Opinion ID: 441672
Heading Depth: 2
Heading Rank: 2

Heading: Plaintiffs' due process claims

Text: 53 The trial court separately analyzed several individual provisions of the challenged legislation and found, with one minor exception, Michigan's licensing requirements for FSOFs do not individually or collectively, unduly burden a woman's right to seek an abortion. 508 F.Supp. at 1389. The district court then upheld the FSOF regulations as rationally related to the State's legitimate interest in assuring adequate standards of health care in facilities where outpatient surgery is performed. Id. 54 In accordance with Akron, we find that, in asking whether the regulations unduly burdened a woman's right to obtain an abortion, the trial court applied an inappropriate analysis. As the Supreme Court's recent decision in Akron has made clear, the appropriate approach in evaluating State regulations touching on a woman's right to an abortion during the first trimester of pregnancy is to ascertain whether the restrictive regulations have a significant impact on the woman's exercise of this right. Akron, 103 S.Ct. at 2492-93. Only if the regulations have no significant impact on a woman's exercise of her fundamental right to choose to terminate her pregnancy during the first trimester can the regulation be sustained. Id. at 2492. In order to apply the no significant impact standard articulated by the Supreme Court in Akron, it is necessary to reevaluate the validity of Michigan's FSOF regulations as applied to abortion clinics. 55
56 The Michigan plan to license FSOFs proposes to regulate all freestanding surgical outpatient facilities, not just abortion clinics. Sec. 20104(5). Nevertheless, because they apply to facilities performing first trimester abortions, the regulations must be evaluated to determine whether they have a significant impact on a woman's exercise of her fundamental right to choose abortion. If there is no significant impact on this right and if the State has met its burden of demonstrating the regulations furthered important health-related State concerns, then the legislation will be upheld. Akron, 103 S.Ct. at 2493. 57
58 Rule 33 of the regulations requires that when procedures having present or future social implications for a patient are performed, such as ... pregnancy terminations, ... a facility shall make available and offer appropriate counseling, interpretation and referral for subsequent indicated care. R. 325.3833 (Rule 33). The plaintiffs contend the State has utilized the counseling requirement to impermissibly probe into a woman's feelings about her decision to abort and that the imposition of counseling upon every woman seeking an abortion is an inappropriate interference with the woman's right of privacy. The trial court found Rule 33 did not unduly burden a woman's right to terminate her pregnancy and upheld the rule as rationally related to a legitimate state interest in insuring informed consent. 508 F.Supp. at 1376. Under Akron, however, the analysis of Rule 33 does not now depend on whether Rule 33 unduly burdens a woman's right to terminate her first trimester pregnancy, but, rather, hinges on whether the rule has any significant impact on a woman's freedom to exercise this right. 59 A State may require a woman, before undergoing even a first trimester abortion, to certify in writing her consent to the abortion procedure. Planned Parenthood v. Danforth, 428 U.S. 52, 67, 96 S.Ct. 2831, 2840, 49 L.Ed.2d 788 (1976). The State's imposition of this written consent requirement is based on the fact that [t]he decision to abort ... is an important, and often stressful one, and it is desirable and imperative that it be made with full knowledge of its nature and consequences. Id. 60 Such informed consent is defined to mean the giving of information to the patient as to just what would be done and as to its consequences, id. at 67 n. 8, 96 S.Ct. at 2840 n. 8, and in the abortion context, it is narrowly construed. The State may not attempt to influence a woman's choice between abortion and childbirth under the guise of informed consent counseling. Akron, 103 S.Ct. at 2500-01. Nor may the State require that only a physician do preabortion counseling. Id. 103 S.Ct. at 2502-03. The State may define the physician's responsibility to include verification that adequate counseling has been provided and that the woman's consent is informed, and a State can establish reasonable minimum qualifications for those people who perform the primary counseling function. Id. 103 S.Ct. at 2502-03 (footnotes omitted). 61 Michigan's Rule 33 does not attempt to dictate the content of any preabortion counseling nor does it seek to influence the woman's decision toward either childbirth or abortion. The trial court found from the evidence at trial FSOFs were not required to counsel every woman seeking an abortion, but rather were required only to make counseling available. 