2d 1418, 1420 (9th 

Cir. 1991). “Section 1983 ‘is not itself a source of substantive rights,’ but merely 

provides ‘a method for vindicating federal rights elsewhere conferred.’” Albright v. 

 5

 Plaintiffs further sued the members of the Arizona Board of Osteopathic Examiners in Medicine and Surgery and the Executive Director of the Osteopathic Board, Jenna Jones. Those parties have been dismissed by stipulation. (Doc. 111.) 

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 Finding the challenges to standing are either duplicative or overlapping with issues presented in the pending motions, as a matter of judicial efficiency and uniformity, the Court resolves them here. 

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Oliver, 510 U.S. 266, 271 (1994) (quoting Baker v. McCollan, 443 U.S. 137, 144, n.3 

(1979)). Defendants argue that Plaintiffs fail to sufficiently state a § 1983 claim because 

they do not set forth the statutory elements and “make reference to 42 U.S.C. § 1983 only 

once.” (Docs. 41 at 7; 44 at 8; 46 at 8.) This argument is flatly rejected. Plaintiffs allege 

that they bring a cause of action under 42 U.S.C. § 1983 for declaratory relief declaring 

the Act unconstitutional, and for prospective injunctive relief restraining Defendants, and 

their employees, agents, and successors in office from enforcing the Act, which, unless 

enjoined, will violate their First and Fourteenth Amendment rights. (Docs. 1 ¶¶ 1-4 and § 

VI; 81-1 ¶¶ 1-4 and § VI.) Nothing more is required. See Johnson v. City of Shelby, Miss., 

574 U.S. ___, 135 S. Ct. 346, 347 (2014).7

 Second, Defendants argue that Plaintiffs fail to state a claim under § 1983 because 

they do not sufficiently allege facts showing Defendants’ personal participation. This 

argument, while having some surface appeal, misses the mark. True, a state official sued 

in his or her official capacity for injunctive relief is “a person under § 1983 because 

‘official-capacity actions for prospective relief are not treated as actions against the 

State.’” Will v. Michigan Dept. of State Police, 491 U.S. 58, 71 n.10 (1989) (citing 

Kentucky v. Graham, 473 U.S. 159, 165-166 (1985)). However, a plaintiff seeking 

prospective injunctive relief against a state official “is not required to allege a named 

official’s personal involvement in the acts or omissions constituting the alleged 

constitutional violation.” Hartmann v. Cal. Dep’t of Corr. & Rehab., 707 F.3d 1114, 

1127 (9th Cir. 2013). “Rather, a plaintiff need only identify the law [] challenged as a 

constitutional violation and name the official within the entity who can appropriately 

respond to injunctive relief.” Id. Plaintiffs have done just that. (See Docs. 1 ¶¶ 1, 11-14; 

81-1 ¶¶ 1, 11-14.) 

 Defendants nonetheless press that, as a matter of law, they do not have authority to 

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 See also Verizon Md., Inc. v. Pub. Serv. Comm’n of Md., 535 U.S. 635, 645 (2002) 

(in determining whether the Eleventh Amendment bars a suit from the onset, “a court 

need only conduct a ‘straightforward inquiry into whether [the] complaint alleges an ongoing violation of federal law and seeks relief properly characterized as prospective.’” (citation omitted)). 

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enforce the Act and therefore are improperly named parties that should be dismissed. 

Whether Defendants, acting in their official capacities as state officials, are “proper 

defendants,” is “really the common denominator of two separate inquiries: first, there is 

the requisite causal connection between their responsibilities and any injury that the 

plaintiffs might suffer, such that relief against the defendants would provide redress [i.e., 

Article III standing], and second, whether [] jurisdiction over the defendants is proper 

under the doctrine of Ex parte Young, 209 U.S. 123 (1908), which requires ‘some 

connection’ between a named state officer and enforcement of a challenged state law.” 

Planned Parenthood of Idaho, Inc. v. Wasden, 376 F.3d 908, 919 (9th Cir. 2004) 

(citations omitted). See also Culinary Workers Union, Local 226 v. Del Papa, 200 F.3d 

614 (9th Cir. 1999) (discussing that attorney general’s authority to enforce the challenged 

state statute was a question of traceability); National Audubon Society, Inc. v. Davis, 307 

F.3d 835, 846 (9th Cir. 2002) (“whether a named state official has direct authority and 

practical ability to enforce the challenged statute” is a question of whether a plaintiff is 

“circumventing the Eleventh Amendment under Ex parte Young simply by suing any

state executive official”). These questions, along with Defendants’ remaining challenges 

to Plaintiffs’ standing, will therefore be addressed in turn below. 

III. Legal Standards 

 A. Article III Standing 

 Article III federal courts are limited to deciding “cases” and “controversies.” U.S. 

Const. art. III, § 2; Valley Forge Christian Coll. v. Ams. United for Separation of Church 

& State, Inc., 454 U.S. 464, 471 (1982). “Article III standing” is among one of the 

components that enforces the “case-or-controversy requirement.” Hein v. Freedom from 

Religion Found., Inc., 551 U.S. 587, 597-98 (2007). The doctrine of standing 

encompasses both constitutional requirements and prudential considerations. See Valley 

Forge Christian Coll., 454 U.S. at 471; Sahni v. American Diversified Partners, 83 F.3d 

1054, 1057 (9th Cir. 1996). The plaintiff bears the burden of establishing the existence of 

a justiciable case or controversy, and “‘must demonstrate standing for each claim he 

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seeks to press’ and ‘for each form of relief’ that is sought.” Davis v. Federal Election 

Comm’n, 554 U.S. 724, 734 (2008) (quoting DaimlerChrysler Corp. v. Cuno, 547 U.S. 

332, 352 (2006)). 

 The “irreducible constitutional minimum of standing” is comprised of three 

elements. Lujan v. Defenders of Wildlife, 504 U.S. 555, 560 (1992). First, “the plaintiff 

must have suffered an injury in fact - an invasion of a legally protected interest.” Id. “An 

injury sufficient to satisfy Article III must be ‘concrete and particularized’ and ‘actual or 

imminent,’ not ‘conjectural’ or ‘hypothetical.’” Susan B. Anthony List v. Driehaus, 573 

U.S. __, 134 S. Ct. 2334, 2341 (2014) (quoting Lujan, 504 U.S. at 560). “An allegation of 

future injury may suffice if the threatened injury is ‘certainly impending,’ or there is a 

‘substantial risk’ that the harm will occur.” Id. (quoting Clapper v. Amnesty Int’l USA, 

568 U.S. ___, 133 S. Ct. 1138, 1150 n.5 (2013)). Where a plaintiff will sustain “a direct 

injury as a result of the statute’s operation,” Babbitt v. United Farm Workers Nat’l 

Union, 442 U.S. 289, 298 (1979), and there is a responsive threat of state action, “an 

actual arrest, prosecution, or other enforcement action is not a prerequisite to challenging 

the law,” Driehaus, 134 S. Ct. at 2342. Under these circumstances, where a plaintiff 

brings a pre-enforcement challenge, he “satisfies the injury-in-fact requirement where he 

alleges ‘an intention to engage in a course of conduct arguably affected with a 

constitutional interest, but proscribed by a statute, and there exists a credible threat of 

prosecution thereunder.’” Driehaus, 134 S. Ct. at 2342 (quoting Babbitt, 442 U.S. at 

298). See also Libertarian Party of Los Angeles County v. Bowen, 709 F.3d 867, 870 (9th 

Cir. 2013); Lopez v. Candaele, 630 F.3d 775, 785 (9th Cir. 2010).8

 

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 “The constitutional component of ripeness overlaps with the ‘injury in fact’ analysis for Article III standing. Whether framed as an issue of standing or ripeness, the inquiry is largely the same: whether the issues presented are ‘definite and concrete, not hypothetical or abstract.’” Wolfson v. Brammer, 616 F.3d 1045, 1058 (9th Cir. 2010) 

(citations omitted). See also LSO, Ltd. v. Stroh, 205 F.3d 1146, 1154 (9th Cir. 2000) 

(“‘the maturity of such disputes for resolution before a prosecution begins is decided on a case-by-case basis, by considering the likelihood that the complainant will disobey the law, the certainty that such disobedience will take a particular form, any present injury occasioned by the threat of prosecution, and the likelihood that a prosecution will actually ensue.’” (quoting Blanchette v. Conn. Gen. Ins. Corp., 419 U.S. 102, 143 n.29 (1974))). 

