Document: 462 U.S. 476 103 S.Ct. 2517 76 L.Ed.2d 733 PLANNED PARENTHOOD ASSOCIATION OF KANSAS CITY, MISSOURI, INC., et al., Petitioners,v.John ASHCROFT, Attorney General of Missouri, al. John Petitioners, v. Petitioners. Nos. 81-1255, 81-1623. Argued Nov. 30, 1982. Decided June 15, 1983. Syllabus Missouri statutes require abortions after 12 weeks pregnancy to be performed in a hospital (§ 188.025); pathology report for each abortion 188.047); the presence second physician during viability 188.030.3); and minors secure parental consent or from juvenile court an 188.028). In action challenging constitutionality these provisions, District Court invalidated all provisions except § 188.047. The Appeals reversed as §§ 188.028 188.047 but affirmed 188.030.3 188.025. Held: Section 188.025 is unconstitutional, 188.047, 188.030.3, are constitutional. 655 F.2d 848 (8th Cir., 1981), part, vacated remanded; 664 687 affirmed. Justice POWELL delivered opinion with respect Parts I, II, VI, concluding that second-trimester hospitalization requirement "unreasonably infringes upon woman's constitutional right obtain abortion." City Akron Center Reproductive Health, Inc., --- ----, 2481, 75 ----. Pp.481-482 POWELL, joined by THE CHIEF JUSTICE, concluded III, IV, V that: 1. second-physician reasonably furthering State's compelling interest protecting lives viable fetuses. Pp. 482-486. 2. pathology-report On its face effect, such related generally accepted medical standards furthers important health-related state concerns. light substantial benefits pathologist's examination can have, small additional cost does not significantly burden pregnant decision. 486-490. 3. A immature will sustain substitute, either judicial. And interpreted mean cannot deny minor's application "for good cause" unless first finds minor was mature enough make her own decision, provides judicial alternative consistent established legal standards. See at S.Ct., 2497-2499. 490-493. O'CONNOR, WHITE REHNQUIST, 1 because State has interest, extant throughout pregnancy, preserving fetal life. P. 505. 2 it imposes no undue on limited undergo abortion, validity contingent trimester which imposed. 3 Assuming, arguendo, Sta e impose veto decision provision 188.028.2 any may have abortion. 4 Frank Susman, Clayton, Mo., Planned Parenthood Ass'n Kansas City, 5 Ashcroft, Atty. Gen., Jefferson Gen. 6 V, JUSTICE joins. 7 These cases, like Simopoulos Virginia, 2532, present questions regulating performance abortions. 8 * two physicians who perform abortions, clinic ("plaintiffs") filed complaint Western challenging, several sections relevant here include Mo.Rev.Stat. (Supp.1982), requiring hospital;1 performed;2 188.030, viability;3 188.028, consent.4 9 After hearing testimony number expert witnesses, requirement. 483 F.Supp. 679, 699-701 (D.C.1980).5 Eighth Circuit Court's judgment thereby upholding It also held erred sustaining affirmed, case remanded further proceedings findings relating 848, 872-873 Cir.1981). remand, holding unconstitutional. this judgment. 687, 691 We granted certiorari. 456 988, 102 2267, 73 1282 (1982). 10 today Akron, supra, U.S., ---- - 2490-2493, stated fully principles govern review need repeated here. With mind, we turn issue. II 11 city ordinance general special hospitals accredited Joint Commission Accreditation Hospitals (JCAH) American Osteopathic Association. Supra, 2493. Missouri's requirements similar those enacted must general, acute-care facilities.6 For reasons 2497-2498. same reasons, affirm Appeals' III now Roe Wade, 410 113, 93 705, 35 147 (1973), recognized life fetus: "[T]he promoting potentiality human may, if chooses, regulate, even proscribe, where necessary, appropriate judgment, preservation health mother." Id., 164-165, 732-733. Colautti Franklin, 439 379, 386-387, 99 675, 680-681, 58 596 (1979); Beal Doe, 432 438, 445-446, 97 2366, 2371-2372, 53 464 (1977). Several undertake regulation. Post-viability proscribed when necessary preserve woman. 188.030.1 (Supp.1982). forbids use o procedures fatal fetus pose greater risk 188.030.2. 13 statutory issue requires attendance fetus. 188.030.3. This section "take reasonable steps keeping practice . unborn child; provided increased woman." n. 3, supra. "shall take control provide immediate care child born result 14 lower courts 188.030.3.7 plaintiffs, respondents issue, urge affirmance grounds distorts traditional doctor-patient relationship, both impractical costly. They note other surgical procedure, including childbirth delivery premature infant. 