PUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

No. 14-1150

GRETCHEN S. STUART, MD, on behalf of herself and her 

patients seeking abortions; JAMES R. DINGFELDER, MD, on 

behalf of himself and his patients seeking abortions; DAVID 

A. GRIMES, MD, on behalf of himself and his patients 

seeking abortions; AMY BRYANT, MD, on behalf of herself and 

her patients seeking abortions; SERINA FLOYD, MD, on behalf 

of herself and her patients seeking abortions; DECKER & 

WATSON, INC., d/b/a Piedmont Carolina Medical Clinic; 

PLANNED PARENTHOOD OF CENTRAL NORTH CAROLINA; A WOMAN'S 

CHOICE OF RALEIGH, INC.; PLANNED PARENTHOOD HEALTH SYSTEMS, 

INC.; TAKEY CRIST, on behalf of himself and his patients 

seeking abortions; TAKEY CRIST, M.D., P.A., d/b/a Crist 

Clinic for Women,

Plaintiffs - Appellees,

v.

PAUL S. CAMNITZ, MD, in his official capacity as President 

of the North Carolina Medical Board and his employees, 

agents and successors; ROY COOPER, in his official capacity 

as Attorney General of North Carolina and his employees, 

agents and successors; ALDONA ZOFIA WOS, in her official 

capacity as Secretary of the North Carolina Department of 

Health and Human Services and her employees, agents and 

successors; JIM WOODALL, in his official capacity as 

District Attorney ("DA") for Prosecutorial District ("PD") 

15B and his employees, agents and successors; LEON STANBACK, 

in his official capacity as DA for PD 14 and his employees, 

agents and successors; DISTRICT ATTORNEY DOUGLAS HENDERSON, 

in his official capacity as DA for PD 18 and his employees, 

agents and successors; BILLY WEST, in his official capacity 

as DA for PD 12 and his employees, agents and successors; C. 

COLON WILLOUGHBY, JR., in his official capacity as DA for PD 

10 and his employees, agents and successors; BENJAMIN R. 

DAVID, in his official capacity as DA for PD 5 and his 

employees, agents and successors; ERNIE LEE, in his official 

capacity as DA for PD 4 and his employees, agents and 
2

successors; JIM O'NEILL, in his official capacity as DA for 

PD 21 and his employees, agents and successors,

Defendants - Appellants,

JOHN THORP,

 Intervenor/Defendant,

FRANCIS J. BECKWITH, MJS, PhD; GERARD V. BRADLEY; TERESA S. 

COLLETT; DAVID K. DEWOLF; RICK DUNCAN; EDWARD M. GAFFNEY; 

STEPHEN GILLES; MICHAEL STOKES PAULSEN; RONALD J. RYCHLAK; 

RICHARD STITH; RUTH SAMUELSON; PAT MCELRAFT; PAT HURLEY; 

MARILYN AVILA; SUSAN MARTIN; CAROLYN M JUSTICE; RENA W. 

TURNER; MICHELE D. PRESNELL; SARAH STEVENS; JACQUELINE 

MICHELLE SCHAFFER; DEBRA CONRAD; MARK BRODY; CHRIS WHITMIRE; 

ALLEN MCNEILL; DONNY LAMBETH; GEORGE CLEVELAND; LINDA 

JOHNSON; DAVID CURTIS; JOYCE KRAWIEC; SHIRLEY RANDLEMEN; DAN 

SOUCEK; NORMAN SANDERSON; WARREN DANIEL; BUCK NEWTON; KATHY 

L. HARRINGTON; ANDREW BROCK,

Amici Supporting Appellant,

AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS; 

AMERICAN MEDICAL ASSOCIATION; AMERICAN PUBLIC HEALTH 

ASSOCIATION,

Amici Supporting Appellee.

Appeal from the United States District Court for the Middle 

District of North Carolina, at Greensboro. Catherine C. Eagles, 

District Judge. (1:11-cv-00804-CCE-LPA)

Argued: October 29, 2014 Decided: December 22, 2014

Before TRAXLER, Chief Judge, and WILKINSON and DUNCAN, Circuit 

Judges.
3

Affirmed by published opinion. Judge Wilkinson wrote the 

opinion, in which Chief Judge Traxler and Judge Duncan joined.

ARGUED: John Foster Maddrey, NORTH CAROLINA DEPARTMENT OF 

JUSTICE, Raleigh, North Carolina, for Appellants. Julie 

Rikelman, CENTER FOR REPRODUCTIVE RIGHTS, New York, New York, 

for Appellees. ON BRIEF: Roy Cooper, Attorney General, Gary R. 

Govert, Assistant Solicitor General, I. Faison Hicks, Special 

Deputy Attorney General, NORTH CAROLINA DEPARTMENT OF JUSTICE, 

Raleigh, North Carolina, for Appellants. Christopher Brook, 

AMERICAN CIVIL LIBERTIES UNION OF NORTH CAROLINA LEGAL 

FOUNDATION, Raleigh, North Carolina; Andrew D. Beck, AMERICAN 

CIVIL LIBERTIES UNION FOUNDATION, New York, New York; Jennifer 

Sokoler, CENTER FOR REPRODUCTIVE RIGHTS, New York, New York; 

Walter Dellinger, Anton Metlitsky, Leah Godesky, O'MELVENY & 

MYERS LLP, Washington, D.C.; Diana O. Salgado, New York, New 

York, Helene T. Krasnoff, PLANNED PARENTHOOD FED. OF AMERICA, 

Washington, D.C., for Appellees. Anna R. Franzonello, Mailee R. 

Smith, William L. Saunders, Denise M. Burke, AMERICANS UNITED 

FOR LIFE, Washington, D.C., for Amici Francis J. Beckwith, MJS, 

PhD, Gerard V. Bradley, Teresa S. Collett, David K. Dewolf, Rick 

Duncan, Edward M. Gaffney, Stephen Gilles, Michael Stokes 

Paulsen, Ronald J. Rychlak, and Richard Stith. Scott W. 

Gaylord, Jennings Professor, Thomas J. Molony, Associate 

Professor of Law, ELON UNIVERSITY SCHOOL OF LAW, Greensboro, 

North Carolina, for Amici Ruth Samuelson, Pat McElraft, Pat 

Hurley, Marilyn Avila, Susan Martin, Carolyn M. Justice, Rena W. 

