Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca10-88-02251/USCOURTS-ca10-88-02251-0/pdf.json

Nature of Suit Code: 890
Nature of Suit: Other Statutory Actions
Cause of Action: 

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PUBLISH 

FILED 

Uaited StttQ§ ~!!~of Appnls 

Tenth Clrrott 

SEP 6 1990 

UNITED STATES COURT OF APPEALS ROBERT l. I..JOECKER 

Cle!rk - TENTH CIRCUIT 

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PLANNED PARENTHOOD FEDERATION OF 

AMERICA, PLANNED PARENTHOOD OF THE 

ROCKY MOUNTAINS, PLANNED PARENTHOOD 

ASSOCIATION OF UTAH, BOULDER VALLEY 

WOMEN'S HEALTH CENTER, MARILYN 

FOELSKI, M.D., PHILIP FREEDMAN, M.D.,) 

and KIRTLY JONES, M.D., 

Plaintiffs-Appellees, 

v. 

LOUIS SULLIVAN, M.D., individually 

and in his capacity as Secretary of 

the United States Department of 

Health and Human Services, 

Defendant-Appellant. 

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No. 88-2251 

Appeal from the United States District Court 

for the District of Colorado 

(D.C. Civil No. 88-Z-158) 

Alfred Mellin, Attorney, Appellate Staff, Civil Division, 

Department of Justice, Washington, D.C., (John R. Bolton, 

Assistant Attorney General: Michael J. Norton, United States 

Attorney: and John F. Cordes, Attorney, Department of Justice, 

Washington, D.C.: Of Counsel: Joel Mangel, Deputy Chief Counsel, 

Public Health Service: and Carol Conrad, Attorney, Office of the 

General Counsel, Department of Health and Human Services, with him 

on the briefs), for Defendant-Appellant. 

Roger K. Evans (Dara Klassel and Beth Otten, also of Planned 

Parenthood Federation of America, Inc., New York, New York; 

Edwin S. Kahn and James W. Hubbell of Kelly/Haglund/Garnsey and 

Kahn, Denver, Colorado, with him on the brief) for PlaintiffsAppellees. 

Appellate Case: 88-2251 Document: 01019708272 Date Filed: 09/06/1990 Page: 1 
Kent Masterson Brown, Lexington, Kentucky; Charles Onofrio, 

Denver, Colorado; and Clarke D. Forsythe, Americans United for 

Life Legal Defense Fund, Chicago, Illinois, filed an amici curiae 

brief on behalf of American Academy of Medical Ethics, Association 

of American Physicians & Surgeons, American Association of Pro 

Life Obstetricians & Gynecologists, American Association of ProLife Pediatricians, National Doctors for Life, Christian Medical 

Society, Christian Medical Foundation, Alabama Physicians for 

Life, Physicians for Moral Responsibility, National Association of 

Pro-Life Nurses, California Pro-Life Nurses Association, Georgia 

Nurses for Life, Indiana Nurses Concerned for Life, Missouri 

Nurses for Life, New York State Nurses for Life, Inc., 

Pennsylvania Nurses for Life, Rhode Island Nurses for Life, 

Washington Pro-Life Nurses Association, Southern Center for Law 

and Ethics, and Certain Fellows and Members of the American 

College of Obstetricians and Gynecologists and of the American 

Medical Association in support of Defendant-Appellant. 

Paul Lewis, Denver, Colorado; James Bopp, Jr. and Richard E. 

Coleson of Brames, McCormick, Bopp & Abel, Terre Haute, Indiana, 

filed an amici curiae brief on behalf of Senator Gordon J. 

Humphrey and Congressmen Thomas J. Tauke, Thomas A. Luken, 

Thomas J. Bliley, Dan Coats, Christopher H. Smith, Henry J. Hyde, 

Alan B. Mollohan, and Vin Weber in support of Defendant-Appellant. 

John H. Hall and Mary Sue Henifin of Debevoise & Plimpton, New 

York, New York; Of Counsel: Nadine Taub, Rutgers University 

School of Law, Newark, New Jersey; and Sarah E. Burns, Legal 

Director, NOW Legal Defense and Education Fund, New York, New 

York, filed an amici curiae brief on behalf of NOW Legal Defense 

and Education Fund, National Abortion Rights Action League, 

American Association of University Women, Black Women's Agenda, 

Catholics for a Free Choice, Center for Population Options, 

Colorado Women's Bar Association, National Abortion Federation, 

National Council of Jewish Women, National Emergency Civil 

Liberties Committee, National Organization for Women, National 

Women's Conference Committee, National Women's Health Network, 

National Women's Political Caucus, Public Citizen Health Research 

Group, United Church of Christ, Women's Equity Action League, 

Women's Law Project, Young Women's Christian Association of 

Boulder County, Young Women's Christian Association of 

Metropolitan Denver, and Young Women's Christian Association of 

U.S.A. in support of Plaintiffs-Appellees. 

Jack R. Bierig, David F. Graham, Lynn D. Fleisher and Richard D. 

Raskin, Sidley & Austin, Chicago, Illinois; Of Counsel: Kirk B. 

Johnson and Edward B. Hirshfeld, American Medical Association, 

Chicago, Illinois; Ann E. Allen, American College of Obstetricians 

and Gynecologists, Washington, D.C., filed an amici curiae brief 

on behalf of the American Medical Association, American College of 

Obstetricians and Gynecologists, and American Society of Human 

Genetics in support of Plaintiffs-Appellees. 

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Bruce S. Wolff, Charles s. Sims, Suzette Brooks and William S. 

Koenig of Proskauer, Rose, Goetz & Mendelsohn, New York, New York, 

filed an amici curiae brief on behalf of The American Public 

Health Association, The Association of State and Territorial 

Health Officers, The Association of Schools for Public Health, The 

American College of Physicians, The American Medical Student 

Association, The Association of Reproductive Health Professionals, 

The California Coalition of Nurse Practitioners, The Colorado 

Academy of Family Physicians, The Colorado Department of Health, 

Colorado Physicians for Choice, Colorado/Wyoming Chapter of the 

American College of Nurse Midwives, The Intermountain Medical 

Society, The Maryland Department of Health and Mental Hygiene, The 

National Association of Nurse Practitioners in Family Planning, 

The National Urban League, The Nurses Association of the American 

College of Obstetricians and Gynecologists, The Ohio Department of 

Health, The South Dakota State Department of Health, The Wisconsin 

Nurse Practitioners in Reproductive Health, and Dr. Allan 

Rosenfield, Dean of the Columbia University School of Public 

Health in support of Plaintiffs-Appellees. 