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 Second, for Article III standing, “there must be a causal connection between the 

injury and the conduct complained of - the injury has to be fairly... traceable to the 

challenged action of the defendant, and not... the result of the independent action of some 

third party not before the court.” Lujan, 504 U.S. at 560. See also Salmon Spawning & 

Recovery Alliance v. Gutierrez, 545 F.3d 1220, 1227 (9th Cir. 2008). The “line of 

causation” between a defendant’s actions and a plaintiff’s alleged harm must be more 

than “attenuated.” Allen v. Wright, 468 U.S. 737, 757 (1984). “A causal chain does not 

fail simply because it has several ‘links,’ provided those links are ‘not hypothetical or 

tenuous’ and remain ‘plausib[le].’” Maya v. Centex Corp., 658 F.3d 1060, 1070 (9th Cir. 

2011) (quoting Nat’l Audubon Soc., 307 F.3d at 849). Third, “it must be likely, as 

opposed to merely speculative, that the injury will be redressed by a favorable decision.” 

Lujan, 504 U.S. at 561. See also Cantrell v. City of Long Beach, 241 F.3d 674, 679 (9th 

Cir. 2001); United States v. City of Arcata, 629 F.3d 986, 989 (9th Cir. 2010). 

 The prudential limitations on federal court jurisdiction dictate that: (1) a party 

must ordinarily assert its own legal rights and interests, and not those of others; (2) the 

harm asserted must not be a mere “generalized grievance” (i.e. “abstract questions of 

wide public significance”); and (3) the interest claimed must fall within “the zone of 

interests to be protected or regulated by the statute or constitutional guarantee in 

question.” Valley Forge Christian Coll., 454 U.S. at 474-75; see also Stormans, Inc. v. 

Selecky, 586 F.3d 1109, 1122 (9th Cir. 2009). 

B. Ex parte Young and Eleventh Amendment Immunity

 Under the Eleventh Amendment to the Constitution of the United States, a State 

may not be sued in federal court without its consent. Pennhurst State Sch. and Hosp. v. 

Halderman, 465 U.S. 89, 100 (1984). Eleventh Amendment immunity extends to state 

departments, agencies, boards, and commissions, and to state employees acting in their 

official capacity because a suit against them is regarded as a suit against the State itself. 

Will, 491 U.S. at 71. An exception to this rule exists under Ex parte Young, supra, which 

permits a state official to be sued under § 1983 in his or her official capacity for 

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prospective declaratory or injunctive relief for an alleged violation of federal law. 

Association des Eleveurs de Canards et d’Oies du Quebec v. Harris, 729 F.3d 937, 943 

(9th Cir. 2013); Jackson v. Hayakawa, 682 F.2d 1344, 1351 (9th Cir. 1982). “[I]n a suit 

to enjoin the enforcement of an act alleged to be unconstitutional,” the state officer “must 

have some connection with the enforcement of the act, or else it is merely making him a 

party as a representative of the state, and thereby attempting to make the state a party.” 

Ex Parte Young, 209 U.S. at 157. “[T]hat connection ‘must be fairly direct; a generalized 

duty to enforce state law or general supervisory power over the persons responsible for 

enforcing the challenged provision will not subject an official to suit.’” Coalition to 

Defend Affirmative Action v. Brown, 674 F.3d 1128, 1134 (9th Cir. 2012) (quoting L.A. 

Cnty. Bar Ass’n v. Eu, 979 F.2d 697, 704 (9th Cir. 1992)). 

 C. Rule 12(b)(1)

 Under Rule 12(b)(1) of the Federal Rules of Civil Procedure, an action may be 

dismissed for lack of jurisdiction.9

 A Rule 12(b)(1) motion can either be “facial,” 

attacking a pleading on its face and accepting all allegations as true, or “factual,” 

contesting the truth of some or all of the pleading’s allegations as they relate to 

jurisdiction. Wolfe v. Strankman, 392 F.3d 358, 362 (9th Cir. 2004). In considering a 

facial challenge to jurisdiction, as here, the Court determines whether the allegations in 

the complaint are insufficient on their face to demonstrate the existence of jurisdiction, 

and dismissal is appropriate only where the plaintiff fails to allege an element necessary 

for subject matter jurisdiction. Safe Air for Everyone v. Meyer, 373 F.3d 1035, 1039 (9th 

Cir. 2004). The material factual allegations of the complaint are presumed to be true and 

construed in favor of the complaining party. Maya, 658 F.3d at 1068. 

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 Because “Article III standing is a species of subject matter jurisdiction[,]” Carijano v. Occidental Petroleum Corp., 643 F.3d 1216, 1227 (9th Cir. 2011), it is 

properly raised in a Rule 12(b)(1) motion to dismiss[,]” Chandler v. State Farm Mut. 

Auto. Ins. Co., 598 F.3d 1115, 1122 (9th Cir. 2010), not in a Rule 12(b)(6) motion for 

failure to state a claim upon which relief can be granted, White v. Lee, 227 F.3d 1214, 

1242 (9th Cir. 2000). Likewise, “[a]lthough sovereign immunity is only quasi- jurisdictional in nature, Rule 12(b)(1) is still a proper vehicle for invoking sovereign immunity from suit.” Pistor v. Garcia, 791 F.3d 1104, 1111 (9th Cir. 2015). See also

Maya, 658 F.3d at 1068. 

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IV. Discussion 

 A. Foreground10 

 In Planned Parenthood of Southeastern Pennsylvania v. Casey, the Supreme Court 

held that a woman has a fundamental liberty interest, protected by the due process clause 

of the Fourteenth Amendment, “to choose to have an abortion before viability and to 

obtain it without undue interference from the State.” 505 U.S. 833, 846 (1992) (plurality 

opinion of Justices O’Connor, Kennedy, and Souter),11 reaffirming in part Roe v. Wade, 

410 U.S. 113 (1973). Casey observed that states also have two legitimate interests that 

may justify regulation of abortion: an interest in promoting potential life and an interest 

in protecting the health of the woman. 505 U.S. at 878. Casey then “struck a balance,” 

Gonzales v. Carhart, 550 U.S. 124, 146 (2007), creating an “undue burden” framework 

to reconcile “the State’s interest with the woman’s constitutionally protected liberty,” 

Casey, 505 U.S. at 876. 