15 physician's primary concern Many third-trimester emergency operations,8 permits late only they unreasonable assume operation attention skills directed health, actual fetuses survive procedure. Viable grave danger their birth. physician, situations assistance child. 16 By giving alive, assure interests protected more than alone would able do. given life, say unusual circumstances Preserving aborted often possible,9 legitimately choose safeguards comparatively few instances live birth occur. believe fetuses, reverse IV 17 services within State, "[a]ll tissue surgically removed exception tonsils, adenoids, hernial sacs prepuces, shall examined pathologist, premises arrangement outside hospital." Mo.Admin.Code 50-20.030(3)(A)7 whether some facility, pathologist "file copy Division Health. ." 2, required "provide facility induced." Thus, appears following well almost surgery hospitals, submitted merely performing doctor. narrow question before us lawfully clinics pathologist. 18 "further[s] concerns." As recognized, examinations clearly "useful cases," "abnormalities warn serious, possibly disorders." F.2d, 870.10 rule, submit pathologist.11 particularly remain long-range complications effect subsequent pregnancies. App. 72-73 (testimony Dr. Willard Cates, Jr.); Levin, Association Induced Abortion Subsequent Pregnancy Loss, 243 J.A.M.A. 2495, 2499 (1980). Recorded reports, concert complication statistical basis studying complications. Cf. Central Mo. Danforth, 428 52, 81, 96 2831, 2846, 49 788 (1976). 19 Plaintiffs argue qualified examination. argument disregards fact physician—to examine every type surgery. Although many included statute customarily outpatient clinics. No reason been suggested why prudence should equally clinic. Indeed, there stricter hospitals.12 indicates, differs widely question. Record 623; 749-750, 798-800, 845-847; There support case, example, Bernard Nathanson, experienced practitioner, testified he 60,000 under his direction New York Sexual He considers "absolutely specimen matter procedure involved removal body." 143-144. 146-147 Keitges); 798-799 Schmidt).13 20 weighing balance between protection examination, Constitution subordinate minimize extent Even early "[c]ertain regulations significant impact exercise decide permissible justified objectives." 2492-2493. 80-81, 2846-2847. think estimated compliance plaintiff Health Services $19.40 per performed, F.Supp., 700, 48, justified. unanimously upheld recordkeeping female citizens, [as] resource decisions involving experience judgment," 2846.14 view comparable relatively insignificant burden. Accordingly, 21 noted dispute. 2497; Bellotti Baird, 443 622, 640-642, 643-644, 3035, 3046-3047, 3048-3049, 61 797 (1979) (plurality opinion) (Bellotti ); id., 656-657, 3054-3055 (WHITE, J., dissenting).15 clear, owever, "the whereby demonstrate she sufficiently herself that, despite immaturity, best interests."16 2497-2498.17 one purely construction: standards.18 22 statute, 188.028.2,19 provides: 23 "(4) decree, cause: 24 "(a) Grant petition majority rights purpose consenting abortion; 25 "(b) Find give setting forth so finding; 26 "(c) Deny petition, denied[.]" 27 face, 188.028.2(4) authorizes courts20 among alternatives outlined section. denial permitted subsection (c) "would initially find emancipated interests." 858. contend interpretation unreasonable. do agree. 28 Where fairly possible, construe avoid unconstitutionality. aware, discretion permission "good cause," arguably violate set forth. Ibid. however, exercising option, receive evidence emotional development, maturity, intellect understanding minor." 188.028.2(3) then reached logical conclusion "findings ultimate supported showing 'good cause.' " found could found—after having received evidence—that 647-648, 3048, 3050 opinion). conclude correctly interpreted, avoids infirmities.21 VI 29 Appeals, insofar provision, invalidating attend reversed. vacate award attorney's fees hours expended plaintiffs' attorneys remand Hensley Eckerhart, 1933, 40 (1983). 30 ordered. 31 BLACKMUN, whom BRENNAN, MARSHALL, STEVENS join, concurring part dissenting part. 32 ante, invalidates Akron's host infringe terminate through I agree invalid analysis, join POWELL's cases. agree, remaining challenged cases satisfy prior decisions. 33 law whenever sample "board eligible certified pathologist" report. applies later pregnancy. Our past establish first-trimester left 'free interference State.' 