508 F.Supp. at 1375. This appears consistent with the Supreme Court's view that since the need for information and/or counseling varies with the patient, individual counseling should be available to those who need it. Akron, 103 S.Ct. at 2502 n. 38. The trial court's analysis makes it clear Rule 33's requirement that an FSOF make counseling available to its abortion patients has no significant impact on a woman's exercise of her right to obtain an abortion, and we agree with the trial court that Rule 33 is rationally related to a legitimate State interest in health. Therefore, we affirm the trial court's finding that Rule 33 on its face is constitutionally valid. 62 In upholding Rule 33, we take special note of the trial court's admonition to the Michigan Department of Public Health that the State should refrain from imposing requirements regarding the content of the counseling sessions or the retention of a counselor's notes. 508 F.Supp. at 1377. It remains primarily the responsibility of the physician to ensure that appropriate information is conveyed to the woman seeking an abortion, and the physician must have the freedom to gauge the informational and counseling needs of each individual patient. Akron, 103 S.Ct. at 2500. Even informal attempts by health department officials to influence the extent or specific content of the preabortion counseling required to be made available by FSOFs would be an impermissible State interference. 63
64 Regulations 47(5) and 47(6), occasionally referred to in the trial court opinion as 45(5) and 45(6), apply only to FSOFs where abortions are performed; they require that FSOFs file reports and statistical information with the health department. A half-page abortion report must be completed for every abortion performed at the FSOF and then the form must be signed by the physician who performed the abortion. The abortion form does not reveal the patient's name. 65 We agree with the conclusion of the trial court that these reporting requirements do not violate the constitutional rights of any of the plaintiffs or their patients, and are rationally related to a legitimate governmental interest in gathering statistical information to protect the health of its citizens. 508 F.Supp. at 1380. The guidelines laid down by the Supreme Court in Danforth, supra, dictate this result. 66 In Danforth the Supreme Court upheld Missouri's record keeping and reporting requirements even for first trimester abortions. Because the Missouri record keeping and reporting had no legally significant impact or consequence on the abortion decision or on the physician-patient relationship, and because they reasonably furthered the State's interest in protecting the health of its female citizens, the Court was willing to find the requirements constitutionally valid as long as the State did not utilize them in such a way as to accomplish, through sheer burden of recordkeeping detail, ... an otherwise unconstitutional restriction. Planned Parenthood v. Danforth, 428 U.S. at 81, 96 S.Ct. at 2847. 67 The amount of paperwork imposed by Rule 47(5) and 47(6) is minimal and appears to involve very little time or expense. From the record and from the trial court's opinion, it is clear Rule 47(5) and 47(6) have no significant impact on a woman's exercise of her right to choose to terminate her pregnancy. The trial court found Michigan's important health related concerns are furthered by gathering the data required by the rule. Therefore, we uphold the trial court and find Rule 47(5) and 47(6) valid. 68 Two of the plaintiff physicians contend that requiring the physician who performs the abortion to sign the abortion report violates the physician's own right to privacy. We agree with the trial court that in the situation presented here there is no merit to this claim. Where an individual or corporation engages in occupations in which the public has an interest, that occupation may be regulated under the police power of the State. United States v. Tehan, 365 F.2d 191, 194 (6th Cir.1966) (citing Nebbia v. New York, 291 U.S. 502, 54 S.Ct. 505, 78 L.Ed. 940 (1934)), cert. denied, 385 U.S. 1012, 87 S.Ct. 716, 17 L.Ed.2d 548 (1967). We do not believe the right of privacy extends to the boundaries urged here by plaintiff. Cf. Whalen v. Roe, 429 U.S. 589, 598-604, 97 S.Ct. 869, 875-878, 51 L.Ed.2d 64 (1977). 69
70 Rule 35(1) provides that a physician performing surgery at an FSOF must possess adequate qualifications acquired by special training and experience to evaluate the medical ... conditions, potential risks, recognize and adequately treat emergency complications encountered in any procedure undertaken, and perform the procedure in accordance with the usual standards of medical ... practice. R. 325.3835 (Rule 35 At trial, the State clarified Rule 35(1)'s requirement that only a physician possessing qualifications acquired by special training could perform surgery at an FSOF. According to the testimony of the State's witnesses, Rule 35(1) only requires that a physician be qualified to do whatever he or she undertakes;  the rule does not require that only a specialist perform abortions. 508 F.Supp. at 1377. Based on this interpretation of Rule 35(1) we agree with the trial court. Michigan may constitutionally insist that only properly licensed physicians be permitted to perform abortions at FSOFs. 71 Even in the first trimester of pregnancy the State's interest in maternal health is sufficient to justify a requirement that an abortion may be performed only by medically competent personnel. Connecticut v. Menillo, 423 U.S. 9, 11, 96 S.Ct. 170, 171, 46 L.Ed.2d 152 (1975). As the Supreme Court made explicit in Roe v. Wade, a State may define the term 'physician' ... to mean only a physician currently licensed by the State, and may proscribe any abortion by a person who is not a physician as so defined. 410 U.S. at 165, 93 S.Ct. at 732. We therefore uphold Rule 35(1) as interpreted by the trial court. 72
