Opinion ID: 2103784
Heading Depth: 3
Heading Rank: 3

Heading: Analysis of Tennessee's Criminal Abortion Statutes

Text: The Tennessee statute initially provides that abortions are lawful within the first three months of pregnancy if performed with the woman's consent and in accordance with the medical judgment of her attending physician. Tennessee Code Ann. § 39-15-201(c)(2) further provides that [n]o person is guilty of a criminal abortion... when an abortion ... is performed under the following circumstances: .... After three (3) months, but before viability of the fetus, if the abortion or attempt to procure a miscarriage is performed with the pregnant woman's consent and in a hospital.... Tenn.Code Ann. § 39-15-201(c)(2). There is no statutory provision for a medical emergency exception to the second trimester hospitalization requirement. See Tenn.Code Ann. §§ 39-15-201 through 209. The trial court construed the term hospital to include ambulatory surgical centers, bringing the statute into conformity with the standards of the American College of Obstetricians and Gynecologists, and upheld the second trimester hospitalization requirement. The Court of Appeals applied the undue burden standard and concluded that there was no evidence of improper legislative motive nor evidence that the second trimester hospitalization requirement created a substantial obstacle preventing women from obtaining abortions. Under the strict scrutiny standard, it is the State's burden to show that the regulation is justified by a compelling state interest and narrowly tailored to achieve that interest. E.g., Smoky Mountain Secrets, 937 S.W.2d at 912; Hawk, 855 S.W.2d at 579 n. 9. The State concedes that the hospitalization requirement increases the cost of abortions. The State, however, points to evidence in the record that second trimester abortions can result in complications and argues that such complications require a hospital setting for a proper medical response. The State presented testimony that Planned Parenthood's facilities lack necessary instruments, equipment, and supplies to perform abortions after the third month of pregnancy. In light of this evidence, the State argues that the second trimester hospitalization requirement is necessary to protect maternal health. Planned Parenthood points to evidence that second trimester abortions are safe outside the hospital setting up to eighteen weeks of pregnancy and that the hospitalization requirement only serves to increase the cost of second trimester abortions without increasing their safety. The State insists, however, that freestanding outpatient clinics and ambulatory treatment centers like those run by the plaintiffs lack adequate facilities in which to perform second trimester abortions. Although the State has a compelling interest in maternal health from the beginning of pregnancy, Tenn. Const. art. I, § 1, the second trimester hospitalization requirement is not narrowly tailored to further that state interest. Substantial evidence was introduced at trial to indicate that abortions can be performed safely outside the hospital setting through at least the first eighteen weeks of pregnancy. American College of Obstetricians and Gynecologists, Standards for Obstetric-Gynecologic Services (7th ed.1989). As observed by the Court of Appeals, a general agreement exists within the medical community that abortions can be performed safely in physicians' offices and outpatient clinics through the fourteenth week of pregnancy and, further, that physicians agree that abortions through the eighteenth week of pregnancy may be performed safely in free-standing surgical facilities. As noted by the trial court, the evidence is clear that second-trimester abortions are performed in the Nashville community in `ambulatory surgical centers,' which have resulted from advanced medical technology and care, and are also the product of an attempt to lower costs to patients. The State may, of course, adopt standards for licensing facilities where second trimester abortions may be performed such as requiring facilities to be properly equipped and staffed. See, e.g., American College of Obstetricians and Gynecologists, Standards for Obstetric-Gynecologic Services (setting forth suggested qualification standards). However, the State may not simply prohibit all second trimester abortions that are not performed in a hospital. Such a regulation is not narrowly tailored to promote maternal health. Moreover, in light of the complete absence of a medical emergency exception to the hospitalization requirement, the provision is constitutionally infirm even under the federal undue burden standard. Casey, 505 U.S. at 879, 112 S.Ct. at 2821 ([T]he state ... may, if it chooses, regulate, and even proscribe, abortion except where it is necessary, in appropriate medical judgment, for the preservation of the life or health of the mother.  (quoting Roe, 410 U.S. at 164-65, 93 S.Ct. at 732) (emphasis added)). Accordingly, we conclude that the second trimester hospitalization requirement place[s] a substantial obstacle in the path of a woman seeking an abortion. Id. at 878, 112 S.Ct. at 2821.
