Court Opinion

ID: 4787624
Source: CourtListenerOpinion
Date Created: 2021-08-19 15:00:33.975443+00
Date Added: 2024-06-11T09:02:03.337668
License: Public Domain

Case: 17-51060     Document: 00515984856        Page: 1    Date Filed: 08/18/2021

           United States Court of Appeals
                for the Fifth Circuit
                                                                      United States Court of Appeals
                                                                               Fifth Circuit

                                                                             FILED
                                                                       August 18, 2021
                                 No. 17-51060                           Lyle W. Cayce
                                                                             Clerk

   Whole Woman’s Health, on behalf of itself, its staff, physicians and
   patients; Planned Parenthood Center for Choice, on behalf of
   itself, its staff, physicians, and patients; Planned Parenthood of
   Greater Texas Surgical Health Services, on behalf of itself, its
   staff, physicians, and patients; Planned Parenthood South Texas
   Surgical Center, on behalf of itself, its staff, physicians, and patients;
   Alamo City Surgery Center, P.L.L.C., on behalf of itself, its staff,
   physicians, and patients, doing business as Alamo Women’s
   Reproductive Services; Southwestern Women’s Surgery
   Center, on behalf of itself, its staff, physicians, and patients; Curtis
   Boyd, M.D., on his own behalf and on behalf of his patients; Jane Doe,
   M.D., M.A.S., on her own behalf and on behalf of her patients; Bhavik
   Kumar, M.D., M.P.H., on his own behalf and on behalf of his patients;
   Alan Braid, M.D., on his own behalf and on behalf of his patients; Robin
   Wallace, M.D., M.A.S., on her own behalf and on behalf of her patients,

                                                          Plaintiffs—Appellees,

                                     versus

   Ken Paxton, Attorney General of Texas, in his official capacity; Sharen
   Wilson, Criminal District Attorney for Tarrant County, in her official
   capacity; Barry Johnson, Criminal District Attorney for McLennan
   County, in his official capacity,

                                                     Defendants—Appellants.
Case: 17-51060        Document: 00515984856           Page: 2      Date Filed: 08/18/2021

                     Appeal from the United States District Court
                          for the Western District of Texas
                               USDC No. 1:17-CV-690

   Before Owen, Chief Judge, and Jones, Smith, Stewart, Dennis,
   Elrod, Haynes, Graves, Higginson, Costa, Willett, Ho,
   Engelhardt, and Wilson, Circuit Judges. ∗
   Jennifer Walker Elrod and Don R. Willett, Circuit Judges,
   joined by Owen, Chief Judge, and Jones, Smith, Haynes, Ho,
   Engelhardt, and Wilson, Circuit Judges: ∗∗
          We must decide whether the district court erred in permanently
   enjoining Texas’s Senate Bill 8 (SB8), which prohibits a particular type of
   dilation and evacuation (D&E) abortion method.                 SB8    refers to the
   prohibited method as “live dismemberment” because doctors use forceps to
   separate, terminate, and remove the fetus. SB8 requires doctors to use
   alternative fetal-death methods.
          The district court declared SB8 facially unconstitutional. It held that
   SB8 imposes an undue burden on a large fraction of women, primarily
   because it determined that SB8 amounted to a ban on all D&E abortions. But
   viewing SB8 through a binary framework—that either D&Es can be done
   only by live dismemberment or else women cannot receive abortions in the
   second trimester—is to accept a false dichotomy. Instead, the record shows
   that doctors can safely perform D&Es and comply with SB8 using methods
   that are already in widespread use. In permanently enjoining SB8, the district

          ∗
              Judges Southwick, Duncan, and Oldham are recused.
          **
               Chief Judge Owen and Judge Haynes concur in the judgment only.

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   court committed numerous, reversible legal and factual errors: applying the
   wrong test to assess SB8, disregarding and misreading the Supreme Court’s
   precedents in Planned Parenthood of Southeastern Pennsylvania v. Casey and
   Gonzales v. Carhart, and bungling the large-fraction analysis. Accordingly,
   we VACATE the district court’s permanent injunction.
          Moreover, remanding to the district court would be futile here
   because the record permits only one conclusion. The plaintiffs have failed to
   carry their heavy burden of proving that SB8 would impose an undue burden
   on a large fraction of women. We REVERSE and RENDER.
                                         I.
          Dilation and evacuation is an abortion method commonly used after
   the beginning of the 15th week. It begins with the dilation phase, which is
   lengthy and can take two or even three days to complete. First, the woman
   is given the option of conscious sedation and then is administered medication
   for dilation. If medication cannot alone cause sufficient dilation, the doctor
   injects a local anesthetic directly into the woman’s cervix. After the cervix
   has been numbed, the doctor inserts osmotic dilators into the cervical canal,
   which absorb liquid and expand to allow the removal of the fetus and
   placenta.   Starting around 18 weeks gestation, this expansion process
   normally happens overnight, requiring the woman to come back the next day
   for the rest of the abortion procedure.
          Once sufficient dilation has occurred, the second phase begins and the
   doctor evacuates (removes) the fetus. Doctors use three main evacuation
   methods: (1) the suction method alone to terminate, separate, and remove
   the fetus; (2) suction and forceps together to terminate, separate, and remove
   the fetus; or (3) various fetal-death techniques (e.g., digoxin injections) to
   terminate the fetus before using forceps (sometimes combined with suction)

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   to separate and remove the fetus. Unlike the dilation phase, evacuation is
   relatively brief and can be done in “a few minutes.”
           In 2017, the Texas legislature enacted SB8, which allows any abortion
   accomplished by dilation and suction alone (the first method) or
   accomplished by fetal death caused without forceps followed by evacuation
   with forceps (the third method), but regulates the second method by
   prohibiting a doctor from using forceps to separate the fetal tissue and
   thereby terminate the fetus via live dismemberment. 1 SB8 states:
           A person may not intentionally perform a dismemberment
           abortion unless the dismemberment abortion is necessary in a
           medical emergency. 2
   A “dismemberment abortion” is defined by the legislature as:
           an abortion in which a person, with the purpose of causing the
           death of an unborn child, dismembers the living unborn child
           and extracts the unborn child one piece at a time from the
           uterus through the use of clamps, grasping forceps, tongs,
           scissors, or a similar instrument that, through the convergence
           of two rigid levers, slices, crushes, or grasps, or performs any
           combination of those actions on, a piece of a the unborn child’s
           body to cut or rip the piece from the body. 3
   A “medical emergency” is defined as a:
           life-threatening physical condition aggravated by, caused by, or
           arising from a pregnancy that, as certified by a physician, places
           the woman in danger of death or a serious risk of substantial

           1
            See Act of May 26, 2017, 85th Leg. R.S., ch. 441, § 6, 2017 Tex. Gen. Laws 1164,
   1165–67 (eff. Sept. 1, 2017) (codified as Tex. Health & Safety Code §§ 171.151–.154).
           2
               Id. § 171.152.
           3
               Id. § 171.151.

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           impairment of a major bodily function unless an abortion is
           performed. 4
   When a medical emergency arises, the doctor may proceed straight to live
   dismemberment with forceps. 5
           SB8 does not regulate the dilation phase of the abortion or any other
   evacuation method. SB8 does not ban the use of suction during any abortion
   procedure. SB8 does not prohibit a doctor from having forceps “on hand”
   to use after fetal death has occurred or to use if a medical emergency arises. 6
           What SB8 does do is prohibit one particular evacuation method in one
   particular set of circumstances—live dismemberment by forceps when a
   medical emergency does not exist. Thus, doctors may comply with SB8 by
   using only suction to achieve fetal death and remove the fetus—or, at later
   gestational ages, using either suction or a digoxin injection to cause fetal
   death before forcep-dismemberment and removal. 7
           The plaintiffs here, six abortion clinics and five individual doctors who
   provide abortions, brought this facial challenge against SB8 in federal court.
   They allege that SB8 imposes an undue burden on women seeking abortions
   in the second trimester of pregnancy. The defendants are various Texas law

           4
               Id. § 171.002.
           5
               Id. § 171.152.
           6
               Although SB8 prohibits using “clamps, grasping forceps, tongs, scissors,
   or . . . similar instrument[s]” to cause fetal death, id. § 171.151, we will refer to those items
   collectively as “forceps.”
           7
              A potassium-chloride injection and umbilical-cord transection are additional
   alternatives to live dismemberment, and the State presented testimony about them at the
   trial. As far back as Stenberg v. Carhart, 530 U.S. 914, 925 (2000), the Supreme Court has
   recognized potassium chloride, in particular, as an established method of causing fetal
   death. We need not discuss these additional alternatives, however, because digoxin and
   suction are already widely used and are alone sufficient for our holding in this case that the
   plaintiffs failed to prove an undue burden on a large fraction of women in the relevant
   circumstances.

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   enforcement officials. Texas argues that SB8 does not impose an undue
   burden on a large fraction of women in the relevant circumstances because
   there are safe and available alternatives for causing fetal death without
   forceps.
          The district court granted a temporary restraining order preventing
   SB8’s enforcement, followed by a five-day bench trial. The district court
   subsequently ruled that SB8 is facially unconstitutional and entered a
   permanent injunction. Texas appealed.
          A panel of our court held the case in abeyance pending the Supreme
   Court’s decision in June Medical Services L.L.C. v. Russo, 140 S. Ct. 2103
   (2020). Once the June Medical opinion was issued, we ordered supplemental
   briefing from the parties on the effect, if any, of June Medical on this appeal.
   Texas moved for a stay of the district court’s injunction pending appeal. A
   two-member majority of the panel denied the motion with Judge Willett in
   dissent. See Whole Woman’s Health v. Paxton, 972 F.3d 649 (5th Cir. 2020).
   The panel subsequently issued its opinion on the merits, ruling that SB8 is
   unconstitutional under Whole Woman’s Health v. Hellerstedt, 136 S. Ct. 2292,
   2309 (2016), with Judge Willett in dissent again. See Whole Woman’s Health
   v. Paxton, 978 F.3d 896 (5th Cir.), vacated and reh’g en banc granted, 978 F.3d
   974 (5th Cir. 2020). A majority of the members of our court voted to take the
   case en banc.
                                           II.
                                           A.
          We review the district court’s permanent injunction for abuse of
   discretion. Scott v. Schedler, 826 F.3d 207, 211 (5th Cir. 2016). The district
   court abuses its discretion if it “(1) relies on clearly erroneous factual findings
   when deciding to grant or deny the permanent injunction, (2) relies on
   erroneous conclusions of law when deciding to grant or deny the permanent
   injunction, or (3) misapplies the factual or legal conclusions when fashioning

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   its injunctive relief.” Alcatel USA, Inc. v. DGI Techs., Inc., 166 F.3d 772, 790
   (5th Cir. 1999) (alteration omitted) (quoting Peaches Ent. Corp. v. Ent.
   Repertoire Assocs., 62 F.3d 690, 693 (5th Cir. 1995)). We review questions of
   fact for clear error and legal conclusions de novo. Scott, 826 F.3d at 211. A
   clear error has occurred when we are “left with the definite and firm
   conviction that a mistake has been committed.” June Medical, 140 S. Ct. at
   2141 (Roberts, C.J., concurring) (quoting United States v. U.S. Gypsum Co.,
   333 U.S. 364, 395 (1948)).
          If “a district court’s findings rest on an erroneous view of the law,
   they may be set aside on that basis.” Pullman-Standard v. Swint, 456 U.S.
   273, 287 (1982); see also Aransas Project v. Shaw, 775 F.3d 641, 658 (5th Cir.
   2014) (“When, as here, a court’s factual finding ‘rest[s] on an erroneous
   view of the law’, its factual finding does not bind the appellate court.”
   (quoting Swint, 456 U.S. at 287)); Thornburg v. Gingles, 478 U.S. 30, 79
   (1986) (holding that appellate courts’ power to correct extends to “finding[s]
   of fact that [are] predicated on a misunderstanding of the governing rule of
   law” (quoting Bose Corp. v. Consumers Union of U.S., 466 U.S. 485, 501
   (1984))). And “when the record permits only one resolution of the factual
   issue after the correct law is applied, remand is unnecessary.” Aransas
   Project, 775 F.3d at 658 (citing Swint, 456 U.S. at 292); see also Swint, 456 U.S.
   at 292 (“[W]here findings are infirm because of an erroneous view of the law,
   a remand is the proper course unless the record permits only one resolution
   of the factual issue.”).
                                          B.
          In Planned Parenthood of Southeastern Pennsylvania v. Casey, the
   Supreme Court repudiated lower courts’ post-Roe v. Wade practice of
   invalidating abortion regulations that “in no real sense deprived women of
   the ultimate decision” to have an abortion. 505 U.S. 833, 875 (1992). Casey
   established three principles: (1) the woman has a “right . . . to choose to have

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   an abortion before viability . . . without undue interference from the State”;
   (2) the State has the “power to restrict abortions after fetal viability”; and
   (3) the State has “legitimate interests from the outset of the pregnancy in
   protecting the health of the woman and the life of the fetus.” Id. at 846.
           In Casey, the Court set out the familiar undue-burden test, stating that
   “[o]nly where state regulation imposes an undue burden on a woman’s
   ability to make” the decision to have an abortion does the State violate the
   Due Process Clause. Id. at 874. “A finding of an undue burden is a shorthand
   for the conclusion that a state regulation has the purpose or effect of placing
   a substantial obstacle in the path of a woman seeking an abortion of a
   nonviable fetus.” Id. at 877 (emphasis added). The Casey Court further
   explained that “[t]he fact that a law which serves a valid purpose, one not
   designed to strike at the right itself, has the incidental effect of making it more
   difficult or more expensive to procure an abortion cannot be enough to
   invalidate it.” Id. at 874.
           When a plaintiff claims that an abortion law is facially invalid—as
   opposed to unconstitutional as applied to her—we ask whether the law would
   impose a substantial obstacle on a “large fraction” of women in the relevant
   circumstances. Id. at 895. 8 We first determine the denominator of the
   fraction by identifying the number of women “for whom the law is a
   restriction, not the [number of women] for whom the law is irrelevant.” Id.
   at 894. After determining that proper denominator, courts should deduce
   the numerator—the number of women for whom the abortion regulation

           8
              The large-fraction test is a generous exception to the normal burden that litigants
   bear in facial challenges. In non-abortion cases, a plaintiff must establish that no set of
   circumstances exists under which the law would be constitutional. See Women’s Med. Pro.
   Corp. v. Voinovich, 130 F.3d 187, 193–95 (6th Cir. 1997) (noting the Supreme Court’s
   “inconsistent” rules in facial challenges between abortion cases and non-abortion cases);
   see also Planned Parenthood of Cent. N.J. v. Farmer, 220 F.3d 127, 142–43 (3d Cir. 2000)
   (same).

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   would impose an “undue burden.” Id. at 895. The plaintiff bears the burden
   of proving a large fraction—and that burden is “heavy.” Gonzales v. Carhart,
   550 U.S. 124, 167–68 (2007).
                                       III.
         The district court concluded that SB8 amounts to a complete ban on
   “standard D&E” abortions. This conclusion rested on four errors—each of
   which independently compels reversal. First, the district court applied an
   incorrect legal test to assess SB8. Second, the district court disregarded
   Casey, Gonzales, and Hellerstedt by dismissing the State’s interests and
   committing myriad other legal errors. Third, the district court failed to
   properly evaluate SB8’s burdens under Casey and, in doing so, improperly
   concluded that the only safe second-trimester abortion procedure is live
   dismemberment by forceps. Finally, the district court misapplied the large-
   fraction test by incorrectly determining the number of women upon whom
   SB8 would place an undue burden (the numerator) and incorrectly
   determining the number of women to whom SB8 would apply (the
   denominator). In sum, the district court’s opinion rested on bad law, bad
   facts, and bad math. We address each error in turn.
                                       A.
                                        1.
         For decades, Casey’s undue-burden test was the governing standard
   for assessing abortion regulations. Five years ago, in Whole Woman’s Health
   v. Hellerstedt, the Supreme Court stated that Casey’s undue-burden test
   “requires that courts consider the burdens a law imposes on abortion access
   together with the benefits those laws confer.” Whole Woman’s Health v.
   Hellerstedt, 136 S. Ct. 2292, 2309 (2016). This language in Hellerstedt came

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   to be recognized by some as a “balancing test.” Id. at 2324 (Thomas, J.,
   dissenting). 9
           Last summer in June Medical—issued after the district court enjoined
   SB8—the Supreme Court again tackled the meaning of “undue burden.”
   140 S. Ct. at 2112 (plurality opinion). The four-Justice plurality considered
   the law’s benefits together with its burdens. Id. Chief Justice Roberts wrote
   separately, concurring in the judgment but disavowing any balancing test. Id.
   at 2135–37 (Roberts, C.J., concurring). The Chief Justice explained that the
   proper standard is the straightforward undue-burden test and that neither
   Casey nor Hellerstedt established a balancing test. “In neither [Hellerstedt nor
   Casey] was there [a] call for consideration of a regulation’s benefits.” Id. at
   2139. The Chief Justice noted that the Court in Hellerstedt explicitly stated
   that it “appl[ied] the undue burden standard of Casey” and that it needed
   “[n]othing more” than the burdens analysis to hold the challenged law
   unconstitutional. Id. at 2138–39. As the Chief Justice put it, Hellerstedt,
   properly understood, was simply an iteration of Casey’s undue-burden
   standard, which “require[s] a substantial obstacle before striking down an
   abortion regulation.” Id. at 2139. “Laws that do not pose a substantial
   obstacle to abortion access are permissible, so long as they are ‘reasonably
   related’ to a legitimate state interest.” Id. at 2135 (quoting Casey, 505 U.S.
   at 878). The only relevance of an abortion regulation’s asserted “benefits”
   is “in considering the threshold requirement that the State have a ‘legitimate

           9
             Previously, our circuit explicitly eschewed a benefits-versus-burdens balancing
   test. “In our circuit, we do not balance the wisdom or effectiveness of a law against the
   burdens the law imposes.” Whole Woman’s Health v. Cole, 790 F.3d 563, 587 n.33 (5th Cir.)
   (quoting Whole Woman’s Health v. Lakey, 769 F.3d 285, 297 (5th Cir.) (citing Planned
   Parenthood of Greater Tex. Surgical Health Servs. v. Abbott, 748 F.3d 583, 593–94 (5th Cir.
   2014) (Abbott II)), vacated in part, 574 U.S. 931 (2014))), modified, 790 F.3d 598 (5th Cir.
   2015), rev’d and remanded sub nom. Whole Woman’s Health v. Hellerstedt, 136 S. Ct. 2292
   (2016).

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   purpose’ and that the law be ‘reasonably related to that goal.’” Id. at 2138
   (first quoting Casey, 505 U.S. at 878 (plurality opinion); and then quoting id.
   at 882 (joint opinion)).
          The Chief Justice opined in June Medical that trying to weigh the
   State’s interest in protecting fetal life is impossible—and therefore a
   balancing test is impossible—because how do you “assign weight to such
   imponderable values?” Id. at 2136. Agreeing with all but two pages of the
   plurality’s opinion, Chief Justice Roberts said that the inquiry should have
   ended after the plurality analyzed the law’s burdens on abortion access.
                                         2.
          Under the Marks rule, the Chief Justice’s concurrence is June
   Medical’s controlling opinion. In Marks v. United States, the Supreme Court
   instructed that “[w]hen a fragmented Court decides a case and no single
   rationale explaining the result enjoys the assent of five Justices, the holding
   of the Court may be viewed as that position taken by those Members who
   concurred in the judgments on the narrowest grounds.” 430 U.S. 188, 193
   (1977) (internal quotation marks omitted) (quoting Gregg v. Georgia, 428 U.S.
   153, 169 n.15 (1976) (opinion of Stewart, Powell, and Stevens, JJ.)). We have
   clarified that this principle “is only workable where there is some common
   denominator upon which all of the justices of the majority can agree.” United
   States v. Duron-Caldera, 737 F.3d 988, 994 n.4 (5th Cir. 2013) (internal
   quotation marks omitted) (quoting United States v. Eckford, 910 F.2d 216, 219
   n.8 (5th Cir. 1990)).
          In June Medical, the common denominator is the undue-burden
   (substantial-obstacle) analysis, which took up more than 80% of the
   plurality’s reasoning. Indeed, the Chief Justice concluded that, “for the
   reasons the plurality explain[ed],” the law “imposed a substantial obstacle”
   to abortion access. June Medical, 140 S. Ct. at 2139, 2141 (Roberts, C.J.,
   concurring).   The only part the Chief Justice disagreed with was the

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   plurality’s two-page benefits analysis. So the Chief Justice’s test is a
   narrower version (only burdens) of the plurality’s test (benefits and burdens).
   Accordingly, the Chief Justice’s concurrence controls and we do not balance
   the benefits and burdens in assessing an abortion regulation.
           We agree with the Eighth and Sixth Circuits in holding that the Chief
   Justice’s concurrence controls. See Hopkins v. Jegley, 968 F.3d 912, 915 (8th
   Cir.) (“Chief Justice Robert[s]’s vote was necessary in holding
   unconstitutional Louisiana’s admitting-privileges law, so his separate
   opinion is controlling.”), reh’g and reh’g en banc denied, No. 4985329
   (2020); 10 EMW Women’s Surgical Ctr., P.S.C. v. Friedlander, 978 F.3d 418,
   437 (6th Cir.) (“The Chief Justice’s opinion in June Medical Services concurs
   in the judgment on the narrowest grounds, so it is the ‘controlling opinion’
   from that decision.” (quoting Marks, 430 U.S. at 193)), reh’g en banc denied,
   No. 104-1 (6th Cir. Dec. 31, 2020). 11 These circuits held that the Chief