 Under this approach, Casey held that the State may promote its interest in 

respecting potential life through measures designed to inform a woman’s decision and to 

persuade her to choose childbirth over abortion. 505 U.S. at 878. By example, the 

Supreme Court held that a State may enact legislation which requires that a woman be 

provided with “information about the nature of the procedure, the attendant health risks 

and those of childbirth, and the probable gestational age of the fetus,” id. at 881, and “be 

informed of the availability of information relating to fetal development and the 

assistance available should she decide to carry the pregnancy to full term,” id. at 883. 

However, the State regulation may not impose an unconstitutional “undue burden” on a 

woman’s liberty interests, by having “the purpose or effect of placing a substantial 

 10 As the Court does not reach the merits, it presents the following for context. See 

Catholic League for Religious and Civil Rights v. City and County of San Francisco, 624 

F.3d 1043, 1049 (9th Cir. 2010) (the “standing analysis, which prevents a claim from 

being adjudicated for lack of jurisdiction,” is not to be confused with or disguised as the “merits analysis, which determines whether a claim is one for which relief can be granted if factually true”); Warth v. Seldin, 422 U.S. 490, 500 (1975) (“standing in no way depends on the merits of the plaintiff’s contention that particular conduct is illegal”). 11 This summary refers only to the opinion enunciated by the plurality in Casey. 

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obstacle” in a woman’s path in deciding whether to terminate her pregnancy prior to fetal 

viability. Casey, 505 U.S. at 877. The information conveyed or made available to a 

woman must be “truthful and not misleading.” Casey, 505 U.S. at 881. “[T]he means 

chosen by the State to further the interest in potential life must be calculated to inform the 

woman’s free choice, not hinder it,” id. at 877, and “a state measure designed to persuade 

her to choose childbirth over abortion” must be “reasonably related to that goal,” id. at 

878. See also Gonzales, 550 U.S. at 158 (“Where it has a rational basis to act... the State 

may use its regulatory power to... promote respect for life, including life of the unborn”). 

A State may also permissibly enact legislation requiring a physician to convey to a 

woman, and provide her with material containing information mandated by the State “as 

part of obtaining her consent to an abortion.” Casey, 505 U.S. at 884.12 However, that 

requirement must not interfere with the private doctor-patient relationship such that it 

imposes a substantial obstacle on a woman seeking an abortion. Id. 

 In Wooley v. Maynard, the Supreme Court held that the First Amendment protects 

“the right of freedom of thought,” which “includes both the right to speak freely and the 

right to refrain from speaking at all.” 430 U.S. 705, 714 (1977). Citing to Wooley, Casey

observed a physician’s First Amendment “right[] not to speak... as part of the practice of 

medicine.” 505 U.S. at 884. The Supreme Court noted that the right is “subject to 

reasonable licensing and regulation by the State.”13 Casey, 505 U.S. at 884 

(comparatively citing Whalen v. Roe, 429 U.S. 589, 603 (1977) (holding State legislation 

was a reasonable exercise of its broad police powers in regulating the administration of 

drugs by health professionals where “the decision to prescribe, or to use, is left entirely to 

the physician and the patient.”)). 

 12 Casey noted as a preliminary matter, that the Pennsylvania “statute [did] not 

prevent the physician from exercising his or her medical judgment.” Casey, 505 U.S. at 

884. 

13 The parties dispute whether the undue standard espoused by Casey applies to Plaintiffs’ First Amendment claim. The Court in no manner decides that question or alludes to its answer here. 

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 B. Article III Injury-In-Fact 

 The Act requires that prior to performing or inducing an abortion, physicians must 

inform every patient that “i[t] may be possible to reverse the effects of a medication 

abortion,” and of the availability of “[i]nformation on and assistance with reversing the 

effects of a medication abortion.” Ariz. Rev. Stat. § 36-2153(A)(2)(h) and (i). The Act 

requires physicians to convey, and every patient seeking an abortion to receive from the 

physician as a part of the informed consent process, the state-mandated message orally 

and in person, in a private medical setting. § 36-2153(A)(3). 

 Plaintiffs have alleged a sufficiently concrete and imminent injury to physicians 

and patients arising from the operation of the Act, and that Plaintiffs are the appropriate 

parties to challenge it based on an assertion of physicians’ and patients’ constitutional 

rights.

 (1) Physicians 

 Physician-Plaintiffs “have alleged ‘an intention to engage in a course of conduct 

arguably affected with a constitutional interest’” under the First Amendment that is 

“‘proscribed by [the] statute’ they wish to challenge.” Driehaus, 134 S. Ct. at 2344 

(quoting Babbitt, 442 U.S. at 298). See Wooley, supra; Casey, supra. Plaintiffs allege 

that the Act compels physicians to deliver a state-mandated message which is against 

their best medical judgment, contrary to the accepted standard of care, and is one “that 

they would not otherwise tell their patients.” (Docs. 1 ¶¶ 46-57; 81-1 ¶¶ 49-61.) 

 Physician-Plaintiffs have alleged a credible threat of enforcement of the Act. The 

informed consent statute provides that a physician who knowingly fails to comply with 

its provisions, which includes the Act, is guilty of unprofessional conduct and is subject 

to license suspension or revocation. Ariz. Rev. Stat. § 36-2153(I).14 See Driehaus, 134 S. 

Ct. at 2345 (“administrative action, like arrest or prosecution, may give rise to harm 

 14 A physician is also subject to a private cause of action brought in state superior court by a “woman on whom an abortion has been performed without her informed 

consent as required by” the Act, by the woman’s spouse, or the parents of a woman under the age of 18. § 36-2153(J) and (K). 

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sufficient to justify pre-enforcement review”); Doe v. Bolton, 410 U.S. 179, 188 (1973) 

(finding standing where physicians asserted “a sufficiently direct threat of personal 

detriment” for performing an abortion that did not meet statutory conditions); Isaacson v. 

Horne, 716 F.3d 1213, 1221 (9th Cir. 2013) (physician had standing to challenge an 

abortion law that posed a direct threat of prosecution); Los Angeles Haven Hospice, Inc. 

v. Sebelius, 638 F.3d 644, 655 (9th Cir. 2011) (finding standing where plaintiff “is the 

direct object of regulatory action”). As here, “[a] plaintiff who mounts a pre-enforcement 

challenge to a statute that he claims violates his freedom of speech need not show that the 

authorities have threatened to prosecute him; the threat is latent in the existence of the 

statute.” California Pro-Life Council, Inc. v. Getman, 328 F.3d 1088, 1095 (9th Cir. 

2003). “The State has not suggested that the newly enacted law will not be enforced, and 

[the Court] see[s] no reason to assume otherwise.” Virginia v. Am. Booksellers Ass’n, 

Inc., 484 U.S. 383, 393 (1988).15 Cf. Thomas v. Anchorage Equal Rights Comm’n, 220 

F.3d 1134, 1140 (9th Cir. 2000) (“When plaintiffs do not claim that they have ever been 

threatened with prosecution, that a prosecution is likely, or even that a prosecution is 

remotely possible, they do not allege a dispute susceptible to resolution by a federal 

court.”) (citation and quotation marks omitted). 

 Whether physicians perform abortions without advising their patients regarding 

the Act’s medication abortion reversal provisions and face punishment, or unwillingly 

convey the state-mandated message under threat of prosecution, as alleged, their First 

Amendment rights are concretely and imminently affected. See Wasden, 376 F.3d at 916-

17; Human Life of Wash. Inc. v. Brumsickle, 624 F.3d 990, 1000 (9th Cir. 2010) 

(“[W]hen a challenged statute risks chilling the exercise of First Amendment rights, the 

Supreme Court has dispensed with rigid standing requirements and recognized ‘self-

 15 Defendants’ uncertainty as to whether a physician’s failure to comply with the Act would qualify as a basis to seek an emergency injunction does not make the prospect of enforcement under Ariz. Rev. Stat. § 36-2153(I) any less credible or more speculative. (Doc. 46 at 7 n.3.) See § 32-1454(A)(2) (“An injunction shall issue forthwith to enjoin the practice of medicine by... [a] doctor of medicine whose continued practice will or well might cause irreparable damage to the public health and safety...”) 