73 The plaintiffs object to a number of detailed, specific criteria governing the staffing, physical layout and equipment required for FSOF licensure. Although plaintiffs contend compliance with these regulations would be costly, the trial court found the regulations did not unduly burden a woman's right to seek an abortion and then upheld the regulations as reasonably related to the State's legitimate purpose of protecting the health and safety of its citizens. 508 F.Supp. at 1384. 74 Again, we believe that in utilizing the unduly burdensome standard to evaluate these regulations the trial court employed an analysis no longer appropriate under Akron. When regulations affecting first trimester abortions are involved, [c]ertain regulations that have no significant impact on the woman's exercise of her right may be permissible where justified by important state health objectives. Akron, 103 S.Ct. at 2492-93. We must then consider whether these regulations have any significant impact on a woman's ability to choose to terminate her first trimester pregnancy. 75 At trial plaintiffs introduced estimates of the cost of complying with the staffing, equipment and structural regulations. The cost of correcting just the structural violations of the plaintiff clinics ranged from $139,412 to $438,250, according to the plaintiffs' expert witness (Pickens, 5/28/80, Tr. at 41, 48, 55, 59). There was undisputed evidence that abortion clinics already licensed as FSOFs had spent from $10,000 (renovation) to $680,000 (cost of new building) to bring their facilities into compliance with these regulations. Even after large expenditures, most of these licensed facilities did not fully comply with the FSOF regulations (10/22/80, Tr. 23-59). The State's expert agreed the plaintiff clinics would have to undergo structural changes in order to be approved under the regulations; and despite its insistence that plaintiffs' estimates of the cost of compliance were excessive, the State offered no estimates of its own (Drake, 6/26/80, Tr. 78-79, 81-82). 76 The trial court made no findings of fact concerning the costs of compliance and did not determine whether the cost of compliance with the regulations would result in a substantial increase in the cost of abortions. Despite this lack of factual findings, the evidence clearly reveals compliance would involve substantial structural alterations of the plaintiff clinics. For example, in existing FSOFs each procedure room is required to provide a minimum of 120 square feet of usable floor space, while examining rooms must provide a minimum of 70 square feet of usable floor space. R. 325.3866 (Rule 66). In newly constructed or renovated FSOFs, these minimum space requirements are increased to 150 square feet and 80 square feet respectively. Id. Even without a protracted analysis of the staffing, structural and equipment regulations, it appears unquestionable that by requiring expensive alterations these regulations will greatly increase the cost of abortions and thus have a significant impact on a woman's exercise of her right to a first trimester abortion. 77 Although the precise amount of the increased cost here is unknown, a look at the Supreme Court's analysis of what constitutes a significant cost increase is instructive. In Planned Parenthood v. Ashcroft, supra, the Supreme Court held valid a state regulation requiring that a pathologist examine all tissue removed surgically including tissue removed in the course of an abortion. Ashcroft, 103 S.Ct. at 2524. Compliance with the regulation was estimated to increase the cost of each abortion by $19.40, id. 103 S.Ct. at 2524, to $40.00, id. 103 S.Ct. at 2528, an increase a majority of the Court felt did not significantly burden a pregnant woman's abortion decision, id. 103 S.Ct. at 2524. When this increased cost was compared with the substantial benefit that might result from a pathologist's examination, five members of the Court concluded the small increase in cost was justified. Id. 103 S.Ct. at 2524. In contrast, four justices dissented from this conclusion and found that although a $40.00 increase may seem insignificant from the Court's comfortable perspective, [the dissenters] cannot say that it is equally insignificant to every woman seeking an abortion. Id. 103 S.Ct. at 2528 (Blackmun, J., concurring in part and dissenting in part). 