Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca4-07-01234/USCOURTS-ca4-07-01234-0/pdf.json

Parties Involved:
R. Steve Bowden

Skip Bradley

James Brown

Thomas Brown

Roy Cooper

Richard Davis

Dennis Hall

NC Board of Chiropractic Examiners
Appellee
Robert Stroud

D.C. Darcey R. Walraven
Appellant
Staten Wilcox

Document Text:

UNPUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

No. 07-1234

D.C. DARCEY R. WALRAVEN,

Plaintiff - Appellant,

v.

NC BOARD OF CHIROPRACTIC EXAMINERS,

Defendant - Appellee,

and

ROY COOPER, In his official capacity as Attorney General for

the State of North Carolina Department of Justice; RICHARD

DAVIS, In his official capacity as the duly appointed member

of the North Carolina Board of Chiropractic Examiners; THOMAS

BROWN, In his official capacity as the duly appointed member

of the North Carolina Board of Chiropractic Examiners; DENNIS

HALL, In his official capacity as the duly appointed member of

the North Carolina Board of Chiropractic Examiners; JAMES

BROWN, In his official capacity as the duly appointed member

of the North Carolina Board of Chiropractic Examiners; SKIP

BRADLEY, In his official capacity as the duly appointed member

of the North Carolina Board of Chiropractic Examiners; ROBERT

STROUD, In his official capacity as the duly appointed member

of the North Carolina Board of Chiropractic Examiners; STATEN

WILCOX, In his official capacity as the duly appointed member

of the North Carolina Board of Chiropractic Examiners; R.

STEVE BOWDEN, In his official capacity as the duly appointed

member of the North Carolina Board of Chiropractic Examiners,

Defendants.

Appeal from the United States District Court for the Western

District of North Carolina, at Charlotte. Frank D. Whitney,

District Judge. (3:04-cv-00321)

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2

Argued: January 29, 2008 Decided: April 9, 2008

Before GREGORY and SHEDD, Circuit Judges, and Patrick M. DUFFY,

United States District Judge for the District of South Carolina,

sitting by designation.

Affirmed by unpublished per curiam opinion.

ARGUED: James F. McCarthy, III, KATZ, TELLER, BRANT & HILD,

Cincinnati, Ohio, for Appellant. James C. Fuller, Jr., Davidson,

North Carolina; Vance Callahan Kinlaw, Greensboro, North Carolina,

for Appellee. ON BRIEF: Prosser D. Carnegie, MCINTOSH LAW FIRM,

P.C., Davidson, North Carolina, for Appellee.

Unpublished opinions are not binding precedent in this circuit.

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1Cooper moved to be dismissed, asserting that the North

Carolina Attorney General does not enforce the statute and rules

regarding chiropractic practice in North Carolina, and Walraven

stipulated to his dismissal. 

2

Specifically, Walraven challenged sections 90-401 and 90-

401.1 of the North Carolina General Statutes and section

10.0303(a)-(b) of the North Carolina Administrative Code. Section

90-401 of the North Carolina General Statutes provides: 

A health care provider shall not financially compensate

in any manner a person, firm, or corporation for

recommending or securing the health care provider’s

3

PER CURIAM:

Appellant Darcey R. Walraven, D.C., (“Walraven”) appeals the

order of the district court denying her motion for summary judgment

and granting the Appellees’ cross-motion for summary judgment. We

affirm. 

I.

In July 2004, Walraven filed her complaint and motion for

temporary restraining order and injunction against Roy Cooper, in

his official capacity as Attorney General for the State of North

Carolina,1

 and Richard Davis, Thomas Brown, Dennis Hall, James

Brown, Skip Bradley, Robert Stroud, Jr., Staten Wilcox, and R.

Steve Bowden, in their official capacities as the duly appointed

members of the North Carolina Board of Chiropractic Examiners

(collectively “the Board”). In her complaint, Walraven challenged

certain North Carolina statutes that limit the advertising that she

may undertake in the pursuit of her profession as a chiropractor.2

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employment by a patient, or as a reward for having made

a recommendation resulting in the health care provider’s

employment by a patient. No health care provider who

refers a patient of that health care provider to another

health care provider shall receive financial or other

compensation from the health care provider receiving the

referral as a payment solely or primarily for the

referral. This section shall not be construed to

prohibit a health care provider’s purchase of advertising

which does not entail direct personal contact or

telephone contact of a potential patient.