Cynthia P. Delaney, Leanne B. DeVos, Karen H. DuWaldt, Diana Terry 

Reindl, and Kathleen Yurchak, American Civil Liberties Union 

Foundation of Colorado, Denver, Colorado, filed an amicus curiae 

brief on behalf of American Civil Liberties Union in support of 

Plaintiffs-Appellees. 

David M. Becker and Virginia A.S. Kling of Wilmer, Cutler & 

Pickering, Washington, D.C., filed an amici curiae brief on behalf 

of Representative Bill Green, Senators Barbara A. Mikulski, 

Lowell P. Weicker, Jr., Brock Adams, John H. Chafee, Alan 

Cranston, Howard M. Metzenbaum, Paul Simon, Robert T. Stafford, 

William S. Cohen, Daniel J. Evans, Bob Packwood, and Timothy E. 

Wirth, and Representatives Daniel K. Akaka, Les AuCoin, Julian c. 

Dixon, Vic Fazio, William H. Gray III, Steny H. Hoyer, William 

Lehman, Robert J. Mrazek, John Edward Porter, Martin Olav Sabo, 

Henry A. Waxman, Jim Bates, Rick Boucher, Cardias Collins, Mickey 

Leland, James H. Scheuer, Ron Wyden, Gary L. Ackerman, Chester G. 

Atkins, Anthony c. Beilenson, Howard L. Berman, Sherwood L. 

Boehlert, Don Benker, Barbara Boxer, George E. Brown, Jr., 

Albert G. Bustamante, Benjamin L. Cardin, Thomas R. Carper, 

George w. Crockett, Jr., Peter A. DeFazio, Ronald v. Dellums, 

Mervyn M. Dymally, Don Edwards, Lane Evans, Dante B. Fascell, 

Walter E. Fauntroy, Barney Frank, Bill Frenzel, Robert Garcia, Sam 

Gejdenson, Benjamin A. Gilman, Charles A. Hayes, James M. 

Jeffords, Nancy L. Johnson, Robert w. Kastenmeier, Joseph P. 

Kennedy II, Peter H. Kostmayer, Richard H. Lehman, Sander M. 

Levin, Mel Levine, John Lewis, Mike Lowry, Matthew G. Martinez, 

Robert T. Matsui, George Miller, John R. Miller, Jim Moody, 

Constance A. Morella, Bruce A. Morrison, Stephen L. Neal, Nancy 

Pelosi, Claude Pepper, Charles B. Rangel, Marge Roukema, Claudine 

Schneider, Patricia Schroeder, Christopher Shays, David E. Skaggs, 

Louise M. Slaughter, Lawrence J. Smith, Olympia J. Snowe, 

Stephen J. Solarz, Pete Stark, Gerry E. Studds, Edolphus Towns, 

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Morris K. Udall, Ted Weiss, Alan Wheat, and Howard Wolpe in 

support of Plaintiffs-Appellees. 

Before LOGAN, MOORE and BALDOCK, Circuit Judges. 

LOGAN, Circuit Judge. 

This appeal arises out of an action brought by organizations 

and physicians receiving funds under Title X of the Public Health 

Service Act, 42 U.S.C. §§ 300 to 300a-6, who challenge, on behalf 

of themselves and their patients, the 1988 amendments to the 

regulations under which Title X funds are administered. See 53 

Fed. Reg. 2922, 2943-46 (1988) codified at 42 C.F.R. §§ 59.2, 

59.5, 59.7-59.10. The new regulations prohibit Title X 

participants from advising women about abortion as a medical 

option if birth control devices should fail or if they are already 

pregnant, and the regulations require physical, financial, and 

personnel separation of Title X supported facilities from any 

others that counsel about or perform abortions. 

The district court entered a preliminary and then a permanent 

injunction against implementation of the new regulations. Planned 

Parenthood Fed'n of Am. v. Bowen, 680 F. Supp. 1465 (preliminary 

injunction) and 687 F. Supp. 540 (permanent injunction) (D. Colo. 

1988). The district court ruled that the regulations violate the 

intent of Congress as expressed in the statute, informed by its 

contemporaneous and subsequent legislative history. 680 F. Supp. 

at 1468-73; 687 F. Supp. at 542. It also held that the 

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regulations violate the constitutional rights of the women 

patients and their advising physicians. 680 F. Supp. at 1473-78; 

687 F. Supp. at 542-44. On appeal the Secretary of Health and 

Human Services challenges all of these rulings. 

Two other federal courts of appeals have faced the precise 

issues before us. A divided panel of the Second Circuit upheld 

the 1988 regulations against both statutory and constitutional 

challenges, New York v. Sullivan, 889 F.2d 401 (2d Cir. 1989), 

cert. granted, 58 U.S.L.W. 3753 (U.S. May 21, 1990) (Nos. 89-1391, 

89-1392). The First Circuit, en bane with one dissent, struck 

down the new regulations in their entirety, principally on 

constitutional grounds. Massachusetts v. Secretary of Health & 

Human Services, 899 F.2d 53 (1st Cir. 1990) (en bane). That court 

concluded that of the 1988 amendments, only 42 C.F.R. § 59.9 was 

invalid as inconsistent with Congress' intent as expressed in 

Title X or on other nonconstitutional grounds. But the court held 

that all of the amendments violated the constitutional rights of 

women to make informed decisions concerning abortion, and violated 

the consulting physicians' First Amendment rights to properly 

advise their patients. 

We find ourselves in agreement with the First Circuit's 

analysis, and we join it in holding the regulations invalid. 

I 

Congress enacted Title X of the Public Health Service Act, 42 

u.s.c. §§ 300-300a-6, in 1970. The act authorizes the Secretary 

of Health and Human Services "to make grants to and enter into 

contracts with public or nonprofit private entities to assist in 

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the establishment and operation of voluntary family planning 

projects which shall offer a broad range of acceptable and 

effective family planning methods and services." Id. § 300(a). 

Section 1008 of that act provides that "[n]one of the funds 

appropriated under this subchapter shall be used in programs where 

abortion is a method of family planning." Id. § 300a-6. Grants 

and contracts under Title X are to be made "in accordance with 

such regulations as the Secretary may promulgate." Id. § 300a-4. 

Title X funds have never been permitted to be used either to 

perform or to subsidize actual abortions. See 42 C.F.R. 

§§ 59.5(a)(S), 59.9 (1986). Almost since its enactment, however, 

the administrative interpretations permitted, and, since 1981, 

required Title X projects to provide nondirective counseling and 

referrals to pregnant women about all legally available medical 

options, including abortion. 53 Fed. Reg. 2923 (1988) This 

policy was reversed abruptly in 1988 by the promulgation of the 

regulations now under attack. 