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censorship’ as a harm that can be realized even without an actual prosecution.” (citations 

and quotation marks omitted)); Getman, 328 F.3d at 1094 (“In an effort to avoid the 

chilling effect of sweeping restrictions, the Supreme Court has endorsed what might be 

called a ‘hold your tongue and challenge now’ approach rather than requiring litigants to 

speak first and take their chances with the consequences.”); McCormack v. Herzog, 788 

F.3d 1017, 1027 (9th Cir. 2015) (parties “need not even claim a ‘specific intent to violate

the statute,’” they need only possess “reasonable fear a statute would be enforced against 

it if it engaged in certain conduct”) (citations omitted); Arizona Right to Life Political 

Action Committee v. Bayless, 320 F.3d 1002, 1006 (9th Cir. 2003); Bland v. Fessler, 88 

F.3d 729, 737 (9th Cir. 1996). 

 Further, contrary to Defendants’ contention, Planned Parenthood and Desert Star 

are appropriate representatives to litigate and assert the First Amendment rights of the 

third-party physicians that they employ. (Doc. 87 at 5 n.2; Doc. 73.) See Int’l Union, 

United Auto., Aerospace and Agr. Implement Workers of Am. v. Brock, 477 U.S. 274, 281 

(1986) (“injury to an organization’s members will satisfy Article III and allow that 

organization to litigate in federal court on their behalf”); Hunt v. Washington State Apple 

Adver. Comm’n, 432 U.S. 333, 342 (1977) (“an association may have standing solely as 

the representative of its members”); Colwell v. Dept. of Health and Human Servs., 558 

F.3d 1112, 1121 (9th Cir. 2009); cf. Smith v. Pac. Props. & Dev. Corp., 358 F.3d 1097, 

1101 (9th Cir. 2004) (organizational standing, in comparison to representational standing 

by an organization, turns on “whether the organization itself has suffered an injury in 

fact”) (emphasis added). Planned Parenthood and Desert Star are “in every practical 

sense identical” to the physicians it employs. Nat’l Ass’n for Advancement of Colored 

People (NAACP) v. State of Ala. ex rel. Patterson, 357 U.S. 449, 459 (1958). As 

previously addressed, physicians would otherwise have standing to sue in their own right. 

The interests they seek to protect are germane to their purpose of providing reproductive 

health care services. Because the parties are seeking injunctive and declaratory relief, 

individual participation of the physicians employed by Planned Parenthood and Desert 

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Star is unnecessary. See Hunt, supra; San Diego County Gun Rights Comm. v. Reno, 98 

F.3d 1121, 1130-31 (9th Cir. 1996). 

 (2) Patients 

 Plaintiffs have sufficiently alleged a concrete “invasion of [patients’] legally 

protected interests” under the Fourteenth Amendment to decide to have an abortion prior 

to fetal viability without undue government interference. Lujan, 504 U.S. at 560. See 

Casey, supra. Plaintiffs allege that the Act compels patients seeking an abortion to 

receive information from their physician that is untruthful and/or misleading, to receive 

and be offered information from their physician that they allege is irrelevant and not 

tailored to their specific medical situations, and to receive and be offered information 

from their physician that interferes with the informed consent process. (Docs. 1 ¶¶ 49-55, 

59; 81-1 ¶¶ 52-59, 63.) 

 Further, because “the First Amendment has a penumbra where privacy is protected 

from governmental intrusion,” Plaintiffs have also alleged a concrete invasion of patients’ 

legally protected interests under the First Amendment to receive information concerning 

medical treatment from a physician exercising his or her professional medical judgment. 

Griswold v. Connecticut, 381 U.S. 479, 483 (1965); Whalen v. Roe, 429 U.S. 589, 600 

n.25 (1977); Lujan, supra. See also Conant v. Walters, 309 F.3d 629, 643 (2002) (“It is 

well established that the right to hear—the right to receive information—is no less 

protected by the First Amendment than the right to speak.”); Hill v. Colorado, 530 U.S. 

703, 716-18 (2000); Bd. of Educ., Island Trees Union Free Sch. Dist. No. 26 v. Pico, 457 

U.S. 853, 867 (1982) (“the right to receive ideas follows ineluctably from the sender’s 

First Amendment right to send them... the right to receive ideas is a necessary predicate 

to the recipient’s meaningful exercise of his own rights of speech”); Virginia State Bd. of 

Pharmacy v. Virginia Citizens Consumer Council, Inc., 425 U.S. 748, 756-57 (1976) 

(protection under the First Amendment extends “to the communication, to its source and 

to its recipients both.”); Griswold, 381 U.S. at 483 (the right of freedom of speech 

includes “the right to receive, the right to read and freedom of inquiry”) (citation 

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omitted).16

 The alleged injury to patients’ Fourteenth Amendment rights is imminent because 

“[t]he woman’s exercise of her right to an abortion, whatever its dimension, is [] 

necessarily at stake” and is susceptible to “incipient mootness.” Singleton v. Wulff, 428 

U.S. 106, 117, 126 (1976). The danger of sustaining an injury to their First Amendment 

rights is equally imminent; the injury is inherent in the challenged statute and likelihood 

that the state-mandated message will be received is derivative of the likelihood that their 

physician will speak it. See supra.

 Further, as a prudential matter, Plaintiffs are the appropriate parties to challenge 

the Act on the basis of patients’ alleged constitutional rights. As recognized by the 

parties, there is a legion of cases that have come before the Supreme Court and Ninth 

Circuit in which both physicians and abortion facilities were permitted to litigate on 

behalf of third-party patients to enjoin state laws restricting abortion rights. See Griswold, 

381 U.S. at 481 (physicians asserted constitutional rights of patients to whom they 

prescribed contraceptive devices); Singleton, 428 U.S. at 118 (recognizing that “there 

seems little loss in terms of effective advocacy from allowing [an assertion of a woman’s 

right to an abortion] by a physician”); Planned Parenthood of Central Missouri v. 

Danforth, 428 U.S. 52, 62 (1976); Casey, 505 U.S. at 845 (abortion providers challenged 

a state statute on behalf of third-party women who seek abortion services); McCormack, 

788 F.3d at 1027 (“a physician possesses standing on his own behalf and on that of his 

patients to challenge the validity of [an] abortion statute.”); Isaacson, 716 F.3d at 1221 

(allowing physicians to bring challenges to abortion laws on behalf of their patients); 

Wasden, 376 F.3d at 917 (“physicians and clinics performing abortions are routinely 

recognized as having standing to bring broad facial challenges to abortion statutes.”); 

 16 The Court recognizes that Plaintiffs have not advanced this alternative legal theory. Because this case has yet to progress to the merits, the Court raises this question as one of interest that is antecedent to the issues before it. See U.S. Nat’l Bank of Or. v. Indep. Ins. Agents of Am., Inc., 508 U.S. 439, 447 (1993); Kamen v. Kemper Fin. Servs., 

Inc., 500 U.S. 90, 99 (1991). Nevertheless, the decision to pursue their claim under this legal theory remains within Plaintiffs’ discretion. In other words, the Court has offered a 

spoon, but will not stir the pot. 

