Case Name: SINGLETON, CHIEF, BUREAU OF MEDICAL SERVICES, DEPARTMENT OF HEALTH AND WELFARE OF MISSOURI v. WULFF et al.
Court: Supreme Court of the United States
Jurisdiction: United States
Decision Date: 1976-07-01
Citations: 428 U.S. 106
Docket Number: No. 74—1393
Parties: SINGLETON, CHIEF, BUREAU OF MEDICAL SERVICES, DEPARTMENT OF HEALTH AND WELFARE OF MISSOURI v. WULFF et al.
Judges: with whom The Chief Justice, Mr. Justice Stewart, and Mr. Justice Rehnquist join,
Reporter: United States Reports
Volume: 428
Pages: 106–131

Head Matter:
SINGLETON, CHIEF, BUREAU OF MEDICAL SERVICES, DEPARTMENT OF HEALTH AND WELFARE OF MISSOURI v. WULFF et al.
No. 74—1393.
Argued March 23, 1976
Decided July 1, 1976
Michael L. Boicaurt, Assistant Attorney General of Missouri, argued the cause for petitioner. With him on the brief was John G. Danforth, Attorney General.
Frank Busman argued the cause and filed a brief for respondents.

Opinion:
Mr. Justice Blackmun
delivered the opinion of the Court (Parts I, II-A, and III) together with an opinion (Part II-B), in which Mr. Justice Brennan, Mr. Justice White, and Mr. Justice Marshall joined.
• Like its companions, this case involves a claim of a State's unconstitutional interference with the decision to terminate pregnancy. The particular object of the challenge is a Missouri statute excluding abortions that are not "medically indicated" from the purposes for which Medicaid benefits are available to needy persons. In its present posture, however, the case presents two issues not going to the merits of this dispute. The first is whether the plaintiff-appellees, as physicians who perform nonmedically indicated abortions, have standing to maintain the suit, to which we answer that they do. The second is whether the Court of Appeals, exercising jurisdiction because the suit had been dismissed in the District Court for lack of standing, properly proceeded to a determination of the merits, to which we answer that it did not.
I
Missouri participates in the so-called Medicaid program, under which the Federal Government partially underwrites qualifying state plans for medical assistance to the needy. See 42 U. S. C. § 1396 et seq. (1970 ed. and Supp. IV). Missouri's plan, which is set out in Mo. Rev. Stat. § 208.151-208.158 (Supp. 1975), includes, in § 208.152, a list of 12 categories of medical services that are eligible for Medicaid funding. The last is:
"(12) Family planning services as defined by federal rules and regulations; provided, however, that such family planning services shall not in- elude abortions unless such abortions are medically indicated."
This provision is the subject of the litigation before us.
The suit was filed in the United States District Court for the Eastern District of Missouri by two Missouri-licensed physicians. Each plaintiff avers, in an affidavit filed in opposition to a motion to dismiss, that he "has provided, and anticipates providing abortions to welfare patients who are eligible for Medicaid payments." App. 32, 36. The plaintiffs further allege in their affidavits that all Medicaid applications filed in connection with abortions performed by them have been refused by the defendant, who is the responsible state official, in reliance on the challenged § 208.152 (12). App. 32, 36. It is not entirely clear who has filed these applications. One affiant states that "he and [his] patients have been refused," id., at 32; the other refers to "those who have submitted applications for such payments on his behalf" and states that such "payments'have been refused." Id., at 36. Indeed, it is not entirely clear to whom the payments would go if they were made. We assume, however, 'from .the statute's several references to payments "on behalf of" eligible persons, see §208.151 and 208.-152, that the provider of the services himself seeks reimbursement from the State. In any event, each plaintiff states that he anticipates further refusals by the defendant to fund nonmedically indicated abortions. Each avers that such refusals "deter [him] from the practice of medicine in the manner he considers to be most expertise [sic] and beneficial for said patients . . . and chill and thwart the ordinary and customary functioning of the doctor-patient relationship." App. 32, 36.