In the new regulations, § 59.2 redefined the term "family 

planning" to refer solely to preconceptual services, explicitly 

excluding pregnancy care and abortion. Sections 59.7 and 

following were rewritten entirely. Section 59.8(a)(1) expressly 

prohibits Title X projects from providing counseling concerning 

abortion or referrals for abortion. Section 59.8(a)(2) states 

that once a Title X project client is diagnosed as pregnant she 

"must be referred for appropriate prenatal and/or social services" 

by giving her a list of providers that promote welfare of mothers 

and unborn children, and she "must also be provided with 

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information necessary to protect the health of mother and unborn 

child until such time as the referral appointment is kept." She 

may be referred for emergency care. But§ 59(a)(3) says that the 

project may not use emergency referrals as an "indirect means of 

encouraging or promoting abortion" by weighing referrals in favor 

of providers that perform abortions, by including on the list of 

referrals any providers whose principal business is providing 

abortions, by excluding providers who do not perform abortions, or 

by "steering" women to providers who offer abortions. Subsection 

(4) states that the project can provide the woman with medical 

information necessary to assess the risks of different methods of 

contraception, but cannot include counseling with respect to 

abortion. 

Examples of proper and improper actions by Title X providers 

are set out in§ 59.8(b). A pregnant woman requesting prenatal 

care must be referred to appropriate providers of prenatal care 

services. Id. § 59.8(b)(l). But a pregnant woman who directly 

asks for a list of abortion providers may not be given a list that 

includes any clinic which "principally" provides abortion, or a 

list that includes hospitals and clinics which provide abortion in 

addition to prenatal care, unless providers of prenatal care in 

the area that do not provide or refer for abortions are also 

included on the list. Id. § 59.8(b)(3) & (4). The Title X 

project is expressly prohibited from referring a pregnant woman to 

an abortion provider, even upon specific request, and apparently 

must tell one making such an inquiry that "the project does not 

consider abortion an appropriate method of family planning and 

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therefore does not counsel or refer for abortion." Id. 

§ 59.8(b) (5). 

Section 59.9 states specifically that Title X projects have 

to be so organized that they are "physically and financially 

separate" from prohibited abortion activities. This requires that 

the Title X project must have an "objective integrity and 

independence from prohibited activities;" mere bookkeeping 

separation is not sufficient. Id. The objective integrity and 

independence is based on factors that include, but are not limited 

to, separate accounting records, separate facilities, separate 

personnel, and absence of material promoting abortion. Id. 

Section 59.10(a) prohibits "actions to assist women to obtain 

abortions or increase the availability or accessibility of 

abortion." Specific examples of prohibited activities include 

lobbying for legislation increasing the availability of abortions, 

giving patients brochures advertising an abortion clinic, or 

making an appointment for a pregnant woman with an abortion 

clinic. 

II 

Although the Secretary admits that the 1988 regulations are a 

result of a shift in political climate and represent a significant 

departure from the policy of the first seventeen years of Title X 

grants, see New York, 889 F.2d at 418 (Kearse, J., dissenting), he 

defends the regulations as more consistent with the proper 

interpretation of Title X than the earlier practice. Thus, we 

determine first whether the 1988 changes in the regulations are 

permissible under the statute, apart from their constitutionality. 

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The words of the statute are paramount, of course, and we 

must give effect to the "unambiguously expressed intent of 

Congress." Chevron U.S.A., Inc. v. Natural Resources Defense 

Council, Inc., 467 u.s. 837, 843 (1984). Each of the circuit 

courts that have considered the question have found the language 

of § 1008 of the Act, 42 u.s.c. § 300a-6, that no funds 

appropriated "shall be used in programs where abortion is a method 

of family planning," is not free from ambiguity. These courts 

then appropriately considered the contemporaneous and subsequent 

legislative history and past administrative interpretations of the 

section. See Consumer Prods. Safety Comm'n v. GTE Sylvania, Inc., 

447 U.S. 102, 108-120 (1980). They found the contemporaneous 

legislative history ambiguous for the most part, although the 

First Circuit relied upon it to invalidate the new 42 C.F.R. 

§ 59.9, requiring separation of facilities. See Massachusetts, 

899 F.2d at 59-60. These decisions also considered the subsequent 

legislative history in the context of the long-standing 

administrative construction. In the end, however, both circuits, 

except for Massachusetts' ruling on § 59.9, held that the changes 

in the regulations were not beyond the power of the Secretary 

under the statute. 

We agree that the language of 42 u.s.c. § 300a-6 is ambiguous 

in that it does not resolve the issues presented in the challenged 

regulations. Moreover, the contemporaneous legislative history 

does not address whether clinics receiving Title X funds can 

engage in nondirective counseling including the abortion option 

and referrals, upon patient request. While there has been some 

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recent erosion of the federal courts' practice of consulting 

"longstanding and consistent" agency interpretations and some of 

the other techniques for parsing legislative history that we have 

used to ascertain whether a statute commands a particular result, 

the Supreme Court decisions have continued to rely on the 

"traditional tools of statutory construction" in determining 

congressional intent on "the precise question at issue," Chevron, 

467 u.s. at 843 n.9; ~ NLRB v. United Food & Commercial Workers, 

484 U.S. 112, 123 (1987); INS v. Cardozo-Fonseca, 480 u.s. 421, 

446 (1987). We have considered all of those traditional tools, 

but do not discuss them in any detail because we can add little to 

the Massachusetts court's analysis of the statute and the relevant 

interpretative history. 

Like the Massachusetts court, we find that the propriety of 

the regulatory changes is a close question--largely because of 

many years of consistent administrative interpretation, with six 

reenactments of parts of Title X, and numerous reappropriations, 

during which unsuccessful attempts were made at statutory 

amendment to change the practice of counseling and referrals for 

abortion on this highly visible and controversial matter. See Bob 

Jones University v. United States, 461 u.s. 574, 599-602 (1983) 

(agency interpretation of statute confirmed or ratified by 

subsequent congressional failure to change it). In the end, 

however, we agree with the Massachusetts court that, except for 

new 42 C.F.R. § 59.9, the amendments are not statutorily 

impermissible. 

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Title X clearly directs the Secretary to administer a grant 

program to promote family planning under a statute that delegates 

to him some discretion with an admonition not to fund abortions. 

Supreme Court decisions have held that when the mandate of 

Congress is ambiguous we must defer to any reasonable 

interpretation by the agency. See, ~' NLRB v. Curtin Matheson 

Scientific, Inc., 58 U.S.L.W. 4407, 4411 (U.S. Apr. 17, 1990) (No. 