We now turn to consider the statutory provisions that set out the informed consent requirements, the two-day waiting period requirement, and the medical emergency exceptions to each of these requirements. Because each of these provisions are interrelated, and the lower courts considered the combined effect of these subsections, we too will consider them together. The informed consent requirements are codified at Tenn.Code Ann. § 39-15-202(b)(c). Subsection 202(b) states: (b) In order to ensure that a consent for an abortion is truly informed consent, an abortion shall be performed or induced upon a pregnant woman only after she has been orally informed by her attending physician of the following facts and has signed a consent form acknowledging that she has been informed as follows: (1) That according to the best judgment of her attending physician she is pregnant; (2) The number of weeks elapsed from the probable time of the conception of her unborn child, based upon the information provided by her as to the time of her last menstrual period or after a history, physical examination, and appropriate laboratory tests; (3) That if more than twenty-four (24) weeks have elapsed from the time of conception, her child may be viable, that is, capable of surviving outside of the womb, and that if such child is prematurely born alive in the course of an abortion her attending physician has a legal obligation to take steps to preserve the life and health of the child. ... (5) That numerous public and private agencies and services are available to assist her during her pregnancy and after the birth of her child, if she chooses not to have the abortion, whether she wishes to keep her child or place the child for adoption, and that her physician will provide her with a list of such agencies and the services available if she so requests; or (6) Numerous benefits and risks are attendant either to continued pregnancy and childbirth or to abortion depending upon the circumstances in which the patient might find herself. The physician shall explain these benefits and risks to the best of such physician's ability and knowledge of the circumstances involved. Subsection 202(c) states: At the same time the attending physician provides the information required by subsection (b), such physician shall inform the pregnant woman of the particular risks associated with her pregnancy and childbirth and the abortion or child delivery technique to be employed, including providing her with at least a general description of the medical instructions to be followed subsequent to the abortion or childbirth in order to ensure her safe recovery. Id. § 202(b)-(c). [10] These provisions apply to any abortion sought in Tennessee, regardless of the trimester in which it is sought. The two-day waiting period requirement is codified at Tenn.Code Ann. § 39-15-202(d)(1). This subsection states: There shall be a two-day waiting period after the physician provides the required information, excluding the day on which such information was given. On the third day following the day such information was given, the patient may return to the physician and sign a consent form. Id. § 202(d)(1). Thus, after the woman receives the mandated information, she must wait two additional days before she may return to the physician, sign a consent form, and obtain the abortion. Finally, the emergency medical exceptions to both these sections are codified at Tenn.Code Ann. § 39-15-202(d)(3), (g). Subsection 202(d)(3) provides the medical emergency exception to the two-day waiting period requirement and states: This subsection shall not apply when the attending physician, utilizing experience, judgment or professional competence, determines that a two-day waiting period or any waiting period would endanger the life of the pregnant women.... This provision shall not relieve the attending physician of his duty to the pregnant woman to inform her of the facts under subsection (b). Id. § 202(d)(3) (emphasis added). Subsection 202(g) contains the medical emergency exceptions to all requirements of Tenn.Code Ann. § 39-15-202 and states: The provisions of this section shall not apply in those situations where an abortion is certified by a licensed physician as necessary to preserve the life of the pregnant woman. Id. § 202(g) (emphasis added). These are the only medical emergency exceptions to the challenged statutory provisions before this Court. The trial court found that the attending physician need not personally inform the pregnant woman of the required information, but must verify that such counseling has taken place and confirm that the patient is actually supplied adequate information to enable her to make an autonomous decision. The trial court, however, struck the waiting period requirement. Finally, as to the medical emergency exceptions, the trial court interpreted the word life to mean life and health and upheld the exceptions. Although the Court of Appeals generally affirmed the trial court