Turner, Michele D. Presnell, Sarah Stevens, Jacqueline Michelle 

Schaffer, Debra Conrad, Mark Brody, Chris Whitmire, Allen 

McNeill, Donny Lambeth, George Cleveland, Linda Johnson, David 

Curtis, Joyce Krawiec, Shirley Randlemen, Dan Soucek, Norman 

Sanderson, Warren Daniel, Buck Newton, Kathy L. Harrington, and 

Andrew Brock. Kimberly A. Parker, Alathea E. Porter, Thaila K. 

Sundaresan, Tiffany E. Payne, WILMER CUTLER PICKERING HALE AND 

DORR LLP, Washington, D.C., for Amici American College of 

Obstetricians and Gynecologists and American Medical 

Association. Shannon Rose Selden, Courtney M. Dankworth, 

DEBEVOISE & PLIMPTON LLP, New York, New York, for Amicus 

American Public Health Association.
4

WILKINSON, Circuit Judge:

At issue here is a North Carolina statute that requires 

physicians to perform an ultrasound, display the sonogram, and 

describe the fetus to women seeking abortions. A physician must 

display and describe the image during the ultrasound, even if 

the woman actively “avert[s] her eyes” and “refus[es] to hear.” 

N.C. Gen. Stat. § 90-21.85(b). This compelled speech, even 

though it is a regulation of the medical profession, is 

ideological in intent and in kind. The means used by North 

Carolina extend well beyond those states have customarily 

employed to effectuate their undeniable interests in ensuring 

informed consent and in protecting the sanctity of life in all 

its phases. We thus affirm the district court’s holding that 

this compelled speech provision violates the First Amendment.

I.

In July 2011, the North Carolina General Assembly passed 

the Woman’s Right to Know Act over a gubernatorial veto. The Act 

amended Chapter 90 of the North Carolina General Statutes, which 

governs medical and related professions, adding a new article 

regulating the steps that must precede an abortion.

Physicians and abortion providers filed suit after the 

Act’s passage but before its effective date, asking the court to 

enjoin enforcement of the Act and declare it unconstitutional. 

In October 2011, the district court issued a preliminary 
5

injunction barring enforcement of one provision of the Act, the 

Display of Real-Time View Requirement (“the Requirement”), 

codified at N.C. Gen. Stat. § 90-21.85. J.A. 143-44. The court 

subsequently allowed the plaintiffs to amend their complaint. 

The Third Amended Complaint asserted that the Display of RealTime View Requirement violated the physicians’ First Amendment 

free speech rights and the physicians’ and the patients’ 

Fourteenth Amendment due process rights. J.A. 282.1

The Display of Real-Time View Requirement obligates doctors 

(or technicians) to perform an ultrasound on any woman seeking 

an abortion at least four but not more than seventy-two hours 

before the abortion is to take place. N.C. Gen. Stat. § 90-

21.85(a)(1). The physician must display the sonogram so that the 

woman can see it, id. § 90-21.85(a)(3), and describe the fetus 

in detail, “includ[ing] the presence, location, and dimensions 

of the unborn child within the uterus and the number of unborn 

children depicted,” id. § 90-21.85(a)(2), as well as “the 

presence of external members and internal organs, if present and 

viewable,” id. § 90-21.85(a)(4). The physician also must offer 

 1 The Third Amended Complaint also challenged both the 

Display of Real-Time View Requirement and the Informed Consent 

to Abortion provision, N.C. Gen. Stat. § 90-21.82, as 

unconstitutionally vague. J.A. 281. The parties and the district 

court agreed on savings constructions so that the Act was not 

void for vagueness, and the plaintiffs did not appeal that 

ruling. Stuart v. Loomis, 992 F. Supp. 2d 585, 611 (M.D.N.C. 

2014) (district court opinion).
6

to allow the woman to hear the fetal heart tone. Id. § 90-

21.85(a)(2). The woman, however, may “avert[] her eyes from the 

displayed images” and “refus[e] to hear the simultaneous 

explanation and medical description” by presumably covering her 

eyes and ears. Id. § 90-21.85(b).

The Act provides an exception to these requirements only in 

cases of medical emergency. Id. § 90-21.86. Physicians who 

violate the Act are liable for damages and may be enjoined from 

providing further abortions that violate the Act in North 

Carolina. Id. § 90-21.88. Violation of the Act also may result 

in the loss of the doctor’s medical license. See id. § 90-

14(a)(2) (The North Carolina Medical Board may impose 

disciplinary measures, including license revocation, upon a 

doctor who “[p]roduc[es] or attempt[s] to produce an abortion 

contrary to law.”).

Not at issue in this appeal are several other informed 

consent provisions to which physicians, independently of the 

Display of Real-Time View Requirement, are subject. The first is 

the informed consent provision of the Act itself. Id. § 90-

21.82. It requires that, at least twenty-four hours before an 

abortion is to be performed, a doctor or qualified professional 

explain to the woman seeking the abortion the risks of the 

procedure, the risks of carrying the child to term, “and any 

adverse psychological effects associated with the abortion.” Id.
7

§ 90-21.82(1)(b), (d). The physician must also convey the 

“probable gestational age of the unborn child,” id. § 90-

21.82(1)(c), that financial assistance for the pregnancy may be 

available, that the father of the child is obligated to pay 

child support, and that there are alternatives to abortion, id.

§ 90-21.82(2)(a)-(d). Furthermore, the doctor must inform the 

woman that she can view on a state-sponsored website materials 

published by the state which describe the fetus. The doctor must 

also give or mail the woman physical copies of the materials if 

she wishes, and must “list agencies that offer alternatives to 

abortion.” Id. § 90-21.82(2)(e).

Before this Act, physicians were still subject to North 

Carolina’s general informed consent requirements when conducting 

abortions. See id. § 90-21.13(a); 10A N.C. Admin. Code 

14E.0305(a); Appellees’ Br. 6. Prior to its enactment, the 

physicians challenging the Act claim they were “inform[ing] each 

patient about the nature of the abortion procedure, its risks 

and benefits, and the alternatives available to the patient and 

their respective risks and benefits” and “counsel[ing] the 

patient to ensure that she was certain about her decision to 

have an abortion.” Appellees’ Br. 6.

Both parties moved for summary judgment. Applying 

heightened, intermediate scrutiny, Stuart v. Loomis, 992 F. 

Supp. 2d 585, 600-01 (M.D.N.C. 2014), the district court held 
8

that the Display of Real-Time View Requirement violated the 

physicians’ First Amendment rights to free speech. Id. at 607-

09. It thus granted the plaintiffs’ motion for summary judgment 

and entered a permanent injunction. Id. at 610-11. The court 

declined to reach the merits of the due process claim, finding 

it moot in light of the court’s ruling on the First Amendment 

claim. Id. at 611.2

We review a grant of summary judgment de novo. S. 