The complaint sought a declaration of the statute's invalidity and an injunction against its enforcement. A number of grounds were stated, among them that the statute, "on its face and as applied," is unconstitutionally vague, "[d]eprives plaintiffs of their right to practice medicine according to the highest standards of medical practice"; "[d]eprives plaintiffs' patients of the fundamental right of a woman to determine for herself whether to bear children"; "[infringes upon plaintiffs' right to render and their patients' right to receive safe and adequate medical advice and treatment"; and "[d]eprives plaintiffs and their patients, each in their own classification, of the equal protection of the laws." Id., at 16, 12-13.
The defendant's sole pleading in District Court was a pre-answer motion to dismiss. Dismissal was sought upon several alternative grounds: that there was no case or controversy; that the plaintiffs lacked "standing to litigate the constitutional issues raised"; that injunctive relief "cannot be granted" because of absence of "irreparable harm" to the plaintiffs; that the plaintiffs "personally could suffer no harm"; and that in any case they "cannot litigate the alleged deprivation or infringement of the civil rights of their welfare patients." Id., at 2<D25.
The plaintiffs having responded to this motion with a memorandum and also with the affidavits described above, the three-judge panel that had been convened to hear the case dismissed the count now before us "for lack of standing." The court saw no "logical nexus between the status asserted by the plaintiffs and the claim they seek to have adjudicated." Wulff v. State Bd. of Registration for Healing Arts, 380 F. Supp. 1137, 1144 (1974).
The United States Court of Appeals for the Eighth Circuit reversed. 508 F. 2d 1211 (1974). It reasoned that Roe v. Wade, 410 U. S. 113 (1973), and Doe v. Bolton, 410 U. S. 179 (1973), as interpreted in several of its own earlier decisions, had " 'paved the way for physicians to assert their constitutional rights to practice medicine/ " citing Nyberg v. City of Virginia, 495 F. 2d 1342, 1344 (CA8), appeal dismissed and cert. denied, 419 U. S. 891 (1974). Those rights were said to include " 'the right to advise and perform abortions/ " and furthermore to be " 'inextricably bound up with the privacy rights of women who seek abortions.' " 508 F. 2d, at 1213. Clearly, the restriction of Medicaid benefits affected the plaintiff physicians "both professionally and monetarily." Id., at 1214. The result, in the Court of Appeals' view, was that they had alleged sufficient " 'injury in fact,' " and also an interest " 'arguably within the zone of interests to be protected ; . . by the . . constitutional guarantee in question,' " ibid., quoting Data Processing Service v. Camp, 397 U. S. 150, 153 (1970).
Although it found the matter "not without its difficulty," 508 F. 2d, at 1214, the Court of Appeals next concluded that, being "urged by appellants" (respondents here), it should proceed from the standing question to the merits of the case. This, rather than a remand, it considered proper because the question of the statute's validity could not profit from further refinement, and indeed was one whose answer was in no doubt. The statute was "obviously unconstitutional," and it therefore appeared "that the case might well have been decided by one federal judge." Id., at 1215. The court, accordingly, chose "to make final determination of this case." Ibid. Proceeding to the merits, the court found a "clear violation of the Equal Protection Clause." Ibid. The statute constituted a "special regulation on abortion," and discriminated against both the patient and the physician "by reason of the patient's poverty." Id., at 1215-1216. Section 208.152 (12) was therefore declared unconstitutional by the Court of Appeals. Injunctive relief was felt to be unnecessary, it being assumed that the State would comply with the declaration and cease any discrimination between needy patients seeking therapeutic and nontherapeutic abortions. 508 F. 2d, at 1213-1216. We granted certiorari, limited to the two questions identified in the opening paragraph of this opinion. 422 U. S. 1041 (1975).