2492, quoting 163, 732, (1973). regulation touching constitutionally impermissible. But pass muster, affecting "have right" "justified 2492; see 2524. 34 objectives. 2523, report; demands prepared rather attending physician. Contrary assertion, accord "generally standards." routine gross (visual) Only detects abnormalities send College Obstetricians Gynecologists (ACOG) recommend case: "In situation elective termination record description products. Unless definite embryonic parts identified, products interruptions microscopic 36 37 ". Aspirated ensure villi patient's release facility. If identified certainty, sent pathologic ACOG, Standards Obstetric-Gynecologic 54 (1982).1 38 Nor National Federation necessary: 39 "All grossly time trained assistant results recorded chart. absence visible placenta obtained low power microscope detection villi. inconclusive, nearest suitable laboratory examination." (1981) (emphasis deleted). pointed out, trial nonpathologist capable adequate concern" readily detectable 871, (CA8 1981); 135.2 While better "fetal identified." 50-151.030(1) (1981). initial normally responsibility unnecessary. 41 us, "met demonstrating [the requirement] further[s] 2493.3 protect pathologists' reports clinics, hospitals. 50-20.030(3)(A)(7) Moreover, "no impact" undisputed increase much $40. 48. seem comfortable perspective, woman seeking welfare unemployed teenager, put price beyond reach.4 Harper Virginia Board Elections, 383 663, 668, 86 1079, 1082, 169 (1966) ($1.50 poll tax "excludes unable pay"); Burns Ohio, 360 252, 255, 257, 1164, 1167, 1168, 1209 (1959) ($20 docket fee "foreclose[s] access" appellate indigents). 42 (1976), warned "perhaps approach[ed] impermissible limits." Today struck down restrictions "may add providing abortions." 2502; 2502-2503. unquestionably adds shown serves purpose. Under circumstances, hold limits exceeded. 43 When post-viability "there [must be] [second] 732-733, maternal justify prohibition mother. governing stage "tailored 165, 733; H.L. Matheson, 450 398, 413, 101 1173, 67 388 ("statute plainly interests, [and] narrowly drawn interests"); Roe, 155, 728 ("legislative enactments express legitimate stake"). A. 44 "reasonably fetuses." 2522. indeed aid possible method used ordinarily most likely restriction apply 188.030.2 45 dilatation evacuation (D & E) entails chance survival, nevertheless choice women words, considerations preclude might 694.5 D E nothing potential His superfluous. thus overbroad "imposes possibility survival fetus." 865-866. 46 apparently believes justifies methods births. nonexistent. presumably made advance,6 disappears E. Because tailored invalid.7 B 47 addition, statute's failure clear renders recognizes, 8, 2522, arise delay dangerous always available situation; yet one. states, unqualified terms, attendance" of" certain duties attendance." added). resulting harmful woman, impermissibly fails "that prevail over fetus' conflict." 400, 688, (1979). 48 attempts cure defect asserting final clause woman," construed permit without 8. construction contrary plain language statute; relies refers way suggests dispensed with. since proposed binding Missouri,8 rely degree confidence. remains vague; inform proceed emergency, wait imperiled delay. vagueness severe chilling perceives considered failed specify "require[d] 'trade-off' percentage points survival." 688. "where conflicting magnitude involved, least, precision subject criminal sanctions." 400-401, 688-689.9 reasoning here, ground well.10 50 prohibits unemancipated absent order. 51 Until today, never "a judicial," 2525. 74, 2843, authority third party absolute, arbitrary, patient, regardless withholding consent." ), eight Justices agreed Massachusetts permitting 649-650, 3051-3052 (opinion J.); 654-656, 3053-3054 STEVENS, J.). four appropriately structured constitutional, 3050-3051 J.), statement did command majority. Four judicial-consent suffer flaw Danforth: absolute patient. 655-656, 52 continue adhere views expressed II: "It inherent exercised public scrutiny defiance sovereign parties. practical matter, suppose commence order least great as, probably than, imposed parent. once met, standard judge's minor. That little real guidance judge, necessarily reflect personal societal values mores whose enforcement informed decision—is fundamentally odds privacy interes underlying afforded decision." (footnote omitted). 