Appalachian Mountain Stewards v. A & G Coal Corp., 758 F.3d 560, 

562 (4th Cir. 2014). In so doing, we view the facts in the light 

most favorable to the state. Moore-King v. Cnty. of 

Chesterfield, Va., 708 F.3d 560, 566 (4th Cir. 2013).

II.

A.

“Congress shall make no law . . . abridging the freedom of 

speech.” U.S. Const. amend. I. This concept sounds simple, but 

proves more complicated on closer inspection. Laws that impinge 

upon speech receive different levels of judicial scrutiny 

depending on the type of regulation and the justifications and 

purposes underlying it. On the one hand, regulations that 

 2 After the district court’s order granting the preliminary 

injunction, several individuals and pregnancy counseling centers 

moved to intervene as defendants. The district court denied the 

motion, Stuart v. Huff, 2011 WL 6740400 (M.D.N.C. Dec. 22, 

2011), and this court affirmed, Stuart v. Huff, 706 F.3d 345 

(4th Cir. 2013).
9

discriminate against speech based on its content “are 

presumptively invalid,” R.A.V. v. City of St. Paul, Minn., 505 

U.S. 377, 382 (1992), and courts usually “apply the most 

exacting scrutiny,” Turner Broad. Sys., Inc. v. FCC, 512 U.S. 

622, 642 (1994); see also United States v. Playboy Entm’t Grp., 

Inc., 529 U.S. 803, 814 (2000). On the other hand, “area[s] 

traditionally subject to government regulation,” such as 

commercial speech and professional conduct, typically receive a 

lower level of review. Cent. Hudson Gas & Elec. Corp. v. Pub. 

Serv. Comm’n of N.Y., 447 U.S. 557, 562-63 (1980) (regulation of 

commercial speech); see also Keller v. State Bar of Cal., 496 

U.S. 1, 13-16 (1990) (regulation of legal profession). 

We thus must first examine the type of regulation at issue 

to determine the requisite level of scrutiny to apply. Turner, 

512 U.S. at 637 (explaining that “because not every interference 

with speech triggers the same degree of scrutiny under the First 

Amendment, we must decide at the outset the level of scrutiny 

applicable”). As we do, we are mindful of “the First Amendment’s 

command that government regulation of speech must be measured in 

minimums, not maximums.” Riley v. Nat’l Fed’n of the Blind of 

N.C., Inc., 487 U.S. 781, 790 (1988).

The physicians urge us to find that the regulation must 

receive strict scrutiny because it is content-based and 

ideological. See Appellees’ Br. 36-40. The state counters that 
10

the Requirement must be treated as a regulation of the medical 

profession in the context of abortion and thus subject only to 

rational basis review. See Appellants’ Br. 7-15, 20-28. The 

district court chose a different path. Recognizing that the 

Requirement both compelled speech and regulated the medical 

profession, the court applied neither strict scrutiny nor 

rational basis review, but rather the intermediate scrutiny 

standard normally used for certain commercial speech 

regulations. See Stuart v. Loomis, 992 F. Supp. 2d 585, 598-601 

(M.D.N.C. 2014). For the reasons outlined below, we agree with 

the district court that the Requirement is a content-based 

regulation of a medical professional’s speech which must satisfy 

at least intermediate scrutiny to survive.

B.

The Display of Real-Time View Requirement regulates both 

speech and conduct. The physician must convey the descriptions 

mandated by the statute in his or her own voice. The sonogram 

display is also intimately connected with the describing 

requirement. The two are thus best viewed as a single whole. In 

deciding whether an activity “possesses sufficient communicative 

elements to bring the First Amendment into play, we have asked 

whether ‘[a]n intent to convey a particularized message was 

present, and [whether] the likelihood was great that the message 

would be understood by those who viewed it.’” Texas v. Johnson, 
11

491 U.S. 397, 404 (1989) (quoting Spence v. Washington, 418 U.S. 

405, 410–11 (1974)). The state’s avowed intent and the 

anticipated effect of all aspects of the Requirement are to 

discourage abortion or at the very least cause the woman to 

reconsider her decision. See Appellants’ Br. 29-32. The clear 

import of displaying the sonogram in this context -- while the 

woman who has requested an abortion is partially disrobed on an 

examination table -- is to use the visual imagery of the fetus 

to dissuade the patient from continuing with the planned 

procedure. If the state’s intent is to convey a distinct 

message, the message does not lose its expressive character 

because it happens to be delivered by a private party. Whether 

one agrees or disagrees with the state’s approach here cannot be 

the question. In this context, the display of the sonogram is 

plainly an expressive act entitled to First Amendment 

protection. See, e.g., John Doe No. 1 v. Reed, 561 U.S. 186, 

194-95 (2010) (recognizing First Amendment protections for 

signing a referendum petition); Joseph Burstyn, Inc. v. Wilson, 

343 U.S. 495, 501-02 (1952) (commercial film).

The First Amendment not only protects against prohibitions 

of speech, but also against regulations that compel speech. 

“Since all speech inherently involves choices of what to say and 

what to leave unsaid, one important manifestation of the 

principle of free speech is that one who chooses to speak may 
12

also decide what not to say.” Hurley v. Irish-Am. Gay, Lesbian & 

Bisexual Grp. of Bos., 515 U.S. 557, 573 (1995) (citations 

omitted) (internal quotation marks omitted); see also Wooley v. 

Maynard, 430 U.S. 705, 714 (1977) (“[T]he First Amendment . . . 

includes both the right to speak freely and the right to refrain 

from speaking at all.”). A regulation compelling speech is by 

its very nature content-based, because it requires the speaker 

to change the content of his speech or even to say something 

where he would otherwise be silent. Riley, 487 U.S. at 795 

(“Mandating speech that a speaker would not otherwise make 

necessarily alters the content of the speech.”); Centro Tepeyac 

v. Montgomery Cnty., 722 F.3d 184, 189 (4th Cir. 2013) (en banc) 

(same). Compelled speech is particularly suspect because it can

directly affect listeners as well as speakers. Listeners may 

have difficulty discerning that the message is the state’s, not 

the speaker’s, especially where the “speaker [is] intimately 

connected with the communication advanced.” Hurley, 515 U.S. at 

576.

The Requirement is quintessential compelled speech. It 

forces physicians to say things they otherwise would not say. 

