Court Opinion

ID: 9496616
Source: CourtListenerOpinion
Date Created: 2023-08-05 16:31:03.127676+00
Date Added: 2024-06-11T17:57:41.362506
License: Public Domain

TARNOW, District Judge,
dissenting.
The Court must determine whether Ohio’s Substitute House Bill 351 (“HB 351”) provides a constitutionally adequate exception for the health of pregnant women in light of its ban on intact abortion procedures.1, 2 The adequacy of that exception must be judged according to the constitutional requirement that abortion regulations allow exceptions when “necessary, in appropriate medical judgment, for the preservation of the life or health of the mother.” See Roe v. Wade, 410 U.S. 113, 164-165, 93 S.Ct. 705, 35 L.Ed.2d 147 (1973); Planned Parenthood of S.E. Pa. v. Casey, 505 U.S. 833, 879, 112 S.Ct. 2791, 120 L.Ed.2d 674 (1992). For reasons summarized immediately below and discussed in the following sections, I conclude that HB 351 forces some women to use riskier *454methods of abortion and thus fails to meet this requirement in both its pre- and post-viability contexts. See Stenberg v. Carhart, 530 U.S. 914, 931, 120 S.Ct. 2597, 147 L.Ed.2d 743 (2000).
The facial challenge here presents two central questions: 1) What is the constitutional standard for judging the adequacy of a health exception to preserve a woman’s health where a particular method of abortion has been banned? and 2) Does the specific language of the HB 351’s health exception comport with this constitutional standard?
The majority concludes that a ban on the intact method is constitutional as long it contains a health exception allowing the procedure “when necessary to prevent significant, as opposed to negligible, health risks.” Majority Slip Opinion at 445. Further, they conclude that HB 351’s health exception meets this standard.
In terms of the degree of risk to be considered, I agree that a health exception is not constitutionally required for truly negligible health risks. However, when a state bans a method of abortion, it is required to permit an exception whenever a woman faces any risk to her health that is more than negligible.3 See Carhart, 530 U.S. at 931, 120 S.Ct. 2597; Casey, 505 U.S. at 880,112 S.Ct. 2791.
But more important to this case, as to a relevant source of risk, the Supreme Court has instructed that “a State cannot subject women’s health to significant risks ... where state regulations force women to use riskier methods of abortion.” Carhart, 530 U.S. at 931, 120 S.Ct. 2597. Thus, where a woman has a right to an abortion, the state must allow an exception for her to receive a banned method of abortion when it offers a non-negligible safety advantage over other methods.
As to whether HB 351’s health exception meets this standard, the majority offers a construction that is at odds with the plain wording of the statute. In fact, HB 351 allows an exception only when a woman is endangered by a “medically diagnosed condition that ... complicates the pregnancy.” Ohio Rev.Code Ann. § 2919.151(B) (post-viability) and (C) (pre-viability); Ohio Rev.Code Ann. § 2919.151(A)(5) (statutory definition). Thus it does not allow the intact procedure for a healthy woman. When the fetus has not yet attained viability, a healthy woman, like any woman, has a constitutional right to obtain an abortion without being forced to use a riskier procedure. See Carhart, 530 U.S. at 931, 120 S.Ct. 2597. Because the record shows that the intact method may entail significantly less risk than other methods, HB 351’s pre-viability ban is unconstitutional.
HB 351’s failure to address comparative health risks extends also to women for whom a continuing pregnancy or bearing a child would impose a risk of severe and irreversible mental harm. As Ohio stated in the proceedings below, HB 351’s health exception encompasses only risks to a woman’s physical health. This admission comports with the language of the health exception requiring a risk of impairment to “a major bodily function.” Ohio Rev.Code Ann. § 2919.151(B) (post-viability) and (C) (pre-viability); Ohio Rev.Code Ann. § 2919.151(A)(5) (statutory definition) (emphasis added). However, the Supreme Court has made clear that a woman’s mental health must be considered a part of her *455overall health when a state regulates abortion. See Doe v. Bolton, 410 U.S. 179, 191-192, 93 S.Ct. 739 (1973). In accord with this principle, this Court has stated that a health exception must encompass a risk of a serious and irreversible harm to the woman’s mental health. Women’s Med. Prof'l Corp. v. Voinovich, 130 F.3d 187, 209 (6th Cir.1997), cert. denied, 523 U.S. 1036 (1998). Under HB 351, a woman facing a risk of severe and irreversible harm to her mental health would not have access to the intact procedure and would thus be compelled to face the greater physical risks that attend other methods of abortion. This result violates Carhart’s instruction that a woman may not be forced to use riskier methods of abortion. See Carhart, 530 U.S. at 931, 120 S.Ct. 2597. Because HB 351 fails to encompass these risks both before and after fetal viability, it is unconstitutional in both contexts.
For these reasons, I believe the district court’s decision should be affirmed. Thus, I respectfully dissent.
I. HB 351’s Pre-Viability Ban is Unconstitutional Because It Forces Healthy Women to Use Riskier Methods of Abortion
A. The Constitution forbids regulations that force women to use riskier methods of abortion
In Roe, the Supreme Court held that “subsequent to viability, the State in promoting its interest in the potentiality of human life 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.” 410 U.S. at 164-165, 93 S.Ct. 705.4 That holding has been consistently reiterated. See, e.g., Casey, 505 U.S. at 879, 112 S.Ct. 2791; Carhart, 530 U.S. at 930, 120 S.Ct. 2597. Further, because the State’s interest in regulating abortion before fetal viability is much weaker, “the law ... at a minimum requires the same in respect to previability regulation.” Carhart, 530 U.S. at 930, 120 S.Ct. 2597 (citing Casey, 505 U.S. at 880, 112 S.Ct. 2791; Harris v. McRae, 448 U.S. 297, 316, 100 S.Ct. 2671, 65 L.Ed.2d 784 (1980)).
The meaning of the critical phrase “necessary, in appropriate medical judgment, for the preservation of the life or health of the mother” has been clarified by a long line of Supreme Court cases, including Carhart, Thornburgh v. American College of Obstetricians & Gynecologists, 476 U.S. 747, 106 S.Ct. 2169, 90 L.Ed.2d 779 (1986) (overruled in part by Casey, 505 U.S. at 870, 112 S.Ct. 2791), Colautti v. Franklin, 439 U.S. 379, 99 S.Ct. 675, 58 L.Ed.2d 596 (1979), and Planned Parenthood of Central Missouri v. Danforth, 428 U.S. 52, 96 S.Ct. 2831, 49 L.Ed.2d 788 (1976). The case that is both most recent and relevant is Carhart. In striking down a Nebraska statute prohibiting the intact procedure without any exception for the pregnant woman’s health, the Court reaffirmed and explained its rationale behind the preservation standard.