55 REHNQUIST 56 my dissent No. 81-746, 81-1172, Assuming arguendo burden, relate[ ] health." therefore 57 contained possesses concur Court. imposed, 59 However, valid 60 "Every twelve "A representative board file division induced permanent record." "An adducing During it, attendance, practice, used, "1. person knowingly age eighteen years unless: "(1) secured written parent guardian; "(2) minor; "(3) self-consent pursuant section, order, accordance willingly, "2. subdivision (3) sub ection (4) procedures: next friend assist preparing notices thereafter initials names addresses parent, guardian, or, parents deceased guardian appointed, standing loco parentis risks consequences sound mind sufficient intellectual capacity grant appoint ad litem private counsel, counsel. signed friend; merits record, soon five days filing petition. At hearing, hear nature, consequences, useful determining denied; "3. desires orally and, sign 188.039 manner adult person. against will, described awarded claimed attorneys. allocation 872 1981). certiorari raises fees, U.S.C. 1988, proportioned plaintiffs prevailed. define term "hospital" assume, below, 686, 10; 689-690, nn. 6, common meaning 188.015(2) (Supp.1982) (defining "abortion facility" clinic, office, place hospital"). 197.020.2 (1978), licensing laws, reads: 'Hospital' means devoted primarily maintenance facilities diagnosis, treatment less twenty-four week three nonrelated individuals suffering illness, disease, injury, deformity abnormal physical conditions; individuals. 197.200(1) (1978) "ambulatory center" "with organized staff physicians" continuous registered professional nursing patient facility"); 50-30.010(1)(A) (1977) (same). Department Social construction, facilities, administration 50-20.010 50-20.030 unlike JCAH. 16, 2493, 16. below found, BLACKMUN's agrees, post, 499-500, justification 694; 865. them, overbroad. rests assumptions. First, second, trimester. agreement proposition, second. authorities disagree critical assumption, noted, 865, 28. Nevertheless, conclusory language, "method possible." scholarly writing supporting cited dissent. Reliance placed solely Robert Crist, Kansas, referred footnote. 694, 25. slim holding. Crist's testimony, else, remarkable candor. member Federation, "an organization providers people interested pro-choice movement." 415-416. 28-week pregnancies, into methods. 427-428. disinterest evidenced rid growth, called body, dead 431. "[n]ever ha[s] intention trying fetus, saved," finally "as principle" "[t]here fetus," 435. view, thought 433-434. None trial, defendants, indicated. (limiting weeks); 381, 410-413 (Dr. Kretzschmar) up weeks; 787 (almost "inconceivable" viability); safest 110 (doctor 111 (risks oing equivalent weeks). 33, 78-81 (deposition Cates) (16 latest performed). Apparently Crist 334, 368, 428, operating familiar limitations law. explain were "contraindications" viability, situations. ever poses rare viability. instances, hardly addition citing footnote, cited—with elaboration—Dr. Schmidt. reflecting enlightening. conceded point mostly theoretical, "simply [did] comes elected 836. reminded earlier remote stated: "I personally conceive point. legally, [not] standpoint. Given discordant wholly unsupported, though honestly mother's health. Legislation accommodate conceivable contingency. attendance. where, endangered qualified, phrase "provided situation. 407, 14, 1170, (rejecting Utah needs). ACOG Technical Bulletin 56, supra 7, (as high 7% live-birth rate intrauterine instillation uterotonic agents); Stroh Hinman, Reported Live Births Following Abortion: Two One-Half Years' Experience Upstate York, 126 Am.J.Obstet.Gynecol. 83, 83-84 (1976) (26 births saline-induced abortions; hysterotomy; oxtyocin-induced abortion) (one out births); (50-62% mortality 729 (25-92% 837 (50% pathological designed ectopic hydatritaforme moles precancerous growths, variety problems discovered utility clear. See, e.g., (ACOG), (5th ed. 1982); (NAF), (compliance obligatory NAF standing); Brief P blic Amicus Curiae 81-185, 29, (supporting non-hospital constituting "minimum standards"). ACOG's recommended "tissue operative committee" "all obstetric-gynecologic operations." (4th 1974). current rule ambulatory basis, "[t]issue 1982). dissent, recent modification "exception practice" mandatory makes permissive. Not surprisingly, change policy controversial College. 