Moreover, the statement compelled here is ideological; it 

conveys a particular opinion. The state freely admits that the 

purpose and anticipated effect of the Display of Real-Time View 

Requirement is to convince women seeking abortions to change 
13

their minds or reassess their decisions. See Appellants’ Br. 29-

32.

It may be true, as the Fifth Circuit has noted, that “the 

required disclosures . . . are the epitome of truthful, nonmisleading information.” Tex. Med. Providers Performing Abortion 

Servs. v. Lakey, 667 F.3d 570, 577-78 (5th Cir. 2012). But an 

individual’s “right to tailor [his] speech” or to not speak at 

all “applies . . . equally to statements of fact the speaker 

would rather avoid.” Hurley, 515 U.S. at 573; see also Sorrel v. 

IMS Health Inc., 131 S. Ct. 2653, 2667 (2011); Turner, 512 U.S. 

at 645; Riley, 487 U.S. at 797-98. While it is true that the 

words the state puts into the doctor’s mouth are factual, that 

does not divorce the speech from its moral or ideological 

implications. “[C]ontext matters.” Greater Balt. Ctr. for 

Pregnancy Concerns, Inc. v. Mayor of Balt., 721 F.3d 264, 286 

(4th Cir. 2013) (en banc). Of course we need not go so far as to 

say that every required description of a typical fetus is in 

every context ideological. But this Display of Real-Time View 

Requirement explicitly promotes a pro-life message by demanding 

the provision of facts that all fall on one side of the abortion 

debate -- and does so shortly before the time of decision when 

the intended recipient is most vulnerable.

The state protests that the Requirement does not dictate a 

specific script and that the doctor is free to supplement the 
14

information with his own opinion about abortion. Reply Br. 14-

16. That is true; the state does not demand that the doctor use 

particular words. But that does not mean that the Requirement is 

“not designed to favor or disadvantage speech of any particular 

content.” Turner, 512 U.S. at 652. In fact, the clear and 

conceded purpose of the Requirement is to support the state’s 

pro-life position. That the doctor may supplement the compelled 

speech with his own perspective does not cure the coercion --

the government’s message still must be delivered (though not 

necessarily received).

Content-based regulations of speech typically receive 

strict scrutiny. Id. at 642. The state, however, maintains that 

the Requirement is merely a regulation of the practice of 

medicine that need only satisfy rational basis review. We turn 

now to that contention.3

C.

The state’s power to prescribe rules and regulations for 

professions, including medicine, has an extensive history. See

 3 Plaintiffs seem to suggest that the Display of Real-Time 

View Requirement constitutes viewpoint discrimination and that 

we should strike the provision down on that basis. See

Appellees’ Br. 2, 54. Because we find that the Requirement fails 

even intermediate scrutiny, infra Part III, it is unnecessary 

for us to definitively determine whether the compelled speech 

here requires strict scrutiny. See Greater Balt., 721 F.3d at 

288 (cautioning against “precipitately concluding that the 

[provision] is an exercise of viewpoint discrimination”).
15

Dent v. West Virginia, 129 U.S. 114, 122 (1889) (“[I]t has been 

the practice of different states, from time immemorial, to exact 

in many pursuits a certain degree of skill and learning upon 

which the community may confidently rely.”). Licensing and 

regulation by the state “provide clients with the confidence 

they require to put their health or their livelihood in the 

hands of those who utilize knowledge and methods with which the 

clients ordinarily have little or no familiarity.” King v. Gov. 

of N.J., 767 F.3d 216, 232 (3d Cir. 2014). The state may 

establish licensing qualifications, Dent, 129 U.S. at 122, 

oblige the payment of dues to a professional organization for 

purposes such as “disciplining members” and “proposing ethical 

codes,” Keller, 496 U.S. at 16, and even set standards for the 

conduct of professional activities, Barsky v. Bd. of Regents of 

Univ. of State of N.Y., 347 U.S. 442, 449-50 (1954). In the 

medical context, the state may require the provision of 

information sufficient for patients to give their informed 

consent to medical procedures, see Canterbury v. Spence, 464 

F.2d 772, 781 (D.C. Cir. 1972), and patients may seek damages 

when doctors fail to follow statutory and professionally 

recognized norms, see, e.g, N.C. Gen. Stat. § 90-21.88. Simply 

put, “[t]he power of government to regulate the professions is 

not lost whenever the practice of a profession entails speech.” 
16

Lowe v. SEC, 472 U.S. 181, 228 (1985) (White, J., concurring in 

the judgment).

But that does not mean that individuals simply abandon 

their First Amendment rights when they commence practicing a 

profession. See Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 

833, 884 (1992) (plurality opinion) (“[T]he physician’s First 

Amendment rights not to speak are implicated.” (emphasis 

added)); Lowe, 472 U.S. at 229-30 (White, J., concurring in the 

judgment) (“But the principle that the government may restrict 

entry into professions and vocations through licensing schemes 

has never been extended to encompass the licensing of speech per 

se or of the press.”). To the contrary, “speech is speech, and 

it must be analyzed as such for purposes of the First 

Amendment.” King, 767 F.3d at 229. There are “many dimensions” 

to professionals’ speech. Fla. Bar v. Went For It, Inc., 515 

U.S. 618, 634 (1995). And “[t]here are circumstances in which we 

will accord speech by attorneys on public issues and matters of 

legal representation the strongest protection our Constitution 

has to offer.” Id. With all forms of compelled speech, we must 

look to the context of the regulation to determine when the 

state’s regulatory authority has extended too far. Riley, 487 

U.S. at 796.

When the First Amendment rights of a professional are at 

stake, the stringency of review thus slides “along a continuum” 
17

from “public dialogue” on one end to “regulation of professional 

conduct” on the other. Pickup v. Brown, 740 F.3d 1208, 1227, 

1229 (9th Cir. 2013) (emphasis in original). Other circuits have 

recently relied on the distinction between professional speech 

and professional conduct when deciding on the appropriate level 

of scrutiny to apply to regulations of the medical profession. 

See King, 767 F.3d at 224-29, 233-37; Wollschlaeger v. Gov. of 

Fla., 760 F.3d 1195, 1217-25 (11th Cir. 2014).