[T]he governing standard requires an exception “where it is necessary, in appropriate medical judgment for the preservation of the life or health of the mother,” for this Court has made clear that a State may promote but not endan*456ger a woman’s health when it regulates the methods of abortion.
Carhart, 530 U.S. at 931, 120 S.Ct. 2597 (citing Casey, 505 U.S. at 879, 112 S.Ct. 2791; Thornburgh, 476 U.S. at 768-769, 106 S.Ct. 2169; Colautti, 439 U.S. at 400, 99 S.Ct. 675; Danforth, 428 U.S. at 76-79, 96 S.Ct. 2831; Doe, 410 U.S. at 197, 93 S.Ct. 739).
Carhart also reaffirmed that the relevant dangers to a woman’s health are not limited to those created by the pregnancy itself.
[A] State cannot subject women’s health to significant risks both [where the pregnancy itself creates a threat to health], and also where state regulations force women to use riskier methods of abortion. Our cases have repeatedly invalidated statutes that in the process of regulating the methods of abortion, imposed significant health risks. They make clear that a risk to a women’s [sic] health is the same whether it happens to arise from regulating a particular method of abortion, or from barring abortion entirely.
Id. at 931, 120 S.Ct. 2597 (emphasis in original). It is clear then that where a constitutional right to an abortion exists, a state may not “force women to use riskier methods.” In short, the comparative risks between methods are of constitutional import, just as are risks stemming from a woman’s immediate medical condition.
The Court also found that the comparative risks at issue for a ban on the intact procedure are not negligible.
The State fails to demonstrate that banning D & X without a health exception may not create significant health risks for women, because the record shows that significant medical authority supports the proposition that in some circumstances, D & X would be the safest procedure.
Id. at 932,120 S.Ct. 2597. Thus, the Court states that because significant medical authority shows the D & X procedure to be the safest method in some circumstances, banning the procedure will necessarily create significant health risks for some women. This conclusion follows from factual findings accepted by the Court regarding the safety advantages of the intact procedure. See id. at 932. Moreover, it also follows from the fact that a woman who seeks an abortion at the relatively late stage of fetal development where the D & X procedure becomes relevant will necessarily face significant health risks. In short, the serious risk inherent to late term procedures means that the safety advantages offered by the intact method are not negligible. This fact supports the standard allowing a woman to receive the safest procedure, and renders irrelevant the majority’s discussion of “marginal or insignificant risks.” Majority Slip Opinion at 447.5
*457Further, given the Supreme Court’s instruction that the health preservation standard does not require an “absolute necessity” for the medical procedure nor does it require “unanimity of medical opinion,” health risks may be assessed as being significant because “[djoctors often differ in their estimation of comparative health risks.” Carhart, 530 U.S. at 937, 120 S.Ct. 2597.
Where a significant body of medical opinion believes a procedure may bring with it greater safety for some patients and explains the medical reasons supporting that view, we cannot say that the presence of a different view by itself proves the contrary. Rather, the uncertainty means a significant likelihood that those who believe that D & X is a safer abortion method in certain circumstances may turn out to be right. If so, then the absence of a health exception will place women at an unnecessary risk of tragic health consequences.
Id. Thus, in this context where the attendant health risks of abortion are already significant, and doctors reasonably disagree as to comparative safety of available methods, a “safer abortion method in certain circumstances” will help diminish the risk of “tragic health consequences.” With these principles and findings, the Court instructs that the intact procedure must be permitted when it may be the safer procedure for the woman.6
Carhart’s underlying rationale that “a State may promote but not endanger a woman’s health when it regulates the methods of abortion” is not dicta, as the majority suggests. See Majority Slip Opinion at 448. This principle in fact lies at the core of a line of cases leading up to Carhart. For example, in Danforth, the Supreme Court invalidated a ban on saline induction abortions because the record demonstrated its safety advantage over other available methods. The ban was held unconstitutional in part because it “force[d] a woman and her physician to terminate her pregnancy by methods more dangerous to her health than the method outlawed.” Danforth, 428 U.S. at 78-79, 96 S.Ct. 2831.
Later, in Thornburgh, the Court examined a Pennsylvania law concerning post-viability abortions that required the physician to choose an abortion procedure that “would provide the best opportunity for the unborn child to be aborted alive” unless that method “would present a significantly greater medical risk to the life of health of the pregnant woman” than another available method. 18 Pa. Cons.Stat. § 3210(b) (1982). The Court found the statute unconstitutional because it required the pregnant woman “to bear an increased medical risk in order to save her viable fetus.” Thornburgh, 476 U.S. at 769, 106 S.Ct. 2169.
Thombv/rgh’s holding accords with the Court’s earlier decision in Colautti, where the Court expressed its concern over a similar provision in Pennsylvania’s Abortion Control Act that required physicians aborting potentially viable fetuses to use a technique to maximize the fetus’s chance for survival. The Court invalidated the provision on grounds of vagueness because it could be read to “require[ ] the physician *458to make a ‘trade-off between the woman’s health and additional percentage points of fetal survival.” Colautti, 439 U.S. at 400, 99 S.Ct. 675. Thus, far from being dicta, the principle that “a State may promote but not endanger a woman’s health when it regulates the methods of abortion” has in fact guided the decisions of the Supreme Court for more than twenty years.