88-1685); United Food & Commercial Workers Union, 484 u.s. at 123; 

Chevron, 467 U.S. at 844. This rule applies even when the agency 

is changing a prior interpretation. ~' Curtin Matheson, 58 

U.S.L.W. at 4411; Chevron, 467 U.S. at 864-64; Motor Vehicle Mfrs. 

Ass'n v. State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 42 (1983); 

American Trucking Ass'ns, Inc. v. Atchison, Topeka & S.F. Ry. Co., 

387 u.s. 397, 416 (1967). That the interpretation is longstanding is not significant unless we can comfortably conclude 

that a majority of Congress intended the prior interpretation to 

be frozen into law, a conclusion we cannot reach here. See Motor 

Vehicle Mfrs., 463 u.s. at 45. 

The Secretary must justify his change of interpretation with 

"a reasoned analysis," Motor Vehicle Mfrs., 463 u.s. at 42, 57. 

In a lengthy discussion in the Federal Register, the Secretary 

argued that the new regulations are more in keeping with the 

original intent of the statute, justified by client experience 

under the prior policy, supported by a shift in attitude against 

"elimination of unborn children by abortion," 53 Fed. Reg. at 

2944, and consistent with a change in policies by a new political 

administration. Whether or not we personally would approve of 

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these changes, the agency has sufficiently justified them and we 

therefore cannot rule them to be arbitrary and capricious. See 

Chevron, 467 u.s. at 865. 

The one exception is 42 C.F.R. § 59.9, which requires an 

amount of physical, financial, and personnel separation between 

Title X funded activities and any counseling mentioning abortion 

that would seem to put out of business many current grantees. All 

of the Title X grantees must provide at least ten percent 

nonfederal "matching funds," 42 u.s.c. § 300a-4(a). Most provide 

significantly more than that; federal funds apparently account for 

only about fifty percent of the money received by Title X 

grantees. Massachusetts, 899 F.2d at 56. One of the plaintiffs 

in the case before us is a physician in private practice who 

handles Title X patients in his office, I R. tab 1 ,, 10; that 

doctor performs abortions for private, paying patients, id. tab 2, 

Decl. Sylvia Clark. The new § 59.9 clearly prohibits continued 

Title X funding to that doctor, despite the fact that he is not 

providing abortion services for Title X patients. Quite apart 

from the constitutional problems, we agree with the Massachusetts 

court, 899 F.2d at 59-60, and the district court below, 680 

F. Supp. at 1468-69, that new§ 59.9 has the effect of restricting 

the number of permissible grantees beyond the intent of Congress 

as expressed in 42 u.s.c. §§ 300, 300a and Title X as a whole. 

Although it was not enacted as a part of Title X, 42 u.s.c. 

§ 300a-7 lends support to our holding. This provision had its 

origin as a measure to prevent discrimination against those who 

will not perform abortions, but clearly states a general 

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nondiscrimination policy applicable to all grants under the Public 

Health Service Act, of which Title X is a part. That section 

requires that no personnel decisions be made on the basis of 

either "reluctance or willingness" to counsel or perform 

abortions. Id. § 300a-7(d). When the antidiscriminatory 

provisions are considered along with the statements in Title X of 

an intent to provide a "broad range" of services, 42 u.s.c. 

§ 300(a), taking into account the extent "services are needed 

locally," id. § 300(b), that "priority will be given ... to 

furnishing such services to persons from low-income families," id. 

§ 300a-4(c)(l), with suitable "informational or educational 

materials" made available to the targeted population, id. § 300a4(d)(l), we believe it violates congressional intent to deny the 

issuance of Title X grants solely because the grantee is not 

sufficiently funded to meet the separation requirements of 42 

C.F.R. § 59.9. 

III 

We turn now to the constitutional issues raised by plaintiffs 

and passed upon by the district court. The important threshold 

question is whether the instant situation is controlled by the 

line of cases commencing with Maher v. Roe, 432 u.s. 464 (1977), 

which hold that a government constitutionally may encourage 

childbirth over abortion by funding only prenatal and childbirth 

expenses. The Court found that the carrot of state aid, which 

might induce an indigent woman to carry to term rather than abort, 

was not the equivalent of a state-created obstacle in the woman's 

path to an abortion. Id. at 474, 477 n.lO. 

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In Harris v. McRae, 448 u.s. 297 (1980), the Court held that 

the United States government's refusal to fund an indigent woman's 

medically necessary abortion, when it would pay the costs of her 

bearing the child, did not violate her constitutional rights. The 

Court reasoned that her freedom of choice does not carry with it a 

constitutional entitlement to the money necessary to avail herself 

of the full range of protected choices; "although government may 

not place obstacles in the path of a woman's exercise of her 

freedom of choice, it need not remove those not of its own 

creation." Id. at 316. A year ago, the Supreme Court upheld, on 

the same reasoning, the right of a state to prohibit the use of 

state funds or state facilities to perform abortions; "Missouri's 

refusal to allow public employees to perform abortions in public 

hospitals leaves a pregnant woman with the same choices as if the 

State had chosen not to operate any public hospitals at all. The 

challenged provisions only restrict a woman's ability to obtain an 

abortion to the extent she chooses to use a physician affiliated 

with a public hospital." Webster v. Reproductive Health Services, 

109 S. Ct. 3040, 3052 (1989). 

Although the instant case bears superficial resemblance to 

the Maher line of decisions--a governmental choice to use its 

funds to promote childbirth over abortion--there are significant 

differences which we believe make those cases inapposite. The 

government, of course, has not gone so far as to socialize 

medicine and publicly fund all hospitals and physicians, a 

situation the Webster decision said might require a different 

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analysis. 1 109 s. Ct. at 3052 n.8. But it has set up a funding 

system by which approximately 4,000 entities, including state 

governments, have been induced to become Title X grantees by 

offers of up to ninety percent federal funding. The Secretary has 

admitted that the projects serve approximately 1,000,000 

adolescent women. 53 Fed. Reg. at 2944. The total number of 

women served is no doubt much greater. 

"It has been said that Title X, as the single largest 

federally-funded family planning program, serves 4.3 

million people: its targeted population consists of an 

estimated 14.5 million women at risk of unintended 

pregnancy, including 5 million adolescents between the 

ages of 15 and 19, and 9.5 million adult women between 

the ages of 20 and 44, all of whom have an income 150 

percent below the poverty level." 

New York, 889 F.2d at 415 n.1. 