           10
               See also Little Rock Fam. Plan. Servs. v. Rutledge, 984 F.3d 682, 687 n.2 (8th Cir.
   2021) (“Chief Justice Roberts’s concurring opinion [in June Medical] is controlling.”),
   petition for cert. filed, No. 20-1434 (Apr. 13, 2021).
           11
              While noting that the Chief Justice’s concurrence offered the narrowest basis for
   June Medical’s judgment, the Seventh Circuit has taken a somewhat different approach to
   Marks’s application to June Medical. Planned Parenthood of Ind. & Ky., Inc. v. Box, 991 F.3d
   740, 741 (7th Cir. 2021), petition for cert. filed, No. 20-1375 (Mar. 29, 2021). The Seventh
   Circuit views only one part of the Chief Justice’s concurrence as binding—the part where
   the Chief Justice agreed with the plurality that Hellerstedt “was entitled to stare decisis
   effect on essentially identical facts.” Id. at 748.
           The Seventh Circuit also stated that “the Marks rule tells us that June Medical did
   not overrule [Hellerstedt]” and that “[Hellerstedt] remains precedent binding on lower
   courts.” Id. On this point, we agree with the Seventh Circuit. Where we diverge from the
   Seventh Circuit is our respect for the full weight of the Chief Justice’s controlling
   concurrence, which observed that neither Casey nor Hellerstedt established a balancing test.
   “As middle-management circuit judges, we cannot overrule the Supreme Court. But
   neither should we ‘underrule’ it.” Whole Woman’s Health, 978 F.3d at 920 (Willett, J.,

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   Justice’s concurrence “clarified that the undue burden standard is not a
   balancing test.” EMW Women’s Surgical Ctr., P.S.C., 978 F.3d at 437; 12 see
   also Hopkins, 968 F.3d at 915 (“According to Chief Justice Roberts, the
   appropriate inquiry under Casey is . . . ‘not whether benefits outweighed
   burdens’. . . . [Benefits      are]    ‘consider[ed]       [only    in]    the    threshold
   requirement that the State [has] a “legitimate purpose” and that the law be
   “reasonably related to that goal.”’” (first quoting June Medical, 140 S. Ct.
   at 2137–38; then quoting Casey, 505 U.S. at 878)).

   dissenting). “Our duty is to harmonize its decisions as well as possible.” Nelson v.
   Quarterman, 472 F.3d 287, 339 (5th Cir. 2006) (Jones, C.J., dissenting on other grounds).
            Like the Seventh Circuit, the Eleventh Circuit has chosen to underrule the Chief
   Justice’s controlling concurrence. In Reproductive Health Services v. Strange, the court
   noted that the June Medical plurality opinion applied a benefits-versus-burdens balancing
   test. 3 F.4th 1240, 1259 (11th Cir. 2021). The court also explained that the plurality opinion
   and the Chief Justice’s concurrence shared a “common ground,” which is the “conclusion
   that the . . . statute constituted an undue burden.” Id. Despite acknowledging the shared
   analysis and conclusion of the plurality opinion and the Chief Justice’s concurrence, the
   Eleventh Circuit confusingly held that the Chief Justice’s concurrence was not “narrower”
   than the plurality opinion and thus not controlling under Marks. Id.
           12
              Even though it acknowledged that the EMW panel had held that the Chief
   Justice’s opinion in June Medical was controlling under the Marks rule, a subsequent panel
   of the Sixth Circuit decided to disregard the EMW panel’s holding when it denied a state’s
   motion to stay pending appeal in an abortion case involving waiting periods. Bristol Reg’l
   Women’s Ctr., P.C. v. Slatery, 988 F.3d 329, 337–38 (6th Cir.), opinion vacated, 994 F.3d 774
   (6th Cir. 2021). Judge Thapar dissented and pointed out that the panel majority erred
   because “the holding of a published panel opinion [EMW] binds all later panels unless
   overruled or abrogated en banc or by the Supreme Court.” Id. at 346 (Thapar, J.,
   dissenting) (quoting Wright v. Spaulding, 939 F.3d 695, 700 (6th Cir. 2019)). The Sixth
   Circuit decided to take the case straight to en banc review. See Bristol Reg’l Women’s Ctr.,
   P.C. v. Slatery, 993 F.3d 489 (6th Cir. 2021).
           Moreover, a more recent Sixth Circuit opinion confirms that that circuit views the
   Chief Justice’s concurrence as controlling. See Preterm-Cleveland v. McCloud, 994 F.3d 512,
   524 (6th Cir. 2021) (en banc) (explaining that the EMW decision applied Marks “to
   determine that the June Medical concurrence was the narrowest opinion and, therefore, the
   governing law”).

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          Under the Chief Justice’s controlling concurrence in June Medical,
   the district court erred by balancing SB8’s benefits against its burdens. That
   is reason alone to reject the district court’s findings. See Swint, 456 U.S. at
   287 (“[A] district court’s findings [that] rest on an erroneous view of the
   law . . . may be set aside on that basis.”). But, as explained below, the district
   court erred under all of the Supreme Court’s relevant precedents—Casey,
   Hellerstedt, Gonzales, and June Medical.
                                          B.
                                           1.
          Despite Casey’s clear language, repeated in Gonzales, that the State
   has legitimate and substantial interests in fetal life throughout pregnancy, the
   district court dismissed the State’s interests as deserving “only marginal
   consideration” and “having [] primary application once the fetus is capable
   of living outside the womb.” What is more, the State asserted several
   interests in passing SB8 in addition to respect for fetal life—benefits to
   patients both physically and psychologically, medical and societal ethics, and
   informed consent for women seeking abortions.               The Supreme Court
   accepted all of these interests in Gonzales. 550 U.S. at 158, 163. Yet the
   district court disregarded all of them here, contravening both Casey and
   Gonzales. See Casey, 505 U.S. at 846; Gonzales, 550 U.S. at 145–46.
          First, the State asserted its interest in the health and safety of women
   seeking abortions. The State presented evidence showing that women
   seeking abortions benefit physically and psychologically when fetal death
   occurs before dismemberment.         For example, the Planned Parenthood
   Federation of America Manual of Medical Standards and Guidelines tells
   patients that a study showed that                “more than 90 percent of
   women . . . prefer[] knowing that fetal death occurred before the abortion
   surgery began.” The American Institute of Ultrasound and Medicine agrees
   and has also found that doctors have a similar preference and believe that

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   inducing fetal death can help with emotional difficulties for the patient. Casey
   noted that “most women considering an abortion would deem the impact on
   the fetus relevant, if not dispositive, to the decision.” 505 U.S. at 882.
   Beyond psychological benefits, terminating the fetus before dismembering it
   makes the abortion physically easier for the mother. As the Supreme Court
   noted in Gonzales: “Fetal demise may cause contractions and make greater
   dilation possible. Once dead, moreover, the fetus’s body will soften and its
   removal will be easier.” 550 U.S. at 136.
           Second, the State asserted its interest in providing a greater degree of
   dignity in a soon-to-be-aborted fetus’s death. The State argues that, by
   requiring doctors to choose alternatives to a brutal abortion procedure, SB8
   evinces the State’s “profound respect for the life within the woman.” Id. at
   157. Dismemberment D&Es are self-evidently gruesome. It has long been
   illegal to kill capital prisoners by dismemberment. See In re Kemmler, 136 U.S.
   436, 447 (1890). It is also illegal to dismember living animals. Tex. Penal
   Code § 42.092. The State urges that SB8 would simply extend the same
   protection to fetuses. 13
           In its opinion, the district court dismissed the State’s interest in
   respecting fetal life with the comment that “[a]n abortion always results in

           13
              The State also argues that SB8 may protect fetuses from feeling the pain of being
   dismembered alive. The Supreme Court “has given state and federal legislatures wide
   discretion to pass legislation in areas where there is medical and scientific uncertainty.”
   Gonzales, 550 U.S. at 163. The record here reveals that scientists are unsure at what
   gestational age a fetus begins to feel pain. The plaintiffs and the State presented conflicting
   expert testimony and there appears to be a wide range of views. Faced with this
   uncertainty, the State is permitted to exercise its “wide discretion” and err on the side of
   caution—especially in light of the numerous benefits provided by killing the fetus before it
   is dismembered and evacuated. June Medical, 140 S. Ct. at 2136 (Roberts, C.J., concurring)
   (quoting Gonzales, 550 U.S. at 163). “Medical uncertainty does not foreclose the exercise
   of legislative power in the abortion context any more than it does in other contexts.”
   Gonzales, 550 U.S. at 164.

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   the death of the fetus.” The district court also noted that the State’s interest
   “does not add weight to tip the balance in the State’s favor.” The district
   court’s analysis cannot be reconciled with the Supreme Court’s instruction
   in Gonzales:
         The government may use its voice and its regulatory authority
         to show its profound respect for the life within the woman. . . .
         Where it has a rational basis to act, and it does not impose an
         undue burden, the State may use its regulatory power to bar
         certain procedures and substitute others, all in furtherance of
         its legitimate interests in regulating the medical profession in
         order to promote respect for life, including life of the unborn.
   550 U.S. at 157–58 (emphases added).
          Third, the State asserted its interest in promoting societal and medical
   ethics. “There can be no doubt the government ‘has an interest in protecting
   the integrity and ethics of the medical profession.’” Id. at 157 (quoting
   Washington v. Glucksberg, 521 U.S. 702, 731 (1997)). SB8’s provisions are
   supported by general principles of medical ethics, which require accounting
   for the harms to and dignity of both the mother and the fetus.
          Finally, the State asserted its interest in ensuring that women give
   informed consent to abortions. The State contends that SB8 by its very
   nature furthers this important interest. Although SB8’s constitutionality
   does not depend on whether it has an informed-consent requirement, the law
   nevertheless promotes informed consent even without technically requiring
   that abortion providers use more detailed consent forms. In Gonzales, the
   Supreme Court upheld the Partial-Birth Abortion Ban Act despite the fact
   that the law did not include an informed-consent requirement because:
          It is self-evident that a mother who comes to regret her choice
          to abort must struggle with grief more anguished and sorrow
          more profound when she learns, only after the event, what she
          once did not know: that she allowed a doctor to pierce the skull

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          and vacuum the fast-developing brain of her unborn child, a
          child assuming the human form.
   Gonzales, 550 U.S. at 159–60 (emphasis added). “It is . . . precisely [a] lack
   of information concerning the way in which the fetus will be killed that is of
   legitimate concern to the State.” Id. at 159. “The State has an interest in
   ensuring so grave a choice is well informed.” Id.
          What was true in Gonzales is true here. Women who receive live-
   dismemberment D&Es are not being told what is going to happen to the fetus.
   In this case, the plaintiffs’ consent forms do not explain in “clear and precise
   terms” what a live-dismemberment abortion entails. Id. (quoting Nat’l
   Abortion Fed’n v. Ashcroft, 330 F. Supp. 2d 436, 466 n.22 (S.D.N.Y. 2004)).
   For example, Plaintiff Southwestern’s form tells the patient that “the
   pregnancy tissue will be removed during the procedure” and does not explain
   that the fetus’s body parts—arms, legs, ribs, skull, and everything else—will
   be ripped apart and pulled out piece by piece. Plaintiff Alamo’s consent form
   states that the doctor will “empt[y] the uterus either by vacuum aspiration
   or evacuation (manual removal of the fetus by forceps).” Plaintiff Whole
   Woman’s Health’s form states: “The physician will use . . . instruments such
   as forceps to remove the pregnancy from the uterus . . . in multiple
   fragments.”
          The district court cast aside all of these interests—even though each
   was recognized as legitimate and substantial in Gonzales and even though a
   “central premise of [Casey] was that the Court’s precedents after Roe had
   ‘undervalue[d] the State’s interest in potential life.’” Gonzales, 550 U.S. at
   157 (quoting Casey, 505 U.S. at 873).
                                           2.
          In addition to dismissing all of the State’s interests, the district court
   contravened the Supreme Court’s precedents in several other ways. First,
   the district court disregarded Roe by deeming the abortion right “absolute.”

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   “[W]e do not agree” that “the woman’s right is absolute.” Roe v. Wade, 410
   U.S. 113, 153 (1973). Of course, no constitutional rights, even those expressly
   enshrined in the Bill of Rights, are absolute.
          Second, the district court’s faulty framework led it to place the burden
   of proof on the wrong party and turn the State’s legislative power on its head.
   It did so by holding that SB8 was unconstitutional because live
   dismemberment is a common abortion method in the second trimester. This
   was exactly backwards. Since Casey, we have recognized that abortion
   doctors do not get to set their own rules. They are not permitted to self-
   legislate or self-regulate simply by making an abortion method “common.”
   Abortion doctors do not have “unfettered choice[s].” Gonzales, 550 U.S. at
   163. Indeed, not even the woman—the patient—gets “to terminate her
   pregnancy at whatever time, in whatever way, and for whatever reason she
   alone chooses.” Roe, 410 U.S. at 153. To the contrary, when the State enacts
   laws reasonably related to a legitimate interest, abortion doctors must find
   “different and less shocking methods to abort the fetus . . . thereby
   accommodating legislative demand.” Gonzales, 550 U.S. at 160.
          Third, the district court incorrectly defined “substantial obstacle.”
   Casey, 505 U.S. at 877.      “Substantial” is defined as “of considerable
   importance, size, or worth.” Substantial, New Oxford Am. Dictionary 1736
   (3d ed. 2010); see also Toyota Motor Mfg., Ky., Inc. v. Williams, 534 U.S. 184,
   196 (2002) (“‘[S]ubstantially’ in the phrase ‘substantially limits’ suggests
   ‘considerable’ or ‘to a large degree.’”). The definition of “substantial” is
   consistent with the purpose of Casey’s substantial-obstacle test: to establish
   a relatively high bar for striking down laws—especially in facial challenges—
   that regulate abortions. See also Gonzales, 550 U.S. at 156, 167 (explaining
   that a facial-challenge plaintiff bears a “heavy burden” of proving that a law
   would impose a “substantial obstacle”). And yet the district court construed
   “substantial” to mean “no more and no less than ‘of substance.’” This

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   construction would yield essentially all abortion regulations unconstitutional
   and cannot be harmonized with the Supreme Court’s precedent. “[N]ot
   every law which makes a right more difficult to exercise is, ipso facto, an
   infringement of that right.” Casey, 505 U.S. at 873.
          In sum, the district court committed numerous legal errors and
   contravened Casey, Gonzales, and Hellerstedt by balancing SB8’s benefits
   against its burdens; diminishing the State’s compelling, numerous, and
   evidence-supported interests in preventing live-dismemberment abortions;
   granting the right to abortion an “absolute” status; placing the burden of
   proof on the wrong party; and erroneously defining “substantial” in
   “substantial obstacle.” These legal errors undermine the deference that we
   would normally owe the district court’s factual findings. See Thornburg, 478
   U.S. at 79 (holding that appellate courts can correct errors, “including those
   that may infect a so-called mixed finding of law and fact, or a finding of fact
   that is predicated on a misunderstanding of the governing rule of law”
   (quotation and citations omitted)).
                                         C.
          We now turn to the district court’s analysis of SB8’s burdens and its
   attendant factual findings.     Because the district court’s myriad and
   fundamental legal errors evinced “a misunderstanding of the governing rule
   of law,” Bose Corp., 466 U.S. at 501, its factual “findings may be set aside on
   that basis,” Swint, 456 U.S. at 287. See also Aransas Project, 775 F.3d at 658
   (“When, as here, a court’s factual finding ‘rest[s] on an erroneous view of
   the law’, its factual finding does not bind the appellate court.” (quoting
   Swint, 456 U.S. at 287)); Women’s Med. Ctr. of Nw. Hous. v. Bell, 248 F.3d
   411, 419 (5th Cir. 2001) (“Although the ultimate decision whether to grant
   or deny a preliminary injunction is reviewed only for abuse of discretion, a
   decision grounded in erroneous legal principles is reviewed de novo.”). We
   therefore owe no deference to the district court’s factual findings. But, as

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   demonstrated below, even if we were to consider the district court’s factual
   findings under a clear-error standard, they fail to demonstrate an “undue
   burden” on the protected right.
           The district court disregarded and distorted the record to hold that
   SB8 would result in a complete ban on D&E abortions, in large part due to its
   erroneous definition of “substantial obstacle.” The district court first
   assumed, as a matter of law before even alluding to anything in the record,
   that requiring fetal death before live dismemberment by forceps would be
   “banning the standard D&E procedure.” The district court read Gonzales to
   describe the “standard D&E” as the “procedure performed before fetal
   demise.” This was error. In Gonzales, the Supreme Court described the
   typical D&E, and within that description noted that “[s]ome doctors,
   especially later in the second trimester, may kill the fetus a day or two before
   performing the surgical evacuation.         They inject digoxin or potassium
   chloride into the fetus, the umbilical cord, or the amniotic fluid.” 550 U.S.
   at 136. The Court also pointed out that “[o]ther doctors refrain” from
   causing fetal death because they believe it provides no medical benefit. Id.
   After making these statements, the Court proceeded to describe partial-birth
   abortions—“a variation of this standard D & E.” Id. In other words, the
   Court’s description of the “standard D&E” included the option of fetal
   death before live dismemberment. The district court here misread Gonzales
   and thereby incorrectly concluded that there was only one kind of “standard
   D&E.”
          More broadly, the district court failed to sufficiently appreciate the
   direct applicability of Gonzales to the facts and many of the legal issues in this
   case. Gonzales’s facts are extremely similar to the situation presented here.
   In Gonzales, the Supreme Court upheld the federal Partial-Birth Abortion
   Ban Act and vacated two permanent injunctions of it. 550 U.S. at 133, 168.
   The Act proscribed “intact” dilation and extraction abortions, during which

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   the fetus is removed in one—as opposed to, as here, multiple—piece(s). 14 Id.
   at 136–37. The Court concluded that “the medical uncertainty over whether
   the Act’s prohibition create[d] significant health risks provide[d] a sufficient
   basis to conclude . . . that the Act d[id] not impose an undue burden.” Id. at
   164. The Court noted that Congress was legitimately concerned “with the
   effects on the medical community and on its reputation caused by the
   practice of partial-birth abortion” and that the Act furthered the State’s
   legitimate and substantial interests in promoting ethics in the medical
   profession. Id. at 157. Moreover, the Act furthered the State’s interest in
   promoting “respect for life” by prohibiting procedures that are “laden with
   the power to devalue human life.” Id. at 158. Another “consideration[]”
   that supported the Court’s conclusion that the Act did not impose an undue
   burden was that “alternatives” to the prohibited procedure were available.
   Id. at 164. The district court was not at liberty to deviate from the teachings
   of Gonzales, and neither are we.
           Errors also pervaded the district court’s analysis of the alternatives to
   live dismemberment. The district court found that requiring fetal death
   before live dismemberment was an undue burden for “all women seeking a
   second-trimester abortion at 15 weeks” and beyond. Its bases for this
   sweeping conclusion were that the alternative methods would delay a
   woman’s abortion, which, according to the court, was sufficient by itself to
   create an undue burden, and that the alternative methods were unsafe and
   ineffective. 15 So, according to the district court, even if SB8 is not an explicit

           14
               Dismemberment abortions are “brutal.” Gonzales, 550 U.S. at 182 (Ginsburg,
   J., dissenting).
           15
              The district court apparently copied and pasted into its opinion facts from other
   district and circuit court opinions. That was inappropriate. The analysis is case-specific,
   litigation-specific, and fact-specific, and the district court erred by relying on other cases’
   factual descriptions as bases for its ruling. For example, the district court borrowed facts
   from West Alabama Women’s Center v. Miller, 217 F. Supp. 3d 1313, 1339 (M.D. Ala. 2016).

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   ban, it would operate as a functional ban on second-trimester abortions.
   Contrary to the district court’s holding, the record shows that performing a
   D&E that complies with SB8, using either suction or digoxin, is safe,
   effective, and commonplace. 16
                                           1. Suction
           Suction is a relatively simple technique. The woman is dilated enough
   to allow the placement of the “suction catheter” into the woman’s uterus.
   The suction then removes the amniotic fluid and fetus. Relevant to this case,
   the record describes three different ways suction can be used: (1) as a stand-
   alone method to cause fetal death and remove the entire fetus; (2) as a fetal-
   death technique to be followed by forceps for complete removal of the fetus;
   and (3) as a complement to forceps during live-dismemberment abortions to
   ensure that all amniotic fluid and pieces of the fetus have been removed. The

   But Miller involved a truncated preliminary-injunction record that included just one state-
   called witness. Id. Here, the district court held a five-day bench trial with dozens of
   witnesses and hundreds of exhibits. The district court should have relied on the
   voluminous and comprehensive record before it, not other courts’ opinions with materially
   different records.
           16
              We contrast this case with the Eleventh Circuit’s decision in West Alabama
   Women’s Center v. Williamson, 900 F.3d 1310 (11th Cir. 2018), cert. denied sub nom. Harris
   v. W. Ala. Women’s Ctr., 139 S. Ct. 2606 (2019). The most significant difference is that the
   Alabama district court found the fetal-demise law unconstitutional “as applied to the
   plaintiffs” whereas the plaintiffs here argue that SB8 is facially unconstitutional. W. Ala.
   Women’s Ctr. v. Miller, 299 F. Supp. 3d 1244, 1289 (M.D. Ala. 2017). Also, SB8 differs
   from the Alabama statute in meaningful ways, as do the cases’ records. As explained in
   footnote 14 supra, the record evidence in this case is markedly more developed and,
   moreover, flatly contradicts the Alabama record in critical respects. Even so, the smaller
   record in the Alabama case quantified the number of women impacted by the law. Id. at
   1278. And the district court noted that not all doctors in Alabama are trained to perform
   D&Es, so finding any doctors willing to provide abortions in Alabama is difficult. The
   district court there found that requiring doctors to learn not only D&E but also the
   alternative fetal-death techniques would result in a substantial obstacle. Id. at 1284–85. As
   we explain above the line, the plaintiffs here did not even attempt to quantify the number
   of women who would face a substantial obstacle under SB8.