Carhart and its antecedents make clear that when a woman holds a constitutional right to obtain an abortion, the state may not force her to use riskier methods of abortion. Carhart, 530 U.S. at 931, 120 S.Ct. 2597. In light of the rights outlined in Roe and Casey, therefore, a woman must be permitted to choose the safest available method when the fetus is not viable and also at any time the woman’s health is endangered by a continuing pregnancy. This is the relevant meaning of the Supreme Court’s pronouncement that “a State may promote but not endanger a woman’s health when it regulates the methods of abortion.” This is what is required in a state’s constitutional obligation to ensure the “preservation of the life or health” of the woman.
B. The facts of this case and others show that other methods of abortion may be riskier than the intact method and that causing fetal demise in advance may add significant risk to the intact method
Given the foregoing constitutional standard, it is necessary to consider whether “a significant body of medical opinion believes [that the intact procedure] may bring with it greater safety for some patients, and explains the medical reasons supporting that view.” Carhart, 530 U.S. at 937, 120 S.Ct. 2597. This inquiry is relevant to HB 351’s pre- and post-viability bans because the intact procedure is performed in both contexts. See Women’s Med. Prof'l Corp. v. Taft, 114 F.Supp.2d at 668 (granting preliminary injunction). The medical processes entailed by the common methods of abortion, including their risks and benefits, have been extensively detailed by the district court below and others. See Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d 929, 941-952 (S.D.Ohio 2001) (granting permanent injunction); see also, e.g., Carhart, 530 U.S. at 932-933, 935-936, 120 S.Ct. 2597.
These sources demonstrate that the intact procedure may in fact present numerous safety advantages over other methods. See Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d at 947, 950, 951, 954 (finding that the intact method may be safer than other methods); see also Carhart, 530 U.S. at 932-33, 120 S.Ct. 2597 (citing numerous cases where the intact procedure was found to be the safest or most appropriate procedure). For the purposes here, these safety advantages may be summarized.
As compared to the D & E method, the district court found that the intact method may be safer. See Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d at 949-50. This conclusion was based on evidence showing that the intact procedure may have a lower risk of: 1) infection; 2) trauma to the cervix and uterus from an increased number of passes of instruments into the uterus; and, 3) a complication known as disseminated intravascular coagulation (“DIC”), a blood clotting disorder that may be fatal. See id. at 948, 949, 949-50; see also Danforth, 428 U.S. at 96, 96 S.Ct. 2831 (presenting background and risks of DIC); Carhart, 530 U.S. at 932, 120 S.Ct. 2597 (quoting district court’s finding that D & E helps prevent DIC, which is among the two most common causes of maternal death, Carhart v. Stenberg, 11 F.Supp.2d 1099, 1126 (D.Neb.1998), aff'd, 192 F.3d 1142 (8th Cir.1999), *459aff'd, 580 U.S. 914, 120 S.Ct. 2597, 147 L.Ed.2d 743 (2000)). The intact procedure may also cause less blood loss and require a shorter duration of general anesthesia, which carries its own attendant health risks including the risk of death. See Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d at 948. Further, the intact procedure reduces the possibility of leaving fetal tissue inside the uterus. See id. at 950. The Court in Carhart similarly noted this danger, citing the complications that may arise from remaining bony fragments and retained fetal parts. 530 U.S. at 932, 120 S.Ct. 2597.
The district court also found the intact procedure to be safer than the induction/instillation method of abortion. See Women’s Med. Prof'l Corp., 162 F.Supp.2d at 951. The Court heard evidence that induction/instillation may present the following comparative disadvantages: 1) a protracted induction time averaging 19 hours, as compared to 15 minutes, not including the dilation period, for the intact procedure; 2) the use of a labor inducing agent known to cause nausea, vomiting, and diarrhea; 3) an increased risk of hemorrhage and infection; and 4) an additional surgical procedure to remove a remaining placenta. See id. at 948, 949, 950.
As compared to hysterectomy or hyster-otomy, the district court noted the obvious fact that the intact procedure was generally far less traumatic than those major surgical procedures. See id. at 942; see also Planned Parenthood of Cent. New Jersey v. Farmer, 220 F.3d 127, 145 (3rd Cir.2000) (finding that these procedures have an “enhanced risk of morbidity and mortality to the woman due to the incidence of hemorrhage” and that hysterectomy leaves a woman sterile).
It is clear then that the intact procedure may be significantly safer in some circumstances than other available methods of abortion.7 But because HB 351 does not in effect ban the intact procedure when the delivered fetus is already dead, see Ohio Rev.Code Ann. § 2919.151(A)(3)(b) and (c), the safety of procedures used to cause fetal demise must also be examined to determine whether they present non-negligible risk. The district court found that ensuring fetal death, both by injection of a feticidal agent such as digoxin and by severing the umbilical cord, increased the risk to the woman. See Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d at 957, 958.
As to the digoxin injection, various experts testified at the district court that various complications may arise from its use, including: 1) amniotic embolism, which may be fatal; 2) bleeding and injury to the bowel; 3) piercing of other internal structures such as blood vessels and the uterus; 4) arrhythmia possibly leading to cardiac arrest for women with preexisting cardiac problems; 5) vomiting; 6) vaginal bleeding; and, 7) other injury to the uterus requiring hospitalization. See id. at 956-57; see also Carhart, 530 U.S. at 932, 120 S.Ct. 2597 (quoting district court’s finding that amniotic embolism is the other of the two most common causes of maternal death, 11 F.Supp.2d at 1126). Other courts have found similar risks. For example, in Evans v. Kelley, 977 F.Supp. 1283 (E.D.Mich.1997), the court found that “injections have serious potential health risks” including those of hemorrhage, infection, and uterine necrosis. Id. at 1301. The Evans court also found that many physicians do not have the appropriate skills to perform the injection and that some women have conditions that make the injection impossible. Id.