II
Although we are not certain that they have been clearly separated in the District Court's and Court of Appeals' opinions, two distinct standing questions are presented. We have distinguished them in prior cases, e. g., Data Processing Service v. Camp, 397 U. S., at 152-153; Flast v. Cohen, 392 U. S. 83, 99 n. 20 (1968); Barrows v. Jackson, 346 U. S. 249, 255 (1953), and they are these: First, whether the plaintiff-respondents allege "injury in fact," that is, a sufficiently concrete interest in the outcome of their suit to make it a case or controversy subject to a federal court's Art. Ill jurisdiction, and, second, whether, as a prudential matter, the plaintiff-respondents are proper proponents of the particular legal rights on which they base their suit.
A. The first of these questions needs little comment, for there is no doubt now that the respondent-physicians suffer concrete injury from the operation of the challenged statute. Their complaint and affidavits, described above, allege that they have performed and will continue to perform operations for which they would be reimbursed under the Medicaid program, were it not for the limitation of reimbursable abortions to those that are "medically indicated." If the physicians prevail in their suit to remove this limitation, they will benefit, for they will then receive payment for the abortions. The State (and Federal Government) will'be out of pocket by the amount of the payments. The relationship between the parties is classically adverse, and there clearly exists between them a case or controversy in the constitutional sense. Simon v. Eastern Ky. Welfare Rights Org., 426 U. S. 26, 37-39 (1976); Investment Co. Institute v. Camp, 401 U. S. 617, 620-621 (1971); Data Processing Service v. Camp, 397 U. S., at 151-156.
B. The question of what rights the doctors may assert in seeking to resolve that controversy is more difficult. The Court of Appeals adverted to what it perceived to be the doctor's own "constitutional rights to practice medicine." 508 F. 2d, at 1213. We have no occasion to decide whether such rights exist. Assuming that they do, the doctors, of course, can assert them. It appears, however, that the Court of Appeals also accorded the doctors standing to assert, and indeed granted them relief based partly upon, the rights of their patients. We must decide whether this assertion of jus tertii was a proper one.
Federal courts must hesitate before resolving a controversy, even one within their constitutional power to resolve, on the basis of the rights of third persons not parties to the litigation. The reasons are two. First, the courts should not adjudicate such rights unnecessarily, and it may be that in fact the holders of those rights either do not wish to assert them, or will be able to enjoy them regardless of whether the in-court litigant is successful or not. See Ashwander v. TV A, 297 U. S. 288, 345-348 (1936) (Brandéis, J., concurring) (offering the standing requirement as one means by which courts avoid unnecessary constitutional adjudications). Second, third parties themselves usually will be the best proponents of their own rights. The courts depend on effective advocacy, and therefore should prefer to construe legal rights only when the most effective advocates of those rights are before them. The holders of the rights may have a like preference, to the extent they will be bound by the courts' decisions under the doctrine of stare decisis. See, e. g., Baker v. Carr, 369 U. S. 186, 204 (1962) (standing requirement aimed at "assuring] that concrete adverseness which sharpens the presentation of the issues upon which the court so largely depends"); Holden v. Hardy, 169 U. S. 366, 397 (1898) (assertion of third parties' rights would come with "greater cogency" from the third parties themselves). These two considerations underlie the Court's general rule: "Ordinarily, one may not claim standing in this Court to vindicate the constitutional rights of some third party." Barrows v. Jackson, 346 U. S., at 255. See also Flast v. Cohen, 392 U. S., at 99 n. 20; McGowan v. Maryland, 366 U. S. 420, 429 (1961).