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   first two of these methods are allowed by SB8 because SB8 is violated only
   when a fetus is killed by dismemberment with forceps. See Tex. Health &
   Safety Code § 171.151.
          There was substantial trial testimony about suction. According to the
   record, some doctors use suction as a stand-alone method up to 17 weeks,
   while others begin using alternative methods, like digoxin or live
   dismemberment, at an earlier point. 17 Plaintiffs’ expert, Dr. Amna Dermish,
   the Regional Medical Director for Plaintiff Planned Parenthood of Greater
   Texas, testified that she could “guarantee” compliance with SB8 in the
   “vast majority of cases” through 16 weeks, 6 days using suction alone to
   cause fetal death and complete the procedure. The State’s expert, Dr.
   Chireau, reviewed over 100 studies to offer her opinion that suction alone is
   sufficient to complete abortions through 16 weeks, 6 days. Another plaintiffs’
   expert, Dr. Mark Nichols, a Medical Director for Planned Parenthood,
   testified that he has used suction to cause fetal death and complete an
   abortion through 15 weeks, 6 days. Plaintiff Dr. Robin Wallace, a Family
   Physician for Plaintiff Southwestern Women’s Surgery Center, testified that
   some doctors rely on suction through 16 weeks, 6 days. Dr. Edward Aquino,
   who provides abortions at Plaintiff Alamo’s San Antonio location, testified
   that the increased size of suction cannulas in recent years has allowed doctors
   to more commonly use suction as a stand-alone method.

          17
             Judge Dennis’s dissent quibbles at some length on a perceived distinction
   between “alternative” methods and “additional” procedures. In Gonzales, the Supreme
   Court upheld the Partial-Birth Abortion Ban Act and described the same procedures
   proposed by Texas in this case as “alternatives”—despite the fact that more steps had to
   be taken to complete an abortion under the Act. 550 U.S. at 136, 164, 166–67. Even if
   Texas’s proposed alternatives to live dismemberment could be construed as “additional”
   procedures, that would not render SB8 unconstitutional. See Casey, 505 U.S. at 873
   (“[N]ot every law which makes a right more difficult to exercise is, ipso facto, an
   infringement of that right.”).

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          The district court’s only reference to suction was in a footnote, which
   stated that “before 15 weeks,” doctors do not usually use forceps because
   “the fetus and all other in utero materials will pass through a dilated cervix
   using only suction.” That suction is commonly used “before 15 weeks” says
   nothing about whether it can also be used safely and effectively after 15
   weeks. Indeed, according to the plaintiffs and their own witnesses, this safe
   and common abortion procedure can be used to comply with SB8 up to
   almost 17 weeks.
          In 2015, 1,520 of the 3,150 abortions (48%) performed in Texas during
   weeks 15–22 occurred in weeks 15 and 16. The testimony of the plaintiffs
   themselves, their experts, and their doctors that suction can be used to
   comply with SB8 in many abortions during weeks 15 and 16 casts serious
   doubt on the plaintiffs’ efforts to carry their heavy burden of proving an
   undue burden on a large fraction of women. As we show below, adding the
   second alternative to live dismemberment—digoxin—removes any doubt
   that plaintiffs have failed to carry their burden.
                                      2. Digoxin
          The district court found that using digoxin to cause fetal death is
   unsafe, ineffective, and would delay a woman’s abortion procedure. The
   district court found that digoxin use before 18 weeks would be experimental.
   Many of the district court’s digoxin findings are contradicted by the
   plaintiffs’ own evidence and practices; others are simply unsupported by the
   record.
                 a. Safety and Risk
          Digoxin has long been recognized as a common method of causing
   fetal death during an abortion. Two decades ago, in Stenberg, the Supreme
   Court noted that “[s]ome physicians use . . . digoxin to induce fetal demise
   prior to a late D & E (after 20 weeks), to facilitate evacuation.” Stenberg v.
   Carhart, 530 U.S. 914, 925 (2000) (quoting Carhart v. Stenberg, 11 F. Supp.

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   2d 1099, 1104 (D. Neb. 1998)). 18 Seven years later, in Gonzales, the Supreme
   Court again acknowledged that “[s]ome doctors, especially later in the
   second trimester, may kill the fetus [using digoxin] a day or two before

           18
              As discussed below, three of the plaintiffs in this case require the use of digoxin
   to achieve fetal demise prior to D&Es performed after 18 or 20 weeks. SB8 follows the lead
   of these plaintiffs and requires fetal demise prior to all D&E procedures, whether by digoxin
   or suction. In no way then is SB8 a ban on D&Es; rather it is a regulation of the method of
   performing a D&E.
           Judge Dennis’s dissent nevertheless mischaracterizes SB8 as a ban and contends
   that “the Supreme Court has already decided this exact case, holding that a Nebraska law
   was unconstitutional because it could be interpreted to be the sort of ban that the Texas
   statute openly embodies.” Post at 67 (citing Stenberg, 530 U.S. at 945). Not so. The
   Supreme Court struck down the partial-birth-abortion ban in Stenberg primarily because it
   lacked a necessary health exception for the mother. See Stenberg, 530 U.S. at 930–31. SB8
   has a health exception. The Stenberg Court then noted that, although the law targeted
   “D&X”—dilation and extraction—abortions in which the fetus is pulled into a breech
   position in the vaginal cavity before dismemberment, the law could also be read to cover
   the more common D&E method. Id. at 926–27. And the Court noted as well that, at least
   in 2000, “[t]he D & E procedure carries certain risks. The use of instruments within the
   uterus creates a danger of accidental perforation and damage to neighboring organs. Sharp
   fetal bone fragments create similar dangers. And fetal tissue accidentally left behind can
   cause infection and various other complications.” Id. at 926. Fast forward twenty-one
   years and some, including Judge Dennis’s dissent, consider D&Es “very safe.” Post at 69.
            We see no principled reason to decline to analyze Texas’s SB8 on its own terms,
   cognizant of the current medical realities. Indeed, we glean from Supreme Court precedent
   a duty to test the statute before us given the facts before us—that is what the Supreme
   Court did in Gonzales when it considered (and upheld) the federal Partial-Birth Abortion
   Ban Act in its own right rather than simply invalidating it on loose analogy to the Nebraska
   statute at issue in Stenberg. See Gonzales, 550 U.S. at 140–41, 161–62, 168. Under Judge
   Dennis’s dissent’s approach, any regulation affecting abortion procedures in any way can
   be deemed unconstitutional simply because another regulation has been so deemed—
   despite any differences between the regulations or the facts. But cf. Hellerstedt, 136 S. Ct.
   at 2306 (“A statute valid as to one set of facts may be invalid as to another.” (quoting
   Nashville, C. & St. L. Ry. Co. v. Walters, 294 U.S. 405, 415 (1935))). That itself would fly
   in the face of Roe and its progeny, which recognize that states can impose regulations
   affecting abortion in some circumstances. Roe, 410 U.S. at 164–65; Casey, 505 U.S. at 846.
   Moreover, it would disavow any possibility of progress in medicine and science and instead
   shackle the states’ regulatory power to abortion standards from the last century.

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   performing” the D&E. 550 U.S. at 136. In fact, the Court in Gonzales found
   that “an injection that kills the fetus” allows a doctor to perform the D&E
   without violating the Partial-Birth Abortion Ban Act. Id. at 164. The use of
   digoxin to cause fetal death before a D&E is hardly a novel phenomenon. The
   plaintiffs here know this because they have used and continue to use digoxin.
          In 2007, one month after the Supreme Court described digoxin as a
   “safe alternative” fetal-death method in Gonzales, the nation’s largest
   abortion provider, Planned Parenthood Federation of America, mandated
   that all of its affiliates use digoxin to cause fetal death before most surgical
   abortions at or above 18 weeks. Plaintiff Alamo is so sure that digoxin is safe
   that it requires digoxin’s use to cause fetal death in abortions after 18 weeks.
   Plaintiff Southwestern requires digoxin beginning at 20 weeks. Plaintiff
   Planned Parenthood of Greater Texas required the use of digoxin starting at
   18 weeks. During the district court’s five-day bench trial, every doctor who
   testified had used digoxin to cause fetal death except one, and he works with
   other doctors who have used it.
          Plaintiff Planned Parenthood of Greater Texas’s consent form lists
   some of the “risks and side effects” of digoxin (like extramural delivery and
   pain), then tells patients that “there are no published reports of serious
   problems from using digoxin before abortion.” The form also assures
   patients that “[s]ome clinicians also believe that using digoxin makes it easier
   to do the abortion. Studies have shown that it is safe to use digoxin for this
   purpose.” Despite arguing in this case that digoxin provides no health
   benefits to the woman, Alamo’s consent form also assures patients that “the
   injection [of digoxin] . . . help[s] the woman’s body prepare for the abortion
   process” and that “the abortion process is made easier and safer by injecting
   the fetus” with digoxin. Even with all of this evidence in the plaintiffs’ own

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   documents, the district court found that digoxin presents “significant health
   risks.” 19 This holding contradicted the State’s and the plaintiffs’ evidence.
           The district court also found that the “pain and invasiveness” of
   digoxin was one reason that its use was “a substantial obstacle” to a woman’s
   abortion right. This finding ignored the record evidence that patients
   undergoing D&E are given the option of sedation even when digoxin is not
   administered. And Plaintiff Dr. Wallace admitted that, when she performs
   an abortion involving digoxin, she injects a local numbing anesthetic before
   injecting the digoxin. Plaintiff Planned Parenthood of Greater Texas tells its
   patients that any pain from the digoxin injection will “go away quickly.”
                   b. Efficacy
           When digoxin is used, its success rate is between 90 and 100%.
   Plaintiffs Southwestern and Alamo describe digoxin failures as “unusual.”
   Plaintiff Dr. Wallace testified that digoxin is 98% successful. Plaintiffs’
   expert Dr. Dermish testified that digoxin is 95% successful. Another expert
   testified that several studies have shown either 0% failure rates or 99%
   effectiveness rates.        Plaintiff Southwestern’s “Consent for Digoxin
   Injection” form states in unequivocal terms that digoxin failing to cause fetal
   death “is uncommon and may or may not delay the expected completion time
   of your abortion procedure.” Dr. Chireau testified extensively about myriad
   studies that found digoxin safe and effective. One study found digoxin “safe
   and effective” with a 100% success rate for intra-fetal injections in a study

           19
                The plaintiffs also argue that digoxin presents significant risks and is
   contraindicated for women with certain heart conditions. And the plaintiffs state that for
   obese women or women with fibroids, administering digoxin is “difficult or impossible.”
   Plaintiffs ignore that their own documents state that obese women and women with fibroids
   are considered to have “special conditions requiring special evaluation and management”
   for the D&E itself. In other words, according to the plaintiffs’ arguments, if digoxin is
   unsafe, then D&E itself is unsafe. Indeed, it is unclear whether certain women with these
   conditions are able to receive a D&E abortion at all.

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   with 107 abortions performed in weeks 17–24. Another study showed a 98%
   success rate with digoxin for 1,600 abortions performed in weeks 18–22.
          What is more, the plaintiffs admit that if digoxin does not cause fetal
   death after one attempt, it can be injected again. 20 Plaintiff Alamo’s digoxin
   consent form tells patients: “If fetal death has not been induced [on the first
   attempt], a second injection of Digoxin can be administered at the
   physician’s discretion.” Plaintiff Southwestern tells its patients that digoxin
   failure is “unusual” and that a “second injection may be administered” if
   the first fails. In ruling for the plaintiffs on digoxin’s efficacy, the district
   court ignored the plaintiffs’ own extensive documentation that digoxin is
   highly effective.
                  c. Delay
          The district court’s holding as to the delay digoxin would cause was
   both factually and legally incorrect. The record does not support the district
   court’s factual finding that digoxin’s use would cause a delay for all women
   seeking what “otherwise is a one-day standard D&E procedure.” The
   district court found that a woman “undergoing a digoxin injection would be
   required to make an additional trip to the clinic 24 hours before her
   appointment for the standard D&E procedure.” The district court assumed
   that for women receiving a digoxin injection, that injection would happen a
   day after the State’s mandatory 24-hour waiting period and a day before the
   one-day D&E. This finding is refuted in several ways by the plaintiffs’
   documents.
          First, many D&E abortions are not one-day procedures. The plaintiffs
   admit that starting at 18 weeks, doctors use laminaria to achieve the necessary

          20
              Judge Dennis’s contention that a second digoxin injection is “wholly
   experimental” and “too dangerous to administer” stands at odds with what the plaintiffs
   have been telling their patients for years. Post at 98–99.

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   dilation. “Because laminaria expand gradually, patients usually have them
   inserted and return the next day to complete the procedure.” So, according
   to the plaintiffs, the “standard D&E” is a two-day procedure starting at 18
   weeks. Their documents also say that the D&E can become a two-day
   procedure as early as 16 weeks, 6 days. At trial, one of the plaintiffs’ doctors
   also noted that later in the second trimester, the dilation process can take up
   to two days such that the D&E procedure is not completed until the third
   day. Second, digoxin works within several hours, and it can be administered
   at the same time or close to the beginning of the dilation process. Thus, it is
   not true that using digoxin would add another day to every woman’s one-day
   D&E abortion.
          Even so, the district court also legally erred by concluding that a one-
   day delay is sufficient, by itself, to create an undue burden. The Supreme
   Court has approved regulations embodied in 24-hour waiting periods for all
   women and parental-consent and judicial-bypass laws covering minors that,
   by their nature, may entail many days (and even weeks) before an abortion is
   finally approved. See Casey, 505 U.S. at 885–86 (holding that Pennsylvania’s
   24-hour waiting period, even if it caused “a delay of much more than a day,”
   was not an undue burden); June Medical, 140 S. Ct. at 2136–37 (Roberts, C.J.,
   concurring) (explaining that Casey held that Pennsylvania’s 24-hour waiting
   period and parental-consent and doctor-notification requirements did not
   create substantial obstacles even though they risked delays, increased costs,
   and “had little if any benefit”); see also Tex. Fam. Code Ann. §§ 33.003,
   33.004 (requiring trial and appellate courts to rule on a minor’s application
   for judicial bypass within five business days of the initial request or notice of
   appeal). If these procedures are not constitutionally infirm because of the
   delays involved, then—even assuming that the district court was right on the
   facts of delay—adding a one-day delay to assure a less brutal pregnancy

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   termination and vindicate the State’s interest in human dignity is not an
   undue burden.
                  d. Before 18 Weeks
          As for the beginning of week 15 up through 17 weeks, 6 days, the
   district court held that administering a digoxin injection during that period
   would be “arguably experimental” and weighed that against the State.
   Under Gonzales, this was yet another legal error made by the district court.
          In Gonzales, the Supreme Court confronted a record with conflicting
   testimony about the safety of intact D&E abortions and the alternatives. See
   550 U.S. at 161–62. The question became, then, whether the Partial-Birth
   Abortion Ban Act was constitutional in light of that medical uncertainty. Id.
   at 163. The answer was a resounding yes: “The Court’s precedents instruct
   that the Act can survive this facial attack. . . . [S]tate and federal legislatures
   [have] wide discretion to pass legislation in areas where there is medical and
   scientific uncertainty.”       Id. (emphasis added).          Indeed, “medical
   uncertainty” about whether the Act’s requirements “create[d] significant
   health risks provide[d] a sufficient basis to conclude” that the law there did
   not impose an undue burden. Id. at 164 (emphasis added).
          Gonzales was not the first time that the Court emphasized legislatures’
   right to regulate in areas “fraught with medical and scientific uncertainties.”
   Kansas v. Hendricks, 521 U.S. 346, 360 n.3 (1997) (quoting Johnson v. United
   States, 463 U.S. 354, 370 (1983)). “Legislative options must be especially
   broad” in this context and “courts should be cautious not to rewrite
   legislation.” Id. (emphasis added) (quoting Johnson, 463 U.S. at 370); see also
   Marshall v. United States, 414 U.S. 417, 427 (1974) (“[L]egislative options
   must be especially broad” in areas “fraught with medical and scientific
   uncertainties.”).
          In his June Medical concurrence, the Chief Justice reaffirmed courts’
   obligation to give legislatures broad deference in the context of scientific or

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   medical uncertainty—as taught by both Casey and Gonzales. June Medical,
   140 S. Ct. at 2136 (Roberts, C.J., concurring) (“[W]e have explained that the
   ‘traditional rule’ that ‘state and federal legislatures [have] wide discretion to
   pass legislation in areas where there is medical and scientific uncertainty’ is
   ‘consistent with Casey.’” (quoting Gonzales, 550 U.S. at 163)). Judges are
   simply ill-suited to make such decisions. “Attempting to do so would be like
   ‘judging whether a particular line is longer than a particular rock is heavy.’”
   Id. (quoting Bendix Autolite Corp. v. Midwesco Enters., Inc., 486 U.S. 888, 897
   (1988) (Scalia, J., concurring in the judgment)). Staying in our judicial lane
   accords with our broader duty to recognize and respect the institutional
   competency of legislatures. 21
           Medical uncertainty does not foreclose the exercise of legislative
   power in the abortion context any more than it does in other contexts. Cf.
   Hendricks, 521 U.S. at 360 n.3. The Court specifically addressed this in
   Gonzales:
         A zero tolerance policy would strike down legitimate abortion
         regulations, like the present one, if some part of the medical
         community were disinclined to follow the proscription. This is
         too exacting a standard to impose on the legislative power,
         exercised in this instance under the Commerce Clause, to
         regulate the medical profession. Considerations of marginal
         safety, including the balance of risks, are within the legislative
         competence when the regulation is rational and in pursuit of
         legitimate ends. When standard medical options are available,
         mere convenience does not suffice to displace them; and if
         some procedures have different risks than others, it does not
         follow that the State is altogether barred from imposing
         reasonable regulations. The Act is not invalid on its face where
         there is uncertainty over whether the barred procedure is ever

           21
              Judge Dennis’s dissent chides us for deferring to the legislature. Post at 99–100.
   But that is precisely what the Supreme Court has directed us to do in situations like this.

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           necessary to preserve a woman’s health, given the availability
           of other abortion procedures that are considered to be safe
           alternatives.
   Gonzales, 550 U.S. at 166–67.
           This case is even easier than Gonzales because the plaintiffs here did
   not contradict the State’s evidence about digoxin’s use before 18 weeks,
   much less show that its use presents “significant health risks.” Id. at 164.
   Dr. Chireau testified about a study that noted Planned Parenthood of Los
   Angeles’s mandatory use of digoxin for all second-trimester abortions (weeks
   13–26). 22 Dr. David Berry, a maternal-fetal medicine specialist in Austin,
   testified that he knows of doctors who have administered digoxin before 18
   weeks. The plaintiffs do not refute this evidence; they just blame the State
   (the party without the burden of proof) for not producing more evidence.
           In sum, in making its findings about digoxin, the district court failed
   to apprehend that the plaintiffs’ own extensive use of digoxin, notices and
   consent forms, and written minimization of risks not only conflict with their
   testimony in this case, but also certainly raise serious questions about the
   debatability of the actual risk of using digoxin to cause fetal death. The
   plaintiffs have long used digoxin to ensure that they do not violate the Partial-

           22
              In their en banc brief and at oral argument, the plaintiffs argued that the sentence
   in the study referencing the policy was a “typo.” The disputed sentence says: “Although
   PPLA . . . protocols dictate use of digoxin for all second-trimester abortion. . . .” The study
   was published in 2009 and concluded that intra-fetal or intra-amniotic “injection of digoxin
   is safe and effective for inducing fetal death prior to second-trimester surgical abortion.”
   The abstract is available here: https://www.contraceptionjournal.org/article/S0010-7824
   (09)00409-0/fulltext. Ten years later, while this case was pending before this court, in
   2019, the author of the study, Dr. Deborah Nucatola, sent a letter to the editor and
   explained that the original statement was “not correct” because, she says, Planned
   Parenthood of Los Angeles’s description of its digoxin policy in other years shows that the
   original statement could not have been true: https://www.contraception
   journal.org/article/S0010-7824(19)30386-5/fulltext.

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   Birth Abortion Ban Act. Surely, no reasonable abortion provider would
   subject women to “significant” health risks from digoxin just to avoid their
   own federal liability. See Gonzales, 550 U.S. at 164.
           Because there are safe, medically recognized alternatives to live-
   dismemberment-by-forceps D&E (suction and digoxin), and because women
   seeking a D&E abortion are not significantly affected by a non-forceps fetal-
   death requirement, the district court’s undue-burden analysis is incorrect as
   a matter of law. SB8 falls comfortably within the orbit of Casey/Gonzales as
   a regulation that respects the important state and societal interests involved
   in proscribing a brutal procedure, yet does not pose a substantial obstacle to
   women seeking abortions in the relevant circumstances.
                                              D.
           The district court’s final flaw was its large-fraction analysis. In this
   facial challenge, it is the plaintiffs who bear the “heavy burden” of showing
   that SB8 would be unconstitutional in a “large fraction of relevant cases.”
   Gonzales, 550 U.S. at 167–68. The numerator is the number of women for
   whom the law is an undue burden. And the denominator is the number of
   women in the relevant circumstances—i.e., the women for whom the law “is
   an actual rather than an irrelevant restriction.” Hellerstedt, 136 S. Ct. at 2320.
           Because the district court concluded that SB8 was a complete ban on
                                                                                    1
   the standard D&E, it found that the fraction of burdened women was . The
                                                                                    1
   district court botched both numbers in this fraction.
           First, the district court erred by finding that the denominator included
   only women with fetuses at the gestational age of 15–20 weeks. 23 In fact, the

           23
              The second trimester spans from 13 to 26 weeks gestation. Texas law bans
   abortions after 22 weeks unless the abortion is necessary to protect the woman’s health or
   the fetus has a severe abnormality. Tex. Health & Safety Code §§ 171.044, .046. After 15
   weeks, the D&E procedure is a common abortion method. So SB8 affects only abortions
   between 15 and 22 weeks, which make up about 5% of total abortions in Texas. See Induced

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   correct denominator, as all parties to the case acknowledge, is all women with
   fetuses in the gestational age of 15–22 weeks. The relevant denominator is
   therefore larger by two weeks gestation than the district court stated. The
   extra duration is important because, as discussed above, the plaintiffs already
   use (and even require) digoxin after 18 weeks. 24
           Second, the numerator is not equal to the denominator, which is what
   the district court implicitly found by holding that SB8 constituted a “ban.”
   There are safe and widely used alternatives to live-dismemberment D&E for
   the entire second trimester. Regarding suction, the record shows that
   doctors can sometimes use this method to complete abortions up through 16
   weeks, 6 days. As for digoxin, and as explained by Chief Judge Owen,
   “[t]here is no basis in the record for concluding that the use of digoxin,
   standing alone, constitutes a substantial obstacle . . . at or after 15 weeks
   gestation.” Post at 40. Indeed, digoxin is used ubiquitously, including by the
   plaintiffs themselves, beginning at the first day of the 18th week.
           The plaintiffs bear the heavy burden here. If there are actual cases in
   which neither suction nor digoxin is medically indicated and only live-
   dismemberment D&E by forceps is medically approved, the plaintiffs did not
   describe them. The plaintiffs made no effort to quantify the number of

   Termination of Pregnancy Statistics, Tex. Health & Human Servs., https://hhs.texas.gov/
   about-hhs/records-statistics/data-statistics/itop-statistics (last visited June 21, 2021).
          Texas presented evidence that 92% of countries ban almost all abortions after 12
   weeks gestation. Only three countries’ abortion laws are roughly as permissive as Texas
   (Singapore, the Netherlands, and the United Kingdom), whereas only six countries are
   more permissive than Texas (China, North Korea, Vietnam, Canada, Cuba, and Bahrain).
           24
              Judge Dennis’s dissent contends that “the appropriate denominator is the class
   of women actually affected by SB8, which is composed of only those women who would
   undergo a forceps-assisted D&E in Texas without their doctors’ first inducing fetal demise
   in the absence of SB8.” Post at 103. This is not how the district court characterized the
   denominator, nor is it what the parties agree is the correct denominator: women seeking
   abortions in the gestational age of 15–22 weeks.

