Opinion ID: 4538315
Heading Depth: 4
Heading Rank: 2

Heading: Potassium Chloride Injections

Text: As a second possibility, the Secretary suggests that an abortion provider may induce fetal demise by injecting potassium chloride into the fetus or the fetal heart. As described by the district court, physicians using this method “begin by using an ultrasound machine to visualize the patient’s uterus and fetus. The physician then inserts a long surgical needle through the woman’s skin, abdomen, and uterine muscle, and then into either the fetus or, more specifically, the fetal heart.” Meier, 373 F. Supp. 3d at 819. At this stage, the fetal heart is approximately the size of a dime. Id. If injected into the fetal heart, potassium chloride causes fetal demise almost immediately. Id. The physician may then perform a standard D&E. The district court found that potassium chloride injections were not a feasible method for inducing fetal demise for three reasons. First, potassium chloride injections cannot be completed on every individual seeking a D&E. Id. at 820. Second, they subject patients to serious health risks. Id. Third, potassium chloride injections are extremely challenging and require substantial technical training to perform—training that the physician Plaintiffs do not have and cannot easily acquire. Id. at 819–20. In contesting the district court’s first finding, the Secretary again quibbles with the district court’s decision to credit Plaintiffs’ expert testimony over his own. But ample evidence grounded the district court’s conclusion that potassium chloride injections would not be successful for many seeking a D&E—because of factors including obesity, fetal and uterine position, cesarean-section or other scar tissue, and uterine fibroids—in addition to the procedure’s independent possibility of failure. (Tr. Vol. I, R. 106 at PageID ##4423, 4551–52; Tr. Vol. IV, R. 103 at PageID ##3966, 4187–89.) With regard to the district court’s second finding, the Secretary does not dispute that potassium chloride injections pose health risks to patients. And the record clearly suggested that No. 19-5516 EMW Women’s Surgical Center, et al. v. Friedlander, et al. Page 20 potassium chloride injections increased patients’ risks of infection, bleeding, cramping, uterine or bowel perforation, uterine atony and hemorrhaging, and cardiac arrest. (See, e.g., Tr. Vol. I, R. 106 at PageID ##4423–24, 4561–62; Tr. Vol. III-B, R. 102 at PageID ##3802–06; Tr. Vol. IV, R. 103 at PageID ##4198–99.) The Secretary does contest the significance of these risks, but this argument fails for the same reasons it failed previously. H.B. 454 cannot be said to impose only marginal or insignificant risks because no safe alternative exists and because it requires every individual seeking a D&E abortion to expose themselves to these risks. Again, every court to consider whether potassium chloride injections present substantial risk has agreed that they do. Williamson, 900 F.3d at 1322, 1324, 1327; Farmer, 220 F.3d at 145–46; Bernard, 392 F. Supp. 3d at 950–51, 960; Yost, 375 F. Supp. 3d at 860, 868; Paxton, 280 F. Supp. 3d at 950–51; Hopkins, 267 F. Supp. 3d at 1040, 1062–63; Verniero, 41 F. Supp. 2d at 500, aff’d sub nom. Farmer, 220 F.3d 127; Evans, 977 F. Supp. at 1301, 1318; accord Meier, 373 F. Supp. 3d at 820. Regarding the district court’s finding that potassium chloride injections require technical skill and training that is not available to Plaintiffs, the Secretary argues that this is no issue. Even if the physician Plaintiffs themselves do not have and cannot acquire the requisite training, the Secretary says, EMW can simply hire physicians who do. According to the Secretary, because EMW has not attempted to hire such physicians, Plaintiffs themselves have caused this obstacle to abortion access, not H.B. 454. This argument misses the point. Whether Plaintiffs could find some way to provide potassium chloride injections is only relevant if those injections otherwise present a feasible workaround to H.B. 454. They do not. Potassium chloride injections cannot be performed on many patients and present substantial added health risks even when they can be. It would be irrational to require Plaintiffs to go to the effort and expense of attempting to hire other physicians in order to prove that they cannot make a dangerous and potentially ineffective procedure available to their patients. The burden here is undoubtedly caused by H.B. 454. But even setting this analysis aside, the Secretary’s argument also fails for other reasons. First, neither Supreme Court precedent nor this Court’s precedent requires Plaintiffs to prove that EMW could not have hired