The record establishes that many women who visit these Title 

X providers do so because they suspect they are pregnant; the 

clinic provides pregnancy testing, and many are indeed found to be 

pregnant. Had the regulations directed that once pregnancy is 

established the clinic must say, "Go away, we only give advice on 

prepregnancy planning," then it might be said the government has 

1 Webster also expressed reservation regarding the 

constitutionality of a state's denying use of public facilities to 

doctors who perform abortions for private patients at private 

facilities. 109 s. Ct. at 3052 n.8. Such a situation is 

analogous to the regulations before us now, because the 

regulations deny public funding to grantees who perform or counsel 

concerning abortions, even for private, non-publicly funded 

patients. See 53 Fed. Reg. 2922 ("[S]ection 1008 [42 u.s.c. 

§ 300a-6)] extends to all activities conducted by the federally 

funded project, not just the use of federal funds for abortions 

within the project."); 53 Fed. Reg. 2927 ("The Department's 

concern is that all funds allocated to the Title X program or 

project--whether they are direct Title X grant funds, program or 

grant-related income, or matching [private] fund [sic]--be spent 

in compliance with Section 1008 and that the program be separate 

and distinct from prohibited abortion activities."). 

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done no more than subsidize a permissible activity. The 

regulations, however, require the clinic to go one step further in 

its treatment of the patient. When a patient is diagnosed as 

pregnant she must be provided with both referrals to prenatal 

service providers and with interim information on prenatal care. 

42 C.F.R. § 59.8(a)(2). Even if the patient specifically requests 

information on abortion, the clinic is not permitted to advise her 

about it. We can summarize this no better than did Judge Kearse 

in her dissent in New York: 

"There can be no doubt that the Secretary intends this 

regulation to forbid a grantee from informing a pregnant 

woman of the availability of abortion and even from 

telling her where she can get abortion-related 

information. For example, though the regulations permit 

a grantee to give the woman a list of prenatal-care 

service providers that might also offer abortions, the 

list must comply with several requirements. It must 

include any available prenatal-care providers that do 

not perform abortions; it cannot include providers that 

offer abortions as their 'principal business'; and it 

cannot 'weigh[]' in favor of abortion providers. 42 

C.F.R. § 59.8(a)(3). The grantee is not allowed to 

inform the woman which providers on the list, in 

addition to offering prenatal care, also perform 

abortions. Rather, care providers that also perform 

abortions may be included only if 'the referral is 

specifically made to the providers of prenatal care 

services.' 53 Fed. Reg. 2922, 2938 (1988). Indeed, the 

grantee is required to inform the client about care to 

preserve the unborn fetus. Section 59.8(a)(2), for 

example, provides that 'once a client served by a Title 

X project is diagnosed as pregnant, she must be referred 

for appropriate prenatal and/or social services £y 

furnishing a list of available providers that promote 

the welfare of mother and unborn child.' 

• . . In addition to the regulations discussed 

above, for example, § 59.8(b)(4) provides that when a 

woman asks for a list of abortion providers, the grantee 

is not permitted to give her a list that includes 

entities whose principal business is abortion, or a list 

that does not include 'providers of prenatal care in the 

area which do not provide or refer for abortions.' In 

contrast, § 59.8(b)(5) provides that when a woman asks 

for information on abortion, the grantee is permitted to 

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'tell[] her that the project does not consider abortion 

an appropriate method of family planning and therefore 

does not counsel or refer for abortion'; it is permitted 

to 'tell[] the client that the project can help her to 

obtain prenatal care and necessary social services, and 

provide[] her with a list of such providers from which 

the client may choose.' 

Thus, the express prescriptions and proscriptions 

in the regulations require the grantee to emphasize 

prenatal care and prohibit it from identifying any 

entity as a provider of abortions. Plainly, the 

regulations facially discriminate on the basis of 

viewpoint and control the content of the grantee's 

permitted speech." 

889 F.2d at 415-16 (emphasis in original). 

If we could conclude that the pregnant women who are patients 

of Title X clinics are knowledgeable about their abortion option, 

or will seek advice from doctors not fettered by the Title X 

regulations, then we might conclude that Maher controls, because 

poverty alone does not give a woman the right to government-funded 

benefits. But it seems clear that government funding, which fuels 

virtually all "birth control" clinics in the nation, lures 

poverty-level women to these clinics for pregnancy testing, 

medical advice, and referrals to other health care providers. The 

promise of the clinics, and their goal under law, is to provide 

"comprehensive voluntary family planning services" upon request. 

H.R. Rep. No. 572, 91st Cong., 2d Sess., reprinted in 1970 u.s. 

Code Cong. & Admin. News 5068, 5075. Fees for the services are 

determined on a sliding scale, based on the woman's income. 

Absent a warning that the advice given at Title X clinics is 

incomplete, many patients no doubt will rely, without obtaining a 

second opinion, on the advice given them. At least many of the 

poorest, most naive and ignorant women--who are the persons 

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targeted by Title X--will rely on that information. 2 Thus, by 

denying Title X providers the right to mention abortion, to refer 

to abortion as an option, or to provide professional referrals to 

others whom they know will counsel about all medical options that 

are legal, including abortion, the government has placed a statecreated "obstacle in the path of a woman's exercise of her freedom 

of choice." Harris, 448 u.s. at 316. 3 

2 Of course, the Secretary is in fact anticipating that women 

will rely on the information provided and will not therefore 

either need or desire abortions. See 42 C.F.R. § 59.2 

("[A]bortion may not be included as a method of family planning in 

the Title X project. Family planning, as supported under this 

subpart, should reduce the incidence of abortion."); 42 C.F.R. 

§ 59.8(b)(5) (example of pregnant woman who requests information 

on abortion providers and is given only prenatal care referrals). 

Information and referrals are an integral part of the services 

envisioned in the regulations. 53 Fed. Reg. 2923. 

3 We will not assume, as the government apparently does, 

Appellant's Brief at 44 n.38, that the effect of the Title X 

provider's failure to mention abortion is mitigated or eliminated 

by a woman's access to abortion information from other sources. 

In fact, a provider's failure to mention abortion as a legal 

option, in the context of an otherwise neutral medical 

consultation, could well cause the woman to conclude that abortion 

is not a legal or medical option for her under the circumstances. 

Many states have recently undertaken measures to modify their 

abortion laws, which efforts receive extensive media attention. 