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   women who might be subjected to an additional burden if a digoxin injection
   is used and the injection prolongs the entire procedure by an additional day.
   The sum total of the plaintiffs’ efforts in this area is one expert’s testimony
   about the negative effects an “additional trip to an abortion clinic” would
   have on low-income women in Texas.              Even if this were true, some
   (unspecified number of) women does not constitute a large fraction. Plus,
   under Casey, that would not constitute an undue burden, without more,
   anyway. See 505 U.S. at 886 (rejecting the argument that a waiting period
   imposed on women with the “fewest financial resources” would constitute
   an undue burden).
          Similarly, the plaintiffs made no effort to quantify the “unreliability”
   of digoxin beyond stressing a 90–100% success rate for a single injection and
   conceding heightened effectiveness with a second injection. The district
   court acknowledged that digoxin’s failure rate is only “between 5% and 10%.”
   This high efficacy rate made the plaintiffs’ “burden” even heavier to show
   that digoxin’s high success rate is not enough. Some or all of this data should
   have enabled the district court to determine whether in fact a “large
   fraction” of the women seeking second-trimester abortions in Texas would
   suffer a substantial obstacle through the operation of SB8. Instead, the
   district court accepted plaintiffs’ all-or-nothing “ban” argument.
          The district court did not just err by accepting the plaintiffs’ false
   dichotomy; it also turned facial validity on its head and placed the burden of
   proof on the wrong party. The district court concluded that prohibiting only
   one method of D&E (live dismemberment by forceps) is unconstitutional all
   of the time because the other methods that achieve fetal death (like digoxin)
   do not work some of the time. This distorts the State’s burden. The State
   need not prove that every alternative works every time for every woman. As
   Gonzales instructs, a prohibition of a particular method is “permissible”
   when “a woman [can] still obtain an abortion through an acceptable

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   alternative method.” Preterm-Cleveland, 994 F.3d at 534. The plaintiffs’
   own practices show that such alternatives are available and widely used for
   the vast majority of abortions in most of the relevant weeks of gestation.
   Thus, the plaintiffs cannot show that SB8 poses a substantial obstacle in a
   large fraction of cases. See Gonzales, 550 U.S. at 164; Stenberg, 530 U.S. at
   931–36.
          Finally, because the plaintiffs rested only on their argument that SB8
   is a ban on all D&E abortions, they did not develop any evidence related to
   SB8’s specific impact on abortion access.          During oral argument, the
   plaintiffs’ attorney said that there was record evidence that “at least three
   providers would stop providing abortions if SB8 took effect.” En Banc Oral
   Argument at 39:31–39:48. Actually, the record shows that one doctor
   testified that she would alter her practice only to stop providing abortions
   after 17 weeks. This same doctor testified that another doctor at her clinic
   told her that he would also stop providing abortions after 17 weeks; this
   testimony was struck as hearsay. One other abortion doctor, who has been
   practicing for over 40 years, said that he would retire.
          Contrast this to Hellerstedt where these same plaintiffs argued to the
   Supreme Court that 50% of Texas’s abortion clinics (20 out of 40 clinics)
   would close if the challenged law had taken effect. 136 S. Ct. at 2301. That
   argument was crucial to the Supreme Court’s determination that the
   admitting-privileges law was facially invalid. See id. at 2312. No reading of
   this record supports anything remotely similar here. Indeed, at en banc oral
   argument, the plaintiffs conceded that they were not arguing that clinics
   would close because of SB8.
                                         IV.
          SB8 was signed into law four years ago—four years in which federal
   courts have halted Texas’s duly enacted and modest legislation from taking
   effect. The parties produced mountains of evidence and presented that

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   evidence to the district court during a week-long trial. The district court
   abused its discretion by applying the wrong legal test to assess SB8,
   dismissing and ignoring the State’s important and substantial interests,
   placing the burden of proof on the wrong party, explicitly and erroneously
   stating that the abortion right is “absolute” and evaluating SB8 under that
   view, erroneously defining “substantial obstacle,” incorrectly determining
   that SB8 constitutes a “ban” on D&E abortions, ignoring vast swaths of
   testimony about suction, making findings about digoxin that contradict the
   plaintiffs’ own digoxin use and practices, weighing medical uncertainty
   against the State, and incorrectly determining both the numerator and
   denominator in the large-fraction analysis.
            As it was in Gonzales, remanding to the district court would be futile
   here because the voluminous record permits only one conclusion. 25 The
   safety, efficacy, and availability of suction to achieve fetal death during
   abortions in weeks 15 and 16 combined with the safety, efficacy, and
   availability of digoxin to do the same in weeks 18–22 mean that the plaintiffs
   have utterly failed to carry their heavy burden of showing that SB8 imposes
   an undue burden on a large fraction of women in the relevant circumstances.
                                          *        *         *
           The district court’s permanent injunction is VACATED.                                 We
   REVERSE the judgment of the district court and RENDER judgment in
   the State’s favor. SB8 is constitutional.

            25
               Our effort to apply Supreme Court precedent to SB8 very well may be called
   “Sisyphean,” but that does not dissuade us from the task. See post at 67. Nor should it, as
   we intermediate court judges must always roll the stones of Supreme Court precedent up
   the hills before us. As it is with Sisyphus, so it is with us: “The struggle itself . . . is enough
   to fill a man’s heart. One must imagine Sisyphus happy.” Albert Camus, The Myth of
   Sisyphus 123 (Justin O’Brien, trans. 1955).

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   Priscilla R. Owen, Chief Judge, concurring in the judgment:
          I concur in reversing the district court’s judgment, which held
   Texas’s prohibition of dismemberment abortions 1 facially unconstitutional
   and permanently enjoined its enforcement. 2 Reversal is required because
   prohibiting dismemberment of a living fetus with the purpose of causing the
   death of an unborn child by a means described in Texas Health and Safety
   Code § 171.151 3 does not “operate as a substantial obstacle to a woman’s
   choice to undergo an abortion” “in a large fraction of the cases in which [it]
   is relevant.” 4 All agree that the relevant focus is on abortions occurring from
   15 to 22 weeks of gestation.
          In order to avoid the risk of violating Texas law and incurring criminal
   penalties, abortion providers can cause fetal demise before proceeding to use
   forceps or the other devices described in § 171.151 to perform an abortion.
   The record developed in this case clearly reflects that fetal demise prior to

          1
              See Tex. Health and Safety Code Ann. §§ 171.151-154 (West 2017).
          2
              ROA.1615-17.
          3
              See Tex. Health & Safety Code Ann. § 171.151 (West 2017):
                     In this subchapter, “dismemberment abortion” means an
                     abortion in which a person, with the purpose of causing the death
                     of an unborn child, dismembers the living unborn child and
                     extracts the unborn child one piece at a time from the uterus
                     through the use of clamps, grasping forceps, tongs, scissors, or a
                     similar instrument that, through the convergence of two rigid
                     levers, slices, crushes, or grasps, or performs any combination of
                     those actions on, a piece of the unborn child’s body to cut or rip
                     the piece from the body. The term does not include an abortion
                     that uses suction to dismember the body of an unborn child by
                     sucking pieces of the unborn child into a collection container. The
                     term includes a dismemberment abortion that is used to cause the
                     death of an unborn child and in which suction is subsequently used
                     to extract pieces of the unborn child after the unborn child’s death.
          4
              Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 895 (1992).

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   extraction with forceps or similar devices can be accomplished with little or
   no risk to the mother’s health by using digoxin.
           The remaining question is whether prohibiting dismemberment
   abortion creates a delay that amounts to a substantial obstacle to obtaining an
   abortion. The record reflects that ensuring fetal demise after 17 weeks and
   six days of gestation can be accomplished without any delay at all in the
   abortion process. In abortions performed at 15 weeks to 17 weeks and six
   days, there may be an additional delay for some women of approximately 24
   hours beyond Texas’s statutory 24-hour waiting period. This additional 24-
   hour delay does not constitute a substantial obstacle and does not render the
   Texas statutes at issue unconstitutional. 5
           Even were an additional 24-hour delay a substantial obstacle, there
   would not be such a delay for a large fraction of women seeking an abortion
   at 15 to 22 weeks of gestation.
                                                 I
           As a preliminary matter, it is unnecessary to decide whether Chief
   Justice Roberts’s concurring opinion in June Medical Services L.L.C. v.
   Russo 6 governs and therefore supersedes the balancing test set forth in Whole
   Woman’s Health v. Hellerstedt,7 as Judge Elrod and Judge Willett’s

           5
             See ante at 29-30 (first citing Casey, 505 U.S. at 885-86, and then citing June Med.
   Servs. L.L.C. v. Russo, 140 S. Ct. 2103, 2136-37 (Roberts, C.J., concurring)).
           6
             See 140 S. Ct. at 2135-39 (Roberts, C.J., concurring) (rejecting a balancing
   test and concluding that, so long as the state has a “legitimate purpose” and the statute is
   “reasonably related to that goal,” “the only question for a court is whether a law has the
   ‘effect of placing a substantial obstacle in the path of a woman seeking an abortion of a
   nonviable fetus’” (quotation at 2138) (quoting Casey, 505 U.S. at 877, 878, 882)).
           7
            See 136 S. Ct. 2292, 2309 (2016) (“The rule announced in Casey . . . requires that
   courts consider the burdens a law imposes on abortion access together with the benefits
   those laws confer.”).

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   plurality opinion posits that it does. 8 Under either view of the governing
   parameters, the Texas laws are constitutional because they do not place a
   substantial obstacle in the path of a woman seeking to abort a nonviable fetus.
                                               II
           As discussed in Judge Elrod and Judge Willett’s opinion, the
   record reflects that digoxin is a means of causing fetal demise that has been
   widely and successfully used by many of the abortion providers who are
   parties to this litigation. The use of digoxin rarely causes injury to or
   complications for the mother. There is no basis in the record for concluding
   that the use of digoxin, standing alone, constitutes a substantial obstacle to
   obtaining an abortion at or after 15 weeks of gestation. As the plurality
   opinion explains, the record is clear regarding digoxin’s safety and efficacy. 9
   The remaining potential obstacle digoxin poses to women seeking an abortion
   is delay.
           The district court concluded that administering digoxin would create
   an additional 24-hour delay for “all women” seeking an abortion past 15
   weeks. 10 This conclusion was clearly erroneous. Based on the record
   evidence, administering digoxin would create approximately an additional
   24-hour delay (beyond Texas’s 24-hour waiting period) for some, but not all,
   or even most, abortions occurring from 15 weeks to 17 weeks and six days. It
   would create no additional delay for abortions performed after 17 weeks and
   six days.

           8
            See ante at 9-13 (discussing the two standards of review and concluding that, under
   Marks v. United States, 430 U.S. 188, 193 (1977), Chief Justice Roberts’s
   formulation controls).
           9
               See ante at 24-28.
           10
                ROA.1610.

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           In Texas, a physician cannot begin an abortion, including the dilation
   process, until the 24-hour waiting period has concluded. 11 Patients must first
   attend an initial office visit, during which the physician performs an
   ultrasound and provides state-mandated information. 12 The patients may
   then return 24 hours later for the actual abortion procedure, beginning with
   dilation. 13
           The duration of dilation varies depending on the method used, which
   in turn depends on the fetus’s “gestational age.” 14 For pregnancies from 15
   weeks to 17 weeks and six days of gestation, dilation is often achieved with
   medication. 15 The physician administers the medication, which is effective
   within several hours. 16 Once the medication takes effect, the physician may
   begin the evacuation portion of the abortion procedure. 17
           Importantly, however, dilation and evacuation are not always
   performed on the same day in abortions occurring between 15 weeks and 17
   weeks and six days.             A potential delay arises for logistical reasons: a
   physician’s ability to perform the evacuation on the same day as the dilation
   depends on the timing of the patient’s initial appointment, which sets the 24-
   hour waiting period. 18 As one of the physicians who is also a plaintiff in this
   case explained, if the patient’s initial visit occurs early enough in the

           11
                See ROA.2012-15, 2111-12.
           12
                See ROA.2012-13, 2111.
           13
                See ROA.2014-15, 2111-12.
           14
                ROA.2111.
           15
                See ROA.1918, 2014-15, 2111-12.
           16
                See ROA.1923, 1924, 2014-15.
           17
                See ROA.1924, 2111-12.
           18
                See ROA.2111-13.

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   morning, the patient is able to return and receive dilation medication the
   following morning, and several hours later, the physician may perform the
   evacuation. 19 But if the initial appointment—and the patient’s subsequent
   return—occur “beyond a certain time of day, usually 10:00 or 11:00 in the
   morning,” the physician may not be able to “assure enough time for adequate
   dilation with the remainder of the clinic day.” 20 In such cases, the physician
   “place[s] . . . dilators and allow[s] them to work overnight and ask[s] the
   patient to return on a third day to have her D&E procedure completed.” 21
   This plaintiff estimated that “[a]bout half” of patients between 15 weeks’
   and 17 weeks and six days’ gestation were able to undergo dilation and
   evacuation on the same day, while the other half had to undergo dilation and
   evacuation over a two-day period. 22
          For pregnancies at and beyond 18 weeks, dilation is achieved using
   osmotic dilators, or laminaria. 23 The physician places the laminaria inside
   the patient’s cervix on one day, and the patient generally returns the
   following day for the evacuation. 24 In some cases, however, a second set of
   laminaria is required, such that the first set of laminaria is placed one day, the
   patient returns the following day for removal of the first set and placement of
   a second set, then the patient returns once more on the third day for removal

          19
               See ROA.2111-12.
          20
               ROA.2112, 2113.
          21
               ROA.2113.
          22
               ROA.2113.
          23
               See ROA.1918, 1923.
          24
               See ROA.1923, 2015.

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   of the second set of laminaria and the actual evacuation procedure. 25 The
   record does not clearly indicate how often two sets of laminaria are needed.
          The evidence reflects that even without the use of digoxin to ensure
   fetal demise, many second-trimester dilation and evacuation abortions are
   multi-day procedures. Including the waiting period, roughly one-half of
   abortions performed between 15 weeks and 17 weeks and six days take two
   days, while the remaining half take three days. Most abortions performed
   during and after week 18 take three days, but some may take up to four.
          The use of digoxin to ensure fetal demise would have no effect on
   approximately two-thirds or more of abortions occurring from 15 to 22 weeks
   of gestation. In theory, digoxin becomes effective over a period of 30 minutes
   to 24 hours, depending on its method of administration—intra-cardiac, intra-
   fetal, or intra-amniotic. 26 In practice, however, the record reflects that
   physicians choose to administer it and wait 24 hours to ensure fetal death
   before performing the evacuation. 27 Digoxin can be administered on the day
   that dilation begins. 28 Accordingly, for abortions in which physicians would
   otherwise be able to perform dilation and evacuation on the same day—
   roughly one-half of abortions performed between 15 weeks and 17 weeks and
   six days—digoxin might add an additional day to the procedure. But for the
   other half of abortions performed between 15 weeks and 17 weeks and six
   days, and all abortions performed past 17 weeks and six days, using digoxin
   to cause fetal demise would not result in any delay in the abortion process.

          25
               See ROA.1923-24.
          26
               See ROA.4433, 4582-83, 4653; see also ROA.2101-04, 2659.
          27
               See ROA.1937, 1941, 2029, 2041, 2101-04, 2113, 2150.
          28
               See ROA.2091, 4312.

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          The record in the present case contains data about abortions in Texas
   from 2011 to 2015. The number of late-term abortions (15 weeks to 22 weeks)
   pales in comparison to the number of abortions performed up to 15 weeks of
   gestation: 29

                                    Abortions at Less than Abortions at 15 Weeks
                                    15 Weeks               to 22 Weeks
                2011                       69,913                       2,287
                2012                       65,642                       2,434
                2013                       60,915                       2,147
                2014                       50,979                       3,135
                2015                       50,746                       3,175
          If, as the record evidence reflects, about one-half of abortions
   performed between 15 weeks and 17 weeks and 6 days of gestation will not be
   delayed at all by using digoxin to cause fetal demise prior to proceeding with
   evacuation, the data also reflects that only about one-third of all abortions
   performed from 15 weeks up to the 22nd week of gestation would be delayed
   by approximately an additional 24 hours (that is, delayed another 24 hours
   beyond the initial waiting period): 30

                       Abortions at     One-Half of      Abortions
                       15 weeks to      Abortions at     from      15
                       17 weeks and     15 weeks to      weeks to 22            %
                       6 days           17 weeks and     weeks
                                        6 days
        2011               1503              752             2287           32.88%
        2012               1639             820              2434           33.69%
        2013               1425              713             2147           33.21%
        2014               2315             1158             3135           36.94%

          29
               See ROA.4242-4259.
          30
               See ROA.4242-4259.

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         2015                 2088                1044                3175           32.88%
           But even were a delay to occur in all abortions from 15 to 22 weeks, as
   already noted above, a 24-hour delay, in addition to a 24-hour waiting period,
   does not constitute a substantial obstacle. 31 Requiring someone seeking to
   abort a fetus at or beyond 15 weeks of gestation to wait 24 hours to reflect
   upon the decision, 32 and to wait an additional 24 hours to ensure the demise
   of the fetus in utero before proceeding with an abortion that may or will
   involve the use of forceps or similar devices to dismember the fetus does not
   present a substantial obstacle to a woman seeking an abortion.
           Judicial bypass proceedings for minors that can delay an abortion well
   beyond 48 hours have been upheld by the Supreme Court. The Court’s
   opinion in Ohio v. Akron Center for Reproductive Health 33 is instructive. The
   Court explained that “the Bellotti principal opinion indicated that courts
   must conduct a bypass procedure with expedition to allow the minor an
   effective opportunity to obtain the abortion.” 34                       The judicial bypass
   procedure under consideration in Akron Center required the trial court to
   render its decision no more than five business days after the minor filed a
   complaint, required the state court of appeals to docket an appeal no more
   than four days after the minor filed a notice of appeal, and required the court

           31
            See ante at 29-30 (framing the issue in terms of an “undue burden” rather than a
   “substantial obstacle”).
           32
              See Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 885 (1992) (upholding a
   “24–hour waiting period between the provision of the information deemed necessary to
   informed consent and the performance of an abortion,” reasoning in part that “[t]he idea
   that important decisions will be more informed and deliberate if they follow some period of
   reflection does not strike us as unreasonable, particularly where the statute directs that
   important information become part of the background of the decision.”).
           33
                497 U.S. 502 (1990).
           34
                Id. at 513 (citing Bellotti v. Baird, 443 U.S. 622, 644 (1979)).

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   of appeals to render its decision no more than five days after docketing the
   appeal. 35 The Supreme Court held that these bypass procedures withstood a
   facial challenge. 36 It did so even though the Sixth Circuit had construed
   “days” to mean business days and had calculated that the statute permitted
   a delay of up to 22 days, and even though the record included an affidavit
   averring that “a 3–week delay could increase by a substantial measure both
   the costs and the medical risks of an abortion.” 37 Though the Supreme Court
   questioned the soundness of construing “day” to mean “business day,” it
   proceeded to hold that “the mere possibility that the procedure may require
   up to 22 days in a rare case is plainly insufficient to invalidate the statute on
   its face.” 38 The Supreme Court pointed out that in Planned Parenthood of
   Kansas City, Missouri, Inc. v. Ashcroft, 39 “for example, [it had] upheld a
   Missouri statute that contained a bypass procedure that could require 17
   calendar days plus a sufficient time for deliberation and decisionmaking at
   both the trial and appellate levels.” 40
           In Ashcroft, the Eighth Circuit had rejected Planned Parenthood’s
   argument that “the statute does not assure that the procedure will be . . .
   expeditious.” 41           The Eighth Circuit concluded that Missouri’s bypass
   “statute sets forth reasonable time requirements for court action on the
   petition” and explained that “[a]lthough the statute does no more than direct

           35
                See id.
           36
                See id. at 514.
           37
                Id. at 513.
           38
                Id. at 514.
           39
                462 U.S. 476 (1983).
           40
                Akron Ctr., 497 U.S. at 514 (citing Ashcroft, 462 U.S. at 477 n.4, 491 n.16).
           41
              Planned Parenthood Ass’n of Kansas City, Mo., Inc. v. Ashcroft, 655 F.2d 848, 860
   (8th Cir. 1981), aff’d in part & rev’d in part, 462 U.S. 476 (1983).