Like any general rule, however, this one should not be applied where its underlying justifications are absent. With this in mind, the Court has looked primarily to two factual elements to determine whether the rule should apply in a particular case. The first is the relationship of the litigant to the person whose right he seeks to assert. If the enjoyment of the right is inextricably bound up with the activity the litigant wishes to pursue, the court at least can be sure that its construction of the right is not unnecessary in the sense that the right's enjoyment will be unaffected by the outcome of the suit. Furthermore, the relationship between the litigant and the third party may be such that the former is fully, or very nearly, as effective a proponent of the right as the latter. Thus in Griswold v. Connecticut, 381 U. S. 479 (1965), where two persons had been convicted of giving advice on contraception, the Court permitted the defendants, one of whom was a licensed physician, to assert the privacy rights of the married persons whom they advised. The Court pointed to the "confidential" nature of the relationship between the defendants and the married persons, and reasoned that the rights of the latter were "likely to be diluted or adversely affected" if they could not be asserted in such a case. Id., at 481. See also Eisenstadt v. Baird, 405 U. S. 438, 445-446 (1972) (stressing "advocate" relationship and "impact of the litigation on the third-party interests"); Barrows v. Jackson, 346 U. S., at 259 (owner of real estate subject to racial covenant granted standing to challenge such covenant in part because she was "the one in whose charge and keeping repose [d] the power to continue to use her property to discriminate or to discontinue such use"). A doctor-patient relationship similar to that in Griswold existed in Doe v. Bolton, where the Court also permitted physicians to assert the rights of their patients. 410 U. S., at 188-189. Indeed, since that right was the right to an abortion, Doe would flatly control the instant case were it not for the fact that there the physicians were seeking protection from possible criminal prosecution.
The other factual element to which the Court has looked is the ability of the third party to assert his own right. Even where the relationship is close, the reasons for requiring persons to assert their own rights will generally still apply. If there is some genuine obstacle to such assertion, however, the third party's absence from court loses its tendency to suggest that his right is not truly at stake, or truly important to him, and fhe party who is in court becomes by default the right's best available proponent. Thus, in NAACP v. Alabama, 357 U. S. 449 (1958), the Court held that the National Association for the Advancement of Colored People, in resisting a court order that it divulge the names of its members, could assert the First and Fourteenth Amendments rights of those members to remain anonymous. The Court reasoned that "[tjo require that [the right] be claimed by the members themselves would result in nullification of the right at the very moment of its assertion." Id., at 459. See also Eisenstadt v. Baird, 405 U. S., at 446; Barrows v. Jackson, 346 U. S., at 259.
Application of these principles to the present case quickly yields its proper result. The closeness of the relationship is patent, as it was in Griswold and in Doe. A woman cannot safely secure an abortion without the aid of a physician, and an impecunious woman cannot easily secure an abortion without the physician's being paid by the State. The woman's exercise of her right to an abortion, whatever its dimension, is therefore necessarily at stake here. Moreover, the constitutionally protected abortion decision is one in which the physician is intimately involved. See Roe v. Wade, 410 U. S., at 153-156. Aside from the woman herself, therefore, the physician is uniquely qualified to litigate the constitutionality of the State's interference with, or discrimination against, that decision.
As to the woman's assertion of her own rights, there are several obstacles. For one thing, she may be chilled from such assertion by a desire to protect the very privacy of her decision from the publicity of a court suit. A second obstacle is the imminent mootness, at least in the technical sense, of any individual woman's claim. Only a few months, at the most, after the maturing of the decision to undergo an abortion, her right thereto will have been irrevocably lost, assuming, as it seems fair to assume, that unless the impecunious woman can establish Medicaid eligibility she must forgo abortion. It is true that these obstacles are not insurmountable. Suit may be brought under a pseudonym, as so frequently has been done. A woman who is no longer pregnant may nonetheless retain the right to litigate the point because it is " 'capable of repetition yet evading review.' " Roe v. Wade, 410 U. S., at 124-125. And it may be that a class could be assembled, whose fluid membership always included some women with live claims. But if the assertion of the right is to be "representative" to such an extent anyway, there seems little loss in terms of effective advocacy from allowing its assertion by a physician.