The Display of Real-Time View Requirement resides somewhere 

in the middle on that sliding scale. It is a regulation of 

medical treatment insofar as it directs doctors to do certain 

things in the context of treating a patient. In that sense, the 

government can lay claim to its stronger interest in the 

regulation of professional conduct. But that is hardly the end 

of the matter. The government’s regulatory interest is less 

potent in the context of a self-regulating profession like 

medicine. Moore-King v. Cnty. of Chesterfield, Va., 708 F.3d 

560, 570 (4th Cir. 2013). Moreover, the Requirement is a clearly 

content-based regulation of speech; it requires doctors to “say” 

as well as “do.” As the district court found, the confluence of 

these factors points toward borrowing a heightened intermediate 

scrutiny standard used in certain commercial speech cases. 

Stuart, 992 F. Supp. 2d at 600. Thus, we need not conclusively 

determine whether strict scrutiny ever applies in similar 
18

situations, because in this case “the outcome is the same 

whether a special commercial speech inquiry or a stricter form 

of judicial scrutiny is applied.” Sorrel, 131 S. Ct. at 2667.

D.

Insofar as our decision on the applicable standard of 

review differs from the positions taken by the Fifth and Eighth 

Circuits in cases examining the constitutionality of abortion 

regulations under the First Amendment, we respectfully disagree. 

Both courts relied heavily on a single paragraph in Casey:

All that is left of petitioners' argument is an 

asserted First Amendment right of a physician not to 

provide information about the risks of abortion, and 

childbirth, in a manner mandated by the State. To be 

sure, the physician's First Amendment rights not to 

speak are implicated, see Wooley v. Maynard, 430 U.S. 

705 (1977), but only as part of the practice of 

medicine, subject to reasonable licensing and 

regulation by the State, cf. Whalen v. Roe, 429 U.S. 

589, 603 (1977). We see no constitutional infirmity in 

the requirement that the physician provide the 

information mandated by the State here.

505 U.S. at 884; see also Lakey, 667 F.3d at 574-76; Planned 

Parenthood Minn., N.D., S.D. v. Rounds, 686 F.3d 889, 893 (8th 

Cir. 2012) (en banc) (“Rounds II”); Planned Parenthood Minn., 

N.D., S.D. v. Rounds, 530 F.3d 724, 733-35 (8th Cir. 2008) (en 

banc) (“Rounds I”). That is the sum of the First Amendment 

analysis in Casey.

In considering an ultrasound display-and-describe 

requirement similar to the one at issue here, the Fifth Circuit 
19

interpreted Casey as employing “the antithesis of strict 

scrutiny.” Lakey, 667 F.3d at 575. It further noted that in 

Gonzales v. Carhart, the Supreme Court “upheld a state’s 

‘significant role . . . in regulating the medical profession.’” 

Lakey, 667 F.3d at 575-76 (quoting Gonzales v. Carhart, 550 U.S. 

124, 157 (2007)). Therefore, the Lakey court reasoned, 

provisions such as the one at issue here -- that is, laws that 

“require truthful, nonmisleading, and relevant disclosures,” id.

at 576 -- “do not fall under the rubric of compelling 

‘ideological’ speech that triggers First Amendment strict 

scrutiny,” id. The Eighth Circuit similarly drew from Casey and 

Gonzales the rule that the First Amendment permits the state to 

“use its regulatory authority to require a physician to provide 

truthful, non-misleading information relevant to a patient’s 

decision to have an abortion.” Rounds I, 530 F.3d at 734-35; see 

also Rounds II, 686 F.3d at 893.

With respect, our sister circuits read too much into Casey

and Gonzales. The single paragraph in Casey does not assert that 

physicians forfeit their First Amendment rights in the 

procedures surrounding abortions, nor does it announce the 

proper level of scrutiny to be applied to abortion regulations 

that compel speech to the extraordinary extent present here. The 

plurality opinion stated that the medical profession is “subject 

to reasonable licensing and regulation by the State” and that 
20

physicians’ speech is “part of the practice of medicine.” Casey, 

505 U.S. at 884. But the plurality did not hold sweepingly that 

all regulation of speech in the medical context merely receives 

rational basis review. Rather, having noted the physicians’ 

First Amendment rights and the state’s countervailing interest 

in regulating the medical profession, the plurality simply 

stated that it saw “no constitutional infirmity in the 

requirement that the physician provide the information mandated 

by the State here.” Id. (emphasis added). That particularized 

finding hardly announces a guiding standard of scrutiny for use 

in every subsequent compelled speech case involving abortion.

Furthermore, the Fifth and Eighth Circuits’ reliance on 

Gonzales seems inapposite. Gonzales was not a First Amendment 

case; the plaintiffs there did not bring free speech claims. See

Carhart v. Ashcroft, 331 F. Supp. 2d 805, 814 (D. Neb. 2004); 

Planned Parenthood Fed’n of Am. v. Ashcroft, 320 F. Supp. 2d 

957, 967 (N.D. Cal. 2004). Thus Gonzales does not elucidate the 

First Amendment standard applied in Casey. Gonzales provides 

valuable insight into the relationship between the state and the

medical profession and the role the state may play in ensuring 

that women are properly informed before making what is 

indisputably a profound choice with permanent and potentially 

harmful impacts. See infra Part III. But it says nothing about 

the level of scrutiny courts should apply when reviewing a claim 
21

that a regulation compelling speech in the abortion context 

violates physicians’ First Amendment free speech rights. The 

fact that a regulation does not impose an undue burden on a 

woman under the due process clause does not answer the question 

of whether it imposes an impermissible burden on the physician 

under the First Amendment. A heightened intermediate level of 

scrutiny is thus consistent with Supreme Court precedent and 

appropriately recognizes the intersection here of regulation of 

speech and regulation of the medical profession in the context 

of an abortion procedure.4

III.

Under an intermediate standard of scrutiny, the state bears 

the burden of demonstrating “at least that the statute directly 

advances a substantial governmental interest and that the 

measure is drawn to achieve that interest.” Sorrel v. IMS Health 

Inc., 131 S. Ct. 2653, 2667-68 (2011). This formulation seeks to 

“ensure not only that the State's interests are proportional to 

the resulting burdens placed on speech but also that the law 

 4 The state’s amici insist that the decision we reach today 

will permit future litigants to use the First Amendment “as a 

‘trump card’ in a multitude of challenges to abortion 

regulations, allowing abortion proponents to provoke a ‘backdoor,’ strict scrutiny approach” that will override Casey’s 

undue burden standard. Law Professors’ Br. 27. We think this 

concern is overdrawn. The great majority of abortion regulations 

do not compel anyone’s speech, and the great majority of 

litigants do not raise First Amendment concerns.
22

does not seek to suppress a disfavored message.” Id. at 2668. 