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   the Missouri Supreme Court to promulgate rules for expedited appellate
   review, we are confident the Missouri Supreme Court will exercise its
   jurisdiction in a manner that recognizes the serious dangers caused by
   delay.” 42 The Supreme Court affirmed the Eighth Circuit’s judgment
   “insofar as it . . . upheld the State's parental and judicial consent
   provision.” 43
           An additional delay of 24 hours caused by the use of a medical
   procedure to ensure that a living fetus in not dismembered or disemboweled
   in utero does not constitute a substantial obstacle for women seeking an
   abortion. At least some of the Supreme Court’s rationale in upholding a
   State’s imposition of a 24-hour waiting period before proceeding with an
   abortion provides support for this conclusion. In Casey, the Supreme Court
   reasoned that the statute at issue “permit[ted] avoidance of the waiting
   period in the event of a medical emergency and the record evidence show[ed]
   that in the vast majority of cases, a 24–hour delay does not create any
   appreciable health risk.” 44 Texas’s prohibition of dismemberment abortions
   does not apply in cases of medical emergency. 45 There is no indication in the
   record that when an additional day to perform an abortion would be necessary
   to induce fetal demise, such a delay would create an appreciable risk to the
   woman seeking an abortion. The Supreme Court reasoned in Casey that,
   “[i]n theory, at least, the waiting period is a reasonable measure to implement
   the State's interest in protecting the life of the unborn, a measure that does

           42
                Id.
           43
            Ashcroft, 462 U.S. at 494 (holding that bypass provisions in the version of MO.
   REV. STAT. § 188.028 (2019) in effect in 1981, see Act of June 29, 1979, No. 523, § 188.028,
   1979 Mo. Laws 375, 376-78, were constitutional).
           44
                Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 885 (1992).
           45
                See Tex. Health & Safety Code Ann. § 171.152(a) (West 2017).

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   not amount to an undue burden.” 46 Prohibiting dismemberment of a living
   fetus by the use of forceps or similar devices in the manner described in Texas
   Health and Safety Code § 171.151 (including removing the living “unborn
   child” from the uterus “one piece at a time” and “cut[ting]” or “rip[ping]”
   “piece[s]” from the living unborn child’s body with forceps or other similar
   devices) 47 is a reasonable measure to protect the unborn and does not amount
   to an undue burden.
          The Texas laws at issue in the present appeal should not have been
   struck down by the district court.
                                               III
          Though I conclude that any delay caused by the Texas laws at issue is
   not a substantial obstacle in the path of a woman seeking to abort a nonviable
   fetus because of the brevity of any additional delay beyond the waiting period,
   even assuming that a 24-hour delay were a substantial obstacle, the
   prohibition of dismemberment abortions would not “be unconstitutional in a
   large fraction of relevant cases.” 48 The record reflects that there would be
   an additional delay of 24 hours for something less than approximately one-
   third, at most, of those obtaining an abortion from 15 to 22 weeks of gestation.
   That is because not all physicians would use digoxin from 15 weeks to 16
   weeks and 6 days of gestation to cause fetal demise. They would use suction
   to cause the death of the fetus.
          Physicians and experts disagreed as to when digoxin would be used
   during 15 weeks to 17 weeks six days of gestation, which is the only time frame

          46
               Casey, 505 U.S. at 885.
          47
               Tex. Health and Safety Code Ann. § 171.151 (West 2017).
          48
               Gonzales v. Carhart, 550 U.S. 124, 167-168 (2007).

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   during which digoxin might cause a 24-hour delay, since the record reflects
   that all abortions performed at and beyond 18 weeks take longer than 48
   hours. The fraction of women for whom the use of digoxin might cause an
   additional 24-hour delay is therefore less than all abortions from 15 to 22
   weeks. The number does not exceed or even reach 37% of all abortions from
   15 to 22 weeks based on the record, and there is considerable evidentiary
   support for the conclusion that the fraction is much smaller, ranging from
   4.63% to 9.57% in a given year. Some of Plaintiffs’ own experts testified that
   digoxin would not be used until 17 weeks of gestation because suction or
   vacuum abortions would cause fetal demise up through 16 weeks and six days
   of gestation. That testimony supports the much smaller fractions ranging
   from 4.63% to 9.57 % and certainly a fraction of less than 36.9%.
           In determining the “fraction of relevant cases,” the denominator
   consists of the cases in which the statute is “relevant,” 49 encompassing
   “those [women] for whom [the provision] is an actual rather than an
   irrelevant restriction.” 50 The Supreme Court explained in Gonzales v.
   Carhart that “relevant cases” means “all instances in which the doctor
   proposes to use the prohibited procedure.” 51 The denominator in the
   present case is comprised of women who seek an abortion from 15 to 22 weeks
   of gestation, the period in which the record reflects that physicians might
   perform a dismemberment abortion.
           As noted, there is conflicting evidence as to the numerator, again,
   assuming for the sake of argument that a delay of 24 hours is a substantial

           49
                Id. at 168; see Casey, 505 U.S. at 895.
           50
              Whole Woman’s Health v. Hellerstedt, 136 S. Ct. 2292, 2320 (2016) (alterations in
   original) (quoting Casey, 505 U.S. at 895).
           51
                Gonzales, 550 U.S. at 168.

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   obstacle. The number of women who might experience a delay depends on
   the number of women whose abortion procedure would be extended 24 hours
   due to the injection of digoxin. One of the plaintiffs’ witnesses testified that
   “in the vast majority of cases . . . in a situation of normal anatomy, I would be
   able to absolutely complete [a suction abortion causing fetal demise] through
   16.6 [sixteen weeks and six days of gestation].” 52 This witness stated that
   “there may be a few select cases” 53 in which the “uterine anatomy might
   make the use of a suction cannula difficult or impossible,” 54 but even if SB8
   went into effect, this physician would continue to perform suction abortions
   through 16 weeks and six days of gestation. 55 She would not use digoxin
   during abortions at 15 weeks to 16 weeks and 6 days. 56 So, if the numerator
   were based on this witness’s testimony, potential delay due to the use of
   digoxin might only occur at week 17 through week 17 and 6 days. Up to the
   17th week, digoxin would not be used to cause fetal demise; only suction
   would be used, so there would be no additional delay from 15 weeks to 16
   weeks and 6 days of gestation. A witness for the State similarly testified that
   suction could be used to cause fetal demise through 16 weeks and 6 days of
   gestation, and digoxin would not be necessary. 57 If we considered only the
   testimony of these witnesses, the percentage of abortions delayed due to use
   of digoxin would range from 4.63% to 9.57% from 2011 to 2015: 58

          52
               ROA.2227-2228.
          53
               ROA.2227.
          54
               ROA.2223.
          55
               ROA.2221.
          56
               ROA.2221.
          57
               See ROA.2587-2590 (Chireau, a witness for the State).
          58
               See ROA.4242-59.

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                        Abortions   One-Half of Abortions
                        during Week Abortions   from      15
                        17          During      weeks to 22
                                    Week 17     weeks                                  %
         2011                 211               106              2287              4.63%
         2012                 249               125              2434              5.14%
         2013                 217               109              2147              5.08%
         2014                 599               300              3135              9.57%
         2015                 568               284               3175             8.94%
           But there is testimony from other witnesses indicating that suction
   alone does not or cannot always cause fetal demise and therefore, some other
   means of ensuring the death of the fetus prior to use of forceps or a similar
   device would be employed. Some physicians would use digoxin instead of
   suction alone at varying stages of gestation from 15 weeks up to the end of the
   16th week. 59 There was testimony that, from 15 weeks up to 18 weeks, some
   abortion providers have forceps at hand in case suction aspiration cannot
   fully evacuate the fetus. 60 Some providers said they were unwilling to risk
   violating Texas law if they began, but were unable to complete, an abortion

           59
              See, e.g., ROA.1921 (one physician stating that he generally stops completing
   abortions without the use of forceps, i.e., with suction alone, at 15 weeks); ROA.1972 (the
   same physician explaining that he does not use suction alone during week 16, although he
   sometimes uses suction alone during week 15); ROA.2012 (another physician stating that
   he “commonly prepare[s] for the use of forceps [and not suction alone] around 15 ½
   weeks”); ROA.2176-77 (another physician stating that she “switch[es]” from suction to
   forceps at 15 weeks (quotation at 2177)); ROA.2205 (another physician explaining that she
   began keeping forceps on hand at 15 weeks, and that she could not generally know before
   beginning a procedure whether she would need to use forceps); ROA.2223-24, 2226-28
   (that same physician explaining that there were some cases before 16.6 weeks in which she
   would not be able to use suction to comply with the statute); ROA.2689 (another physician
   stating that he could not offer the opinion that the use of suction would be possible in every
   case up to 16 weeks); ROA.2807 (another physician describing the ability to use suction
   alone at 15 to 16 weeks as “unpredictable”).
           60
                See, e.g., ROA.2012, 2205.

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   using suction, then switched to forceps to complete the procedure without
   having first caused fetal demise. 61 (The record reflects that virtually all
   physicians cause fetal demise before performing an abortion at and after 18
   weeks of gestation in order to avoid the risk of violating the federal ban on
   partial-birth abortion. However, as discussed above, using digoxin causes no
   additional delay when aborting a fetus at 18 to 22 weeks of gestation because
   the abortion process in all of those cases already extends more than 24 hours
   beyond Texas’s initial statutory 24-hour waiting period.)
          Different physicians employ differing practices. The Plaintiffs did not
   quantify how many women across Texas would experience a delay of an
   additional 24 hours due to causing fetal demise by the use of digoxin. It was
   their burden to do so in this facial challenge.
                                          IV
          To the extent that consideration of the benefits of Texas’s prohibition
   on fetal demise by dismemberment is a relevant inquiry, the record is silent
   as to how a means of bringing about fetal demise prior to dismemberment,
   such as digoxin, actually affects the fetus. Other than reflecting that digoxin
   causes fetal death in a large percentage of cases in which it is administered
   within 24 hours before an abortion, there is no evidence as to how digoxin
   brings about fetal death. There is no evidence as to potential pain or suffering
   while the fetus succumbs after introduction of digoxin into the womb, and if
   there is such a potential, the nature and duration of any pain or suffering.
          The State has expressed its interest in prohibiting the dismemberment
   of a living fetus. This is congruent with the widely accepted principle that
   dismemberment of living mammals should be prohibited. For example,

          61
               See ROA.2223-28.

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   unwanted dogs, cats, puppies and kittens in shelters must be humanely
   euthanized under Texas law. 62 The plaintiffs have not demonstrated that
   causing fetal demise by the use of digoxin is morally or even factually
   equivalent to fetal demise by dismemberment.                      Both procedures are
   abhorrent. But it cannot be said on this record that Texas has no legitimate
   interest in requiring fetal demise by a means other than dismemberment
   during an abortion.
                                        *        *         *
           I concur in reversing the district court’s judgment and rendering
   judgment that the facial challenges asserted in this case to the
   constitutionality of Texas’s prohibition of dismemberment abortion fail.

           62
               See 25 Tex. Admin. Code § 169.84(a), (c) (2013) (for dogs and cats in the
   custody of an animal shelter, requiring the animal be euthanized only by sodium
   pentobarbital, and for any animal other than a dog or cat in the custody of an animal shelter,
   requiring the animal “be humanely euthanized only in accordance with the methods,
   recommendations, and procedures of the American Veterinary Medical Association” in
   their latest guidelines for the euthanasia of animals “applicable to that species of animal”);
   Tex. Health & Safety Code Ann. § 821.052 (West 2015) (same).

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   James C. Ho, Circuit Judge, concurring:
          The plurality opinion chronicles the numerous errors committed by
   the district court. I write separately to focus on one particular error.
          Constitutional challenges to abortion laws are governed, not by the
   text or original meaning of the Constitution, but by decisions of the Supreme
   Court. “[W]hat distinguishes abortion from other matters of health care
   policy in America—and uniquely removes abortion policy from the
   democratic process established by our Founders—is Supreme Court
   precedent.” Jackson Women’s Health Org. v. Dobbs, 945 F.3d 265, 277 & n.1
   (5th Cir. 2019) (Ho, J., concurring in the judgment), cert. granted, _ S. Ct. _.
   Compare, e.g., Jacobson v. Massachusetts, 197 U.S. 11, 26 (1905) (rejecting
   substantive due process claim that “a compulsory vaccination law is . . .
   hostile to the inherent right of every freeman to care for his own body” and
   “nothing short of an assault upon his person”).
          So we focus on Supreme Court precedent. That precedent recognizes
   that scientists and medical experts disagree over a number of issues affecting
   abortion policy in states across the country. And when experts disagree,
   legislators decide—and judges defer. See, e.g., Gonzales v. Carhart, 550 U.S.
   124, 163 (2007) (“The Court has given state and federal legislatures wide
   discretion to pass legislation in areas where there is medical and scientific
   uncertainty.”) (collecting cases); id. at 164 (“Medical uncertainty does not
   foreclose the exercise of legislative power in the abortion context any more
   than it does in other contexts.”); see also June Medical Servs. v. Russo, 140 S.
   Ct. 2103, 2136 (2020) (Roberts, C.J., concurring in the judgment) (same).
          This is not only the “‘traditional rule,’” but the only sensible one.
   June Medical, 140 S. Ct. at 2136 (Roberts, C.J., concurring in the judgment)
   (quoting Gonzales, 550 U.S. at 163). As the Chief Justice has observed, courts

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   should focus on the “sort of inquiry familiar to judges”—namely, the
   resolution of legal disputes—and not the heady medical and scientific
   controversies for which judges lack the proper qualifications to decide. Id.
          The district court here repeatedly violated these principles and failed
   to defer, as the plurality details. See ante, at 15–16 & n.13. So did the 2–1
   panel majority, which chastised state officials for relying on experts that the
   panel deemed “less mainstream” on such hotly debated matters as the
   gestational age at which an unborn child begins to feel pain. Whole Woman’s
   Health v. Paxton, 978 F.3d 896, 910 (5th Cir. 2020), vacated and reh’g en banc
   granted, 978 F.3d 974 (5th Cir. 2020). And three of our dissenting colleagues
   today make the same move. They acknowledge that scientists disagree on
   these issues. Yet they insist that legislatures must take one particular side of
   that debate over the other. Post, at 100 n.8 (Dennis, J., dissenting).
          “Follow the science,” it’s often said. And rightly so. But what do we
   do when scientists disagree? The Supreme Court’s abortion precedents are
   unequivocal: Judges have no business deciding which scientists are right and
   which ones are wrong.
          Moreover, this principle is especially vital because, as it turns out,
   scientists don’t always follow the science themselves. I write separately to
   explore this concern.
                                          I.
          We take for granted today the overwhelming medical and scientific
   consensus that germs cause disease, and that handwashing is therefore
   essential to basic human hygiene.
          But it was not always so.        To the contrary, germ theory and
   handwashing were once the subject of severe scorn and ridicule among
   “mainstream” scientists. In fact, it took the outspoken efforts of a few

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   dissenters within the medical community who were willing to withstand
   years of ridicule and peer pressure in order to challenge—and eventually,
   change—the reigning consensus.
                                        A.
          Ignác Semmelweis was a Hungarian physician who practiced
   obstetrics in the maternity clinic of the Vienna General Hospital during the
   late 1840s. At the time, a disease known as “childbed fever” was killing many
   of the women who gave birth there. Sherwin B. Nuland, The
   Doctors’ Plague: Germs, Childbed Fever, and the
   Strange Story of Ignác Semmelweis 79–85 (2004).
          The maternity clinic had two wards: one attended only by midwives,
   and the other attended only by physicians. And significantly, the physicians
   not only delivered babies—they also performed autopsies on women who
   succumbed to childbed fever. Id. at 97.
          Semmelweis observed that women who gave birth in the ward
   attended by midwives died at significantly lower rates than women who gave
   birth in the ward attended by physicians. Id. He hypothesized that the
   physicians who were also examining the bodies of women dying of childbed
   fever were transmitting contaminated particles from the infected patients to
   healthy women during childbirth.      Id. at 100–01.      At the time, those
   physicians saw no reason to wash their hands between conducting autopsies
   and treating healthy women in the delivery ward. So they didn’t. Id. at 100.
         To test his hypothesis, Semmelweis advised physicians to wash their
   hands in chlorine solution after performing autopsies and before treating
   healthy women. Id. at 101. As a result, “something remarkable [began] to
   happen.” Id. Childbed fever deaths in the physicians’ ward plummeted.
   The death rate fell to “virtually equal” in the two wards. Id. Semmelweis

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   proved that the hospital could virtually eliminate the spread of infection
   simply by insisting that physicians wash their hands. Id. at 104–05.
             Semmelweis’s discovery saved lives. But instead of being praised or
   even accepted, he was ridiculed as an “agitator” and marginalized within the
   scientific community for his “unorthodox and highly irregular ways of doing
   things.” Id. at 147, 157. More senior colleagues expressed “alarm [at] the
   increasing influence of younger physicians” like Semmelweis. Id. at 120.
             So, to use modern parlance, they cancelled him. Semmelweis was
   denied another term as an instructor at the medical school because of “the
   way he kept demanding that students and staff wash in the chloride
   solution.” Id. at 125. And even when he was later accepted for another
   teaching position, he was restricted in what courses he could teach and what
   materials he could access. Id. at 128. A European medical publication
   advised readers: “We thought that this theory of chlorine disinfection had
   died out long ago . . . . [O]ur readers should not allow themselves to be misled
   by this theory.” Id. at 144–45.
             Why did the scientific community “turn[] its collective back on”
   Semmelweis, even when it turned out that he was so obviously right—and on
   a matter so critical to patients’ lives? Id. at 158. Why couldn’t he “change
   their fatalistic attitude about the inevitability of recurrent epidemics”? Id. at
   157.
             Those who have studied the events observe that it would “prove to be
   intolerable” for respected (“mainstream,” if you will) doctors to admit that
   they were horribly, brutally wrong—for they could not accept “the
   possibility that they had been killing their patients for years or decades.” Id.
   at 118.

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                                         B.
          A similar fate befell Joseph Lister. A British surgeon nearly twenty
   years after Semmelweis’s discovery, Lister sought to explain the causes of
   infection in surgical wounds that led to post-operation deaths. Lindsey
   Fitzharris, The Butchering Art: Joseph Lister’s Quest
   to Transform the Grisly World of Victorian Medicine
   155–60 (2017).
          Lister developed a “germ theory of disease”—that certain diseases
   are caused by the invasion of the body by microscopic organisms. Id. at 159.
   And he sought out to find a “means of destroying microorganisms within the
   wound itself before infection could set in.” Id. He began the practice of
   treating wounds with a carbolic-acid antiseptic to disinfect the skin, “prevent
   germs from entering wounds, [and] destroy[] those that had already entered
   the body.” Id. at 168–70. And he advanced the technique of sterilizing
   surgical instruments with his antiseptic solutions before using them on
   patients. Id. at 177.
          By the time of his death, Lister would be acclaimed as “the greatest
   modern Englishman” and “the world’s greatest surgeon.” Laurence
   Farmer, Master Surgeon: A Biography of Joseph Lister
   129 (1962). But throughout his career, he encountered fierce opposition,
   even mockery. His contemporaries could not accept his suggestion that
   invisible germs floating in the air could somehow cause disease. So they
   dismissed him as “crazy, rash, and blinded by enthusiasm.” Id. at 76. Others
   denigrated him as “mentally unhinged” and possessed by “a ‘grasshopper
   in the head.’” Fitzharris, supra, at 220. They disparaged his work as
   “the latest toy in medical science,” “unnecessary and overly complicated
   distractions,” “quackery,” and “medical hocus-pocus.” Id. at 203, 215, 218.
   One renowned English surgeon, in an address to the British Medical

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   Association, ridiculed Lister’s work as worse than “an innocent fallacy”—
   as nothing more than “unsupported fancies, which have little other existence
   than what is found in the imagination of those who believe in them.” Id. at
   193. The editor of the magazine Medical Record captured the dominant mood
   this way: “We are likely to be as much ridiculed in the next century for our
   blind belief in the power of unseen germs, as our forefathers were for their
   faith in the influence of spirits, of certain planets and the like, inducing
   certain maladies.” Candice Millard, Destiny of the Republic:
   A Tale of Madness, Medicine and the Murder of a
   President 184 (2012).
          As with Semmelweis, Lister’s colleagues resisted his methods for the
   simple reason that they “direct[ly] conflict[ed] with [their own]
   technique[s].”    Fitzharris, supra, at 180. “It was difficult for many
   surgeons at the height of their careers to face the fact that for the past fifteen
   or twenty years they might have been inadvertently killing patients by
   allowing wounds to become infected.” Id. at 185.
                                          II.
          The reaction of the “mainstream” scientific community to
   Semmelweis and Lister may seem outrageous to us today.                 But it is
   surprisingly typical, as explained by academics in a field known as the
   philosophy of science.
          Scientific progress is often arduous work. For science is at bottom “a
   conservative activity.” Samir Okasha, Philosophy of Science:
   A Very Short Introduction 71, 75 (2nd ed. 2016). That is, scientists
   typically “accept the [prevailing] paradigm unquestioningly,” and devote
   their research primarily to “develop[ing] and extend[ing] the existing
   paradigm.” Id. at 75. Scientists generally assume that any “experimental
   result which conflicts with the paradigm . . . is faulty, not that the paradigm