with regard to the informed consent provisions, the appellate court disagreed with the trial court's conclusion that the waiting period created an undue burden. The intermediate court expressed concern that its research had failed to reveal a single case upholding a waiting period longer than twenty-four hours, but the court declined to strike the statute based solely on the length of the waiting period. The Court of Appeals did conclude, however, that under the facts of this case, the combined effect of the physician-only counseling requirement and the mandatory two-day waiting period unduly burdens a woman's exercise of her procreational rights. The court disagreed with the trial court's analysis concerning the attending physician requirement, stating that pursuant to the plain language of the statute, a physician may not delegate his or her informed consent obligations to any other person. Finally, the court disagreed with the trial court's construction of the medical emergency exception contained in Tenn.Code Ann. § 39-15-202(g), reasoning that pursuant to the plain meaning of § 202(g), a physician may bypass the requirements of Tenn.Code Ann. § 39-15-202 only when necessary to preserve the life of the pregnant woman, regardless of her health. Accordingly, the appellate court held the medical emergency exceptions to be unconstitutional under Casey . It is the State's burden to show that the regulation is justified by a compelling state interest. E.g., Smoky Mountain Secrets, 937 S.W.2d at 912; Hawk, 855 S.W.2d at 579 n. 9. The State, however, has chosen to primarily argue that the Court of Appeals was correct in reviewing the challenged provisions under the undue burden standard announced in Casey . Planned Parenthood, on the other hand, argues that none of these provisions are narrowly tailored to further compelling state interests.
Planned Parenthood challenged the statutory requirement that before a woman consents to an abortion, her attending physician must orally inform her of certain information about the procedure and her options. Tenn.Code Ann. § 39-15-202(b) and (c). The legislature has spoken on the issue of informed consent in another context. Tenn.Code Ann. § 29-26-118. This section applies to all other actions involving the issue of informed consent except for abortion. Section 29-26-118, captioned Proving inadequacy of consent, provides that a plaintiff to a malpractice action proves lack of informed consent by presenting evidence that the physician did not supply appropriate information to the patient in obtaining his informed consent ... in accordance with the recognized standard of acceptable professional practice in the profession and in the speciality, if any ... Id. The legislature has provided for a cause of action based on the lack of informed consent and has recognized that informed consent is intended to benefit the patient, i.e., the pregnant woman. Accord, e.g., Bryant v. HCA Health Services of Tennessee, Inc., 15 S.W.3d 804, 809-10 (Tenn.2000). Although it is important that a woman contemplating abortion be informed in accordance with the recognized standard of acceptable professional practice, the physician-only counseling requirement is not narrowly tailored to accomplish this requirement. The State argues that medical ethics require the attending physician to impart the required information to the woman. The State suggests that nothing in the statute prevents the attending physician from informing the woman of the required information over the telephone, thereby reducing any burden which could result from the combined effect of the physician-only counseling requirement and the two-day waiting period requirement. In our view, however, this interpretation disregards the plain language contained in Tenn.Code Ann. § 39-15-202(d)(1) that a woman may return to the physician's office following the two-day waiting period. In requiring that a woman wait two days before she may return to her physician, id., the legislature clearly intended that the woman make two trips to the physician in order to fulfill the informed consent requirements. In any event, the State maintains that these provisions are constitutionally sound, pointing to evidence in the record that Planned Parenthood has been providing similar information to its patients. Medical experts for Planned Parenthood testified that most women have already made up their minds before going to the abortion provider, and for those who seem uncertain upon arrival, that doctors either discuss the matter further or will not perform the abortion. Moreover, evidence indicates that it is standard throughout the medical community for health care professionals other than the attending physician to provide needed counseling and that the attending physician's role should be to ensure that the patient has received appropriate information. See also Akron, 462 U.S. at 448, 103 S.Ct. at 2502 (The State's interest is in ensuring that the woman's consent is informed and