The court can and should take into account the effect of the 

regulation on the intended recipient of the compelled speech, 

especially where she is a captive listener. See Hill v. 

Colorado, 530 U.S. 703, 716-18 (2000); Va. State Bd. of Pharmacy 

v. Va. Citizens Consumer Council, Inc., 425 U.S. 748, 756-57 

(1976); Greater Balt. Ctr. For Pregnancy Concerns, Inc. v. Mayor 

of Balt., 721 F.3d 264, 286 (4th Cir. 2013) (en banc); cf. Lee 

v. Weisman, 505 U.S. 577, 598 (1992).

The protection of fetal life, along with the companion 

interests of protecting the pregnant woman’s psychological 

health and ensuring that “so grave a choice is well informed,” 

Gonzales, 550 U.S. at 159, is undeniably an important state 

interest. The Supreme Court has repeatedly affirmed the state’s 

“important and legitimate interest” in preserving, promoting, 

and protecting fetal life. Roe v. Wade, 410 U.S. 113, 162 (1973) 

(quoted in Casey, 505 U.S. at 871); see also Gonzales, 550 U.S. 

at 145. We shall presume for the purpose of this appeal that 

this statute protects fetal life by increasing the likelihood 

that a woman will not follow through on the decision to have an 

abortion. Nonetheless, the means used to promote a substantial 

state interest must be drawn so as to directly advance the 

interest without impeding too greatly on individual liberty 

interests or competing state concerns. Sorrel, 131 S. Ct. at 
23

2667-68. The means employed here are far-reaching -- almost 

unprecedentedly so -- in a number of respects and far outstrip 

the provision at issue in Casey. See Casey, 505 U.S. at 881. 

This statutory provision interferes with the physician’s right 

to free speech beyond the extent permitted for reasonable 

regulation of the medical profession, while simultaneously 

threatening harm to the patient’s psychological health, 

interfering with the physician’s professional judgment, and 

compromising the doctor-patient relationship. We must therefore 

find the Display of Real-Time View Requirement unconstitutional.

A.

Before addressing the provision’s constitutional 

infirmities, it is well worth identifying briefly the various 

state interests at stake in this case. As we noted above, the 

Supreme Court has forcefully reiterated that the state’s 

interest in protecting fetal life is important and profound. 

This interest derives from the state’s general interest in 

protecting and promoting respect for life, and has been 

recognized in abortion decisions without number. See, e.g., 

Gonzales, 550 U.S. at 158; Casey, 505 U.S. at 871; Greenville 

Women’s Clinic v. Bryant, 222 F.3d 157, 165-66 (4th Cir. 2000). 

We do not question the substantial state interest at work here.

As part of its general interest in promoting the health of 

its citizens, the state also has an interest in promoting the 
24

psychological health of women seeking abortions. Appellants’ Br. 

17. The state may seek to protect women both from the 

psychological harm of “com[ing] to regret their choice,” 

Gonzales, 550 U.S. at 159, as well as the psychological harm 

from the process of obtaining an abortion itself. The Supreme 

Court has also recognized a state interest in maintaining “the 

integrity and ethics of the medical profession,” which includes 

promoting a healthy doctor-patient relationship, Washington v. 

Glucksberg, 521 U.S. 702, 731 (1997); see also Gonzales, 550 

U.S. at 157, and respecting physicians’ professional judgment, 

see Casey, 505 U.S. at 884. 

However, that important state interests are implicated in 

the abortion context is only the starting point for our 

analysis. Though physicians and other professionals may be 

subject to regulations by the state that restrict their First 

Amendment freedoms when acting in the course of their 

professions, professionals do not leave their speech rights at 

the office door. See Lowe v. SEC, 472 U.S. 181, 229-30 (1985) 

(White, J., concurring in the judgment). Any state regulation 

that limits the free speech rights of professionals must pass 

the requisite constitutional test. The Display of Real-Time View 

Requirement must directly advance an important state interest in 

a manner that is drawn to that interest and proportional to the 

burden placed on the speech. See Sorrel, 131 S. Ct. at 2667-68.
25

B.

North Carolina contends that the Display of Real-Time View 

Requirement is merely “reasonable . . . regulation by the State” 

of the medical profession that does not violate the physicians’ 

First Amendment rights any more than informed consent 

requirements do. Appellants’ Br. 22-25 (quoting Tex. Med. 

Providers Performing Abortion Servs. v. Lakey, 667 F.3d 570, 575 

(5th Cir. 2012) (quoting Casey, 505 U.S. at 882)). The 

requirements the provision imposes on physicians, however, 

resemble neither traditional informed consent nor the variation 

found in the Pennsylvania statute at issue in Casey. The North 

Carolina statute goes much further, imposing additional burdens 

on the physicians’ free speech and risking the compromise of 

other important state interests.

Traditional informed consent requirements derive from the 

principle of patient autonomy in medical treatment. Grounded in 

self-determination, obtaining informed consent prior to medical 

treatment is meant to ensure that each patient has “the 

information she needs to meaningfully consent to medical 

procedures.” Am. Coll. of Obstetricians & Gynecologists & the 

Am. Med. Ass’n (“ACOG & AMA”) Br. 5; see also AMA, Op. 8.08 –

Informed Consent (2006). As the term suggests, informed consent 

consists of two essential elements: comprehension and free 

consent. ACOG & AMA Br. 7; ACOG, Comm. Op. No. 439 - Informed 
26

Consent, at 2 (2012). Comprehension requires that the physician 

convey adequate information about the diagnosis, the prognosis, 

alternative treatment options (including no treatment), and the 

risks and likely results of each option. ACOG & AMA Br. 7; ACOG, 

Comm. Op. No. 439, at 3, 5; see also J.A. 359 (declaration of 

Dr. Anne Drapkin Lyerly); Canterbury v. Spence, 464 F.2d 772, 

780-81 (D.C. Cir. 1972). Physicians determine the “adequate” 

information for each patient based on what a reasonable 

physician would convey, what a reasonable patient would want to 

know, and what the individual patient would subjectively wish to 

know given the patient’s individualized needs and treatment 

circumstances. ACOG, Comm. Op. No. 439, at 5. Free consent, as 

it suggests, requires that the patient be able to exercise her 

autonomy free from coercion. Id. at 3, 5. It may even include at 

times the choice not to receive certain pertinent information 

and to rely instead on the judgment of the doctor. Id. at 7; 

ACOG & AMA Br. 8. The physician’s role in this process is to 

inform and assist the patient without imposing his or her own 

personal will and values on the patient. J.A. 359-60 

(declaration of Dr. Anne Drapkin Lyerly); ACOG, Comm. Op. No. 