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   is wrong.” Id. at 76. So challenges to prevailing scientific wisdom are often
   dismissed. And the more entrenched the existing paradigm, the greater the
   upheaval, and the more vigorous the resistance will be to any challenge to the
   governing paradigm—as “a burgeoning sense of crisis envelops the scientific
   community.” Id. at 76.
          It may not be enough, then, that an existing paradigm deserves to be
   supplanted, and that a new paradigm proves to be superior. The most
   scientifically sound and intellectually rigorous viewpoint does not necessarily
   prevail. Scientists may be subject to “peer pressure” and even “mob
   psychology.” Id. at 77. So which view ultimately prevails may depend more
   on personality than merit. “If a given paradigm has very forceful advocates,
   it is more likely to win widespread acceptance.” Id.
          As a result, some academics have even begun to wonder whether
   “[s]cience . . . can no longer be construed simply as the ideal of the quest for
   truth (i.e., pure science).” Fabrice Jotterand, The Politicization of Science and
   Technology: Its Implications for Nanotechnology, 34 J.L. Med. & Ethics
   658, 658 (2006). After all, “[s]cience, through its technological applications,
   has become the source of economic power and, by extension, political
   power.” Id. As a result, “[s]cience, with its political implications, has
   entered what [one scholar] calls the era of ‘post-academic’ science.” Id. And
   “[t]he role played by cultural-political factors in scientific research lies at the
   basis of a shift in how scientific inquiry is conducted.” Id. at 661.
          Indeed, scientific resistance to novel ideas is so pervasive that medical
   historians have coined a term for it: “the term ‘Semmelweis reflex’ is used
   to refer to the knee-jerk tendency to reject new evidence because it
   contradicts established norms.” Lindsey Fitzharris, The Unsung Pioneer of
   Handwashing,      Wall       St.    J.    (Mar.     19,   2020),    available   at

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   https://www.wsj.com/articles/the-unsung-pioneer-of-handwashing-
   11584627614.
           The bottom line is this: Of course we should “follow the science.”
   But that doesn’t mean we should always blindly follow the scientists.
   Because, like the rest of us, scientists are, first and foremost, human beings.
   They’re susceptible to peer pressure, careerism, ambition, and fear of cancel
   culture, just like the rest of us—as courts have recognized. See, e.g., Ott v.
   St. Luke Hosp. of Campbell Cnty., Inc., 522 F. Supp. 706, 711 (E.D. Ky. 1981)
   (a “Lister or Semmelweis” might well discover the need for “salutary
   changes in [medical or scientific] procedures,” yet his views “may be
   excluded simply because he ‘makes waves’”); Kosilek v. Spencer, 774 F.3d 63,
   78 (1st Cir. 2014) (en banc) (noting concern that medical debate over sex
   reassignment surgery may be “politically” driven); Gibson v. Collier, 920
   F.3d 212, 222 (5th Cir. 2019) (same). 1

           1
              Similar concerns about intimidation and politicization within the scientific
   community have been expressed in a number of recent press accounts. See, e.g., Adam
   O’Neal, A Scientist Who Said No to Covid Groupthink, Wall St. J. (June 11, 2021),
   available at https://www.wsj.com/articles/a-scientist-who-said-no-to-covid-groupthink-
   11623430659 (profiling Filippa Lentzos, a scientist and expert on biological threats who was
   “wary” about voicing her theory on the origins of COVID-19 because it “challenged the
   enforced consensus,” noting that “there are power plays,” “agendas,” and “strong vested
   interests” in the scientific community that cause dissenters to “fear[] for their careers
   [and] for their grants”); Katherine Eban, The Lab-Leak Theory: Inside the Fight to Uncover
   COVID-19’s Origins, Vanity                     Fair (June 3, 2021), available at
   https://www.vanityfair.com/news/2021/06/the-lab-leak-theory-inside-the-fight-to-
   uncover-covid-19s-origins (“[F]ormer Centers for Disease Control director Robert
   Redfield received death threats from fellow scientists after telling CNN that he believed
   COVID-19 had originated in a lab. ‘I was threatened and ostracized because I proposed
   another hypothesis,’ Redfield told Vanity Fair. ‘I expected it from politicians. I didn’t
   expect it from science.’”); John Tierney, The Panic Pandemic: Fearmongering from
   journalists, scientists, and politicians did more harm than the virus, City Journal (Summer
   2021), available at https://www.city-journal.org/panic-pandemic (“There’s always a
   certain amount of herd thinking in science, but I’ve never seen it reach this level.”)

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                                              III.
           Doctors and scientists deserve enormous respect. We ignore their
   advice at our peril. But we also follow them blindly at our peril.
           Consider the story of Baby Richard. Born at just 21 weeks, he weighed
   less than a pound, small enough to fit in the palm of a hand. He had small air
   sacs instead of developed lungs. Oxygen was not flowing to his brain. He
   needed IV fluid, a breathing tube, and blood pressure support to sustain
   himself. He was immediately rushed to a neonatal intensive care unit.
   Tommy Brooksbank, ‘Miracle baby’ born at 21 weeks heads home from hospital
   just in time for Christmas, Good Morning America (Dec. 25, 2020),
   available at https://www.goodmorningamerica.com/family/story/miracle-
   baby-born-21-weeks-heads-home-hospital-74848084.
           Richard’s doctors gave him a “0% chance of survival.” Id. As his
   neonatologist, Dr. Stacy Kern, later noted, “many NICUs around the world
   are not even resuscitating babies born at 22 weeks.” Id. See also id. (noting
   that, “[a]ccording to the Department of Health and Human Services, babies
   born before 22 weeks are typically not resuscitated because their bodies are
   simply too immature to be treated with intensive care”).

   (quoting Harvard epidemiologist Martin Kulldorff); see also, e.g., Lesley Stahl, State Bills
   Would Curtail Health Care for Transgender Youth, 60 Minutes (May 23, 2021), available
   at     https://www.cbsnews.com/news/transgender-health-care-60-minutes-2021-05-23/
   (quoting Dr. Laura Edwards-Leeper, a psychologist at a major youth gender clinic in Boston
   who has “helped hundreds of teens and young adults transition successfully after a
   comprehensive assessment”: “It greatly concerns me where the field has been going. I
   feel like what is happening is unethical and irresponsible in some places. . . . Everyone is
   very scared to speak up because we’re afraid of not being seen as affirming or being
   supportive of these young people or doing something to hurt the trans community. But
   even some of the providers are trans themselves and share these concerns.”).

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          For weeks, Richard was hooked up to two ventilators to keep him
   breathing. But his oxygen levels continued to decline. So doctors invited his
   mother to Baby Richard’s bedside—to say goodbye.
          But then they touched. “She puts her hand on him and all the sudden
   his oxygen saturation goes up to the 80s then 90s, and I look at her and go, ‘I
   guess he just needed his mom,’” Dr. Kern later said. Id. “It was one of the
   most incredible things I’ve ever seen. He just continued to surprise us day
   after day.” Id.
          After six months in the hospital, Baby Richard came home—just in
   time for Christmas. Id. He recently celebrated his first birthday. See Sydney
   Page, A newborn weighed less than a pound and was given a zero percent chance of
   survival. He just had his first birthday., Wash. Post (June 23, 2021),
   available     at    https://www.washingtonpost.com/lifestyle/2021/06/23/
   premature-baby-survive-birthday-record/.
                                         IV.
          States have a profound interest in respecting unborn life. See, e.g.,
   Gonzales, 550 U.S. at 157 (“The government may use its voice and its
   regulatory authority to show its profound respect for the life within the
   woman.”).      Surely that interest includes protecting the unborn from
   unnecessary pain and suffering. See, e.g., Jackson Women’s, 945 F.3d at 280
   (Ho, J., concurring in the judgment) (“A State has an unquestionably
   legitimate (if not compelling) interest in preventing gratuitous pain to the
   unborn.”).
          Indeed, if states must avoid unnecessary pain to convicted murderers
   on death row as a matter of constitutional mandate, then surely states may
   avoid unnecessary pain to innocent unborn babies as a matter of
   constitutional discretion. “It would be surprising if the Constitution requires
   States to use execution methods that avoid causing unnecessary pain to

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   convicted murderers, but does not even permit them from preventing
   abortions that cause unnecessary pain to unborn babies.” Id. at 280 (citing
   Baze v. Rees, 553 U.S. 35, 49 (2008) (plurality opinion)).
          “Not surprisingly, then, members of the Supreme Court have
   acknowledged that avoidance of pain is indeed a valid state interest in the
   abortion context.” Id. (citing Webster v. Reprod. Health Servs., 492 U.S. 490,
   552 (1989) (Blackmun, J., concurring in part and dissenting in part) (“I
   should think it obvious that the State’s interest in the protection of an embryo
   . . . increases progressively and dramatically as the organism’s capacity to feel
   pain, to experience pleasure, to survive, and to react to its surroundings
   increases day by day.”) (quoting Thornburgh v. Am. Coll. of Obstetricians &
   Gynecologists, 476 U.S. 747, 778 (1986) (Stevens, J., concurring)); Webster,
   492 U.S. at 569 (Stevens, J., concurring in part and dissenting in part)
   (“There can be no interest in protecting the newly fertilized egg from
   physical pain or mental anguish, because the capacity for such suffering does
   not yet exist; respecting a developed fetus, however, that interest is valid.”).
          The record of this case demonstrates that scientists disagree about
   what gestational phase an unborn child begins to feel pain. See ante, at 15
   n.13; see also Jackson Women’s, 945 F.3d at 274–75; id. at 279–80 (Ho, J.,
   concurring in the judgment). Accordingly, the Supreme Court’s abortion
   precedents require courts to defer to legislators to resolve those debates. See,
   e.g., Gonzales, 550 U.S. at 163–64.
          But rather than defer to Texas legislators to make that judgment call,
   the 2–1 panel scolded them for relying on doctors the panel majority deemed
   outside the “mainstream.” Whole Woman’s, 978 F.3d at 910.
          If society takes seriously its obligation to protect the most innocent
   among us from unnecessary pain, it’s hard to imagine a more important issue

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   on which to defer to legislative judgments than the medical debate over an
   unborn child’s capacity to feel pain.
                                           ***
          Someday, scientists may look back on today’s abortion debates as
   shocking and barbaric—just as we look back in disbelief at those who
   ridiculed and ostracized proponents of handwashing and sterilizing surgical
   instruments to prevent disease and infection.
          Indeed, many have that view today. According to Carter Snead, one
   of the nation’s leading scholars on public bioethics and an expert witness in
   this case, “132 countries out of 194 that I looked at ban abortion outright, at
   all gestational stages, with certain exceptions defined by law,” while 178
   countries generally ban abortion after a gestational age of 12 weeks. So “92
   percent of all countries presumptively ban abortions at 12 weeks or less.”
          Texas does not ban abortion until 22 weeks. So Texas law is not only
   valid under the Constitution and Supreme Court precedent—it’s also more
   permissive than the overwhelming majority of laws around the world.
          Yet federal courts have blocked it for four years. This in spite of the
   fact that, when it comes to medical disputes surrounding abortion, Supreme
   Court precedent requires judges to defer to—not overturn—the will of the
   voters and the judgment of the legislators they elected to office. “The right
   to vote means nothing if we abandon our constitutional commitments and
   allow the real work of lawmaking to be exercised by [federal judges], rather
   than by elected officials accountable to the American voter.” Texas v. Rettig,
   993 F.3d 408, 410–11 (5th Cir. 2021) (Ho, J., dissenting from denial of
   rehearing en banc). After four years, the court today finally allows the law to
   take effect. I concur.

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   James L. Dennis, Circuit Judge, joined by Stewart and Graves, Cir-
   cuit Judges, dissenting:
          In Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S.
   833, 846 (1992) (plurality opinion), three Supreme Court Justices set forth
   the core principles that have come to guide the modern jurisprudence of abor-
   tion. The foremost among these was that women have a constitutional right
   “to choose to have an abortion before [fetal] viability and to obtain it without
   undue interference from the State.” Id. In other words, “[b]efore viability,
   the State’s interests are not strong enough to support a prohibition of abor-
   tion or the imposition of a substantial obstacle to the woman’s effective right
   to elect the procedure.” Id. The corollary to this principle is known as the
   undue burden standard, under which state regulations that have “the pur-
   pose or effect ” of “plac[ing] a substantial obstacle in the path of a woman
   seeking an abortion before the fetus attains viability” are unconstitutional.
   Id. at 877.
          Notwithstanding Casey’s clear statement that “[u]nnecessary health
   regulations that have the purpose or effect of presenting a substantial obstacle
   to a woman seeking an abortion impose an undue burden on the right,” id. at
   878, our court has frequently failed to identify and strike down laws that tar-
   get abortion rights under the semblance of regulating the procedure. Five
   years ago, the Supreme Court reversed our upholding of a Texas law that,
   although ostensibly a medical regulation, provided very few if any actual
   medical benefits and instead mainly served to hinder a woman’s right to a
   previability abortion. See Whole Woman’s Health v. Hellerstedt, 136 S. Ct.
   2292, 2318 (2016). Only two years later, our court declined to heed the Hel-
   lerstedt decision and approved a virtually identical Louisiana law, substituting
   our own strained reading of the evidence for the findings of the district court
   in order to conclude that the burdens the law placed on women’s abortion

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   choice did not outweigh its benefits. June Med. Servs., L.L.C. v. Gee, 905
   F.3d 787, 815 (5th Cir. 2018). As one might expect, the Supreme Court again
   reversed our decision, reprimanding us for defying on-point binding prece-
   dent and failing to defer to the district court’s factual findings that were plau-
   sible in light of the full record, as an appeals court must on clear error review.
   June Med. Servs., L.L.C., v. Russo, 140 S. Ct. 2103, 2121, 2124-25 (2020) (plu-
   rality opinion); id. at 2133-34, 2141 (Roberts, C.J., concurring).
          Today, in a Sisyphean return to form, our court upholds a Texas law
   that, under the guise of regulation, makes it a felony to perform the most
   common and safe abortion procedure employed during the second trimester.
   In an opinion that fortunately lacks fully binding precedential effect, the en
   banc plurality disregards the two major lessons of June Medical. First, it ig-
   nores on-point Supreme Court precedent in multiple ways. For one, the plu-
   rality wrongly declares a single Justice’s concurrence to be precedential in
   order to impose a variation of the undue burden standard that the Court has
   explicitly rejected. See Hellerstedt, 136 S. Ct. at 2309. And, even under the
   plurality’s preferred standard, the Supreme Court has already decided this
   exact case, holding that a Nebraska law was unconstitutional because it could
   be interpreted to be the sort of ban that the Texas statute openly embodies.
   Stenberg v. Carhart, 530 U.S. 914, 945(2000). Second, just as in June Medical,
   the en banc plurality fails to defer to the district court’s well-reasoned and
   well-supported factual findings regarding the burdens and benefits associated
   with the Texas law, instead substituting its own reading of the evidence to
   make findings of fact in the first instance. This would be bad enough on its
   own, but the actual findings that the plurality makes are contrary to the great
   weight of the evidence in the record and place us at odds with virtually every
   other court to have considered the matter.
          In a final, entirely new sort of error, the plurality faults the district
   court for “botch[ing]” the large fraction analysis, Plurality at 33, which asks

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   whether the challenged restriction is an undue burden for a large portion of
   the women affected by it. But the plurality “bungl[es]” the analysis itself,
   Plurality at 3, incorrectly minimizing the statute’s impact by wrongly includ-
   ing in its evaluation a large number of women whose lives will be wholly un-
   affected by SB8.
          The court’s decision today will, in the name of “medical ethics,”
   force many women to unnecessarily undergo what the en banc plurality
   wrongfully characterizes as “alternatives” to the very common and safe pro-
   cedure that Texas has banned—painful, invasive, expensive, and in some
   cases experimental additional treatments that carry with them significantly
   elevated risks to the women’ health and well-being. Further burdening abor-
   tion access, many abortion providers will likely decline to perform later-term
   abortions rather than face the dilemma today’s ruling foists upon them: be-
   come a felon or do a risky procedure that is contrary to the doctor’s medical
   judgment regarding the patient’s best interests. This outcome is neither cor-
   rect as a logical matter nor consistent with our duties as a lower federal ap-
   pellate court, and I respectfully but emphatically dissent.
                                            I.
                                         A.
          As courts have long recognized, dilation and evacuation (“D&E”) is
   “the most commonly used method for performing previability second tri-
   mester abortions.” Stenberg, 530 U.S. at 945. The procedure is generally
   performed as a two-step process. The first step remains the same throughout
   all stages of the pregnancy: doctors induce dilation through medication alone
   or in combination with small sticks made from an expanding organic or syn-
   thetic material called laminaria. But the technique employed at the second
   step—evacuation—varies depending on how advanced the woman’s preg-
   nancy is at the time of the procedure.

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           The en banc plurality claims that there are three seemingly equally ac-
   ceptable “main” options that a doctor may elect to employ during the evac-
   uation phase of the D&E. Plurality at 3. According to the plurality, once a
   woman’s cervix has been dilated, a doctor may evacuate the contents of her
   uterus using either suction alone, a combination of suction and forceps, or
   various “fetal-death” techniques in conjunction with suction and forceps.
   Plurality at 3. This characterization of the procedure is inaccurate. The rec-
   ord and the district court’s findings make clear that there are only two ways
   to perform the second step of a D&E: suction alone or in conjunction with
   forceps or similar implements, with the gestational age of the fetus the pri-
   mary factor dictating which technique the doctor can safely and effectively
   employ.
           Generally, during the first trimester, 1 the contents of the uterus can
   be evacuated via suction with a plastic tube called a “cannula” in a process
   termed “suction aspiration.” The suction causes the fetal tissue to separate,
   resulting in fetal demise, and it removes the residual contents of the womb.
   But beginning during the second trimester at around fifteen weeks of preg-
   nancy, the most common method of abortion both in Texas and nationally
   involves the additional use of forceps or similar handheld medical imple-
   ments. Performed in an outpatient setting, this very safe, approximately ten-
   minute procedure differs from the early-stage procedure in that, rather than
   relying solely on suction during the step-two evacuation phase, the physician
   uses forceps to reach into the uterine cavity and manually remove the fetal
   tissue through the cervix. Because of its size and position, doctors use the

           1
            The gestational age of a fetus is measured by the time elapsed since the woman’s
   last menstrual period. Pregnancy is commonly separated into three trimesters. The first
   trimester runs from the first through twelfth week and the second trimester runs from the
   thirteenth through twenty-sixth week. See Stenberg, 530 U.S. at 923-25. The third tri-
   mester begins the twenty-seventh week and continues through the end of the pregnancy.

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   forceps to “disarticulate” or separate the fetal tissue into pieces small
   enough to be removed through the dilated opening. Once the removal is com-
   plete, the doctor uses suction to remove any residual material remaining in
   the uterus.
           As other courts have recognized and as will be discussed, there are
   some additional measures that doctors can perform during a D&E wherein
   various techniques are used to independently produce fetal demise prior to
   evacuation, but these are not an alternative method of evacuation as the en
   banc plurality seems to claim. See EMW Women’s Surgical Ctr., P.S.C. v.
   Friedlander, 960 F.3d 785, 798 (6th Cir. 2020) (“Fetal-demise procedures are
   not, by definition, alternative procedures. A patient who undergoes a fetal-
   demise procedure must still undergo the entirety of a standard D&E. Instead,
   fetal-demise procedures are additional procedures.”), cert. granted in part on
   other grounds sub nom. Cameron v. EMW Women’s Surgical Ctr., P.S.C., 141 S.
   Ct. 1734 (2021). The tissue separation that occurs during a forceps-assisted
   D&E results in fetal demise, and the procedure does not require an addi-
   tional, antecedent step of producing fetal demise through other methods. As
   is discussed in more detail below, performing such an extra step significantly
   increases the health risks and physical, emotional, and financial costs associ-
   ated with the procedure.
                                               B.
           In 2017, Texas enacted Senate Bill 8 (“SB8”). Along with a number
   of other provisions exhibiting hostility to a woman’s constitutional right to
   obtain a previability abortion, the law prohibits so-called “dismemberment
   abortions.” 2 Act of May 26, 2017, 85th Leg. R.S., ch. 441, § 6, 2017 Tex.

           2
             SB8 does not contain any legislative findings, and the district court did not make
   any factual findings regarding the Texas legislature’s intent in enacting it. But when con-
   sidering similar bans, well-respected jurists have posited that the abortion method was

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   Gen. Laws 1164, 1165–67 (eff. Sept. 1, 2017) (codified as TEX. HEALTH &
   SAFETY CODE §§ 171.151–.154). Obviously, this pejorative label, which the
   en banc plurality largely adopts, is not found in any medical texts. But the
   statute defines the procedure as one in which the physician, “with the pur-
   pose of causing the death of an unborn child, dismembers the living unborn
   child and extracts the unborn child one piece at a time from the uterus
   through the use of clamps, grasping forceps, tongs, scissors, or a similar in-
   strument.” 3 Id. Violation of the statute is a felony offense punishable by a
   minimum of 180 days to a maximum of two years in jail and a fine of up to
   $10,000.
           Texas asserts in the present litigation that SB8 proscribes the use of
   forceps or similar instruments to produce fetal demise during the second step
   of the D&E procedure. The State concedes that SB8 does not prohibit a suc-
   tion-aspiration abortion, and it likewise asserts that an abortion in which fetal
   demise occurs prior to the evacuation of the uterus with forceps is outside
   the statute’s ambit. In other words, a physician performing a D&E in which
   forceps are needed could typically avoid criminal liability only by taking the

   targeted “not because the procedure kills the fetus, not because it risks worse complica-
   tions for the woman than alternative procedures would do, not because it is a crueler or
   more painful or more disgusting method of terminating a pregnancy.” Stenberg, 530 U.S.
   at 951-52 (Ginsburg, J., concurring) (quoting Hope Clinic v. Ryan, 195 F.3d 857, 881 (7th
   Cir. 1999) (Posner, J., dissenting)). “Rather . . . the law prohibits the procedure because
   the state legislators seek to chip away at the private choice shielded by Roe v. Wade, 410
   U.S. 113 (1973), even as modified by Planned Parenthood of Southeastern Pa. v. Casey, 505
   U.S. 833 (1992).” Id. at 952. “[I]f a statute burdens constitutional rights and all that can
   be said on its behalf is that it is the vehicle that legislators have chosen for expressing their
   hostility to those rights, the burden is undue.” Hope Clinic, 195 F.3d. at 881 (Posner, J.,
   dissenting); see also, Casey, 505 U.S. at 877 (stating that a law imposes an undue burden if
   it has “the purpose or effect ” of “plac[ing] a substantial obstacle in the path of a woman
   seeking an abortion before the fetus attains viability” (emphasis added)).
           3
           The statute includes an exception for medical emergencies. TEX. HEALTH &
   SAFETY CODE § 171.152.