For these reasons, we conclude that it generally is appropriate to allow a physician to assert the rights of women patients as against governmental interference with the abortion decision, and we decline to restrict our holding to that effect in Doe to its purely criminal context. In this respect, the judgment of the Court of Appeals is affirmed.
III
On this record, we do not agree, however, with the action of the Court of Appeals in proceeding beyond the issue of standing to a resolution of the merits of the case. Petitioner urges that this action was particularly inappropriate because the case is one in which the requested injunctive relief could be granted or denied on the merits only by a three-judge district court, with direct appeal here. We find it unnecessary to reach this contention, or the respondents' arguments that a three-judge court was not required because the statute is so patently unconstitutional and because in any event only declaratory relief is warranted. Quite apart from these considerations, the Court of Appeals' resolution of the merits seems to us to be an unacceptable exercise of its appellate jurisdiction.
As noted, with respect to the complaint's count that is before us, petitioner filed in the District Court only a pre-answer motion to dismiss for lack of standing. He filed no answer, and no other pleading addressed to the merits. He did answer some interrogatories, App. 26, but stipulated to no facts, and gave no intimation of what defenses, if any, he might have other than the plaintiffs' alleged lack of standing. The District Court granted his motion to dismiss and no more. That dismissal was the "final decision" appealed from, see 28 U. S. C. § 1291, and on appeal petitioner limited himself entirely to the standing determination that underlay it. In short, petitioner has never been heard in any way on the merits of the case.
It is the general rule, of course, that a federal appellate court does not consider an issue not passed upon below. In Hormel v. Helvering, 312 U. S. 552, 556 (1941), the Court explained that this is "essential in order that parties may have the opportunity to offer all the evidence they believe relevant to the issues . . . [and] in order that litigants may not be surprised on appeal by final decision there of issues upon which they have had no opportunity to introduce evidence." We have no idea what evidence, if any, petitioner would, or could, offer in defense of this statute, but this is only because petitioner has had no opportunity to proffer such evidence. Moreover, even assuming that there is no such evidence, petitioner should have the opportunity to present whatever legal arguments he may have in defense of the statute. We think he was justified in not presenting those arguments to the Court of Appeals, and in assuming, rather, that he would at least be allowed to answer the complaint, should the Court of Appeals reinstate it.
The matter of what questions may be taken up and resolved for the first time on appeal is one left primarily to the discretion of the courts of appeals, to be exercised on the facts of individual cases. We announce no general rule. Certainly there are circumstances in which a federal appellate court is justified in resolving an issue not passed on below, as where the proper resolution is beyond any doubt, see Turner v. City of Memphis, 369 U. S. 350 (1962), or where "injustice might otherwise result." Hormel v. Helvering, 312 U. S., at 557. Suffice it to say that this is not such a case. The issue resolved by the Court of Appeals has never been passed upon in any decision of this Court. This being so, injustice was more likely to be caused than avoided by deciding the issue without petitioner's having had an opportunity to be heard.
Assuming, therefore, that the Court of Appeals had jurisdiction to proceed to the merits in this case, we hold that it should not have done so. To that extent, its judgment is reversed, and the case is remanded with directions that it be returned to the District Court so that petitioner may file an answer to the complaint and the litigation proceed accordingly.
It is so ordered.
Planned Parenthood of Missouri v. Danforth, ante, p. 52, Bellotti v. Baird, post, p. 132.
The complaint contained two additional counts directed against the Missouri State Board of Registration for the Healing Arts, and concerning other Missouri statutes relating to abortions upon minors. The District Court's dismissal of those counts has not been appealed and is not now before us.
Plaintiffs sued on their own behalf and on behalf of the class of similarly situated physicians. App. 15. Apparently, however, the suit was dismissed by the District Court before any such class was certified.
Defendant Singleton, petitioner herein, is Chief of the Bureau of Medical Services in the Division of Welfare of Missouri's Department of Public Health and Welfare. Id., at 16.