439, at 3. The informed consent process typically involves a 

conversation between the patient, fully clothed, and the 

physician in an office or similar room before the procedure 

begins. ACOG & AMA Br. 8, 23; ACOG, Comm. Op. No. 439, at 4. 
27

Once the patient has received the information she needs, she 

signs a consent form, and treatment may proceed. See, e.g., N.C. 

Gen. Stat. § 90-21.13(b).

The Pennsylvania statute challenged in Casey prescribes a 

modified form of informed consent for abortions. To provide 

informed consent, the statute first requires the physician to 

orally inform the woman of the nature of the abortion procedure, 

the “risks and alternatives to the procedure . . . that a 

reasonable patient would consider material to the decision” 

whether to have an abortion, the risks of carrying the child to 

term, and the “probable gestational age of the unborn child” 

when the abortion is to be performed. 18 Pa. Cons. Stat. 

§ 3205(a)(1). The physician must give this information at least 

twenty-four hours prior to the abortion. Id. Aside from the 

gestational age of the fetus, this information is the same type 

that would be required under traditional informed consent for 

any medical procedure. 

The statute continues on, however, to require that the 

physician must inform the woman, at least twenty-four hours in 

advance, that the state prints materials that describe the 

unborn child, and a copy must be provided to her if she wants 

it. 18 Pa. Cons. Stat. § 3205(a)(2)-(3). Finally, the statute 

requires the physician to provide some additional information 

about financial and other assistance that may be available from 
28

the state and the father. 18 Pa. Cons. Stat. § 3205(a)(2). These 

provisions deviate only modestly from traditional informed 

consent. They also closely resemble the informed consent 

provisions of North Carolina’s Woman’s Right to Know Act that 

are not under challenge in this appeal. N.C. Gen. Stat. § 90-

21.82(1)-(2). The challenged Display of Real-Time View

Requirement, N.C. Gen. Stat. § 90-21.85, however, reaches beyond 

the modified form of informed consent that the Court approved in 

Casey. In so doing, it imposes a virtually unprecedented burden 

on the right of professional speech that operates to the 

detriment of both speaker and listener. 

C.

The burdens trace in part from deviations from the 

traditions of informed consent. The most serious deviation from 

standard practice is requiring the physician to display an image 

and provide an explanation and medical description to a woman 

who has through ear and eye covering rendered herself 

temporarily deaf and blind. This is starkly compelled speech 

that impedes on the physician’s First Amendment rights with no 

counterbalancing promotion of state interests. The woman does 

not receive the information, so it cannot inform her decision. 

In fact, “[t]he state’s own expert witness agrees that the 

delivery of the state’s message in these circumstances does not 

provide any information to the patient and does not aid 
29

voluntary and informed consent.” Stuart v. Loomis, 992 F. Supp. 

2d 585, 602 (M.D.N.C. 2014). And while having to choose between 

blindfolding and earmuffing herself or watching and listening to 

unwanted information may in some remote way influence a woman in 

favor of carrying the child to term, forced speech to unwilling 

or incapacitated listeners does not bear the constitutionally 

necessary connection to the protection of fetal life. Moreover, 

far from promoting the psychological health of women, this 

requirement risks the infliction of psychological harm on the 

woman who chooses not to receive this information. She must 

endure the embarrassing spectacle of averting her eyes and 

covering her ears while her physician -- a person to whom she 

should be encouraged to listen -- recites information to her. We 

can perceive no benefit to state interests from walling off 

patients and physicians in a manner antithetical to the very 

communication that lies at the heart of the informed consent 

process.

The constitutional burden on the physicians’ expressive 

rights is not lifted by having a willing listener. The 

information the physician had to convey orally in Casey was no 

more than a slight modification of traditional informed consent 

disclosures. The information conveyed here in the examining room 

more closely resembles the materials that in Casey were provided 

by the state in a pamphlet. Casey, 505 U.S. at 881. A physician 
30

in Pennsylvania need only inform the patient that such 

information is available and, if requested, provide her with a 

copy of the state-issued pamphlet. 18 Pa. Cons. Stat. 

§ 3205(a)(2)(i) & (a)(3). Informing a patient that there are 

state-issued materials available is not ideological, because the 

viewpoint conveyed by the pamphlet is clearly the state’s -- not 

the physician’s. It is no wonder then that the Casey court found 

no First Amendment infirmities in that requirement. By contrast, 

the North Carolina statute compels the physician to speak and 

display the very information on a volatile subject that the 

state would like to convey. See N.C. Gen. Stat. § 90-

21.85(a)(2)-(4). The coercive effects of the speech are 

magnified when the physician is compelled to deliver the state’s 

preferred message in his or her own voice. This Requirement 

treads far more heavily on the physicians’ free speech rights 

than the state pamphlet provisions at issue in Casey. 

Though the information conveyed may be strictly factual, 

the context surrounding the delivery of it promotes the 

viewpoint the state wishes to encourage. As a matter of policy, 

the state may certainly express a preference for childbirth over 

abortion, Webster v. Reprod. Health Servs., 492 U.S. 490, 511 

(1989), and use its agents and written materials to convey that 

message. However the state cannot commandeer the doctor-patient 

relationship to compel a physician to express its preference to 
31

the patient. As the district court noted, “[b]y requiring 

providers to deliver this information to a woman who takes steps 

not to hear it or would be harmed by hearing it, the state has 

. . . moved from ‘encouraging’ to lecturing, using health care 

providers as its mouthpiece.” Stuart, 992 F. Supp. 2d at 609. 

Transforming the physician into the mouthpiece of the state

undermines the trust that is necessary for facilitating healthy 

doctor-patient relationships and, through them, successful 

treatment outcomes. See Am. Pub. Health Ass’n (“APHA”) Br. 9-10. 

The patient seeks in a physician a medical professional with the 

capacity for independent medical judgment that professional 

status implies. The rupture of trust comes with replacing what 

the doctor’s medical judgment would counsel in a communication 

with what the state wishes told. It subverts the patient’s 

expectations when the physician is compelled to deliver a state 

message bearing little connection to the search for professional 

services that led the patient to the doctor’s door.

Furthermore, by failing to include a therapeutic privilege 

exception, the Display of Real-Time View Requirement interferes 

with the physician’s professional judgment and ethical 

obligations. The absence of a therapeutic exception means that 

the state has sought not only to control the content of the 

physician’s speech, but to dictate its timing. Under the 

Requirement, the physician must display and describe the fetus 
32

simultaneously with the ultrasound procedure, and he must do 

this at least four and not more than seventy-two hours prior to 

the abortion procedure. See N.C. Gen. Stat. § 90-21.85(a). 