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Planned Parenthood Arizona, Inc. v. Humble, 753 F.3d 905, 910 (9th Cir. 2014) 

(physicians and clinics “brought their claims on behalf of themselves, their patients, and 

the physicians they employ”). 

 Physician-Plaintiffs are appropriate parties to assert the rights of patients seeking 

an abortion. See Singleton, 428 U.S. at 117 (“it is generally appropriate to allow a 

physician to assert the rights of women patients as against governmental interference with 

the abortion decision”). The intimacy inherent to the physician-patient relationship and 

the necessary involvement of the physician in the abortion process makes them uniquely 

qualified to advocate on behalf of patients and their abortion rights. See Singleton, 428 

U.S. at 117 (third-party standing looks to “the relationship of the litigant to the person 

whose right he seeks to assert”); Isaacson, 716 F.3d at 1221. The difficulty for women to 

directly vindicate their rights without compromising their privacy and the imminent 

mootness of their claims makes it appropriate for physicians to do so. Singleton, 428 U.S. 

at 118 (third-party standing looks to “the ability of the third party to assert his own 

right”); Isaacson, 716 F.3d at 1221. See also Broadrick v. Oklahoma, 413 U.S. 601, 612 

(1973) (“Litigants, therefore, are permitted to challenge a statute not because their own 

rights of free expression are violated, but because of a judicial prediction or assumption 

that the statute’s very existence may cause others not before the court to refrain from 

constitutionally protected speech or expression.”); NAACP, supra (allowing standing to 

assert First and Fourteenth Amendments rights on behalf of third parties). Physicians 

have a direct stake in the informed consent process as a corollary of their professional 

responsibilities, and in challenging the specific provision of the Act because they are 

vulnerable to prosecution if they do not carry out its requirements. See Doe, 410 U.S. at 

188. 

 The Court observes that none of the precedents cited above examined whether 

abortion facilities, as entities, could assert the rights of patients, either deferring the 

question because other parties had standing to assert the claims at issue, or justiciability 

was not questioned. Undertaking that consideration, the Court sees no reason to arrive at 

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a different conclusion. Where, as here, the exercise of patients’ rights is inextricably 

bound with the activities of their physicians, so is the provider whose operation is 

dependent on the existence of that relationship. In this regard, an abortion facility has a 

“‘direct stake’ in the abortion process.” McCormack, 788 F.3d at 1028; Am. Booksellers 

Ass’n, 484 U.S. at 393 (bookseller organizations and booksellers had standing to sue 

based on alleged infringement of bookbuyers’ First Amendment rights); see also 

Eisenstadt v. Baird, 405 U.S. 438, 445 (1972) (distributor of contraceptives who acted as 

“an advocate of the rights of persons to obtain contraceptives and those desirous of doing 

so” had third-party standing); Pierce v. Society of the Sisters of the Holy Names of Jesus 

and Mary, 268 U.S. 510, 536 (1925) (enterprises permitted to litigate against interference 

with the freedom of patrons or customers). The ability to advocate for the interests of 

physicians and the patients they serve is not severed by the corporate form, nor does its 

entity status diminish the reasons which endorse third-party representation of women 

seeking an abortion. See Pennsylvania Psychiatric Soc. v. Green Spring Health Servs., 

Inc., 280 F.3d 278, 293 (3rd Cir. 2002) (“So long as the association’s members have or 

will suffer sufficient injury to merit standing and their members possess standing to 

represent the interests of third-parties, then associations can advance the third-party 

claims of their members without suffering injuries themselves.”). Therefore, Planned 

Parenthood and Desert Star are also appropriate parties to assert the constitutional rights 

of patients. 

 Defendants argue that this case is distinguishable from the litany, and maintain it 

would be inappropriate to allow Plaintiffs to challenge the Act based on the asserted 

rights of patients. First, Defendants argue that unlike its predecessors that necessarily 

involved challenges to law regulating the right to seek or obtain an abortion, this case 

challenges government-regulated informed consent. (Doc. 87 at 5.) This argument is 

summarily rejected. See Casey, 505 U.S. at 884 (the “abortion right” evolves from two 

“general rights... the right to make family decisions and the right to physical autonomy”). 

 Defendants next argue that this case is distinguishable because “there is no ‘close 

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relationship’ which makes it appropriate for Plaintiffs to step into the shoes of patients 

and assert their legal rights.” (Doc. 87 at 7; see also Doc. 60 at 31-33.) While a patient 

seeks “to obtain information concerning all available treatment options,” Defendants 

contend that Plaintiffs are “seeking to prevent her from doing so.” (Doc. 87 at 7.) 

Because Plaintiffs seek “to withhold information from patients which might otherwise aid 

such patients in making a more free and informed abortion decision,” their “position and 

purpose in this matter are adverse to the interests and welfare of those patients.” (Doc. 87 

at 5-7.) This rationale is spurious and amounts to nothing but a poorly veiled attempt to 

litigate the merits in reverse. 

 C. Article III Traceability and Ex parte Young Exception 

 (1) Members of Arizona Medical Board and Executive Director 

 Plaintiff sues the members of the Arizona Medical Board (“Members” or 

“Board”),17 and Patricia E. McSorley, the Board’s Executive Director, in their official 

capacities. Plaintiffs allege that they have the authority to enforce the Act. (Docs. 1 ¶¶ 

13-14; 81-1 ¶¶ 13-14.) 

 “The primary duty of the board is to protect the public from unlawful, 

incompetent, unqualified, impaired or unprofessional practitioners of allopathic medicine 

through licensure, regulation and rehabilitation of the profession” in Arizona. Ariz. Rev. 

Stat. § 32-1403;18 (Docs. 1 ¶ 14; 81-1 ¶ 14). Board Members have statutory authority to 

initiate investigations of physician unprofessional conduct, and to discipline licensed 

physicians. § 32-1403(A)(2) and (5); § 32-1451(A) and (J); (Docs. 1 ¶ 14; 81-1 ¶ 14). 

The Executive Director, who is not a member of the Board, has the authority to “employ, 

evaluate, dismiss, discipline and direct professional, clerical, technical, investigative and 

 17 The named Board Members include: Richard T. Perry, M.D. (Board Chair), James Gillard, M.D. (Board Vice Chair), Jodi A. Bain, Marc D. Berg, M.D., Donna Brister, R. Screven Farmer, M.D., Gary R. Figge, M.D., Robert E. Fromm, M.D., Paul S. Gerding, Lois Krahn, M.D., Edward G. Paul, M.D., and Wanda J. Salter. (Docs. 1 ¶ 14; 81-1 ¶ 14.) 

18 “Administrative agencies have no common law or inherent powers-their powers are limited by their enabling legislation.” Ariz. State Bd. of Regents ex rel. Ariz. State 

Univ. v. Ariz. State Pers. Bd., 985 P.2d 1032, 1034 (Ariz. 1999). 

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administrative personnel necessary to carry on the work of the board.” § 32-1405(A) and 

(C)(1). She has authority to “[i]nitiate an investigation if evidence appears to demonstrate 

that a physician may be engaged in unprofessional conduct,” § 32-1405(C)(12), and to 

review complaints alleging unprofessional conduct, § 32-1405(C)(21). (Docs. 1 ¶ 13; 81-

1 ¶ 13.) She has authority to “[p]rovide assistance to the attorney general in preparing and 

sign and execute disciplinary orders, rehabilitative orders and notices of hearings as 

directed by the board,” § 32-1405(C)(14), and performs “all other administrative, 

licensing or regulatory duties required by the board,” § 32-1405(C)(28). 