*460As to severing the umbilical cord, the district court found that the passing of sharp instruments into the uterus increases the risk of uterine perforation as the physician locates and severs an umbilical cord that does not spontaneously present itself. See Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d at 957. This finding is consistent with those of other courts. See Carhart v. Stenberg, 11 F.Supp.2d 1099 at 1123 (“Cutting the umbilical cord and waiting for the fetus to die before completing the D & X procedure carries appreciable maternal risks, no maternal benefits, and is not always possible.”); Planned Parenthood of Cent. New Jersey v. Verniero, 41 F.Supp.2d 478, 500 (D.N.J.1998) (finding-risk of uterine perforation and hemorrhage from passing of sharp instruments into the uterus and generally that “[h]ealth risks to women would be significantly increased if physicians are required to ensure fetal demise in útero”), ajfd, 220 F.3d 127 (3rd Cir.2000).
On these findings, it is clear then that requiring fetal demise before completion of the intact procedure may present additional risks of serious health consequences for some women.
C. HB 351 does not allow an exception to its ban on the intact procedure when the woman does not have a “medically diagnosed condition that ... complicates the pregnancy,” even if the intact procedure is safer than other methods
Given that it is unconstitutional for a state to “force women to use riskier methods of abortion” and the fact that the intact method may be a safer procedure for some women, it must be determined whether HB 351 allows an exception to its ban when the intact procedure is safer than other available procedures. As the following shows, it does not.
HB 351 permits the “partial birth procedure” only when it is “necessary, in reasonable medical judgment, to preserve the life or health of the mother as a result of the mother’s life or health being endangered by a serious risk of the substantial and irreversible impairment of a major bodily function.” Ohio Rev.Code Ann. § 2919.151(B) (post-viability) and (C) (pre-viability). HB 351 defines the “serious risk of the substantial and irreversible impairment of a major bodily function” to mean “any medically diagnosed condition that so complicates the pregnancy of the woman as to directly or indirectly cause the substantial and irreversible impairment of a major bodily function.” Ohio Rev.Code Ann. § 2919.151(A)(5).
Thus, HB 351’s health exception will not apply when a woman who seeks the intact method is not endangered by a “medically diagnosed condition that ... complicates the pregnancy.” Id. In limiting its exception to pre-existing physical conditions, HB 351 fails to contemplate the increased risks imposed on a woman by other methods of abortion. No exception would be permitted for a woman who is healthy, even if the intact procedure would likely avert highly serious health risks.
The majority and defendants assert that “the exception is triggered when other procedures, relative to the partial birth procedure, would expose a woman to significant risks.” Majority Slip Opinion at 450. However, their reading conflicts with the plain language of the statute stating that a woman may not receive the intact method unless she is endangered by a “medically diagnosed condition that ... complicates the pregnancy.” Ohio Rev. Code Ann. § 2919.151(A)(5). Because an abortion ends a pregnancy, it is not possible to characterize a health consequence of *461abortion as a “medically diagnosed condition that ... complicates the pregnancy.” This language excludes the prospective risks of other methods of abortion, thus violating Carhart’s instruction. The majority ignores this part of the statute and offers a plainly unreasonable interpretation of the statute’s clear language.
As noted in Carhart, the clear statutory definition is controlling. See Carhart, 530 U.S. at 942, 120 S.Ct. 2597 (stating that “[w]hen a statute includes an explicit definition, we must follow that definition”). Likewise, the Court in Colautti noted that “[a]s a rule, a definition which declares what a term means ... excludes any meaning that is not stated.” 439 U.S. at 392-93 n. 10, 99 S.Ct. 675 (quotation and citation omitted). Despite our duty to attempt to construe statutes to preserve their constitutionality, see Frisby v. Schultz, 487 U.S. 474, 483, 108 S.Ct. 2495, 101 L.Ed.2d 420 (1988), such is not possible here in light of the statute’s unambiguous wording.
D. HB 351’s pre-viability ban fails to provide a constitutionally adequate exception to preserve the health of a woman who does not have a medically diagnosed condition that complicates the pregnancy
The foregoing establishes the following:
1) it is unconstitutional for a state to maintain regulations that “force women to use riskier methods of abortion” when a woman has a constitutional right to abortion, viz.,
a) when the fetus is not viable; and,
b) whenever a continuing pregnancy would threaten the woman’s life or health;
2) substantial medical evidence shows that intact procedure may pose a lesser risk to some women;
3) the common methods of causing fetal demise may add significant risk to an abortion procedure and offer no benefit to the pregnant woman; and,
4) HB 351 does not permit a health exception for the intact procedure when it poses less risk to a pregnant woman who does not have a medically diagnosed condition that complicates the pregnancy.
Taken together, these findings and conclusions show that HB 351’s pre-viability ban is unconstitutional because it does not allow an exception for a woman who faces heightened risks from other methods but who does not have a medically diagnosed condition complicating the pregnancy. In the pre-viability context, the exception’s limiting conditions render it unconstitutionally narrow.8 HB 351’s pre-viability *462ban fails to offer the protection necessary to ensure the “preservation of the life or health” of the pregnant woman and is therefore unconstitutional.
II. HB 351’s Pre- and Post-viability Bans Are Unconstitutional Because They Force Women Facing Severe and Irreversible Harm to Their Mental Health to Use Riskier Methods of Abortion
As discussed above, HB 351’s pre-viability ban is unconstitutional because it forces a woman who does not have a “medically diagnosed condition that ... complicates the pregnancy” to use riskier methods of abortion. But there is another circumstance in which HB 351 would force a woman to use riskier methods of abortion, viz. when a continuing pregnancy or bearing a child would present a risk of severe and irreversible harm to the woman’s mental health. Because HB 351 limits its exception to risks from pre-existing physical conditions, it fails to allow an exception where the risks are to the woman’s mental health. As discussed below, this failure renders HB 351 unconstitutional in both its pre- and post-viability contexts.