We have reiterated that holding today in Planned Parenthood of Missouri v. Danforth, ante, at 62.
Mr. Justice Powell objects that such an obstacle is not enough, that our prior cases allow assertion of third-party rights only when such assertion by the third parties themselves would be "in all practicable terms impossible." Post, at 126. Carefully analyzed, our cases do not go that far. The Negro real-estate purchaser in Barrows, if he could prove that the racial covenant alone stood in the way of his purchase (as presumably he could easily have done, given the amicable posture of the seller in that case), could surely have sought a declaration of its invalidity or an injunction against its enforcement. The Association members in NAACP v. Alabama could have obtained a similar declaration or injunction, suing anonymously by the use of pseudonyms. The recipients of contraceptives in Eisenstadt (or their counterparts in Griswold and Doe, for that matter) could have sought similar relief as necessary to the enjoyment of their constitutional rights. The point is not that these were easy alternatives, but that they differed only in the degree of difficulty, if they differed at all, from the alternative in this case of the women themselves seeking a declaration or injunction that would force the State to pay the doctors for their abortions.
Mr. Justice Powell would so limit Doe, and the other cases cited, explaining them as cases in which the State "directly interfered with the abortion decision" and "directly interdicted the normal functioning of the physician-patient relationship by criminalizing certain procedures." Post, at 128, There is no support in the language of the cited cases for this distinction, and we are given no logical reason why "direct" interference with a litigant's conduct should provide a special reason for allowing him to assert third-party rights. Moreover, a "direct interference" or "interdiction" test does not appear to be supported by precedent. We have allowed jus tertii assertion where the interference was no more direct than it is here, In Pierce v. Society of Sisters, 268 U. S. 510 (1925), for example, private schools were permitted to assert the rights of parents as against a state requirement that their children receive a public education, even though the private schools were not thereby "interdicted" at all, but only reduced to the role of supplementing the public school education. Conversely, we regularly disallow jus tertii assertion even though the State has "interdicted" the litigant's conduct to the point of "criminalizing" it. See Brown v. United States, 411 U. S. 223, 230 (1973) (Fourth Amendment rights of others); Broadrick v. Oklahoma, 413 U. S. 601, 610 (1973) (rights of others to be free from application of same statute); McGowan v. Maryland, 366 U. S, 420, 429-430 (1961) (store owners convicted of violating Sunday closing laws could not assert religious liberty rights of customers). Finally, it is not clear why a "direct interference" or "interdiction" test would not allow the jus tertii assertion in this case. For a doctor who cannot afford to work for nothing, and a woman who cannot afford to pay him, the State's refusal to fund an abortion, is as effective an "interdiction" of it as would ever be necessary. Furthermore, since the right asserted in this case is not simply the right to have an abortion, but the right to have abortions nondiscriminatorily funded, the denial of such funding is as complete an "interdiction" of the exercise of the right as could ever exist.
MR. Justice Powell also voices the concern that our decision today will be "difficult to cabin," and threatens to allow "any provider of services . to assert his client's or customer's constitutional rights, if any, in an attack on a welfare statute that excludes from coverage his particular transaction." Post, at 129, 129-130. It is true that it is mofe difficult to predict the pattern of results in future cases when the Court elects to proceed, as it does today, by assessing relevant factors in individual cases (and we give no decisive or pre-eminent importance to any one of these factors), rather than by adopting a set of per se rules, such as those Mr. Justice Powell would apparently prefer based on the "direct interdiction" of the litigant's conduct and the impossibility of third-party assertion. Still, we cannot share the Justice's alarm. Unless the "provider of services" that he has in mind enjoys with his "client" a confidential relationship such as that of the doctor and patient, unless the "client's" claim is imminently moot, as the pregnant woman's technically is, the standing issue in such a future case will not be definitively controlled by this one. Beyond that, we simply decline to speculate on cases not before us.
These examples are not intended to be exclusive.