78 By comparison, compliance with these Michigan regulations would involve far greater expenditures than those involved in Ashcroft. In the instant case, there was evidence that compliance with the FSOF regulations would increase the weekly operating expenses of one plaintiff clinic by 156% and of another by 54% (Chelian, 6/20/80, Tr. 78, 80). Moreover, these figures do not include any price increases that might be necessitated by complying with the structural regulations. The State offered evidence that some abortion clinics already licensed as FSOFs did not charge substantially more for abortions than did the plaintiff clinics. Most of these licensed clinics, however, had not fully complied with the regulations being challenged by the plaintiffs. 79 In light of this clear evidence of the significant impact which these staffing, structural and equipment regulations would have on a woman's access to abortion, we hold them to be an unconstitutional infringement on her right to privacy. In so doing, we are mindful of the State's interest in assuring that abortion, like any other medical procedure, is performed under circumstances that insure maximum safety for the patient. Roe v. Wade, 410 U.S. at 150, 93 S.Ct. at 725. We also note, however, that first trimester abortions are relatively safe and have a mortality rate as low or lower than the rates for normal childbirth. Roe v. Wade, 410 U.S. at 149, 93 S.Ct. at 725 (footnote omitted); Connecticut v. Menillo, 423 U.S. at 11, 96 S.Ct. at 171. Abortion, at least during the first trimester, is generally considered a minor surgical procedure. See Akron, 103 S.Ct. at 2500 and n. 35. In view of the significant impact which these staffing, structural and equipment regulations have on a woman's right to terminate her first trimester pregnancy, we hold these rules unconstitutional. 80
81 Rule 38 requires that FSOFs arrange for impartial medical surveillance and a review of the quality of care provided by their facility at regular and periodic intervals. R. 325.3838 (Rule 38). The medical review requirements of Rule 38 apparently would require that each FSOF engage a physician not a member of its staff to visit the FSOF at least quarterly to review those charts that have recorded complications and a few other unspecified number, selected at random, and merely give a written report to the facility indicating any suggestions or comments that [the reviewing physician] might have relative to possible ways of improving the quality of medical care. 508 F.Supp. at 1377. Plaintiffs object that such a medical review process is expensive and would lead to higher costs for abortions, and there was evidence that a reviewing physician might charge $200.00 per hour to review an FSOF's records (Acosta, 5/29/80, Tr. 167). The trial court made no factual findings concerning the cost of medical review but concluded Rule 38 did not in any way burden a woman's right to seek an abortion. 508 F.Supp. at 1378. The trial court then sustained the medical review regulation as rationally related to the State's legitimate interest in assuring compliance with health regulations. Id. 82 Faced with undisputed testimony that Rule 38 would involve some increased expenditure by the plaintiff clinics, we cannot ignore the possibility that the medical review regulation might have more than an insignificant impact on a woman's exercise of her fundamental right. The district court's opinion, however, does not contain facts that would enable us to determine the significance of the impact, if any, of Rule 38 on a woman's right to abortion. When an appellate court discerns that additional fact findings are necessary, the usual rule is to remand for further proceedings to permit the trial court to make the necessary findings. Pullman-Standard v. Swint, 456 U.S. 273, 287, 102 S.Ct. 1781, 1789, 72 L.Ed.2d 66 (1982). Therefore, we remand this aspect of the case to the district court for additional fact-finding to allow that court to determine whether the medical review process required by Rule 38 is a minor regulation having no significant impact on the plaintiffs' patients' access to abortion. If, on remand, the trial court finds this regulation has no significant impact on a woman's fundamental right to abortion, then that court must further determine whether the State has established that the regulation is rationally related to an important State interest in health. The Supreme Court's recent decisions offer new guidance to the district court in this matter. 83
84 Rule 68(8) requires that all FSOF corridors used for patient entry, egress and for surgical care areas be at least six feet wide. The trial court found Rule 68(8) is not reasonably related to the State's interest in assuring adequate health care for its citizens. 508 F.Supp. at 1384. In accordance with our reasoning in section IV(B)(1)(d) above, we affirm the trial court's holding. 85