unpressured; the critical factor is whether she obtains the necessary information and counseling from a qualified person, not the identity of the person from whom she obtains it.). Because it is not necessary that the physician personally impart the required information to the woman in order for informed consent to occur, the physician-only counseling requirement is not narrowly tailored to further a compelling state interest and will not be upheld. We likewise conclude that the physician-only counseling requirement cannot be upheld, even under the less exacting undue burden analysis. Because the information may be provided to the woman contemplating abortion by another health care professional and the same result be achieved, we can only conclude that the purpose or effect of the physician-only requirement is to place a substantial obstacle in the path of a woman seeking an abortion. Casey, 505 U.S. at 878, 112 S.Ct. at 2821. Our analysis of the physician-only counseling requirement, as well as the lower court's conclusion and the State's concession that § 39-15-202(b)(4) ([t]hat abortion in a considerable number of cases constitutes a major surgical procedure) is unconstitutional, pretermits our discussion of each of the informed consent provisions individually. We decline to simply elide those portions of subsections (b) and (c) relating to the specific information the woman is to be told. See State ex rel. Barker v. Harmon, 882 S.W.2d 352, 353 (Tenn.1994). In Harmon, we explained that [t]he doctrine of elision allows a court, under appropriate circumstances when consistent with the expressed legislative intent, to elide an unconstitutional portion of a statute and find the remaining provisions to be constitutional and effective. Id. at 355. Even though the General Assembly included a severability clause when the statutes were recodified in 1989, 1989 Tenn.Pub. Acts, ch. 591, § 120, the State's arguments have not only stressed the importance of having the physician personally inform the woman but have further insisted that medical ethics require the physician to inform the woman. Accordingly, we conclude that the legislature would not have enacted the informed consent provisions in absence of the physician-only counseling requirement, and that consequently, the doctrine of elision cannot apply to save the remaining informed consent provisions. [11]
We further conclude that the two-day waiting period requirement contained in Tenn.Code Ann. § 39-15-202(d)(1) fails to pass constitutional muster. The State appears to argue that the waiting period requirement furthers its interest in potential life and explicitly argues that this provision protects maternal health by ensuring that the woman has adequate time to reflect on her decision after hearing the statutorily prescribed information. The State has not argued that the waiting period provision is narrowly tailored to further a compelling state interest, but instead points to evidence that while the waiting period was in effect, the District Court for the Western District of Tennessee made a finding of fact that over 3,000 abortions were performed during the year preceding the hearing in the case, see Planned Parenthood of Memphis v. Alexander, No. 78-2310 (W.D.Tenn. March 23, 1981), p. 7, and that, consequently, this requirement does not create an undue burden. [12] In Akron , the United States Supreme Court struck down a twenty-four hour waiting period, reasoning that careful consideration of the abortion decision by the woman `is beyond the state's power to require.' 462 U.S. at 450, 103 S.Ct. at 2503 (citation omitted). The Court characterized the twenty-four hour waiting period as arbitrary and inflexible and reasoned that the city had failed to show that the requirement increased the safety of abortion or otherwise furthered a legitimate state interest. Id. The Court concluded: The decision whether to proceed with an abortion is one as to which it is important to affor[d] the physician adequate discretion in the exercise of his medical judgment. In accordance with the ethical standards of the profession, a physician will advise the patient to defer the abortion when he thinks this will be beneficial to her. But if a woman, after appropriate counseling, is prepared to give her written informed consent and proceed with the abortion, a State may not demand that she delay the effectuation of that decision. Id. at 450-51, 103 S.Ct. at 2503 (emphasis added) (citation omitted) (footnote omitted). Although later the authors of the Casey opinion determined that a 24-hour waiting period did not violate the undue burden standard, 505 U.S. at 887, 112 S.Ct. at 2826, the reasoning of the Supreme Court in Akron is equally applicable to the challenge made here under the Tennessee Constitution. As the trial court stated, a woman contemplating an abortion should be allowed sufficient time for reflection before she makes an informed decision. However, a sufficient amount of time varies with each