A. Both the Supreme Court and this Court have recognized that a woman’s mental health must be preserved as part of her overall health
Since the day Roe was decided, the Supreme Court has recognized the emotional and psychological aspects of a woman’s overall health. To determine whether an abortion is medically “necessary,” the Court in Doe stated that “medical judgment may be exercised in the light of all factors — physical, emotional, psychological, familial, and the woman’s age — relevant to the well-being of the patient. All these factors may relate to health.” Doe, 410 U.S. at 191-192, 93 S.Ct. 739 (emphasis added). Decided on the same day and meant “to be read together,” id. at 165, 93 S.Ct. 705, Doe and Roe indicate that a woman’s mental health, in addition to her physical health, must be considered in assessing whether an exception to an abortion regulation actually preserves the health of the pregnant woman.
This Court has specifically held so, stating that in the post-viability context, a maternal health exception must encompass a risk of severe and irreversible harm to the woman’s mental health. Voinovich, 130 F.3d at 209-210. The Court stated:
The State’s substantial interest in potential life must be reconciled with the woman’s constitutional right to protect her own life and health. We believe that in order to reconcile these important interests, the Constitution requires that if the State chooses to proscribe post-viability abortions, it must provide a health exception that includes situations where a woman is faced with the risk of severe psychological or emotional injury which may be irreversible.
Id. at 210. The Voinovich court also found that the health exception at issue there unconstitutionally limited “the physician’s discretion to determine whether an abortion is necessary to preserve the woman’s health, because it limits the physician’s consideration to physical health conditions.” Id. (citing Colautti, 439 U.S. at 387, 99 S.Ct. 675). Thus, it must be determined whether some women face risks of severe and irreversible harm to their mental health and whether HB 351’s health exception would encompasses such risks.
B. The facts of this case show that some women face a risk of severe and irreversible mental harm from a continuing pregnancy or bearing a child
The record makes clear the factual bases for concern over the mental health con*463ditions of some pregnant women. Plaintiffs’ psychological expert testified that certain women face very significant mental health risks from a continuing pregnancy or bearing a child. Women who may face such risk include victims of rape, incest, and other kinds of abuse, and those with severe emotional disorders such as severe depression, obsessive-compulsive disorder, and manic-depressive illness. See J.A. at 954, 957-58, 973-77; see also Women’s Med. Prof'l Corp. v. Voinovich, 911 F.Supp. 1051, 1078-1081 (S.D.Ohio 1995) (listing examples of relevant psychological harms), aff'd, 130 F.3d 187 (6th Cir.1997). Thus, although the district court did not make detailed findings on risks to mental health in this case,9 the record clearly shows that some women face very serious mental health risks from a continuing pregnancy. See Voinovich, 130 F.3d at 192 (“[A]n appellate court is to conduct an independent review of the record when constitutional facts are at issue.”) (citing Jacobellis v. Ohio, 378 U.S. 184, 190 & n. 6, 84 S.Ct. 1676, 12 L.Ed.2d 793 (1964)).
C. HB 351 does not allow an exception to its ban on the intact procedure when the woman faces a risk of severe and irreversible harm to her mental health, even if the intact procedure is safer than other methods
HB 351 will permit the intact procedure only when it is “necessary, in reasonable medical judgment, to preserve the life or health of the mother as a result of the mother’s life or health being endangered by” a “medically diagnosed condition that so complicates the pregnancy of the woman as to directly or indirectly cause the substantial and irreversible impairment of a major bodily function.” Ohio Rev.Code Ann. § 2919.151(B) (post-viability) and (C) (pre-viability), incorporating Ohio Rev. Code Ann. § 2919.151(A)(5) (statutory definition). By its plain wording, then, the exception will apply only if all of the following conditions are met:
1) there is a danger to the pregnant woman’s life or health;
2) the danger arises from a medically diagnosed condition;
3) the medically diagnosed condition complicates the pregnancy;
4) the complication directly or indirectly causes a substantial and irreversible impairment; and,
5) the impairment is of a major bodily function.
As to whether the exception would apply for a woman facing a risk of severe and irreversible mental harm, it is clear that the first four of the five conditions would be met.10 However, the fifth condition that the impairment be of “a major bodily function” does not appear to be met when the serious risk is purely to the woman’s *464mental health. Indeed, in considering the substantially similar health exception in Voinovich,11 this Court stated that “[o]n its face, this definition appears to be limited to physical health risks, as opposed to mental health risks.” Voinovich, 130 F.3d at 206. The same is true here. In fact, the defendants have admitted that the exception is limited to physical health risks. Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d at 960. The Ohio defendants admitted the same with respect to the highly similar provision in Voinovich. 130 F.3d at 206-207.12 Thus, the health exception cannot be understood to encompass mental health risks and conditions, regardless of their nature or severity.
A woman facing a risk of severe and irreversible mental harm would not be permitted to receive the intact procedure. While the woman would still be able to receive an abortion by another method, she would nonetheless be compelled to face the comparative risks that HB 351 unconstitutionally fails to encompass. See Dissenting Slip Opinion at 455-461. Thus, no exception would extend to a woman who faces a severe and irreversible risk to her mental health from a continuing pregnancy, even when the intact procedure would carry significantly less physical risk than other procedures.13
D. HB 351’s pre- and post-viability bans fail to provide a constitutionally adequate exception to preserve the health of a woman who faces a risk of severe and irreversible harm to her mental health
The foregoing establishes that HB 351 is unconstitutional because it fails to encompass comparative physical risks and risks of severe and irreversible harm to a woman’s mental health. As the district court stated in granting the preliminary injunction:
