Opinion ID: 1309503
Heading Depth: 1
Heading Rank: 5

Heading: the hospital requirement

Text: The principal constitutional challenge is addressed to the hospital requirement of § 18.2-73. The defendant's attack is two-fold. First, he argues that the requirement violates the Due Process clause because, he says, it is not reasonably related to maternal health and, therefore, transcends the regulatory powers of the state. Second, he contends that it limits a pregnant woman's access to medical care, and thus, abridges her constitutional right to choose abortion over maternity. In the definition of a woman's right to abort, the watershed case is Roe v. Wade, 410 U.S. 113, 93 S.Ct. 705, 35 L.Ed.2d 147 (1973). There, the Supreme Court, referring to the First, Fourth, Fifth, Ninth, and Fourteenth Amendments as the roots of a constitutional right of privacy, held that the right is broad enough to encompass a woman's decision whether or not to terminate her pregnancy. Id. at 153, 93 S.Ct. at 727. Classifying that right as one of the fundamental rights, the Court said that state regulation limiting these rights may be justified only by a `compelling state interest'. Id. at 155, 93 S.Ct. at 728. Balancing the personal right of privacy against the state's power to regulate, the Court explained: [T]he State does have an important and legitimate interest in preserving and protecting the health of the pregnant woman... and ... it has still another important and legitimate interest in protecting the potentiality of human life. These interests are separate and distinct. Each grows in substantiality as the woman approaches term and, at a point during pregnancy, each becomes `compelling.' With respect to the State's important and legitimate interest in the health of the mother, the `compelling' point ... is at approximately the end of the first trimester. This is so because of the now-established medical fact ... that until the end of the first trimester mortality in abortion may be less than mortality in normal childbirth. It follows that, from and after this point, a State may regulate the abortion procedure to the extent that the regulation reasonably relates to the preservation and protection of maternal health. Examples of permissible state regulation in this area are requirements as to the qualifications of the person who is to perform the abortion; as to the licensure of that person; as to the facility in which the procedure is to be performed, that is, whether it must be a hospital or may be a clinic or some other place of less-than-hospital status; as to the licensing of the facility; and the like. This means, on the other hand, that, for the period of pregnancy prior to this `compelling' point, the attending physician, in consultation with his patient, is free to determine, without regulation by the State, that, in his medical judgment, the patient's pregnancy should be terminated. If that decision is reached, the judgment may be effectuated by an abortion free of interference by the State. With respect to the State's important and legitimate interest in potential life, the `compelling' point is at viability.... Id. at 162-63, 93 S.Ct. at 731-32. Doe v. Bolton, 410 U.S. 179, 93 S.Ct. 739, 35 L.Ed.2d 201 (1973), was decided the same day as Roe. Finding that the evidence adduced at trial was insufficient to show that a hospital requirement in a Georgia statute was reasonably related to maternal health, the Court ruled that the regulation was invalid because it fails to exclude the first trimester of pregnancy. Id. at 195, 93 S.Ct. at 749. Article 9 of the Virginia Code excludes the first trimester; the hospital requirement applies to the second and third trimesters only. Under the principles and the standard of review announced in Roe and Doe we consider whether the evidence in this case supports a conclusion that the regulation reasonably relates to the preservation and protection of maternal health. Roe, 410 U.S. at 163, 93 S.Ct. at 732.
Contending that it does not, the defendant points to the testimony of several medical experts. Dr. Harold Schulman testified that saline injections are often administered in ill-equipped treatment rooms at hospitals from which the patient is discharged to await labor. He suggested that hospitalization during the waiting period is not necessarily wise and could be dangerous to an expectant mother. He mentioned the possibility that some members of a hospital staff might be unsupportive or critical of unwed mothers and some might attempt to hasten expulsion by manipulation or instrumentation and thereby cause uterine or cervical perforation. A study he conducted showed that 65 percent of those injected as out-patients expelled the fetus at home, enroute to the hospital, or upon arrival and thereafter required no hospitalization. Yet, on cross-examination, Dr. Schulman conceded that the saline injection procedure entails certain risks which make it necessary to observe the patient to see if there are any unusual reactions to the instillation of the solution. Such reactions may occur for some unexplained reason or when a disproportionate amount of the salt solution somehow gets into her blood stream. This can cause thirst or headache, nausea, vomiting and on rare occasions the uterus will abruptly begin to swell. Dr. Schulman agreed that the saline solution can interfere with the clotting capacity of the blood and result in extensive hemorrhaging. He characterized this as a very serious problem, but one which occurs for the most part only during labor. He was familiar with some reported cases of maternal death due to total evacuation of blood. Although he felt that the defendant's clinic was better furnished than most facilities used for saline procedures, he recalled that it was not equipped to handle blood transfusions. In his own practice, Dr. Schulman instructs patients injected with saline to go to the hospital when labor begins. He follows this policy because of the danger that's inherent in this whole process. Dr. Samuel M. Belinsky testified that he had administered 93 second-trimester saline injections in a treatment room at Fairfax Hospital. As appears from his testimony, Dr. Belinsky considers an out-patient saline injection a reasonably safe medical