individual woman, and the inflexibility of a two-day waiting period as it applies to every woman except in a medical emergency situation requires its invalidation. The majority of the expert testimony seemed to acquiesce in the fact that most women have seriously contemplated their decision before making their appointment ...; several of the witnesses testified that many of the patients at Planned Parenthood were referred by other private physicians, indicating that the woman already has at the very least a basic understanding of her situation and the decisions now before her. To mandate that she wait even longer insults the intelligence and decision-making capabilities of a woman.... Evidence in the record indicates that patient mortality rates for abortions increase as the length of pregnancy increases. Studies also suggest that a large majority of women who have endured waiting periods prior to obtaining an abortion have suffered increased stress, nausea and physical discomfort, but very few have reported any benefit from having to wait. Moreover, evidence in the record indicates that the waiting period increases a woman's financial and psychological burdens, since many women must travel long distances and be absent from work to obtain an abortion. Planned Parenthood presents a compelling argument that, because the waiting period requires a woman to make two trips to the physician, the waiting period is especially problematic for women who suffer from poverty or abusive relationships. The States reliance on a district court's finding of fact, that the waiting period failed to decrease abortions, is misplaced. The finding was made over twenty years ago without any apparent consideration of the actual number of abortions sought in each year. Further, the State has simply failed to carry its burden to show that the two-day waiting period requirement, mandating the longest waiting period in the country, is narrowly tailored to further its compelling interest in maternal health. The two-day waiting period therefore is unconstitutional. We likewise conclude that the two-day waiting period has the effect of placing a substantial obstacle in the path of a woman seeking an abortion, and therefore fails to pass muster under an undue burden analysis. See Casey, 505 U.S. at 878, 112 S.Ct. at 2821. While the statute refers to a two-day waiting period, the waiting period is actually a three-day waiting period because the patient may not sign the consent form until the third day following the day [the required] information was given. Tenn.Code Ann. § 39-15-202(d)(1). This extremely long waiting period, the longest in the nation, suggests that the waiting period requirement is not intended as an opportunity for reflection, but is actually intended as an obstacle to abortion.
Finally, it is clear that the medical emergency exceptions are not narrowly tailored to advance the State's interests in maternal health. As the Court of Appeals noted, these medical emergency exceptions are too narrow to pass constitutional muster even under the less exacting undue burden standard. Casey, 505 U.S. at 880, 112 S.Ct. at 2822. The statutes contain two emergency medical exceptions, Tenn.Code Ann. § 39-15-202(d)(3) and -202(g). Subsection 202(d)(3) is a narrow provision addressing the waiting period and states that the two-day waiting period will not apply when the attending physician determines that a waiting period would endanger the life of the pregnant woman. Subsection 202(g) provides an exception to the informed consent and physician-only requirements and the two-day waiting period requirement when necessary to preserve the life of the pregnant woman. We initially agree with Planned Parenthood and the Court of Appeals that both exceptions should be read to only cover circumstances where a woman's pregnancy is endangering her life. We decline to read the word life to mean life and health. If the legislature had intended these medical emergency exceptions to cover life and health it could have easily said so. See Tenn.Code Ann. § 39-15-201(c)(3) (medical emergency exception to prohibition against post-viability abortions if necessary to preserve the woman's life or health). It is well settled that when the words of a statute are plain, clear, and unambiguous, we merely look to the statute's plain language to interpret its meaning. E.g., Schering-Plough v. State Bd. of Equal., 999 S.W.2d 773, 775-76 (Tenn.1999). In our view, the legislature intended the medical emergency exceptions at issue to protect only the life, as opposed to the health, of the woman. As written, the medical emergency exceptions fail to pass constitutional muster. They impermissibly impinge upon a woman's fundamental procreational autonomy because they do not contain adequate provisions that will permit immediate abortions necessary to protect a woman's health. For this reason, they also fail to satisfy an undue burden analysis. See Stenberg v. Carhart, 530 U.S. at ___, 120 S.Ct. at 2613.