Given that a State cannot prohibit a woman from aborting a viable fetus to preserve her own psychological or emotional health, it follows naturally from Carharb that she cannot be deprived of the safest method of doing so. Indeed, just as a woman who is suffering from a serious physical health condition must be permitted to undergo the safest abortion procedure available, a woman who is suffering from a mental health condition of the type described by this Court in Voinovich is entitled to no less.
114 F.Supp.2d at 695-96 (emphasis in original) (footnote omitted). Further in contravention of Voinovich, HB 351 admits no discretion to the physician on this issue. See 130 F.3d at 210.
*465Contrary to the majority’s assertion, the issue is not whether the woman “would suffer severe and irreversible mental harm from being limited to a D & E procedure when she or her physician might prefer a D & X.” Majority Slip Opinion at 448 n. 1. Rather, once it is established that a continuing pregnancy or bearing a child would pose a risk of severe and irreversible mental harm, the issue is whether the woman will be permitted to obtain an abortion by the means that presents the least risk to her physical health. Carhart requires such an exception, but none is afforded by HB 351.
In short, HB 351 does not provide what is explicitly required by Carhart and Voi-novich. Its health exception fails to heed the Supreme Court’s longstanding recognition of the importance of mental health to a woman’s overall health. Though Voino-vich held that a woman’s mental health must be considered with respect to a post-viability ban, that holding also applies in the pre-viability context because “the law ... at a minimum requires [preservation of the woman’s health] in respect to previ-ability regulation.” Carhart, 530 U.S. at 930, 120 S.Ct. 2597. The majority’s contrary assertion is unavailing. See Majority Slip Opinion at 448 n. 1. Indeed, it would be illogical to force a woman-for example, a woman impregnated by rape or ineest-to wait until the fetus attained viability before recognizing the risk to her mental health from a continuing pregnancy or giving birth. Thus, in both the pre- and post-viability contexts, HB 351 is unconstitutional because it forces women confronting the risk of severe and irreversible mental harm to use riskier methods of abortion. See Carhart, 530 U.S. at 931, 120 S.Ct. 2597.
III. The Health Exception Approved in Casey Is Constitutionally Inadequate for HB 351
In an attempt to save the constitutionality of HB 351, the defendants make much of the similarity between the provisions of HB 351’s health exception and the health exception to the general abortion regulations at issue in Casey.14 In essence, they argue that the health exception must be constitutionally adequate because its provisions mirror those approved in Casey, as construed broadly by the Third Circuit. See 947 F.2d 682, 701 (1991). However, Ohio’s attempt to import the provisions of Pennsylvania’s health exception into HB 351 fails because the Ohio law is very different in nature. As this Court noted in Voinovich, there is an important difference between regulations such those as in Casey that merely delay abortions and those at issue here and in Voinovich that ban some abortions. See 130 F.3d at 208.
In Casey, one of the main regulations at issue delayed the legal provision of an abortion until 24 hours after a woman had given her informed consent. 18 Pa. Cons. Stat. § 3205 (1990). It is obvious that requiring a 24-hour delay imposes a far lesser restriction and risk on a woman than a ban on a method of abortion. Unlike the regulations at issue in Casey, a ban with an overly narrow health exception does not have a mere “incidental effect of increasing the cost or decreasing the availability of medical care.” Casey, 505 U.S. at 874, 112 S.Ct. 2791. Further, *466HB 351’s ban is not a “structural mechanism,” id. at 877, 112 S.Ct. 2791, that asks a woman to stop and think about her choice; it is a ban whose narrow exception substantively forecloses a woman’s right in some circumstances to receive the type of procedure that is safest for her. Unlike HB 351, Casey’s regulations did not “force women to use riskier methods of abortion.” Carhart, 530 U.S. at 931, 120 S.Ct. 2597. This is the crucial distinction between the regulations at issue in Casey and the regulations in Carhart, where Court underscored its longstanding concern regarding state regulations that ban a method of abortion: “Our cases have repeatedly invalidated statutes that in the process of regulating the methods of abortion, imposed significant health risks.” Id. (emphasis in original).
Another important distinction between the regulations in Casey and Carhart likewise arises from the different circumstances in which their respective exceptions might become relevant. In Casey’s relevant context, when a woman’s health condition is such that she needs an abortion to be performed within only 24 hours of seeking one, her need will almost certainly be severe enough to trigger the “medical emergency” exception. However, in the unframed context of HB 351’s narrowly excepted ban, no passing of time would allow the woman to obtain the intact procedure, even though it might be a significantly less risky procedure than other available methods.
This fatal flaw itself derives from the forced fit of Pennsylvania’s exception unto Ohio’s ban of the intact procedure. The health exception in both sets of regulations would be triggered only by a “condition” that “complicates the pregnancy.” For a general 24-hour waiting period, one may understand the rationale behind the exception’s specific requirement that a medically diagnosed condition necessitate, in effect, an immediate abortion. However, as imported into HB 351, the requirements of Pennsylvania’s health exception fail to account for the risks the state may create when a method of abortion is banned. This is unsurprising given that Pennsylvania’s exception did not contemplate a ban.
Finally, it should be noted that the general abortion regulations at issue in Casey were ostensibly intended to provide a benefit to the pregnant woman by informing her and promoting her considered choice. See Casey, 505 U.S. at 885, 112 S.Ct. 2791 (“[IJmportant decisions will be more informed and deliberate if they follow some period of reflection.”). Here, the ban on the intact procedure provides no benefit to the woman. It serves only to deny the woman a medical option and violates Car-hart’s instruction that a state may not “force women to use riskier methods of abortion.” Carhart, 530 U.S. at 931, 120 S.Ct. 2597.
In sum, Casey’s very different regulatory context makes the Pennsylvania health exception an inapposite and unconstitutional fit for HB 351.