799-800. "[n]o consensus exists regarding aspirated case," recognized—on inquiries institutions—that them Report Committee Gynecologic Practice, Item # 6.2.1 (June 27-28, 1980). position disclose consideration inadequately regulated conform ethical 641, 21, 3047, ) (minors resort "incompetent unethical" clinics); 91, 2851, (Stewart, concurring). Sun-Times Chicago, series disclosed widespread questionable practices proper reports. "The Profiteers," Chicago 25-26 (Special Reprint 1978). therefore, neces ary suggesting "comfortable perspective" disregard "woman teenager." Post, 498. seek expensive available. highest, protection. suggest infirm 496-497, misses someone independent tissue. 12, supra; 750 Pierre Keitges, pathologist). H. Cove, Surgical Pathology Endometrium ("To sort evaluated microscopically establishing diagnosis pregnancy.") Danforth "[t]he added confidentiality, sole officers, retention seven years, period length, persuade our determination 2846. extends identical reassuring 188.055.2, 188.060 dissenters open one, II. 503-504. adopted Court, while quite differing views. (1981); opinion); dissenting). plurality "assure" resolution "will completed anonymity expedition effective opportunity obtained." 644, 3048. Confidentiality assured allows 188.028.2(1) appeals, 188.028.2(6) part: notice intent appeal date issuance perfected appeal. essence supreme shall, expedited appealed section." framework expediting proceedings. Immediately enactment, enjoined enforcement. comply time, promulgate rules concerning review. expedite mandate opinions. 406-407, 411, 1169-1170, 1172 (upholding notification extending detrimental interests). 188.028's 873; 701. sought posture review, contains notification. exempts "emancipated" proceeding. word context void vagueness, disagree. 1170 (using describe minor). turns facts individual guide determination, usage Black Cole, 626 S.W.2d 397, 398 (Mo.App.1981) (quoting C.J.S. Parent Child 86, 811 (1950)); re Marriage Heddy, 535 276, 279 Mo.App.1976) (same); Wurth Wurth, 313 161, 164 (Mo.App.1958) (same), rev'd grounds, 322 745 (Mo.1959). 4, unconstitutional unmarried 18. 75, 2844. response new became shortly indicated opinions access "independent decisionmaker." 420, 1177 (POWELL, decisionmaker. consider nonjudicial decisionmaker appropriate. 643, 22, 22. ambiguity 188.028.2(4), interpretations course restraint abstention. approach 132, 146-147, 2857, 2865-2866, 844 ). not, abstain, certification refer court. 861, 20; C. Wright, Miller Cooper, Federal Practice Procedure 4248, 525, (1978 Supp.1982). Such "greatly simplifie[d]" analysis 151, 2868. susceptible t fair obviates render saving federal abstain. 66 (1982): "Tissue An terminations definitive identified. point, noting witnesses had "pathology done" (WD Mo.1980). draw "questionable practices" occur others highest." 2524, 12. evidence, Missouri. $40 20% more. 869, (cost $170); F. Jaffe, B. Lindheim, Lee, Politics: Private Morality Public Policy ranges approximately $185 $235); Henshaw, Freestanding Clinics: Services, Structure, Fees, Family Planning Perspectives 248, 255 (1982) (average $190); Membership Director 18-19 (1982/1983) (NAF charge $180 $225 abortion). relied Doctors Richard Doctor contraindicated" condition, 438-439, example hemolytic anemia aggravated prostaglandins labor-inducing methods, 428. Schmidt very be" contraindicated. previously "almost inconceivable," attorney "[a]bsent extreme contraindication saline, hysterotomy." 787. Any inconsistencies Schmidt's resolved favor. factual finding sometimes 665 Absent exceptional concurred. Branti Finkel, 445 507, 512, 100 1287, 1292, 63 574 select long presents "certify techniques choosing technique employed." ensures reasoned argues "[i]f specifically excepted procedures, abortionists encouraged frequently expense prevent observe malpractice safety viewpoint, fetus-destroying awakening newborn." Cross-Petitioners 81-1623, p. 44. rejected purported Doe Bolton, , 199, 739, 751, 201 (1973): "If licensed acceptable clinical this, censure deprivation license remedies. Required acquiescence co-practitioners rational connection needs unduly practice." "Only [Missouri] supply requisite 'we lack jurisdiction authoritatively legislation.' Gooding Wilson, 405 518, 520, 92 1103, 1105, 408 (1972), United States Thirty-seven Photographs, 402 363, 369, 91 1400, 1404, 822 (1971). f ils faces penalties loss license. 188.065, 188.075 reach interferes relationship. note, newborn infant, product normal until another. 133; ("The delivers baby responsible post-delivery another assumes duty"). sense. Consultation teamwork fundamental room depend split-second shared lines unclear, precious moments lost detriment

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