 Board Members do not dispute that they have authority to enforce violations of the 

Act by Physician-Plaintiffs. Rather, the Board Members argue that Planned Parenthood 

and Desert Star may not bring claims against them because the Board “does not have any 

power or duty to administer or enforce licensure requirements for abortion clinics.” (Doc. 

41 at 4.) The Board’s authority to sanction institutions and clinics is immaterial to 

whether their conduct is fairly traceable to Plaintiffs’ alleged injuries, or whether they 

have some connection with the enforcement of the Act. Rather, as previously addressed, 

Planned Parenthood and Desert Star sue on the basis of the alleged injuries of third-party 

physicians licensed to practice medicine by the Board. This is sufficient. 

 Next, McSorley argues that she lacks the necessary statutory authority to enforce 

the Act. Instead, she contends, her duties “are largely administrative and ministerial.” 

(Doc. 40 at 1.) She argues that although she has authority to “initiate investigations into 

potential unprofessional conduct under A.R.S. § 32-1405(C)(12),” and “review 

complaints filed under A.R.S. § 32-1451,” she has no power to “discipline.” (Doc. 72 at 

3.) McSorley further argues that while she “can ‘provide assistance to the attorney 

general in preparing and sign and execute disciplinary orders, rehabilitative orders and 

notices of hearing’... she has no ability to take any of those actions absent Board 

approval and direction.” (Doc. 72 at 3.) Her authority to “sign orders as directed by the 

Board... is purely ministerial.” (Doc. 40 at 2.) 

 Contrary to her characterization, neither the initiation of an investigation or the 

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review of complaints qualifies as an inconsequential step in the road to license 

suspension or revocation. See Webb v. State ex rel. Ariz. Bd. of Med. Exam’rs, 48 P.3d 

505, 508 (Ariz. Ct. App. 2002) (noting that a physician has a property interest embodied 

in a license to practice medicine, and even in an investigation for professional censure, 

must be afforded with due process of law). McSorley need only have some connection 

with and be fairly traceable to the enforcement of the Act from which Plaintiffs’ alleged 

injuries arise; her conduct need not be the first or final step “in the chain of causation.” 

Bennett v. Spear, 520 U.S. 154, 168-169 (1997). See also Lexmark Int’l, Inc. v. Static 

Control Components, Inc., 572 U.S. ___, 134 S. Ct. 1377, 1390 (2014) (“the proximatecause requirement generally bars suits for alleged harm that is ‘too remote’ from the 

defendant’s unlawful conduct.”). 

 Nor is McSorley’s authority to sign and issue an order of license suspension or 

revocation simply paperwork. McSorley has “a powerful coercive effect on the action 

agency” because she is assigned with the authority to assist and give effect to the Act 

through her authority to carry out vital steps in the disciplinary process. Bennett, 520 U.S. 

at 169. See also Ritland v. Ariz. State Bd. of Med. Exam’rs, 140 P.3d 970, 972 (Ariz. Ct. 

App. 2006) (it is the action of the Board, not the ALJ, “that ultimately finds a person 

guilty of unprofessional conduct and enters disposition of the person’s license.” (citing 

Ariz. Rev. Stat. § 32-1451(M))). If Plaintiffs’ alleged injuries were the result of “the 

independent action of some third party not before the court,” those injuries would not be 

fairly traceable to McSorley or to the actions of the other Defendants before the Court. 

Bennett, 520 U.S. at 169. However, the nexus between her conduct and Plaintiffs’ alleged 

injuries does not cease simply because there are others who are necessary links in the 

causal chain. See Maya, 658 F.3d at 1070 (“A causal chain does not fail simply because it 

has several ‘links,’ provided those links are ‘not hypothetical or tenuous” and remain 

‘plausible.’”) (quoting Nat’l Audubon Soc., 307 F.3d at 849); Clapper, 133 S. Ct. at 1148 

(injury cannot be the result of an “attenuated chain of possibilities”). 

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connection to Plaintiffs’ alleged injuries arising from the Act. Their specific statutory 

authority to prosecute violations of the Act, along with their duty to do so, establishes 

that they both have the requisite “connection with the enforcement” of the Act. See 

Culinary Workers Union, 200 F.3d at 619 (citing Okpalobi v. Foster, 190 F.3d 337, 347 

(5th Cir. 1999) (observing that Article III justiciability and Eleventh Amendment 

immunity present “a closely related—indeed, overlapping—inquiry”); Harris, 729 F.3d 

at 943. 

 (2) Arizona Attorney General 

 Mark Brnovich is sued in his official capacity as the Arizona Attorney General. 

Plaintiffs allege that Brnovich has the authority to enforce the Act because the Attorney 

General is in “charge of” the Department of Law, is the “chief legal officer of the state,” 

Ariz. Rev. Stat. § 41-192(A), and serves as “the legal advisor of the departments of this 

state and render such legal services as the departments require,” § 41-192(A)(1). (Docs. 1 

¶ 11; 81-1 ¶ 11.) 

 Brnovich argues that he is not a proper party because, in his capacity as Attorney 

General, he is not conferred with independent authority to take disciplinary action against 

physicians and therefore lacks the requisite authority to enforce the Act. (Doc. 75 at 3.) 

He maintains that the Attorney General lacks authority to initiate license revocation or 

injunction proceedings against physicians (Docs. 46; 75 at 7);19 he serves only in the 

“role as a legal advisor and not as a policy maker” (Doc. 75 at 7-8); and is merely “the 

attorney for the agency, no more,” (Doc. 46 at 7 (quoting Santa Rita Mining Co. v. Dep’t 

of Prop. Valuation, 530 P.2d 360, 363 (Ariz. 1975)). As above, this argument also falls 

short. The Attorney General’s independent authority, ability to initiate proceedings, and 

advisory responsibilities do not circumscribe whether there is a sufficient causal 

 19 Brnovich argues that the Attorney General lacks authority to “enforce” the Act as defined under Arizona law. (Doc. 75); Ariz. State Land Dep’t v. McFate, 348 F.3d 912 

(Ariz. 1960). While the scope of state statutory authority to administer the law is critical 

to whether Brnovich is a proper party, the State’s common law definition of “enforce” is 

not. The term may often be embedded in Article III standing and Eleventh Amendment discussions, but the ability to “enforce” the law is not a static concept in application. 

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connection between his conduct and the alleged injuries that will arise from the Act’s 

operation. 

 The Attorney General has “a powerful coercive effect on the action agency” 

because he is assigned with the authority to assist and give effect to the Act through his 

authority to prosecute it. Bennett, 520 U.S. at 169. Where a licensee’s right to practice 

medicine is implicated, such as by license revocation or suspension by the Board, a 

formal administrative hearing must be initiated. See Ritland, 140 P.3d at 972; Ariz. Rev. 

Stat. § 32-1451(D) and (J). The representation of an agency official in an administrative 

hearing to revoke or suspend a professional license is the “practice of law,” and is a 

prosecutorial function that may only be performed by a licensed attorney. Romley v. 