procedure; he agrees that the defendant's clinic is adequately equipped for the procedure; he finds that the complication rates are about the same whether the procedure is performed on an in-patient or out-patient basis; he believes it is medically reasonable to release a saline patient following a period of observation, with instructions such as those given by the defendant; and he has some concern about the possibility of patient abuse by hospital staffs. On direct examination, Dr. Thomas Gressinger concurred generally in Dr. Belinsky's opinions. On cross-examination, however, he acknowledged that, if the saline solution enters the bloodstream too fast, it may cause hypernatremia. Although that condition may be corrected before the onset of labor by the body's natural defense mechanisms, he agreed that, when bleeding results, it is a major medical problem. He noted that Fairfax Hospital maintains a special facility apart from the operating room for delivery of patients injected with saline. Dr. Gressinger, who had administered numerous injections at that hospital, advises his patients to deliver there. He said that the saline process should be closely supervised and the facility is set up for close supervision. I feel, he added, it's the best facility around so I feel it's best for my patients. Testifying in his own defense, the defendant was of opinion that the saline procedure is the safest method of abortion, that it rarely causes significant complications, that his clinic is properly equipped to perform the procedure, and that the statutory hospital requirement is medically unnecessary for the protection of the patient. The testimony of Dr. Soyster, a witness for the defense, was to the same effect. It appears that the saline method is the procedure most commonly employed by physicians to induce an abortion in the second trimester. Indeed, saline amnio-infusion [is] the method of choice during that stage of pregnancy. See Colautti v. Franklin, 439 U.S. 379, 398, 99 S.Ct. 675, 687, 58 L.Ed.2d 596 (1979). And a statutory clause which forbids its use after the first trimester is not reasonably related to maternal health. Planned Parenthood of Missouri v. Danforth, 428 U.S. 52, 78-79, 96 S.Ct. 2831, 2845-46, 49 L.Ed.2d 788 (1976). But the method employed is not the issue here. Rather, the question is whether the state can require that the method chosen to initiate a second-trimester abortion be performed in a hospital. As Roe and Doe teach, once pregnancy has entered the second trimester, the state has a compelling interest in maternal health. In the exercise of the regulatory powers of the state, the legislature may adopt any measure reasonably designed to reduce health hazards inherent in the performance of medical practices. [6] Here, unlike the situation in Doe, the medical evidence shows that, from the moment a saline solution is injected to the time the fetus is expelled, the pregnant woman is exposed to certain risks [7]  some minor, others major, none precisely predictable. The state is empowered to license and regulate hospitals, clinics, home health agencies, and other medical care facilities, see generally, Title 32.1 of the Code, and to fix and enforce different standards of medical care for different facilities. The General Assembly has decided that medical procedures employed in second-trimester abortions must be performed in hospitals. Based upon the evidence in this record, we are of opinion that the hospital requirement is reasonably related to the State's compelling interest in preserving and protecting maternal health.
Advancing an alternative theory, the defendant insists that the hospital requirement is constitutionally defective because, he says, it unreasonably limits a pregnant woman's access to medical care and thereby abridges her right under Roe to elect to abort. Dr. Soyster testified that only two hospitals in Northern Virginia permit second-trimester abortions, and Dr. Belinsky knew of none in that area that did not require parental consent for abortions on minors. Noting that his patient, a minor, was anxious to conceal her condition from her parents and that she was unable to afford the expense of hospitalization, the defendant maintains that hospital access was virtually unavailable. This, he argues, shows that the hospital requirement is unreasonable as applied in this State. The defendant cites two opinions of federal district courts in other states. In Margaret S. v. Edwards, 488 F.Supp. 181 (E.D.La.1980), none of the Louisiana hospitals performed second-trimester abortions. In Planned Parenthood Ass'n of Kansas City v. Ashcroft, 483 F.Supp. 679 (W.D.Mo.1980), argued, No. 80-1130 (8th Cir. Nov. 17, 1980), only one hospital in Missouri did so. But, as acknowledged by the defendant on brief, two hospitals in Northern Virginia and 24 hospitals located elsewhere in the State were providing abortion services in 1977. More to the point, to the extent access to hospital abortion services was inconvenient or conditioned upon parental consent, the limitations were not obstacles created by the state. [8] While Code § 18.2-75, the so-called conscience clause, permits private hospital corporations to place certain restrictions on abortion services or to refuse them altogether, it does not require them to do so. And it need not forbid them to do so. [A]lthough government may not place obstacles in the path of a woman's exercise of her freedom of choice, it need not remove those not of its own creation. Harris v. McRae, 100 S.Ct. 2671, 2688 (1980) (rejecting the contention that denial of public funding of abortion services was an unconstitutional infringement of the right to abort). See also Poelker v. Doe, 432 U.S. 519, 97 S.Ct. 2391, 53 L.Ed.2d 528 (1977); Maher v. Roe, 432 U.S. 464, 97 S.Ct. 2376, 53 L.Ed.2d 484 (1977); Beal v. Doe, 432 U.S. 438, 97 S.Ct. 2366, 53 L.Ed.2d 464 (1977). Applying that rule, we reject the defendant's contention here. Courts accord legislative enactments a presumption of constitutionality, and the burden rests upon those who question their validity to overcome the presumption. We find that the defendant has not carried his burden, and we hold that the hospital requirement of Article 9 is constitutionally permissible. [9]