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   additional, medically unnecessary step of inducing fetal demise in utero be-
   fore performing the evacuation phase, regardless of the doctor’s professional
   medical judgment whether such action is safe or appropriate.
          The Plaintiffs in this case, who are six licensed abortion clinics and
   five abortion providers that operate in Texas, filed the present lawsuit against
   the defendants, who are various Texas law enforcement officers acting in
   their official capacity. Plaintiffs contended that SB8 places an unconstitu-
   tional undue burden on a woman’s ability to obtain a previability abortion.
   Following an extensive five-day bench trial and consideration of testimony
   from numerous medical experts and a multitude of professional literature,
   the district court agreed that the statute is unconstitutional.
          The court issued a thorough memorandum opinion that meticulously
   reviewed and parsed the complex evidence the parties had introduced,
   weighed the competing narratives, made credibility determinations, and oth-
   erwise resolved complicated factual disputes in the manner that district
   courts are uniquely situated to do within our judicial system. See Whole
   Woman’s Health v. Paxton, 280 F. Supp. 3d 938, 941 n.5 (W.D. Tex. 2017)
   (“In making these findings and conclusions, the court has considered the rec-
   ord as a whole. The court has observed the demeanor of the witnesses and
   has carefully weighed that demeanor and the witnesses’ credibility in deter-
   mining the facts of this case and drawing conclusions from those facts. Fur-
   ther, the court has thoroughly considered the testimony of both sides’ expert
   witnesses and has given appropriate weight to their testimony in selecting
   which opinions to credit and upon which not to rely.”). The court evaluated
   each of the State’s proposed methods by which a doctor could comply with
   SB8, and, “[a]fter considering all of the medical expert testimony, the court
   conclude[d] that pre-evacuation fetal demise provides no additional medical
   benefit to a woman undergoing a standard D & E abortion.” Id. at 949. In-
   stead, the court found, each of the proposed techniques significantly

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   increases the risk and physical, emotional, and financial cost associated with
   the D&E procedure. Id. at 953. The court acknowledged that Texas has a
   legitimate interest in promoting “respect for the life of the unborn,” but it
   explained that this interest did not outweigh the considerable burden SB8
   imposes on a woman’s ability to obtain the previability abortion to which she
   is constitutionally entitled. Id. The court thus concluded that “requiring a
   woman to undergo an unwanted, risky, invasive, and experimental procedure
   in exchange for exercising her right to choose an abortion, substantially bur-
   dens that right.” Id. And the district court accordingly declared SB8 facially
   unconstitutional and permanently enjoined its enforcement. Id. at 954.
          The State appealed, and we held this case in abeyance while the Su-
   preme Court decided June Medical Services L.L.C. v. Russo, 140 S. Ct. 2103
   (2020), a case much like this one in which a majority of this court defied on-
   point Supreme Court precedent and substituted its own stilted interpretation
   of the evidence for the district court’s first-hand findings. See June Med.
   Servs., L.L.C. v. Gee, 913 F.3d 573, 574, 579-84 (5th Cir. 2019) (Dennis, J.,
   dissenting from denial of en banc rehearing). The Supreme Court in June
   Medical—including the Chief Justice in his separate concurrence—rebuked this
   court’s temerity, chastising us about the importance of stare decisis and the
   deference that appeals courts owe to a district court’s factual findings. See
   140 S. Ct. at 2121, 2124-25 (plurality opinion); id. at 2133-34, 2141 (Roberts,
   C.J., concurring). But after the Supreme Court issued June Medical, Texas
   filed a motion for a stay of the district court’s injunction in this case in light
   of that decision, somehow interpreting the Supreme Court’s admonishment
   that our court should heed controlling precedent and defer to a district
   court’s findings of fact as an invitation for our court to depart from Supreme
   Court jurisprudence and overturn the district court’s factual findings. Rec-
   ognizing the absurdity of this proposition, a majority of a panel of this court
   denied Texas its requested stay, 972 F.3d 649 (5th Cir. 2020), and then

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   affirmed the district court’s decision on the merits, 978 F.3d 896 (5th Cir.
   2020). But an en banc majority of this court vacated that decision, 978 F.3d
   974 (5th Cir. 2020), and it now reverses with only a plurality agreeing upon a
   rationale.
                                           II.
             We review the district court’s decision to permanently enjoin enforce-
   ment of SB8 for abuse of discretion. See Jackson Women’s Health Org. v.
   Dobbs, 945 F.3d 265, 270 (5th Cir. 2019), cert. granted in part, 209 L. Ed. 2d
   748 (May 17, 2021). The court’s underlying conclusions of law are reviewed
   de novo. Guzman v. Hacienda Records & Recording Studio, Inc., 808 F.3d 1031,
   1036 (5th Cir. 2015). Its findings of fact, on the other hand, are reviewed for
   clear error. Anderson v. City of Bessemer City, N.C., 470 U.S. 564, 573 (1985).
   “If the district court’s account of the evidence is plausible in light of the rec-
   ord viewed in its entirety, the court of appeals may not reverse it even though
   convinced that had it been sitting as the trier of fact, it would have weighed
   the evidence differently. Where there are two permissible views of the evi-
   dence, the factfinder’s choice between them cannot be clearly erroneous.”
   Id. at 573-74. And “[w]hen findings are based on determinations regarding
   the credibility of witnesses, [Federal] Rule [of Civil Procedure] 52(a) de-
   mands even greater deference to the trial court’s findings; for only the trial
   judge can be aware of the variations in demeanor and tone of voice that bear
   so heavily on the listener’s understanding of and belief in what is said.” Id.
   at 575.
             The en banc plurality relies on statements in Bose Corp. v. Consumers
   Union of U.S., Inc., 466 U.S. 485, 501 (1984), and Pullman-Standard v. Swint,
   456 U.S. 273, 287 (1982), to boldly state that, because the district court em-
   ployed the wrong legal standard, “[w]e therefore owe no deference to the
   district court’s factual findings.” Plurality at 19. As discussed below, the

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   district court employed the correct legal standard, so this contention fails
   from the start. But even were that not the case, the plurality gives no clear
   reason for its holding that a district court’s mistake regarding the rule for de-
   termining whether an abortion restriction is constitutional relieves us of our
   duty to defer to the underlying factual findings that the district court applied
   that standard to.
          “Clear error review follows from a candid appraisal of the compara-
   tive advantages of trial courts and appellate courts. While we review tran-
   scripts for a living, they listen to witnesses for a living. While we largely read
   briefs for a living, they largely assess the credibility of parties and witnesses
   for a living.” June Med. Servs., L.L.C., 140 S. Ct. at 2141 (Roberts, C.J., con-
   curring) (internal quotes and citation omitted). To be sure, the Supreme
   Court has stated that “[a] finding of fact in some cases is inseparable from
   the principles through which it was deduced,” and there may be times when
   an error of law makes it appropriate to set aside a “so-called mixed finding of
   law and fact, or a finding of fact that is predicated on a misunderstanding of
   the governing rule of law.” Bose, 466 U.S. at 501 & n.17. But when factual
   questions are not intertwined with questions of law, district courts remain in
   a far better position than appellate courts to evaluate credibility and parse
   conflicting evidence in order to resolve them. And while a misunderstanding
   of the governing law might affect which factual disputes a district court
   chooses to resolve, see Swint,456 U.S. at 287 n.17 (“The presence of . . . legal
   errors may justify a remand by the Court of Appeals to the District Court for
   additional factfinding under the correct legal standard.”), it generally has lit-
   tle bearing on whether the purely factual findings that a district court does
   make are accurate.
          The en banc plurality does not explain why the district court’s appli-
   cation of what the plurality believes was an incorrect legal standard—weigh-
   ing SB8’s burdens against its benefits to determine its constitutionality—

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   would in any way undermine the district court’s first-hand reading of the ev-
   idence of what those burdens and benefit are. It thus provides no reason for
   our withholding the clear-error deference mandated for district courts’ fac-
   tual determinations. See id. at 287 (“[Federal] Rule [of Civil Procedure]
   52(a) broadly requires that findings of fact not be set aside unless clearly er-
   roneous. It does not make exceptions or purport to exclude certain categories
   of factual findings from the obligation of a court of appeals to accept a district
   court’s findings unless clearly erroneous.”). The Supreme Court has had to
   remind our court in recent years that, even in abortion cases, we are an ap-
   pellate court that should not second guess a district court’s reading of con-
   flicting evidence. See June Med. Servs., L.L.C., 140 S. Ct. at 2121, 2124-25
   (plurality opinion); id. at 2133-34, 2141 (Roberts, C.J., concurring). I would
   take that lesson to heart and hold that the clear error standard of review ap-
   plies to the district court’s factual findings in the present case.
                                          III.
          On the merits, the en banc plurality claims that the district court com-
   mitted a range of legal errors by employing the wrong legal standard, failing
   to heed binding Supreme Court precedent, not sufficiently crediting the
   State’s legitimate interests in enacting SB8, and making several other miscel-
   laneous mistakes. It also asserts that the district court’s factual findings re-
   garding the burdens SB8 imposes on abortion access are unsupported or con-
   tradicted by the record. And the plurality contends that the district court
   misapplied the “large fraction” analysis when determining what proportion
   of women seeking previability abortions would be unduly burdened by SB8.
   Each of the plurality’s claims of error is wrong and provides no grounds for
   reversal, and each will be considered and rejected in turn.

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                                          A.
          It has been clear since the Supreme Court’s landmark decision in Roe
   v. Wade, 410 U.S. 113 (1973), that the Fourteenth Amendment guarantees a
   woman’s right to choose to undergo a previability abortion. Two decades
   later, in Planned Parenthood of Southeastern Pennsylvania v. Casey, the Court
   reaffirmed Roe’s “essential holding” and set forth a three-part legal frame-
   work for assessing the constitutionality of abortion restrictions:
                  First is a recognition of the right of the woman to choose
          to have an abortion before viability and to obtain it without un-
          due interference from the State. Before viability, the State’s
          interests are not strong enough to support a prohibition of abor-
          tion or the imposition of a substantial obstacle to the woman’s
          effective right to elect the procedure. Second is a confirmation
          of the State’s power to restrict abortions after fetal viability, if
          the law contains exceptions for pregnancies which endanger
          the woman’s life or health. And third is the principle that the
          State has legitimate interests from the outset of the pregnancy
          in protecting the health of the woman and the life of the fetus
          that may become a child.
   505 U.S. at 846.
          “Casey, in short, struck a balance.” Gonzales v. Carhart, 550 U.S. 124,
   146 (2007). On the one hand, it protected women’s fundamental rights by
   mandating that “a State may not prohibit any woman from making the ulti-
   mate decision to terminate her pregnancy before viability.” Casey, 505 U.S.
   at 879. On the other, it recognized that a state may enact previability regula-
   tions designed “to further the health or safety of a woman seeking an abor-
   tion” or “to express profound respect for the life of the unborn.” Id. at 877-
   78. But “a statute which, while furthering the interest in potential life or
   some other valid state interest, has the effect of placing a substantial obstacle
   in the path of a woman’s choice cannot be considered a permissible means of

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   serving its legitimate ends.” Id. at 877. Thus, state regulations may have
   neither “the purpose [n]or [the] effect of placing a substantial obstacle in the
   path of a woman seeking an abortion of a nonviable fetus.” Id. The “short-
   hand” for a substantial obstacle is an undue burden. Id.
                                          1.
          Five years ago, in Whole Woman’s Health v. Hellerstedt, the Supreme
   Court confirmed that the undue burden “rule announced in Casey . . . re-
   quires that courts consider the burdens a law imposes on abortion access to-
   gether with the benefits those laws confer.” 136 S. Ct. at 2309 (citing the
   Casey Court’s balancing of a law’s benefits against its burdens). That is to
   say, in order to determine if a burden on a woman’s right to choose is “un-
   due,” courts must assess the benefits of the state’s regulation relative to the
   obstacles it erects to women obtaining a previability abortion. Id. A majority
   of the Court expressly rejected an approach that considers only the burdens
   imposed by an abortion restriction, stating that this “articulation of the rele-
   vant standard is incorrect.” Id. And, applying the correct balancing test, the
   Court reversed this court’s decision upholding a Texas law that, among other
   things, required abortion providers to obtain admitting privileges at a local
   hospital. Id. at 2313-14. In light of the district court’s findings that the law
   had little if any medical benefit and imposed significant obstacles to many
   women obtaining a previability abortion, the Court held that the law uncon-
   stitutionally erected a substantial barrier to a large fraction of women exercis-
   ing their constitutional right to choose. Id. at 2313-15.
          As noted, the Supreme Court issued its most recent ruling explaining
   and applying the undue burden test during the pendency of this appeal in
   June Medical, in which it once again reversed this court’s ruling upholding an
   abortion restriction. 140 S. Ct. at 2114. June Medical concerned a Louisiana
   admitting-privileges statute that was virtually identical to the one considered

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   in Hellerstedt, and the Court unsurprisingly came to the same conclusion, in-
   validating the law because it imposed an undue burden on a woman’s right to
   obtain a previability abortion. Id. at 2112-13. A four-Justice plurality applied
   the balancing approach elucidated in Hellerstedt, weighing the statute’s as-
   serted benefits against its burdens. See id. at 2121-32. In a solo opinion con-
   curring in the judgment, Chief Justice Roberts rejected the balancing test,
   stating that, other than with respect to the preliminary inquiry as to whether
   the challenged law is rationally related to a legitimate state interest, the undue
   burden test requires looking only to the burdens of an abortion regulation.
   See id. at 2136-37 (Roberts, C.J., concurring in the judgment).
          Citing Marks v. United States, 430 U.S. 188, 193 (1977), the en banc
   plurality declares today that Chief Justice Roberts’s solo concurrence consti-
   tutes June Medical’s holding and is accordingly binding on this court. It
   therefore holds that the district court erred by employing the legal standard
   set forth in Hellerstedt and balancing the benefits of SB8 relative to the bur-
   dens it places on a woman’s constitutional right to choose. Plurality at 11-14.
   For reasons that were discussed at length in the previous panel opinions, the
   plurality is wrong. See Whole Woman’s Health, 972 F.3d at 652-53; Whole
   Woman’s Health, 978 F.3d at 904-05.
          To recapitulate, “[o]rdinarily, ‘[w]hen a fragmented Court decides a
   case and no single rationale explaining the result enjoys the assent of five Jus-
   tices, the holding of the Court may be viewed as the position taken by those
   Members who concurred in the judgment[ ] on the narrowest grounds.’”
   United States v. Duron-Caldera, 737 F.3d 988, 994 n.4 (5th Cir. 2013) (second
   alteration in original) (quoting Marks, 430 U.S. at 193)). But we have long
   held that the Marks “principle . . . is only workable where there is some ‘com-
   mon denominator upon which all of the justices of the majority can agree.’”
   Id. (quoting United States v. Eckford, 910 F.2d 216, 219 n.8 (5th Cir. 1990)).
   When a concurrence does not share a “common denominator” with, or

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   cannot “be viewed as a logical subset of,” a plurality’s opinion, it “does not
   provide a controlling rule” that establishes or overrules precedent. Id.
          In June Medical, the only common denominator between the plurality
   and the concurrence is their shared conclusion that the challenged Louisiana
   law constituted an undue burden. Compare 140 S. Ct. at 2132 (plurality opin-
   ion), with id. at 2141-42 (Roberts, C.J., concurring in the judgment). What
   they obviously disagreed on is the proper test for conducting the undue-bur-
   den analysis: the June Medical plurality applied Hellerstedt’s balancing of the
   law’s burdens against its benefits, while the concurrence analyzed only the
   burdens. In fact, the Chief Justice expressly disavowed the plurality’s test.
   See id. at 2136. Our precedents make clear that a concurrence is not a logical
   subset of a plurality opinion or vice versa in these circumstances. See Duron-
   Caldera, 737 F.3d at 994 n.4 (holding that, in the Supreme Court’s decision
   in “Williams[ v. Illinois, 132 S. Ct. 2221 (2012)], there is no such common
   denominator between the plurality opinion and Justice Thomas’s concurring
   opinion. Neither of these opinions can be viewed as a logical subset of the
   other. Rather, Justice Thomas expressly disavows what he views as ‘the plu-
   rality’s flawed analysis,’ including the plurality’s ‘new primary purpose
   test.’” (quoting Williams, 132 S. Ct. at 2255, 2262 (Thomas, J., concurring)
   (emphasis added))).
          Basic logic reaffirms that a rule that asks simply whether a given factor
   is present in sufficient quantities is not a logical subset of a rule that calls for
   that factor to be weighed against another variable. Consider this counterfac-
   tual: If the June Medical plurality’s rule were “Unconstitutional if A or B is
   present” and the concurrence’s were “Unconstitutional if A is present,”
   then the concurrence would be a logical subset of the plurality’s opinion. 4 All

          4
             This appears to be how the en banc plurality conceptualizes the matter, as it
   stresses that the Chief Justice agreed with the portion of the June Medical plurality’s

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   possible unconstitutional outcomes produced by the concurrence’s test
   would also be unconstitutional outcomes under the plurality’s, and the Venn
   diagram of results would show the circle representing the concurrence fully
   contained within the circle representing the plurality. Contrast this to the
   situation we are now presented with: The June Medical plurality’s rule is
   “Unconstitutional if A (burdens) is greater than B (benefits)” and the Chief
   Justice’s concurrence’s standard is “Unconstitutional if A (burdens) is
   greater than X (an acceptable level).” In situations in which an abortion re-
   striction has virtually no benefits but imposes only modest burdens, it would
   be unconstitutional under the June Medical plurality’s test but not the Chief
   Justice’s. And in situations in which a law has tremendous benefits and im-
   poses a lesser but nonetheless significant burden, the law would be unconsti-
   tutional under the Chief Justice’s test but not the plurality’s. The Venn dia-
   gram is divergent, with neither set of outcomes entirely contained within the
   other. Both the Seventh and Eleventh Circuits have arrived at the same con-
   clusion, recognizing that the Chief Justice’s single-justice concurrence is not
   a logical subset of the June Medical plurality’s opinion. See Reprod. Health
   Servs. v. Strange, 3 F.4th 1240, 1259 (11th Cir. 2021) (“The Chief Justice’s
   concurrence cannot fairly be considered narrower than the plurality opinion
   because, although they came to the same result, the Chief Justice and the
   plurality diverged on the reasoning supporting that result. As a result, the
   only common ground between the plurality and Chief Justice Roberts is in
   the shared conclusion that the Louisiana statute constituted an undue

   opinion analyzing the burdens imposed by the challenged law. Plurality at 11-12. But the
   June Medical plurality did not reason that a previability abortion restriction is unconstitu-
   tional if it has burdens or benefits. It concluded that a previability abortion restriction is
   unconstitutional if the law’s burdens are greater than its benefits. Simply identifying that a
   law imposes burdens on the right to abortion is not sufficient to resolve the case under the
   Hellerstedt formulation that the June Medical plurality applied.

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   burden. The benefits-burdens approach to the undue burden analysis from
   Whole Woman’s Health therefore continues to bind us.”); Planned Parenthood
   of Indiana & Kentucky, Inc. v. Box, 991 F.3d 740, 748 (7th Cir. 2021) (“In June
   Medical, there is one critical sliver of common ground between the plurality
   and the concurrence: Whole Woman’s Health was entitled to stare decisis ef-
   fect on essentially identical facts. The Marks rule therefore applies to that
   common ground, but it applies only to that common ground.”).
             The en banc plurality’s approach to applying the Marks rule would
   have far-reaching consequences, as it would allow “a single Justice writing
   only for himself . . . the authority to bind th[e] Court to propositions it has
   already rejected.” Ramos v. Louisiana, 140 S. Ct. 1390, 1402 (2020) (Gor-
   such, J., plurality opinion). Anytime a fractured opinion arose, any Justice
   on the court could seize the opportunity to rewrite precedent, regardless of
   the disagreement of the rest of the Court. Indeed, in Hellerstedt, a majority
   of the Court explicitly declined to adopt the approach later favored by the
   Chief Justice in June Medical. Hellerstedt, 136 S. Ct. at 2309. The plurality
   allows this binding ruling to be disregarded based on the will of a single Jus-
   tice, which is far from what the Marks court intended when it said that a
   case’s holding can be ascertained when there is agreement on a dispositive
   point by a majority of Justices concurring in the judgment. Marks, 430 U.S.
   at 193.
             Thus, under our precedents, June Medical did not serve to displace
   the balancing test called for by Hellerstedt, which remains controlling law.
   The district court cited and applied the correct legal standard, and the en banc
   plurality errs by concluding otherwise.
                                           2.
             Before I proceed to an in-depth discussion of the en banc plurality’s
   further errors, it is worth noting that this should be an exceptionally easy case

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   even under the plurality’s preferred legal standard because the Supreme
   Court has already decided it. In Stenberg v. Carhart, the Supreme Court con-
   sidered a Nebraska statute that prohibited “deliberately and intentionally de-
   livering into the vagina a living unborn child, or a substantial portion thereof,
   for the purpose of performing a procedure that the person performing such
   procedure knows will kill the unborn child.” 530 U.S. 914, 938 (2000) (quot-
   ing NEB. REV. STAT. ANN. § 28–326(9)). Nebraska contended that the stat-
   ute was constitutional because it merely prohibited “dilation and extraction”
   (“D&X”) abortions, an alternative abortion method that is not implicated in
   the present case. But the Supreme Court struck down the Nebraska law spe-
   cifically because the text of the prohibition could reach the same common
   D&E procedure that SB8 bans. Stenberg, 530 U.S. at 938.
                    Evidence before the trial court makes clear that D & E
          will often involve a physician pulling a “substantial portion” of
          a still living fetus, say, an arm or leg, into the vagina prior to the
          death of the fetus. Indeed D & E involves dismemberment that
          commonly occurs only when the fetus meets resistance that re-
          stricts the motion of the fetus: The dismemberment occurs be-
          tween the traction of the instrument and the counter-traction
          of the internal os of the cervix. And these events often do not
          occur until after a portion of a living fetus has been pulled into
          the vagina. . . .
                  Even if the statute’s basic aim is to ban D & X, its lan-
          guage makes clear that it also covers a much broader category
          of procedures. . . . Both procedures can involve the introduc-
          tion of a “substantial portion” of a still living fetus, through the
          cervix, into the vagina[.]
          ....
                 In sum, using this law some present prosecutors and fu-
          ture Attorneys General may choose to pursue physicians who
          use D & E procedures, the most commonly used method for

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           performing previability second trimester abortions. All those
           who perform abortion procedures using that method must fear
           prosecution, conviction, and imprisonment. The result is an
           undue burden upon a woman’s right to make an abortion deci-
           sion. We must consequently find the statute unconstitutional.
   Id. at 938-39, 945 (internal citations and alterations omitted).
           The Supreme Court explicitly stated that banning the performance of
   a standard D&E, which it repeatedly emphasized involved the evacuation of
   a living fetus in which fetal demise has not yet been induced, resulted in an
   undue burden and was therefore constitutionally impermissible. The Court
   declared the Nebraska law unconstitutional because it could be interpreted
   to include such a ban. See id. at 945. What the Nebraska statute could be
   read to extend to, SB8 does directly, targeting and prohibiting the standard
   D&E procedure. And it is no answer that SB8’s prohibition may be evaded
   through the various fetal demise techniques the State advocates, for the Ne-
   braska law, which only applied to procedures involving a “living unborn
   child,” id. at 922, could have been avoided through the same means. The
   Supreme Court specifically noted that “[s]ome physicians . . . induce fetal
   demise prior to a late D & E (after 20 weeks),” id. at 925, but the possibility
   was immaterial to the Supreme Court’s decision, which should dictate ours.
   If the Nebraska law was unconstitutional, it necessarily follows that SB8 is as
   well.
           Sixteen years prior to Hellerstedt, employing the legal standard that
   the en banc plurality contends June Medical restored, the Supreme Court held
   that prohibiting a standard D&E imposed an undue burden on a woman’s

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   constitutional right to abortion. This is precisely what SB8 does, and that
   should be the end of this case. 5
                                               3.
           Nonetheless, the plurality ignores the binding Stenberg precedent that
   should mandate the resolution of this case under any legal standard, and in-
   stead contends that the district court committed a host of additional legal er-
   rors unrelated to the Marks question. None of these assertions withstand
   even a cursory examination. The plurality argues that the district court com-
   mitted what it characterizes as legal errors by failing to credit a number of the
   State’s valid interests in enacting SB8. The district court did not fail to do
   so, but merely determined either that SB8 failed to advance those interests
   or that they were not sufficient to outweigh the burdens that SB8 imposes on
   access to previability abortion.