Arpaio, 40 P.3d 831, 835 (Ariz. Ct. App. 2002) (citing State Bar of Ariz. v. Ariz. Land 

Title & Trust Co., 366 P.2d 1, 14 (Ariz. 1961); Ariz. Sup. Ct. R. 31(a)(3)). With 

exception to instances where a conflict of interest exists, only the Attorney General may 

serve as counsel and prosecutor in those proceedings. See Ariz. Rev. Stat. § 41-

1092.11(B); § 41-193(A)(2) (“Unless otherwise provided by law the department shall... 

when deemed necessary by the attorney general, prosecute and defend any proceeding in 

a state court other than the supreme court in which the state...is a party or has an 

interest”); § 41-192(D) (“no state agency other than the attorney general shall employ 

legal counsel or make an expenditure or incur an indebtedness for legal services”). If the 

Board wishes to pursue an action or maintain a defense that the Attorney General 

determines is not legally supportable or runs afoul of his constitutional obligations, he 

may not pursue it on the agency’s behalf. See § 41-192(E) and (F); § 38-231(A) and (E); 

Ariz. Sup. Ct. R. 42, ER 3.1; Ariz. Sup. Ct. R. 41(d). Upon a finding that a physician is 

guilty of unprofessional conduct, the Attorney General has authority to prepare 

disciplinary orders. §§ 32-1405(C)(12), 1451(M). 

 Although he may not carry out the first or final act of discipline, Brnovich is 

conferred with sufficient statutory authority to prosecute physicians such that he has 

some connection with the enforcement of the Act, and there is a sufficient nexus between 

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his conduct and Plaintiffs’ alleged constitutional injuries. See Wasden, 376 F.3d at 919; 

Bennett, 520 U.S. at 168-169. Plaintiffs’ alleged injuries are not the result of “the 

independent action of some third party not before the court.” Id. Nor is the Attorney 

General’s conduct simply a single link in an “attenuated chain of possibilities.” Clapper, 

133 S. Ct. at 1148. Rather, the Attorney General’s actions, when considered in tandem 

with the actions of the Board and its Director, form a causal chain that is both clear and 

plausible. See Maya, 658 F.3d at 1070. 

 (3) Director of Arizona Department of Health Services 

 Plaintiffs allege that the Arizona Department of Health Services “has authority to 

assess a penalty, revoke a clinic license, or take other disciplinary action against a clinic 

for violating the Act.” (Docs. 1 ¶ 20; 81-1 ¶ 20.) Plaintiffs sue Cara Christ, M.D. in her 

official capacity as ADHS Director. (Docs. 1 ¶ 12; 81-1 ¶ 12.) 

 Christ moves to dismiss Physician-Plaintiffs’ claim against her because she lacks 

authority to enforce the Act against them. (Doc. 44.)20 In this instance, the Court agrees.

In fact, the Court finds that Plaintiffs do not offer any allegation showing Christ has any 

authority to implement or prosecute violations of the Act – Ariz. Rev. Stat. § 36-

2153(A)(2)(h) and (i). 

 ADHS is vested with the duty to “[p]rotect the health of the people of the state,” 

Ariz. Rev. Stat. § 36-132(A)(1), and is responsible for licensing and regulating health 

care institutions, § 36-132(A)(17). “The direction, operation and control of [ADHS] are 

the responsibility of the director.” § 36-102(B). Christ is responsible for performing “all 

duties necessary to carry out the functions and responsibilities of the department,” § 36-

136(A)(2); for “[a]dminister[ing] and enforc[ing] the laws relating to health and 

sanitation and the rules of [ADHS],” § 36-136(A)(4); and for “mak[ing] and amend[ing] 

rules necessary for the proper administration and enforcement of the laws relating to the 

 20 Plaintiffs respond that Court need not determine whether they have standing to sue Christ because they have demonstrated standing on other grounds. (Doc. 66 at 14-15 (citing Wasden, 376 F.3d at 918).) This argument is misplaced. Unlike in Wasden, there 

remains a question as to whether there is any nexus between Christ’s authority to enforce the Act and Plaintiffs’ alleged injuries. 

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public health,” § 36-136(F), including those “relating to the abortion procedure,” § 36-

449.03(E). 

 Plaintiffs allege that Christ “has the power and duty to administer and enforce 

licensure requirements for healthcare institutions, including abortion clinics.” (Docs. 1 ¶ 

12; 81-1 ¶ 12). Plaintiffs do not, however, allege any basis which suggests health care 

institutions or abortion clinics, such as Planned Parenthood or Desert Star, would be 

penalized for violating the Act. By way of citation, Plaintiffs allege that Christ has 

authority to suspend or revoke the license of any health care institution if its owners, 

officers, agents or employees who violate the “chapter” (i.e., the laws governing health 

care institutions, including abortion clinics)21 or the rules adopted by ADHS, Ariz. Rev. 

Stat. § 36-427(A); to enjoin operation of a health care institution or abortion clinic if she 

believes that a violation of the laws governing health care institutions and abortion clinics 

endanger the health, safety, or welfare of a patient, § 36-429(A)(1); to enjoin operation of 

a health care institution or abortion clinic that exceeds the range of services for which it is 

licensed, § 36-430; to penalize an abortion clinic that “is not adhering to the licensing 

requirements... or any other law or rule concerning abortion,” § 36-449.02(F); to 

penalize an abortion clinic that “is not in substantial compliance” with the laws governing 

abortion clinics or the rules, § 36-449.03(I)(1); and to “assess a civil penalty against a 

person who violates” the laws governing health care institutions and abortion clinics or 

the rules adopted by ADHS, § 36-431.01(A). (Docs. 1 ¶¶ 12, 20; 81-1 ¶¶ 12, 20.) Yet, 

Plaintiffs do not point to any law or rule that requires health care institutions or abortion 

clinics to deliver the Act’s message to patients, to ensure physician compliance with the 

Act, or to otherwise carry out the Act.22 Cf. Planned Parenthood Arizona, Inc. v. Humble, 

 21 The “chapter” regulating health care institutions, including abortion clinics, is contained at Chapter 4, Title 36 of the Arizona Revised Statutes (Ariz. Rev. Stat. §§ 36-

401 – 36-450.02). 

22 Plaintiffs do not allege that Planned Parenthood or Desert Star will knowingly assist or conceal violations of the Act by their physicians. See Ariz. Rev. Stat. § 32-

1451(A) and (B) (discussing that health care institutions and their staff must report to the Arizona Medical Board in good faith if informed of a doctor’s unprofessional conduct). 

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753 F.3d 905 (9th Cir. 2014) (involving a challenge to a state statute and rule regulating 

abortion clinics that required medications used to induce abortions be administered in 

compliance with Food and Drug Administration’s on-label regimen). 

 For example, under the rules adopted by ADHS, an abortion clinic director must 

ensure that before an abortion is performed on a patient, written consent has been signed 

and dated by the patient, and information has been provided to the patient “on the 

abortion procedure including alternatives, risks, and potential complications.” Ariz. 

Admin. Code § R9-10-1508(E)(1)-(2) (eff. Apr, 1, 2014). This rule does not require that 

written consent must be obtained in the manner proscribed by the Act, or any part of the 

informed consent statute. Cf. Ariz. Rev. Stat. § 36-449.03(K) (“The rules adopted by the 

director pursuant to this section do not limit the ability of a physician or other health 

professional to advise a patient on any health issue”). Thus, while Christ has authority to 

penalize a health care institution or abortion clinic that fails to comply with § R9-10-

1508(E), this power has no bearing on her ability to take disciplinary action against an 

institution or clinic for a violation of the Act. 

 Plaintiffs also do not allege that Christ is delegated with any authority to penalize 

physicians. While Plaintiffs allege that “Christ’s Department” is responsible for 

“including information about ‘the reversal of a medication abortion’ on a website,” (Doc. 