86 (a) Rule 51: No post first trimester abortions may be performed in Freestanding Outpatient Surgical Facilities 87 Rule 51 requires that if a FSOF performs abortions there must be a written policy governing the abortion procedures performed there. Included in the policy must be a provision requiring that only uncomplicated pregnancies of not over 14 weeks duration may be performed in a facility unattached to or physically remote from a parent hospital. R. 325.3851 (Rule 51). In effect, Michigan's Rule 51 requires that all second trimester abortions be performed in a facility owned and operated by a parent hospital. By statutory definition, freestanding surgical outpatient facilities do not include surgical facilities owned and operated by a hospital. Sec. 20104(5). Thus, the effect of Rule 51 is to prohibit any abortion clinic, whether or not it is licensed as a FSOF, from performing second trimester abortions unless the clinic is owned and operated by its parent hospital and is attached to or not remote from that hospital. 88 Rule 51 primarily bears on second trimester abortions, and, as reviewed above, the Supreme Court held in Roe v. Wade that during the second trimester the State has a compelling interest in maternal health that justifies the reasonable regulation of second trimester abortions. But, because of the Supreme Court's recent decision in Akron, this analysis now involves an intermediate step. Now, in order to ascertain the reasonableness of second trimester regulation, it must be determined whether the regulation depart[s] from accepted medical practice. Akron, 103 S.Ct. at 2493. 89 In Akron the Supreme Court struck down a city ordinance requiring that after the first trimester an abortion had to be performed in an acute care, full-service hospital. Id. 103 S.Ct. at 2497. The Supreme Court agreed that during the second trimester a State has a compelling interest in maternal health, but the Court reiterated that the existence of this compelling State interest in health is only the first step of the analysis. Before a restrictive regulation can be upheld, the State must also demonstrate that the regulation is reasonably designed to further this State interest. 90 In that case, the city of Akron did argue that the in-hospital requirement was reasonably related to the State's interest in maternal health. However, this was countered by evidence of recent medical developments that show a dramatic increase in the safety of abortions performed early in the second trimester. This present medical knowledge negated Akron's contention that the in-hospital requirement reasonably furthered the State's interest in maternal health. Id. 103 S.Ct. at 2496. Based on the increased safety of second trimester abortions, the Supreme Court concluded that the in-hospital requirement for all post first trimester abortions depart[ed] from accepted medical practice. Id. 103 S.Ct. at 2493. Although it recognized that a State must necessarily have latitude in adopting regulations of general applicability in this sensitive area [of second trimester abortions], the Supreme Court nevertheless invalidated the regulation and warned that if it appears that during a substantial portion of the second trimester the State's regulation 'depart[s] from accepted medical practice,' [then] the regulation may not be upheld simply because it may be reasonable for the remaining portion of the trimester. Id. 103 S.Ct. at 2495 (citation omitted). 91 In light of the Supreme Court's holding in Akron it appears we must reverse the trial court and find invalid Michigan's requirement that only uncomplicated pregnancies of not over 14 weeks duration may be performed in a facility unattached to or physically remote from a parent hospital. It is true that, unlike the legislation in Akron and Ashcroft, the Michigan statute does not require all second trimester abortions be performed in an acute care, general service hospital. The wording of Rule 51, however, leads one to conclude that only facilities owned and operated by a hospital may perform second trimester abortions, since only these facilities would have a parent hospital. Also, to perform a second trimester abortion, such a hospital-owned facility would have to be adjacent to (or at least not physically remote from) the parent hospital. Assuming the existence of a compelling state interest in maternal health that justifies Michigan's regulation of second trimester abortions, Michigan has not advanced any reasonable justification for Rule 51's distinguishing FSOFs from outpatient facilities owned and operated by a parent hospital and not physically remote from that parent hospital. Indeed, Rule 51 ignores the impressive evidence that--at least during the early weeks of the second trimester--D & E [dilatation-and-evacuation] abortions may be performed as safely in an outpatient clinic as in a full-service hospital. Id. 103 S.Ct. at 2496 (footnote omitted). 92 Because it fails to reasonably limit its effect to the period in the [second] trimester during which [the state's] health interest will be furthered, id. 103 S.Ct. at 2495, we conclude Rule 51's requirement that only pregnancies of less than fourteen weeks duration may be performed in a FSOF is invalid.