CONCLUSION

This case is about the health interests of pregnant women and the state’s “substantial interest in potential life.” Casey, 505 U.S. at 876, 112 S.Ct. 2791. With its narrowly excepted ban, HB 351 unconstitutionally compromises the former by forcing women to use riskier methods of abortion. In particular, HB 351 imposes significant risks in the pre-viability context by failing to permit the intact procedure when it may avert health risks for a woman who does not have a medically diagnosed condition that complicates the pregnancy. Further, in both the pre- and post-viability contexts, HB 351 imposes significant physical risks upon a woman for whom a continuing *467pregnancy or bearing a child would cause serious and irreversible harm to her mental health.
HB 351’s pre- and post-viability bans on the intact method do not contain a constitutionally adequate exception to preserve the health of the woman. For the foregoing reasons, the judgment of the district court should be affirmed.

. The parties have also asked the Court to determine whether HB 351 sweeps within its ban the “D & E” procedure, thereby placing an undue burden on women who seek an abortion before the fetus attains viability. For the reasons stated by the district court in its preliminary injunction ruling, I agree that HB 351 does not sweep the D & E procedure within its reach. See Women's Med. Prof'l Corp. v. Taft, 114 F.Supp.2d 664, 683-85 (S.D.Ohio 2000).

. I will use the terms "intact procedure” and "intact method” interchangeably, each signifying what is entailed by the terms "D & X” method, "intact D & E” method, as well as the "partial birth procedure” defined in HB 351, Ohio Rev.Code Ann. § 2919.151(A)(3).