See "States Testing the Limits on Abortion," N.Y. Times, April 2, 

1990, at Al4, col. 4 (citing 100 then-pending abortion bills; 

fourteen floor votes on abortion bills since Webster). One reason 

women might seek information about their medical options at a 

family planning clinic is the confusion that arises from the 

barrage of bills introduced, passed, vetoed, or stayed by judicial 

action. See, ~' id. (Guam, Pennsylvania, and South Carolina 

laws restricting access to abortion stayed in court actions; Idaho 

bill restricting abortion passed by legislature but vetoed by 

governor); "Maryland Legislature Halts an Abortion Move," id., 

March 24, 1990, at A7, col. 1 (Maryland legislature rejects public 

referendum to decide which of two conflicting abortion bills 

becomes law). The two decisions issued at the end of the most 

recent Supreme Court term, Hodgson v. Minnesota, 110 S. Ct. 2926 

(1990), and Ohio v. Akron Center for Reproductive Health, 110 

S. Ct. 2972 (1990) (upholding parental notification statutes), are 

unlikely to reduce the legislative activity or women's confusion 

about their medical options. 

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We must examine whether that obstacle, the government's 

provision of intentionally incomplete information, violates any 

constitutional right previously recognized by the Supreme Court. 

Of course, under current law a pregnant woman in the first stages 

of pregnancy has a federal constitutional right to an abortion. 

Roe v. Wade, 410 u.s. 113 (1973). Even if Roe is overruled, it 

means only that the existence of the right to an abortion is left 

to the political process, probably to the states. No doubt some 

states would continue to permit abortions, and a pregnant woman in 

a state forbidding abortions, by virtue of her right of travel to 

another state, in theory at least still would be able to secure a 

legal abortion. Thus abortion is currently a legally permissible 

option for a woman in the early stages of pregnancy, and it will 

likely remain so. 

Because patients at a Title X clinic are invited to consult 

its physicians and are given intentionally incomplete medical 

advice, which they reasonably can be expected to follow, we think 

this case falls squarely within the prohibition in Thornburgh v. 

American College of Obstetricians and Gynecologists, 476 u.s. 747 

(1986), and City of Akron v. Akron Center for Reproductive Health, 

Inc., 462 u.s. 416 (1983), against state intrusion into the advice 

a woman requests from or is given by her doctor. However Webster, 

Hodgson v. Minnesota, 110 S. Ct. 2926 (1990), and Ohio v. Akron 

Center for Reproductive Health, 110 S. Ct. 2972 (1990), may have 

affected aspects of the Thornburgh and Akron decisions, we see 

nothing to diminish Akron's holding that 

"because abortion is a medical procedure, . . . the full 

vindication of the woman's fundamental right necessarily 

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requires that her physician be given 'the room he needs 

to make his best medical judgment.' The physician's 

exercise of this medical judgment encompasses both 

assisting the woman in the decisionmaking process and 

implementing this decision should she choose abortion." 

462 u.s. at 427 (citations omitted). 4 Stating that "it remains 

primarily the responsibility of the physician that appropriate 

information is conveyed to his patient," the Court struck down 

government-imposed abortion regulations "designed to influence the 

woman's informed choice between abortion or childbirth." Id. at 

443-44. "The State's intent is in ensuring that the woman's 

consent is informed and unpressured; the critical factor is 

whether she obtains the necessary information and counseling from 

a qualified person." Id. at 448. 

These principles were reaffirmed in Thornburgh, 476 u.s. at 

760, 762. Indeed, Thornburgh condemned state rules that 

structured and slanted the dialogue between the physician and the 

pregnant patient in language that seems precisely applicable to 

the situation at bar: 

4 

"Forcing the physician or counselor to present the 

materials [discouraging abortion] and the list 

[including agencies offering alternatives to abortion] 

to the woman makes him or her in effect an agent of the 

State in treating the woman and places his or her 

imprimatur upon both the materials and the list. All 

this is, or comes close to being, state medicine imposed 

upon the woman, not the professional medical guidance 

she seeks, and it officially structures--as it obviously 

was intended to do--the dialogue between the woman and 

her physician." 

The Supreme Court's recent Ohio op~n~on, while approving a 

state requirement that a physician inform one parent when a minor 

patient is considering abortion, continues to recognize the 

importance of the advice of a detached physician with full 

information. Ohio, 110 s. Ct. at 2983. 

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476 u.s. at 763 (citation omitted). 

Again, we cannot improve upon the following statement in 

Judge Kearse's dissent in New York concerning the effect on the 

woman's constitutional rights: 

"The regulations at issue here prohibit the physician in 

a Title X facility from communicating to his patient 

frank and complete advice if it involves consideration 

of abortion. They require him, in referring his patient 

to other health-care providers, to identify only 

prenatal-care facilities. If his pregnant patient 

raises the subject of abortion, he is required to tell 

her that he cannot give her any advice or counseling on 

the subject. If she asks where she can get information, 

the regulations prohibit even an informative response. 

Unlike the regulatory schemes in such cases as 

Harris . . • and Maher . . . in which the regulating 

authority was found merely to have refused to extend an 

affirmative benefit to women who freely chose abortion, 

but not to have placed obstacles in the way of an 

informed choice, the Secretary's regulations here 

plainly interfere with the pregnant woman's freedom to 

decide which course of action she prefers. In some 

cases, the information ban will delay the appropriate 

education of the patient to such an extent that she is 

denied any genuine choice. In some cases, the patient 

will never be fully informed, for as the Secretary has 

acknowledged, '[f]or many clients, family planning 

programs are their only continuing source of health 

information and medical care.' u.s. Dep't of Health and 

Human Services, Program Guidelines for Project Grants 

for Family Planning Services § 9.4 (1981). These 

regulations prevent such a program from giving the 

client any substantive information regarding abortion as 

an option; if she asks where she may obtain such 

information, her Title X physician is prohibited from 

telling her. 

By prohibiting the delivery of abortion information 

and prohibiting communication even as to where such 

information can be obtained, the present regulations 

deny a woman her constitutionally protected right to 

choose. She cannot make an informed choice between two 

options when she cannot obtain information as to one of 

them." 

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889 F.2d 416-17. 

Although the matter has received little separate attention in 

court opinions to this point, the limitations placed on Title X 

physicians in communicating with their patients, and the referral 

obligations imposed upon them, violate the constitutional rights 

of the physicians themselves. The dearth of attention may be 

because the physicians' rights are considered derivative from the 

rights of the patient. See Whalen v. Roe, 429 u.s. 589, 604 n.33 

(1977); Harris, 448 U.S. at 318 n.21. In the context of a right 

to advice in the confidential physician-patient relationship, 

physicians' rights would seem to be entirely coextensive with 

those of their patients, and if the patient's constitutional 

rights are violated so are the physician's. Nevertheless, a 

separate discussion of the physicians' position illuminates their 

predicament under the 1988 regulations and strengthens our belief 

that the new regulations must fail. 