N.C. Gen. Stat. § 90-401 (1994). Section 90-401.1 provides: 

It shall be unlawful for a health care provider or the

provider’s employee or agent to initiate direct personal

contact or telephone contact with any injured, diseased,

or infirmed person, or with any other person residing in

the injured, diseased, or infirmed person’s household,

for a period of 90 days following the injury or the onset

of the disease or infirmity, if the purpose of initiating

the contact, in whole or in part, is to attempt to induce

or persuade the injured, diseased, or infirmed person to

become a patient of the health care provider. This

section shall not be construed to prohibit a health care

provider’s use of posted letters, brochures, or

information packages to solicit injured, diseased, or

infirmed persons, so long as such use does not entail

direct personal contact with the person.

N.C. Gen. Stat. § 90-401.1 (1994). Lastly, the relevant portion of

the North Carolina Administrative Code provides:

(a) In-Person and Telephone Solicitation of Auto

Accident Victims. In order to protect the public from

misrepresentation, coercion or undue influence, it shall

be unlawful for a doctor of chiropractic, or the doctor’s

employee, to initiate direct personal contact or

telephone contact with any person who has been injured in

a motor vehicle collision, or with any person residing in

the injured person's household, for a period of 90 days

following the collision, if the purpose of initiating

contact is, in whole or part, to solicit the injured

person to become a patient of the doctor.

(b) Acceptance of Referrals From Runners. It shall be

4

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unlawful for a doctor of chiropractic to accept as a

patient any person injured in an automobile accident who

was referred by a runner. As used in this Rule, the term

“runner” means any person, firm or corporation that

routinely obtains the names of injured persons from motor

vehicle accident reports or other public records and then

contacts those persons to induce them to seek medical or

chiropractic treatment or pursue legal claims.

21 N.C. Admin. Code 10.0303(a)-(b) (1994).

3Walraven moved to North Carolina from Ohio, where she had

been permitted, pursuant to Ohio Admin. Code § 4734-9-02 and

certain regulations contained therein, to solicit patients

telephonically following an accident.

5

These statutes preclude Walraven and/or anyone acting on her behalf

from soliciting, either in person or telephonically, prospective

patients who may need chiropractic treatment as a result of a motor

vehicle accident for a period of 90 days following the accident. 

In her complaint, Walraven asserted that these North Carolina

statutes constitute an unreasonable and unconstitutional

restriction on commercial speech in violation of the First

Amendment to the United States Constitution. In support of her

challenge, Walraven proposed a less restrictive alternative to

North Carolina’s regulatory scheme; specifically, Walraven proposed

a regulatory scheme akin to Ohio’s that would permit the kind of

marketing that she seeks to undertake.3

 

In response, the Board asserted that North Carolina’s

regulatory scheme is a lawful restriction on commercial speech

reasonably tailored to achieve substantial government interests,

which include the following: (1) to eliminate overreaching or the

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exercise of undue influence by health care providers; (2) to

preserve the privacy of injured or ill persons and their immediate

families; (3) to protect against false or misleading advertising

and “bait and switch” advertising practices; (4) to protect against

one-sided presentations that encourage speedy and uninformed

decision-making concerning the availability, nature, and price of

health care services and the necessity of obtaining such services;

(5) to minimize situations where the exercise of professional

judgment by a health care provider is clouded by pecuniary selfinterest; (6) to protect persons whose injury or illness makes them

more vulnerable and for whom telephonic solicitation would add to

their level of distress; and (7) to maintain standards among

members of licensed health care providers. 

The district court denied Walraven’s motion for a temporary

restraining order as well as her motion for a preliminary

injunction. The parties subsequently filed cross-motions for

summary judgment. In a written order dated February 27, 2007, the

district court denied Walraven’s motion for summary judgment and

granted the Board’s motion for summary judgment, finding that the

Board satisfied its burden to establish the constitutionality of

the North Carolina statutes at issue. 

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II.

A.

This court reviews an award of summary judgment de novo. Hill

v. Lockheed Martin Logistics Mgmt., Inc., 354 F.3d 277, 283 (4th

Cir. 2004) (en banc). Summary judgment is appropriate “if the

pleadings, depositions, answers to interrogatories, and admissions

on file, together with the affidavits, if any, show that there is

no genuine issue as to any material fact and that the moving party

is entitled to judgment as a matter of law.” Fed. R. Civ. P.