. Thus, the word "significant,” as in the phrase "significant risk,” must be taken to mean "non-negligible.” In fact, "negligible risks” and "trivial complications," see Majority Slip Opinion at 450, are irrelevant to this case. I will therefore use and interpret the word "risk” to mean "non-negligible risk.” Likewise, I will use and interpret the word "riskier” to mean "riskier by a non-negligible amount.”

. Modifying Roe, Casey held that prior to fetal viability, a woman has a right to an abortion without an "undue burden" from the state. 505 U.S. at 874-78, 112 S.Ct. 2791. In addition, Casey reaffirmed the “substantial state interest in potential life throughout pregnancy.” Id. at 876, 112 S.Ct. 2791. These central principles also inform the discussion of the adequacy of HB 351's health exception.

. In its focus on "negligible risks” and "trivial complications,” see Majority Slip Opinion at 450, the majority miscasts the plaintiffs' arguments and the district court’s ruling. Neither contend that a health exception must accommodate negligible risks. The district court states "the plain language of HB 351 does not allow the 'partial birth procedure' to be performed when it is simply safer than alternative methods of abortion, and that is what Carhart requires.” Women’s Med. Prof'l Corp. v. Taft, 162 F.Supp.2d 929, 940-41 (2001). The district court does not use the phrase "simply safer” in isolation to mean "an iota safer.” Rather, the court uses the word "simply” to modify the whole phrase "safer than alternative methods of abortion.” As this context makes clear, the court refers to the source of risk, not the degree of risk. Indeed, in accord with the district court’s findings about the comparative safety of the intact procedure, this is not a case about negligible risks. See id. at 941-952.

. In further support of this conclusion, it should be noted that the Court found irrelevant or unpersuasive Nebraska’s contention that "safe alternatives remain available" despite the ban. See Carhart, 530 U.S. at 931-32, 120 S.Ct. 2597. Further, the Court cited as relevant the conclusion of a panel of the American College of Obstetricians and Gynecologists that the intact procedure "may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman.” Id. at 932, 120 S.Ct. 2597.

. Contrary to the majority’s assertion, neither Plaintiffs nor their expert doctors make the assertion that the intact procedure is "always safer.” Majority Slip Opinion at 446.

. In the post-viability context, the state may proscribe abortion altogether, except where the woman's health is threatened by a continuing pregnancy. See Roe, 410 U.S. at 164-165, 93 S.Ct. 705; Casey, 505 U.S. at 879, 112 S.Ct. 2791 (1992). Thus, the state may limit exceptions to cases where the woman has a medically diagnosed condition that complicates the pregnancy, as HB 351's health exception does. In light of our duty to offer reasonable statutory constructions to preserve constitutionality, I believe that the post-viability health exception may be read to apply when the woman has a physical condition that complicates the pregnancy and the intact procedure would be the safest method of abortion. In such a case, HB 351's post-viability ban would not violate Carhart’s prohibition of abortion regulations that force women to use riskier methods of abortion. Nonetheless, as discussed in the following section, both the pre- and post-viability bans are unconstitutional because the exception fails to apply when the woman faces a serious risk to her mental health from a continuing pregnancy and the intact procedure would be the safest method of abortion.

. In granting a preliminary injunction, the district court found a substantial likelihood that HB 351 was unconstitutional because it failed to encompass risks of severe and irreversible harm to a woman’s mental health. See 114 F.Supp.2d at 696. In granting the permanent injunction, however, the district court chose not to reach the issue concerning an exception for mental health risks because the court found HB 351 to be unconstitutional in both the pre- and post-viability contexts. See 162 F.Supp.2d at 962, n. 31. Nonetheless, this Court may affirm the district court's judgment on any basis supported by the record. See Andrews v. Ohio, 104 F.3d 803, 808 (6th Cir.1997).

. As to the third condition, I assume that severe mental health risks, like physical health risks, may be "medically diagnosed” by a doctor, psychiatrist, or other mental health professional. The first, second, and fourth conditions obviously apply in this context.

. The relevant provision in Voinovich proscribed all post-viability abortions except where "a physician determines, in good faith and in the exercise of reasonable medical judgment, that the abortion is necessary to prevent the death of the pregnant woman or a serious risk of the substantial and irreversible impairment of a major bodily function of the pregnant woman.'' Ohio Rev.Code Ann. 2919.17(A)(1) (1996).

. As in Voinovich, this admission forecloses the argument that mental health is a component of the "major bodily function” of the brain. See Voinovich, 130 F.3d at 209 n. 20 (citing A Woman’s Choice-East Side Women's Clinic v. Newman, 671 N.E.2d 104 (Ind.1996)).

.In light of the serious physical and mental harms for which HB 351 fails to account, it cannot be said that this case is about the mere "preferences” of doctors. See Majority Slip Opinion at 444-445. Plaintiffs have not argued "that a health exception, to be constitutional, must give physicians complete freedom to perform abortions using the D & X procedure whenever they wish to do so.” Id. at 446. Plaintiffs do not seek a standardless exception.

. The statute in Casey allowed exceptions to its regulations in cases of “medical emergency,” defined as:
[t]hat condition which, on the basis of the physician’s good faith clinical judgment, so complicates the medical condition of a pregnant woman as to necessitate the immediate abortion of her pregnancy to avert her death or for which a delay will create serious risk of substantial and irreversible impairment of a major bodily function.
18 Pa. Cons.Stat. § 3203 (1990).