Therapeutic privilege, however, permits physicians to decline or 

at least wait to convey relevant information as part of informed 

consent because in their professional judgment delivering the 

information to the patient at a particular time would result in 

serious psychological or physical harm. ACOG, Comm. Op. 439, at 

7. It is an important privilege, albeit a limited one to be used 

sparingly. See id. It protects the health of particularly 

vulnerable or fragile patients, and permits the physician to 

uphold his ethical obligations of benevolence. 

The Casey court found it relevant that the Pennsylvania 

statute contained a therapeutic exception so that it “does not 

prevent the physician from exercising his or her medical 

judgment.” 505 U.S. at 883-84. North Carolina by contrast 

requires the physician to “[d]isplay the images” and “[p]rovide 

a simultaneous explanation of what the display is depicting” 

along with “a medical description of the images,” with no 

exception. N.C. Gen. Stat. § 90-21.85(a)(2)-(4). The lack of a 

provision similar to Pennsylvania’s in North Carolina’s statute 

runs contrary to the state’s interest in “protecting the 

integrity and ethics of the medical profession,” Gonzales, 550 

U.S. at 157, and more generally to its interest in the 
33

psychological and physical well-being of the affected women. 

Particularly for women who have been victims of sexual assaults 

or whose fetuses are nonviable or have severe, life-threatening 

developmental abnormalities, having to watch a sonogram and 

listen to a description of the fetus could prove psychologically 

devastating. See J.A. 332-33 (declaration of Dr. Gretchen S. 

Stuart); Appellees’ Br. 12-13; APHA Br. 8-9. Requiring the 

physician to provide the information regardless of the 

psychological or emotional well-being of the patient, see N.C. 

Gen. Stat. §§ 90-21.85 & 90-21.86, can hardly be considered 

closely drawn to those state interests the provision is supposed 

to promote. 

In sum, though the State would have us view this provision 

as simply a reasonable regulation of the medical profession, 

these requirements look nothing like traditional informed 

consent, or even the versions provided for in Casey and in N.C. 

Gen. Stat. § 90-21.82. As such, they impose an extraordinary 

burden on expressive rights. The three elements discussed so far 

-- requiring the physician to speak to a patient who is not 

listening, rendering the physician the mouthpiece of the state’s 

message, and omitting a therapeutic privilege to protect the 

health of the patient -- markedly depart from standard medical 

practice. 

D.
34

Other aspects of the Requirement are equally unusual. As 

described above, informed consent frequently consists of a 

fully-clothed conversation between the patient and physician, 

often in the physician’s office. It is driven by the “patient’s 

particular needs and circumstances,” J.A. 388 (declaration of 

Dr. Amy Weil), so that the patient receives the information he 

or she wants in a setting that promotes an informed and 

thoughtful choice.

This provision, however, finds the patient half-naked or 

disrobed on her back on an examination table, with an ultrasound 

probe either on her belly or inserted into her vagina. 

Appellees’ Br. 13; APHA Br. 8. Informed consent has not 

generally been thought to require a patient to view images from 

his or her own body, ACOG & AMA Br. 7, much less in a setting in 

which personal judgment may be altered or impaired. Yet this 

provision requires that she do so or “avert[] her eyes.” N.C. 

Gen. Stat. § 90-21.85(a)(3), (b). Rather than engaging in a 

conversation calculated to inform, the physician must continue 

talking regardless of whether the patient is listening. See

Stuart, 992 F. Supp. 2d at 590 & 602 n.34. The information is 

provided irrespective of the needs or wants of the patient, in 

direct contravention of medical ethics and the principle of 

patient autonomy. “[F]orcing this experience on a patient over 

her objections” in this manner interferes with the decision of a 
35

patient not to receive information that could make an 

indescribably difficult decision even more traumatic and could 

“actually cause harm to the patient.” J.A. 330 (declaration of 

Dr. Gretchen S. Stuart). And it is intended to convey not the 

risks and benefits of the medical procedure to the patient’s own 

health, but rather the full weight of the state’s moral 

condemnation. Though the state is plainly free to express such a 

preference for childbirth to women, it is not the function of

informed consent to require a physician to deliver the state’s 

preference in a setting this fraught with stress and anxiety. 

There are few absolutes in the difficult area of 

professional regulation and professional expression. But there 

do exist constraints on the permissible interference with the 

doctor-patient relationship; there are limits on state attempts 

to compel physicians to deliver its message, especially when 

that message runs counter to the physician’s professional 

judgment and the patient’s autonomous decision about what 

information she wants. Though states may surely enact 

legislation to ensure that a woman’s choice is informed and 

thoughtful when she elects to have an abortion, states cannot so 

compromise physicians’ free speech rights, professional 

judgment, patient autonomy, and other important state interests 

in the process. The means here exceed what is proper to promote 

the undeniably profound and important purpose of protecting 
36

fetal life. See, e.g., Sorrel, 131 S. Ct. at 2667-68, 2670 

(holding that Vermont statute unconstitutionally burdened speech 

because “[w]hile Vermont’s stated policy goals may be proper, 

§ 4631(d) does not advance them in a permissible way” under 

intermediate scrutiny).

IV.

“The right to speak and the right to refrain from speaking 

are complementary components of the broader concept of 

‘individual freedom of mind.’” Wooley v. Maynard, 430 U.S. 705, 

714 (1977) (quoting W. Va. State Bd. of Educ. v. Barnette, 319 

U.S. 624, 637 (1943)). Regulations which compel ideological 

speech “pose the inherent risk that the Government seeks not to 

advance a legitimate regulatory goal, but to suppress unpopular 

ideas or information or manipulate the public debate through 

coercion rather than persuasion.” Turner Broad. Sys., Inc. v. 

FCC, 512 U.S. 622, 641 (1994). Abortion may well be a special 

case because of the undeniable gravity of all that is involved, 

but it cannot be so special a case that all other professional 

rights and medical norms go out the window. While the state 

itself may promote through various means childbirth over 

abortion, it may not coerce doctors into voicing that message on 

behalf of the state in the particular manner and setting 

attempted here. The district court did not err in concluding 

that § 90-21.85 of the North Carolina General Statutes violates 
37

the First Amendment and in enjoining the enforcement of that 

provision. Its judgment is in all respects affirmed.

AFFIRMED