physicians with the skills and training necessary to perform potassium chloride injections. For this proposition, the Secretary cites Gonzales, noting that No. 19-5516 EMW Women’s Surgical Center, et al. v. Friedlander, et al. Page 21 physicians need not have “unfettered choice” in what abortion procedures they may use and that regulations may require them to perform procedures that are “standard medical options.” (Def. Br. at 20 (quoting Gonzales, 550 U.S. at 163, 166).) But the point of the district court’s findings is that potassium chloride injection is not a standard medical option, and Plaintiffs could not provide that procedure even if they would so choose, because they have no available avenue to develop the necessary skills. We agree. The Secretary cites to June Medical Services L.L.C. v. Gee, 905 F.3d 787 (5th Cir. 2015), cert. granted, 140 S. Ct. 35 (2019), to support his argument. In that case, the Fifth Circuit upheld a Louisiana law requiring abortion providers to gain admitting privileges at a nearby hospital. The court found that the plaintiff physicians had failed to show that the law presented an undue burden because they had not applied for admitting privileges or otherwise shown that had they “put forth a good-faith effort to comply with [the law], they would have been unable to obtain privileges.” Id. at 807. Because the plaintiffs failed to make this showing, the Fifth Circuit concluded that “[t]heir inaction severs the chain of causation.” Id. But see id. at 830 (Higginbotham, J., dissenting) (explaining that Hellerstedt “did not require proof that every abortion provider . . . put in a good-faith effort to get privileges and had been unable to do so”). The Fifth Circuit thus took issue not with the plaintiffs’ failure to attempt to hire or replace themselves with other physicians who had admitting privileges, but with their failure to show that they could not have obtained admitting privileges had they tried. See id. at 807. In the case at bar, the district court found that Plaintiffs “have no practical way to learn how to perform this procedure safely,” due to “the length of time it would take to learn the procedure and the lack of training available within the Commonwealth.” Meier, 373 F. Supp. 3d at 820. The Secretary does not dispute this finding, and the record supports it. (See, e.g., Tr. Vol. I, R. 106 at PageID ##4573–74; Tr. Vol. II, R. 107 at PageID ##4732–33; Tr. Vol. IV, R. 103 at PageID ##4185– 86.) Thus, plaintiffs succeed even under the heightened showing required by the Fifth Circuit in Gee. Still, Supreme Court precedent does not support such a requirement. Nor does Sixth Circuit precedent. Notably, the Supreme Court granted a stay of the Fifth Circuit’s decision, Gee, 139 S. Ct. 663 (2019) (mem.), and the Court does not stay a decision absent a “significant No. 19-5516 EMW Women’s Surgical Center, et al. v. Friedlander, et al. Page 22 possibility that the judgment below will be reversed,” Philip Morris U.S.A. Inc. v. Scott, 561 U.S. 1301, 1302 (2010). Far from requiring plaintiffs to specifically and affirmatively show goodfaith efforts to comply with a challenged law, Supreme Court precedent suggests that plaintiffs may demonstrate an undue burden “by presenting direct testimony as well as plausible inferences to be drawn” from the evidence, Hellerstedt, 136 S. Ct. at 2313, including the inference that any good-faith efforts would fail to alleviate the burden. Common sense suggests that when only a small subset of physicians have undergone the extensive training required to perform a procedure, it would be difficult to impossible for an abortion clinic to recruit one of those physicians. Still, the relevant question in abortion cases is not whether it would unduly burden a provider to comply with a law, but whether compliance would unduly burden their patients’ right to elect abortion prior to viability. And it is even clearer that should Kentucky require a procedure that only a small subset of physicians can administer—in comparison to the large number who can administer a D&E—it would restrict the number of D&Es that could be provided in Kentucky, thereby burdening those seeking a D&E. Altogether, the district court’s well-supported findings suggest that if patients were required to undergo a potassium chloride injection prior to a D&E, they would be subjected to a medically risky and unreliable procedure, which they may not be able to receive successfully and to which they would have only limited access, given the dearth of Kentucky providers trained to administer the procedure. These findings demonstrate that potassium chloride injections are not a feasible workaround to H.B. 454.