81-1 ¶ 12), they do not show how this authority bears some connection with Christ’s 

ability to enforce violations of the Act.

23 Therefore, Plaintiffs have failed to allege there is 

some casual connection between her conduct, her ability to enforce any violation of the 

Act, and Plaintiffs’ alleged injuries arising from operation of the Act. Christ will 

 23 Plaintiffs do not allege patients are harmed by the availability of or their potential voluntary exposure to information concerning medication abortion reversal that is posted on the ADHS’s website. In other words, Plaintiffs’ alleged injuries arise from the injection of the challenged state-mandated materials into the patient-physician discourse – not from the posting of the material on ADHS’s website. Thus, Plaintiffs’ allegations, as amended, do not allege a basis to sue Christ to enjoin her from maintaining the website or posting information about medication abortion reversal in accordance with Ariz. Rev. 

Stat. § 36-2153(C)(8). 

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therefore be dismissed.24 

 D. Redressability 

 Extracted from their allegations, Plaintiffs seek to enjoin enforcement of 

regulations requiring physicians to inform patients that it may be possible to reverse a 

medication abortion, to refer patients to ADHS’s website that contains information 

concerning medication abortion reversal, and to offer and/or provide patients information 

related to medication abortion reversal. Stated in the alternative, Plaintiffs seek to enjoin 

enforcement of regulations requiring that a patient seeking an abortion be informed by 

her physician that it may be possible to reverse a medication abortion, be referred to 

ADHS’s website by her physician that contains information related to medication 

abortion reversal, and be offered and/or provided information regarding medication 

abortion reversal by her physician. 

 Because “defendants have the power to discipline,” an injunction prohibiting 

Defendants from enforcing violations of the Act will redress some of Plaintiffs’ alleged 

injuries. Wolfson, 616 F.3d at 1056.25 As alleged, physicians would not be compelled to 

deliver the Act’s message under fear of punishment, and would be free to counsel 

patients seeking an abortion in a manner consistent with their medical judgment. See 

Wolfson, 616 F.3d at 1056-1057 (“Without a possibility of the challenged canons being 

enforced, those canons will no longer have a chilling effect on speech”). This relief 

extends to redress patients’ alleged injuries. Physician-Plaintiffs allege that but-for the 

Act, they would not deliver its message to patients. Therefore, as alleged, a woman 

 24 Because the Court cannot say that it is clear that the claim against Christ could not be saved by any amendment, she will be dismissed without prejudice. The Court cautions that should Plaintiffs seek to reinstate Christ by amendment, any such claim must be alleged with specificity. 

25 Declaratory relief would settle “some dispute which affects the behavior of the 

defendant[s] toward the plaintiff[s].” Hewitt v. Helms, 482 U.S. 755, 761 (1987). Further, 

although a finding by the district court that the provision is unconstitutional would not be 

binding, it is likely that a private suit commenced in state superior court based on a 

violation of the Act would not be entertained. See Simon v. E. Ky. Welfare Rights Org., 426 U.S. 26, 38 (1976) (“the relevant inquiry is whether... the plaintiff has shown an injury to himself that is likely to be redressed by a favorable decision.”). 

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seeking an abortion would be free to decide whether to terminate her pregnancy without 

the injection of a message from her physician that is false, misleading, and/or irrelevant, 

and be advised by her physician concerning medical treatment in a manner that is 

consistent with the physician’s medical judgment. 

 Defendants argue that an injunction of the Act responsive to physicians’ First 

Amendment claim would redress all of Plaintiffs’ alleged injuries; “Plaintiffs would 

neither have to inform their patients of the existence of the website nor provide them with 

any information or documentation regarding it.” (Doc. 87 at 3.) Therefore, because 

redress in connection with Plaintiffs’ remaining claims “vis-à-vis the website” would be 

effectively moot, Defendants maintain Plaintiffs lack standing to assert the rights of 

patients. (Doc. 87 at 3.) This reasoning is flawed. The possibility that Plaintiffs would 

prevail on one claim and obtain relief which would redress the other has no bearing on 

whether there is currently a live justiciable controversy. 

 Plaintiffs however do acknowledge that an injunction of the Act, alone, would not 

offer complete redress for the injuries that they have alleged. They observe that 

“[i]ndependent of the Act,” the informed consent statute requires that patients be 

informed by their physician of the ADHS website which contains information regarding 

medication abortion reversal, Ariz. Rev. Stat. § 36-2153(A)(2)(f),26 and be offered and 

provided a printed copy of those materials if they choose to review them, § 36-

2153(A)(2)(g). (Doc. 89 at 3.) In doing so, Plaintiffs appear to allude that they are also 

seeking to enjoin § 36-2153(A)(2)(f) and (g), but deflect by citing they have requested 

“equitable relief” which will “free Plaintiffs from those unconstitutional requirements.” 

(Doc. 89 at 3; see also Docs. 1; 81-1 § VI (requesting that the Court “[g]rant such other 

and further relief as this Court may deem just, proper, and equitable.”).) The Court agrees 

that, under the same reasoning above, Plaintiffs’ alleged injuries could be relieved by an 

injunction enjoining the enforcement of § 36-2153(A)(2)(f) and (g), just as an injunction 

 26 The statutory provision which requires the ADHS to post information on its 

website “on potential ability... to reverse a medication abortion,” § 36-2153(C)(8), went 

into effect in 2015. (See Doc. 81-1 ¶¶ 35-37; 82 at 2.) 

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against § 36-2153(A)(2)(h) and (i) could. However, given the extraordinary nature of 

such relief, Plaintiffs will be called to amend their demand and set forth their additional 

request for injunctive relief with specificity. 

 Nevertheless, while this issue is notable, it is not dispositive of Plaintiffs’ 

standing. Redressability does not require that a favorable decision would relieve “every

injury.” Larson v. Valente, 456 U.S. 228, 243 n.15 (1982). Because the alleged injuries 

would be alleviated to some degree by an injunction of the Act, Plaintiffs have 

sufficiently alleged standing. See Massachusetts v. EPA, 549 U.S. 497, 526 (2007) 

(redressability is satisfied where the risk of harm “would be reduced to some extent if 

petitioners received the relief they seek”). 

V. Conclusion 

 Plaintiffs have made a sufficient showing of Article III standing to pursue 

declaratory and injunctive relief for each of its claims. Finding that Plaintiffs’ have failed 

to offer sufficient facts showing that their alleged injuries are traceable to Christ and that 

she possesses the necessary enforcement authority under Ex parte Young, she will be 

dismissed from this action. For the reasons above, the remaining motions to dismiss will 

be denied. Plaintiffs are directed to file an amended complaint consistent with this Order 

and in accordance with Rule 15.1 of the Local Rules of Civil Procedure. Accordingly, 

IT IS ORDERED: 

1. That the Motions to Dismiss filed by Mark Brnovich (Doc. 46), Patricia E. 

McSorley (Doc. 40), and the Members of the Arizona Medical Board (Doc. 41) are 

denied; 

2. That Defendant Cara Christ’s Motion to Dismiss (Doc. 44) is granted and she 

is dismissed without prejudice from this action; 

3. That Plaintiffs’ Motion for Leave to Amend (Doc. 81) is granted; 

4. That Plaintiffs shall have until April 4, 2016 to file an Amended Complaint 

consistent with this Order and the local rules; and 

5. That Defendants shall have fourteen (14) days from the date of the filing of 

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the Amended Complaint to file an answer. 

Dated this 23rd day of March, 2016. 

Honorable Steven P. Logan

United States District Judge

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