56(c). 

B.

The Supreme Court has extended the protections of the First

Amendment to purely commercial speech; nevertheless, the Court has

afforded commercial speech “a limited measure of protection,

commensurate with its subordinate position in the scale of First

Amendment values, while allowing modes of regulation that might be

impermissible in the realm of noncommercial expression.” Ohralik

v. Ohio State Bar Ass’n, 436 U.S. 447, 456 (1978); see also Florida

Bar v. Went For It, Inc., 515 U.S. 618, 623 (1995) (quoting the

same). In view of this, the regulation of commercial speech is

subject to intermediate scrutiny under the traditional framework

set forth by the Supreme Court in Central Hudson Gas & Elec. Corp.

v. Public Serv. Comm’n of N.Y., 447 U.S. 557, 566 (1980). See

Adventure Comms., Inc. v. Kentucky Registry of Election Fin., 191

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F.3d 429, 439 (4th Cir. 1999) (citing Central Hudson, 447 U.S. at

566). In Central Hudson, the Court stated:

In commercial speech cases, then, a four-part analysis

has developed. At the outset, we must determine whether

the expression is protected by the First Amendment. For

commercial speech to come within that provision, it at

least must concern lawful activity and not be misleading.

Next, we ask whether the asserted governmental interest

is substantial. If both inquiries yield positive

answers, we must determine whether the regulation

directly advances the governmental interest asserted, and

whether it is not more extensive than is necessary to

serve that interest.

447 U.S. at 566. Thus, for a commercial speech regulation to be

constitutionally permissible under the Central Hudson test, the

speech in question must concern lawful activity and not be

misleading; the asserted governmental interest to be served by the

regulation must be substantial; and the regulation must be narrowly

drawn. See Florida Bar, 515 U.S. at 623-34; see also Ficker v.

Curran, 119 F.3d 1150, 1152 (4th Cir. 1997) (citing Central Hudson

and Florida Bar). “The party seeking to uphold a restriction on

commercial speech carries the burden of justifying it.” Bolger v.

Youngs Drug Prods. Corp., 463 U.S. 60, 71, n. 20 (1983). 

III. 

Here, as the district court concluded, there is no question

that the first two prongs of the Central Hudson test are satisfied.

That is to say, it is clear that the non-deceptive advertising of

chiropractic services is protected speech under the First

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Amendment, and North Carolina has several legitimate and

substantial governmental interests in regulating solicitation

concerning chiropractic services. Thus, the real issue is whether

North Carolina’s regulatory scheme directly advances the

governmental interests asserted and whether it is more extensive

than is necessary to serve that interest. 

To establish that the regulation directly advances the

governmental interests asserted, the Board must “demonstrate that

the harms it recites are real and that its restriction will in fact

alleviate them to a material degree.” Edenfield v. Fane, 507 U.S.

761, 770-71 (1993). The Supreme Court has permitted governmental

bodies to justify speech regulations by reference to studies and/or

anecdotal evidence. In fact, the Court has permitted litigants to

justify speech regulations with reference to “studies and anecdotes

pertaining to different locales altogether . . . .” Florida Bar,

515 U.S. at 628 (citations omitted).

Here, the district court agreed with Walraven that “the

regulations at issue may not materially advance some of the

governmental interests that the Board asserts.” Walraven v.

Cooper, et al, No. 3:04-cv-321-W, 2007 WL 656284, at *2 (W.D.N.C.

Feb. 27, 2007). Nevertheless, the district court determined that

the challenged regulations materially advance at least one

substantial governmental interest – that is, “the protection of a

particular segment of the public from invasive (and potentially

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coercive and/or misleading) solicitation tactics under

circumstances in which they may be particularly vulnerable.” Id.

The court quoted the following passage from its previous order

denying Walraven’s motion for a preliminary injunction:

The [Board] proffered evidence in the form of affidavits,

exhibits and testimony, which illustrates the type of

harassment personal injury victims were often subject to

in the days following an injury, prior to the enactment

of the various statutes in question. The evidence

offered by the [Board] also show[s] that victims of

personal injury are often in a heightened state of

vulnerability and distress in the days following an

injury, and that the statutes in question have provided

some form of relief from in-person and telephone coercion

by chiropractors or runners.

Id. at *3 (quoting the court’s July 23, 2004 order denying

preliminary injunction). 