Physicians, of course, need not accept employment with 

grantees of Title X funds if they do not wish to abide by the 

limitations upon the advice they may give patients; presumably 

physicians already working for such organizations may quit if they 

do not like the regulations, although breaking contracts of 

employment might render them liable for damages. Even so, it is a 

well-established principle that, although the government has no 

responsibility to provide funds for a program, it may not 

condition participation in a program it does fund upon a waiver of 

constitutional rights. This is set forth clearly in Perry v. 

Sindermann, 408 U.S. 593, 597 (1972), as follows: 

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This 

"For at least a quarter-century, this Court has made 

clear that even though a person has no 'right' to a 

valuable governmental benefit and even though the 

government may deny him the benefit for any number of 

reasons, there are some reasons upon which the 

government may not rely. It may not deny a benefit to a 

person on a basis that infringes his constitutionally 

protected interests--especially, his interest in freedom 

of speech." 

principle applies fully to employment situations. 

Individuals may not be required to abandon their constitutional 

rights to free speech or due process to obtain employment. Id. at 

597. 

The canons of ethics of the medical profession require 

physicians to give patients advice that includes abortion as an 

alternative to carrying a pregnancy to term when the patient's 

health condition warrants. 5 The health hazards of abortion in a 

particular instance may be less than the health hazards of 

carrying the pregnancy to term. One study comparing mortality 

statistics from abortion and childbirth concluded that "[i]n terms 

of dying, abortion through the 15th week of pregnancy is at least 

tenfold safer than childbearing." Cates, Smith, Rochat & Grimes, 

5 The American Medical Association Standards regarding informed 

consent state that physicians may refer patients to "any other 

provider of health care services permitted by law to furnish such 

services, whenever he believes that this may benefit the patient." 

Current Opin. of Council on Ethical & Judicial Affairs of the 

American Medical Association--1986, 11 304; ~ also id. 11 807 

("physician has an ethical obligation to help the patient make 

choices from among the therapeutic alternatives consistent with 

good medical practice"); American College of Obstetricians & 

Gynecologists (ACOG), Standards for Obstetric-Gynecologic Services 

57 (1985) (in event of unwanted pregnancy the physician should 

counsel patient of abortion option); ACOG, Statement of Policy: 

Further Ethical Considerations in Induced Abortion (Dec. 1977) 

("Counseling directed solely toward either promoting or preventing 

abortion does not sufficiently reflect the full nature of the 

problem or the range of options to which the patient is 

entitled."). 

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Appellate Case: 88-2251 Document: 01019708272 Date Filed: 09/06/1990 Page: 23 
Mortality from Abortion and Childbirth, 248 J. Am. Med. A. 192, 

196 (July 9, 1982). 

The amended regulations, particularly 42 C.F.R. §§ 59.8(a)(1) 

& (4) and 59.10(a), appear to prohibit physicians paid with Title 

X funds from advising women about the alternative of abortion even 

when carrying the baby to full term would involve grave risks for 

the mother. The regulations, particularly§ 59.8(a)(2), appear to 

require Title X physicians to provide pregnant patients with 

literature from health care providers who will not perform 

abortions or counsel abortion as an option, and to forbid those 

physicians from referring pregnant patients to health care 

providers who will provide such services. In complying with the 

regulations, in theory at least, the physician risks censure and 

loss of his right to practice because of his failure to give 

impartial and full advice. 

To condition receipt of Title X funds upon physicians' 

promises not to give advice that the standards of their profession 

require them to give implicates the physicians' First and Fifth 

Amendment rights. See, ~, Thornburgh, 476 u.s. at 763; Akron, 

462 u.s. at 445; Frieman v. Ashcroft, 584 F.2d 247, 251-52 (8th 

Cir. 1978); aff'd mem., 440 U.S. 941 (1979). This conclusion also 

does not depend on the continued efficacy of Roe v. Wade because, 

for the reasons already stated, for most women abortion would 

continue to be a legal alternative that physicians must be free to 

discuss with their patients. 

For the reasons gLated, we hold that the regulations violate 

the Title X providers' and women patients' First and Fifth 

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Amendment rights. We AFFIRM the permanent injunction issued 

against the implementation of the challenged amendments to the 

regulations. 

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No. 88-2251, Planned Parenthood Federation of America v. Sullivan. 

BALDOCK, Circuit Judge, dissenting in part. 

With the apparent exception of the separation requirements 

1 contained in 42 C.F.R. § 59.9, the court today holds unconstitutional the 1988 amendments to the HHS regulations, 42 C.F.R. 

§§ 59.1-59.17, designed to implement the purpose of Section 1008 

of Title X of the Public Health Services Act, 42 u.s.c. § 300a-6. 

According to the court, the limitations placed upon Title X 

recipients by the regulations, namely § 59.8, facially violate a 

pregnant woman's fifth amendment right to choose abortion and her 

physician's first amendment right to speak frankly about abortion. 

Because Supreme Court precedent dictates a contrary result, 

I dissent. 

1 In part II of its op~n~on, the court holds § 59.9 invalid as 

contrary to Congressional intent. Court's Opinion at 12-13. I 

agree. The aim of Title X is to increase and improve family 

planning services to indigents in cooperation with existing state 

and private programs. In enacting Title X, Congress did not 

intend "to restrict the types of projects with which a Title X 

recipient could associate, or to place limitations on the physical 

proximity or the sharing of personnel between Title X projects and 

unrelated programs which may provide abortion services." 

Commonwealth of Mass. v. Bowen, 679 F. Supp. 137, 143 (D. Mass. 

1988), aff'd, 899 F.2d 53 (1st Cir. 1990), cert. pending, No. 89-

1929 (June 8, 1990). Because I concur fully in the court's 

statutory resolution of the challenged regulations, neither I nor 

the court have occasion to address § 59.9's constitutionality. 

See Harris v. McRae, 448 u.s. 297, 306-07 (1980) (where case may 

be decided on either statutory or constitutional basis, court 

should decide case on statutory basis and avoid constitutional 

adjudication). Since the court, however, assumes the severability 

of § 59.9 from the remaining regulations, the constitutionality of 

those regulations is at issue. See Buckley v. Valeo, 424 u.s. 1, 

108 (1976) (statutory severability). 

Appellate Case: 88-2251 Document: 01019708272 Date Filed: 09/06/1990 Page: 26 
I. 

The court reasons that Thornburgh v. American College of 

Obstetricians and Gynecologists, 476 U.S. 747 (1986), and City of 

Akron v. Akron Center for Reproductive Health, 462 u.s. 416 

(1983), control the outcome of this case. Court's Opinion at 20. 

In those cases, however, the Supreme Court struck down "informed 

consent" laws that required all doctors within their respective 

jurisdictions to provide all pregnant patients contemplating 

abortion with a litany of information, regardless of whether the 

patient sought the information or her doctor thought the 

information necessary to the patient's decision to abort. 