Having found the third prong of the Central Hudson test

satisfied, the district court next considered the final prong of

the Central Hudson test, namely, whether the regulatory scheme is

more extensive than is necessary to serve the governmental

interest. The district court noted that to establish this final

prong, the Board needed to demonstrate a reasonable “fit between

the legislature’s ends and the means to accomplish those ends, a

fit that is not necessarily perfect, but reasonable; that

represents not necessarily the single best disposition but one

whose scope is in proportion to the interest served, that employs

not necessarily the least restrictive means but . . . a means

narrowly tailored to achieve the desired objective.” Florida Bar,

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515 U.S. at 632 (quoting Bd. of Trs. of State Univ. of N.Y. v. Fox,

492 U.S. 469, 480 (1989)) (internal quotation marks omitted). 

In addressing the final prong of the Central Hudson test, the

district court first evaluated whether the challenged statutes are

overly broad, such that they restrict more speech than is necessary

to accomplish the state’s objectives. In rejecting Walraven’s

assertion that the statutes amount to a blanket ban, the court

stated:

While the Court agrees that the challenged regulations

significantly burden Dr. Walraven’s ability to advertise

by effectively precluding all telephonic contact with the

class of persons who would be most receptive to a

personal invitation to see a chiropractor, this is a far

cry from a “blanket ban” on Dr. Walraven’s commercial

speech. Dr. Walraven retains the ability to reach

prospective car accident clients by means of the mass

media and even targeted mailings, and she may solicit

potential clients in-person or by telephone so long as

she does not target them on account of their status as

recent car accident victims. By singling out for

regulation only speech which is particularly susceptible

to fraud and overreaching (i.e., in-person and telephonic

solicitation) and which is targeted at a protected class

(i.e., recent victims of car accidents), the North

Carolina regulations are easily distinguished from the

laws of other jurisdictions which have been struck down

as overly broad in the cases cited by Dr. Walraven.

Walraven, 2007 WL 656284, at *3. 

The court next examined whether Walraven’s proposed lessrestrictive alternative would be as feasible and effective as North

Carolina’s current scheme. In considering Walraven’s proposed

script, from which she asserted that her contracted telemarketers

would be instructed not to deviate, the court noted that “the

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content of a telephonic solicitation is inherently more difficult

to regulate than the content of a written solicitation – a

distinguishing feature that may justify a prophylactic ban of the

former but not the latter.” Id. at *4 (citing Shapero v. Kentucky

Bar Assoc., 486 U.S. 466, 476 (1988); Nat’l Funeral Servs., Inc. v.

Rockefeller, 870 F.2d 136, 144 (4th Cir. 1989); and Gregory v.

Louisiana Bd. of Chiropractic Exam’rs, 608 So.2d 987 (La. 1992)).

The district court further noted:

Written solicitations are capable of being screened for

compliance by a state regulatory authority before they

are ever mailed. By contrast, telephonic solicitations

(even scripted ones) do not take place in a controlled

environment and improper deviations from the script are

not susceptible to detection until after the harm is done

(provided that a disgruntled consumer even bothers to

report the violation to the relevant authorities), and

then the only recourse in the event of a violation likely

would be against a party (the “runner” or telemarketer)

not necessarily subject to the Board's disciplinary

jurisdiction. Furthermore, even assuming that Dr.

Walraven’s alternative would be effective at ensuring the

truthful and tactful content of the solicitation, her

proposal does not address the concerns that the Board has

advanced for protecting the privacy of car accident

victims from a barrage of invasive and subtly coercive

phone calls in the immediate wake of experiencing a

traumatic life event.

Id. Based on the foregoing, the district court concluded that the

Board satisfied its burden under the Central Hudson test to

demonstrate that North Carolina’s regulatory scheme directly

advances the governmental interest asserted and is not more

extensive than is necessary to serve that interest. 

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IV.

Having thoroughly reviewed the district court’s order and the

parties’ briefs and submissions on appeal, and having heard oral

argument in this case, we conclude, based on the reasons set forth

by the district court in its order dated February 27, 2007, that

the Board satisfied its burden under the Central Hudson test to

establish the constitutionality of the North Carolina regulations

at issue. Accordingly, we affirm the district court’s award of

summary judgment in favor of the Board and denial of summary

judgment in favor of Walraven.

 AFFIRMED

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