Thornburgh and Akron had nothing to do with a governmental 

decision to encourage childbirth and discourage abortion through 

the funding of services relating to the former and not the latter. 

The possibility that the HHS regulations will discourage some 

women from having an abortion is hardly sufficient to invalidate 

those regulations on their face. 2 See Thornburgh, 476 u.s. at 829 

(O'Connor, J., dissenting). Webster v. Reproductive Health 

Servs., 109 S. Ct. 3040 (1989), Harris v. McRae, 448 u.s. 297 

(1980), and Maher v. Roe, 432 u.s. 464 (1977), all support the 

view that the allocation of government monies to encourage 

2 A facial challenge to the regulations is a most difficult 

challenge since the challenger must establish that the regulations 

would be invalid under all circumstances. That the regulations 

might operate unconstitutionally under some scenario is 

insufficient to render the regulations invalid on their face. 

Webster v. Reproductive Health Servs, 109 s. Ct. 3040, 3060 (1990) 

(O'Connor, J., concurring). 

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childbirth over abortion does not unduly burden a woman's right to 

seek an abortion or place a governmental obstacle in the path of a 

woman choosing to have an abortion. Yet this court rejects this 

line of decisions as bearing only a "superficial resemblance" to 

the instant case. Court's Opinion at 14. 

Roe v. Wade, 410 u.s. 113 (1973), imposes "no limitation on 

the authority of a State to make a value judgment favoring 

childbirth over abortion, and to implement that judgment by the 

allocation of public funds." Maher, 432 U.S. at 474 (emphasis 

added). Section 59.8's restrictions on abortion counseling and 

referrals for Title X recipients leaves a pregnant woman with 

essentially the same choice as if the government had chosen not to 

provide Title X grants at all. Admittedly, this analysis might 

differ if the government had socialized medicine, see Webster, 109 

S. Ct. at 3052 n.8, but the government has not. At this point, 

the regulations interfere with a woman's ability to obtain an 

abortion only if she seeks an abortion with the assistance of 

Title X funds. See id. at 3052. The inability of an indigent 

woman to obtain an abortion would be no less in the absence of 

Title X. See Harris, 448 u.s. at 316. Accordingly, the HHS 

regulations do not infringe upon a woman's right to abortion. 

II. 

The regulations, however, undoubtedly infringe upon the 

doctor-patient relationship by limiting the free flow of 

information from the doctor to the patient regarding abortion 

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services. As Judge Cardamone stated: "[A] Title X physician's 

hands are tied with respect to the response he or she may give to 

a patient seeking abortion information. . . . [The regulations] 

constitute[] a trap for the mostly unsophisticated and unwary 

patients, and jeopardizes the ability of Title X physicians to 

safeguard the health of those people seeking their expert advice." 

State of New York v. Sullivan, 889 F.2d 401, 415 (2d Cir. 1989) 

(Cardomone, J., concurring), cert. granted, 110 S. Ct. 2559 

(1990). 

A physician certainly has a common law duty to discuss 

matters openly and frankly with the patient. See Smith v. Cote, 

513 A.2d 341, 355 (N.H. 1986) (Souter, J., concurring) 

(physician's timely disclosure of professional limits based on 

moral scruples combined with timely referral to physician not so 

constrained may be sufficient defense in action for failure to 

advise). Yet the Constitution provides little protection for the 

"dialogue" a physician undertakes in the course of treating a 

patient. Thornburgh, 476 U.S. at 802 (White, J., dissenting). 

Regulation of the professions is a matter within the competence of 

lawmakers, not federal courts. Id. at 802-803 (Constitution is 

"largely unconcerned" with substantive aspect of professional 

regulation). Because the HHS regulations are rationally related 

to the governmental interest in "protecting potential life," they 

in no way infringe upon a physician's constitutional rights. See 

Akron, 462 u.s. at 466 (O'Connor, J., dissenting). 

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The first amendment does not require the government to 

subsidize the spread of information which as a matter of public 

policy the government finds repugnant. Regan v. Taxation with 

Representation, 461 U.S. 540, 546 (1983). Perry v. Sinderman, 

408 u.s. 593 (1972), cited by the court to support its holding 

that the regulations violate a physician's first amendment rights, 

is not to the contrary. Court's Opinion at 23. In Perry, a state 

supported employer refused to extend the contract of its employee 

because the employee had exercised his first amendment rights 

outside the scope of his employment. Nothing in Title X prohibits 

recipients from saying about abortion whatever they desire outside 

of Title X services. State of New York, 889 F.2d at 412-13. 

Moreover, in Perry, the employer's purpose in suppressing the 

speech was not to avoid subsidizing the speech, but rather to 

punish the employee for political activity. See FCC v. League of 

Women Voters, 468 u.s. 402, 408 (1984) (Rehnquist, J., 

dissenting). 3 Unlike this case, the state action in Perry was 

unrelated to any legitimate governmental objective. Through the 

HHS regulations, the government in this instance merely has chosen 

to encourage childbirth rather than abortion. That policy choice 

3 In League of Women Voters, the Court by a five to four vote 

held unconstitutional a congressional ban on editorializing by 

noncommercial educational television and radio stations where 

federal funding constituted only 1% of the stations' overall 

income. In contrast, federal funds account for 50% of the monies 

received by Title X recipients. Court's Opinion at 12. 

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in no way contravenes the Constitution. 4 

4 In United Pub. Workers v. Mitchell, 330 U.S. 75 (1947) and 

Oklahoma v. United States Civil Serv. Comm'n, 330 U.S. 127 (1947), 

the Supreme Court rejected the notion that Section 12(a) of the 

Hatch Act was unconstitutional because of its interference with an 

employee's freedom of expression in political matters. In his 

dissent in League of Women Voters, Justice Rehnquist cogently 

noted: 

Section 12(a) of the Hatch Act totally prohibits any 

local or state employee who is employed in any activity 

which receives partial or total financing from the 

United States from taking part in any political 

activity. One might just as readily denounce such 

congressional action as prohibiting employees of a state 

or local government receiving even a minor fraction of 

that government's income from federal assistance from 

exercising their First Amendment right to speak. 

468 U.S. at 406 (Rehnquist, J., dissenting). Of course, political 

association constitutes the "core of those activities protected by 

the first amendment." Elrod v. Burns, 427 u.s. 347, 356 (1976). 

But the first amendment does not prohibit government from 

regulating the public political activity of those even partially 

dependent on its monetary benefits. How then, can the first 

amendment be read to prohibit a restriction on the dialogue 

between a physician and patient, when the physician and patient 

rely on federal funding to carry on such diaglogue? 

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