           5
              The plurality mischaracterizes Stenberg’s holding as resting “primarily” on the
   Nebraska law’s lack of a health exception. Plurality at 25 n.18. However, the Court said
   explicitly in Stenberg that the Nebraska law was unconstitutional “for at least two
   independent reasons.” 530 U.S. at 930 (emphasis added). The first independent reason
   was the lack of a health exception. Id. But the Court’s second independent reason was that
   the law “‘impos[ed] an undue burden on a woman’s ability’ to choose a D & E abortion,
   thereby unduly burdening the right to choose abortion itself.” Id. (quoting Casey, 505 U.S.
   at 874). This was so, the Court explained, because D&E was “the most commonly used
   method for performing previability second trimester abortions.” Id. at 945. Thus, Stenberg
   is clear that if a state law unduly burdens “the most commonly used method for performing
   previability second trimester abortions” than “[t]he result is an undue burden upon a
   woman’s right to make an abortion decision.” Id. at 945-46. That is the precise situation
   that we are presented with in evaluating SB8, because, as a factual matter, D&E remains
   the most commonly used method for performing previability second trimester abortions.
   The conclusion that SB8 is unconstitutional is not based on a comparison to “abortion
   standards from the last century” and does not require one to “disavow” medical progress.
   See Plurality at 25 n.18. Rather, this conclusion is based on a straight-forward application
   of the Supreme Court’s precedential Stenberg holding to the facts of the present case. 530
   U.S. at 945-46.

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          The plurality claims that the district court erred by treating the State’s
   interest in preserving fetal life as “only [a] marginal consideration” that has
   “its primary application once the fetus is capable of living outside the
   womb.” Plurality at 14; see Whole Woman’s Health, 280 F. Supp. 3d at 953.
   Similarly, it faults the district court for stating that a woman’s right to a previ-
   ability abortion is “absolute.” Plurality at 17-18; see Whole Woman’s Health,
   280 F. Supp. 3d at 953. As a threshold matter, these offhand and isolated
   statements are gleaned from the conclusion of the district court’s memoran-
   dum opinion, and there is no sign that the district court materially relied upon
   them in its substantive reasoning. Moreover, the district court said little
   more than the Supreme Court stated in Casey, in a passage that the plurality
   conveniently omits from its description of that case’s holding: “Before via-
   bility, the State’s interests are not strong enough to support a prohibition of
   abortion or the imposition of a substantial obstacle to the woman’s effective
   right to elect the procedure.” 505 U.S. at 846; see Plurality at 8. In other
   words, a woman’s right to a previability abortion is absolute in the sense that
   a state’s interests are never enough to justify its placing an undue burden on
   her exercise of that right. Casey, 505 U.S. at 846. Thus, the district court
   was correct that, prior to viability, the State’s interest in protecting fetal life
   is necessarily outweighed by a woman’s right to obtain an abortion free from
   any substantial obstacle imposed by state regulation. As the district court
   stated, “The State’s valid interest in promoting respect for the life of the un-
   born, although legitimate, is not sufficient to justify such a substantial obsta-
   cle to the constitutionally protected right of a woman to terminate a preg-
   nancy before fetal viability.” 280 F. Supp. 3d at 953.
          The plurality also contends that the district court failed to credit sev-
   eral additional interests the State asserted SB8 serves, including the physical
   and psychological benefits to a woman’s health that result from inducing fetal
   demise prior to evacuation, the provision of dignity in death to fetuses

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   immediately prior to the second phase of the D&E procedure, the promotion
   of societal and medical ethics, and ensuring women give informed consent to
   abortions. Plurality at 14-17. But that the State contended that SB8 pro-
   moted these interests does not mean the district court was required to find
   that it was so.
           As I have stated, the district court conducted an extensive hearing and
   reviewed voluminous evidence to make its factual findings. The plurality
   cherry picks evidence in the record stating that some women feel better
   knowing that fetal demise occurred prior to the evacuation phase of a D&E,
   but the district court also heard evidence of the painful, invasive, and risky
   techniques that must be used to induce fetal demise. The district court ulti-
   mately concluded that, on balance, “pre-evacuation fetal demise provides no
   additional medical benefit to a woman undergoing a standard D & E abor-
   tion.” 6 Whole Woman’s Health, 280 F. Supp. 3d at 948. As has been stated

           6
              The plurality chides the district court at length for relying on the decisions of
   other courts considering similar laws, including the well-reasoned opinion in West Alabama
   Women’s Center v. Miller, in which a district court struck down virtually identical legislation
   to SB8. 299 F. Supp. 3d 1244, 1268 (M.D. Ala. 2017), aff’d sub nom. W. Alabama Women's
   Ctr. v. Williamson, 900 F.3d 1310 (11th Cir. 2018). The plurality states the district court
   “should have relied on the voluminous and comprehensive record before it, not other
   courts’ opinions with materially different record.” Plurality at 21 n.15. But the plurality
   fails to heed its own advice and extensively relies on off-hand statements in Stenberg v. Car-
   hart, 530 U.S. 914, 925 (2000), and Gonzales v. Carhart, 550 U.S. 124, 136 (2007), to claim
   that independently inducing fetal demise is both widely practiced and can potentially make
   a D&E easier in various ways. Plurality at 24-26. Needless to say, the prevalence and rel-
   ative advantages of various methods of conducting a complex modern medical procedure
   are not the type of widely known and uncontroversial facts of which we may take judicial
   notice, let alone from sources more than a decade-and-a-half old. See Fed. R. Evid.
   201(b). Based on a wealth of scientific literature and expert testimony, the district court in
   this case found that “pre-evacuation fetal demise provides no additional medical benefit to
   a woman undergoing a standard D & E abortion,” Whole Woman’s Health v. Paxton, 280 F.
   Supp. 3d 938, 948 (W.D. Tex. 2017), and the plurality points to no evidence in the record
   of this case compelling enough to make that finding clearly erroneous.

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   repeatedly, weighing conflicting evidence, judging credibility, and making
   factual determinations about the effects of a medical procedure are the prov-
   ince of a district court, and the evidence on this point contained in the record
   is far from so one-sided as to render the district court’s determination im-
   plausible.
           Similarly, the district court found that, unlike any other medical regu-
   lation, SB8 “requires a doctor—in contravention of the doctor’s medical
   judgment and the best interest of the patient—to conduct a medical proce-
   dure that delivers no benefit to the woman.” Id. at 953. It further found that,
   in some cases, the techniques for inducing fetal demise advocated by the
   State were experimental and without clear evidence as to their safety or effi-
   cacy. Id. at 949. As will be discussed in more detail below, these findings are
   supported by the record, and thus the district court committed no error in
   finding that, on balance, SB8 is inconsistent with principles of medical ethics
   and did not further any state interest in protecting the integrity of the profes-
   sion.
           The plurality also mischaracterizes the district court’s consideration
   of the State’s interest in protecting the dignity of fetuses. It contends that
   the district court stated that “the State’s interest ‘does not add weight to tip
   the balance in the State’s favor.’” Plurality at 16. But the district court’s
   memorandum opinion says just the opposite: “The evidence before the court
   is graphic and distasteful. But this evidence is germane only to the State’s
   interest in the dignity of fetal life and is weighed on the State’s side of the
   scale.” Whole Woman’s Health, 280 F. Supp. 3d at 947. The district court
   merely reasoned that “[a]n abortion always results in the death of a fetus,”
   “[t]he extraction of the fetus from the womb occurs in every abortion,” and
   “[d]ismemberment of the fetus is the inevitable result.” Id. Thus, the court
   found that any increase in fetal dignity afforded by SB8 over the standard

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   D&E procedure was marginal, and thus it was not enough to “tip the balance
   in the State’s favor.” Id. The district court did not err by so finding.
          Finally, the plurality’s reasoning as to how SB8 promotes informed
   consent is circuitous and puzzling. As the plurality concedes, the law says
   nothing regarding what information about the procedure abortion providers
   are required to convey to patients. Plurality at 16. Instead, if I understand
   the en banc plurality correctly, it is arguing that SB8 furthers the interest of
   informed consent by bringing the D&E procedure more into line with
   women’s expectations. In support of this, the plurality posits that “[w]omen
   who receive live-dismemberment D&Es are not being told what is going to
   happen to the fetus.” Plurality at 17.
          First, this is clearly the type of factual finding that appellate courts are
   ill-suited to make, and it is based on little more than the plurality’s supposi-
   tion. The plurality cites various abortion-provider consent forms that were
   introduced into evidence, and it seems to contend that the forms are mislead-
   ing because they describe the procedure in accurate, clinical terms rather
   than containing a graphic and disparaging description that condemns the pro-
   cedure as barbaric. Plurality at 17. And the plurality points to no evidence in
   the record regarding what further details are conveyed to patients orally and
   through other materials, and the district court made findings on neither this
   point nor what women generally believe occurs during an abortion prior to
   receiving information on the procedure.
          Moreover, it is unclear that SB8 would in fact bring the abortion pro-
   cedure more in line with patients’ expectations even accepting the plurality’s
   contentions. The district court found that the women whom SB8 affected
   would be “in a unique position” because no other “medical context” re-
   quires a doctor to perform an unnecessary procedure that the doctor believes
   is contrary to the patient’s best interests. Whole Woman’s Health, 280 F.

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   Supp. 3d at 953. A reasonable inference from this finding is that, even if
   women do not expect fetal demise to specifically occur as a result of the evac-
   uation procedure, they likewise do not expect a doctor to perform an extra
   step that the doctor considers unnecessary and liable to expose the patient to
   additional risk without any reciprocal medical benefit. Further, SB8 imposes
   certain procedures regardless of the choice reached by a woman through dis-
   cussion and consultation with her physician—hardly a situation that respects
   a patient’s informed consent. Thus, the district court did not err in finding
   that SB8 does not on balance promote informed consent, and therefore this
   interest does not add any weight to the benefit side of the equation.
                                           4.
          The en banc plurality next misrepresents the district court’s analysis
   to claim that the district court placed the burden of proof on the wrong party.
   Plurality at 18. The plurality’s entire basis for this contention is that, in hold-
   ing SB8 unconstitutional, the district court relied in part on the fact that a
   standard D&E without the separate step of inducing fetal demise is the most
   commonly used method of surgical abortion in Texas and nationally. Accord-
   ing to the plurality, the district court was permitting abortion providers to
   “set their own rules” and “self-legislate or self-regulate simply by making an
   abortion method ‘common.’” Plurality at 18. But this totally misconstrues
   the district court’s reasoning, which merely considered what proportion of
   abortions would be affected by SB8 in evaluating the burden the legislation
   places on a woman’s right to choose.
          As the district court explicitly noted, the Supreme Court has em-
   ployed this exact analysis in landmark abortion-rights cases. See Whole
   Woman’s Health, 280 F. Supp. 3d at 945 (citing Stenberg, 530 U.S. at 939). In
   Stenberg, the Court struck down a Nebraska abortion restriction specifically
   because it could be interpreted to prohibit “the most commonly used method

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   for performing previability second trimester abortions.” 530 U.S. at 945.
   Similarly, in Planned Parenthood of Central Missouri v. Danforth, the Court de-
   clared unconstitutional a Missouri ban on saline amniocentesis because, at
   the time, it was the “most commonly used” method of abortion “nationally
   by physicians after the first trimester.” 428 U.S. 52, 78 (1976); see also Gon-
   zales , 550 U.S. at 153, 165 (holding that the federal “Partial-Birth Abortion
   Act,” 18 U.S.C. § 1531, which banned the D&X procedure, did “not con-
   struct a substantial obstacle to the abortion right,” because the D&E proce-
   dure—the “most commonly used and generally accepted method” of second
   trimester abortions—remained available). The district court did not err by
   considering the ubiquity and general acceptance of D&E within the medical
   community in determining the degree of burden SB8 imposes on women’s
   constitutional right to obtain a previability abortion.
          The plurality also contends that the district court committed legal er-
   ror by incorrectly defining “substantial obstacle,” focusing on the district
   court’s statement that the term means “no more and no less than ‘of sub-
   stance.’” Plurality at 18-19; see Whole Woman’s Health, 280 F. Supp. 3d at
   944. But the district court’s incidental statement was part of its larger dis-
   cussion of the undue burden standard set forth in Hellerstedt. The sentences
   immediately preceding the excerpt on which the plurality wrongly focuses
   stated the correct standard in no uncertain terms: “Whether an obstacle is
   substantial—and a burden is therefore undue—must be judged in relation to
   the benefits that the law provides. Where a law’s burdens exceed its benefits,
   those burdens are by definition undue, and the obstacles they embody are by
   definition substantial.” Whole Woman’s Health, 280 F. Supp. 3d at 944 (cit-
   ing Hellerstedt, 136 S. Ct. at 2300, 2309-10, 2312, 2318). The district court
   determined that SB8 erected a substantial obstacle because any benefits from
   the law were significantly outweighed by the burdens it places on the consti-
   tutional right to a previability abortion, and there is no indication that the

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   incidental statement the plurality disfavors affected that analysis in the least.
   The plurality is thus also wrong to claim this was legal error.
                                                B.
           I now turn to the true gravamen of the plurality’s dispute with the dis-
   trict court: The plurality disagrees with the district court’s reading of the ev-
   idence regarding the burdens attendant to the various fetal-demise tech-
   niques that the State claims can be used to evade SB8’s prohibition.
           The plurality focuses on two potential fetal-demise methods, suction
   aspiration and digoxin injection, 7 and concludes that the district court clearly
   erred by finding that the techniques are not “safe, effective, and common-
   place.” Plurality at 22. Notably, we—an appellate court that generally
   should not make factual findings—seem to be the only federal court that has
   ever found that safe and effective means of complying with this sort of fetal-
   demise mandate exist, and at least two of our sister circuits have affirmed
   district courts that found that the methods being considered here are not safe
   or effective. See EMW Women’s Surgical Ctr. P.S.C., 960 F.3d at 807-08; W.
   Ala. Women’s Ctr., 900 F.3d at 1324-28; see also Glossip v. Gross, 576 U.S. 863,
   882 (2015) (“Our review is even more deferential where, as here, multiple
   trial courts have reached the same finding, and multiple appellate courts have
   affirmed those findings.”). At the risk of belaboring the point, the plurality
   repeats the errors of the past and does what a majority of the Supreme Court
   in June Medical, including Chief Justice Roberts, clearly told us not to do:
   Substitute our view of conflicting evidence for that of the district court and

           7
             The State also offered potassium-chloride injections and umbilical-cord transec-
   tion as possible methods of complying with SB8. Because the plurality does not rely on
   these possibilities, this dissent will not examine them at length. Suffice it to say, for the
   reasons found by the district court and discussed in the panel opinion, these options are
   even riskier and less feasible than the procedures the plurality contends are viable here.

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   displace its well-considered factual findings simply because we do not like the
   outcome. See June Med. Servs., L.L.C., 140 S. Ct. at 2121, 2124-25 (plurality
   opinion); id. at 2133-34, 2141 (Roberts, C.J., concurring).
          As I said at the outset, there is a “fundamental flaw” in the plurality’s
   description of these fetal-demise procedures as “alternatives.”           EMW
   Women’s Surgical Ctr. P.S.C., 960 F.3d at 798. Instead, they are, “by defini-
   tion, . . . additional procedures,” and “[a]dditional procedures, by nature,
   expose patients to additional risks and burdens.” Id.; see also, e.g., W. Ala.
   Women’s Ctr., 900 F.3d at 1326 (noting the State’s concession that fetal de-
   mise procedures “would always impose some increased health risks on
   women”). This fact alone—that an abortion restriction would require a
   woman to undergo a riskier procedure in order to procure an abortion—has
   been sufficient in other cases for the Supreme Court to conclude that the law
   was unconstitutional. See Danforth, 428 U.S. at 78-79 (invalidating an abor-
   tion restriction that “force[d] a woman and her physician to terminate her
   pregnancy by methods more dangerous to her health than the method out-
   lawed”); Gonzales, 550 U.S. at 161 (“The prohibition in the Act would be
   unconstitutional, under precedents we here assume to be controlling, if it
   ‘subject[ed] [women] to significant health risks.’” (alterations in original)
   (quoting Ayotte v. Planned Parenthood of N. New England, 546 U.S. 320, 327
   (2006))); see also Planned Parenthood of Cent. N.J. v. Verniero, 41 F. Supp. 2d
   478, 500 (D.N.J. 1998) (“By relegating physicians to the performance of
   more risk-laden abortion procedures, the Act imposes an undue burden on
   the woman’s constitutional right to terminate her pregnancy.”), aff’d sub
   nom. Planned Parenthood of Cent. N.J. v. Farmer, 220 F.3d 127 (3d Cir. 2000).
          Moreover, even if the mere existence of increased risk without any re-
   ciprocal medical benefit were not sufficient to invalidate SB8, the plurality
   errs here by doing its own fact finding and second-guessing the district

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   court’s assessment of the efficacy and degree of risk associated with these
   two techniques. I will consider each of them in turn.
                                           1.
          The plurality first contends that inducing fetal demise through suction
   aspiration is a viable method of complying with SB8. Plurality at 22-24. The
   plurality acknowledges that the district court did not make any factual find-
   ings on the feasibility of using suction to induce fetal demise after fifteen
   weeks’ gestation. Plurality at 24. But the plurality takes it upon itself to make
   the factual findings on this point that the district court did not, boldly declar-
   ing that the evidence in the voluminous record is so one-sided as to permit
   only one conclusion. Plurality at 37.
          As a threshold matter, neither the State nor the plurality contends that
   fetal demise can be induced by suction alone at or after seventeen weeks’ ges-
   tation. See Plurality at 24. Texas bans most abortions outright after twenty-
   two weeks, see TEX. HEALTH & SAFETY CODE § 171.044, and even under the
   plurality’s overly generous view of the evidence, suction would be a feasible
   method of inducing fetal demise for only two of the seven weeks during which
   most Texas D&Es are performed using forceps. Less than half of the fifteen-
   to-twenty-two-week abortions conducted in Texas in 2015 fell into this two-
   week period, and thus even the plurality admits that using only suction aspi-
   ration to induce fetal demise would not be feasible in the majority of abortions
   under consideration here. Plurality at 24.
          Moreover, as even one of the judges concurring in the judgment rec-
   ognizes, the actual evidence that suction alone can be used safely and effec-
   tively after fifteen week’s gestation is equivocal at best. The en banc plurality
   makes much of the fact that several witnesses stated that they had at points
   performed suction aspiration abortions after the fifteen-week point and could
   perhaps do so regularly if they were forced to under penalty of law. Plurality

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   at 23. But those same experts testified that it is unpredictable whether suc-
   tion will in fact work at this later stage and “suction alone is often not suffi-
   cient to complete the procedure.” One doctor explained that he generally
   does not know prior to beginning the D&E whether forceps will be required,
   and he has needed to resort to them in some instances as early as ten weeks’
   gestation. Another doctor explained that using suction becomes difficult as
   a practical matter around the fifteen-week point because the larger suction
   cannula that is needed to perform the procedure at that stage is unwieldy,
   which likely leads to an increased risk of injury to the patient undergoing the
   procedure. Additionally, several doctors testified that some women’s uter-
   ine anatomy may make the use of a suction cannula difficult or impossible,
   exposing those women to a heightened risk of injury if the doctor is forced to
   use only suction aspiration.
          In sum, the record at most suggests that, if forced, doctors might be
   able to employ suction aspiration alone to induce fetal demise in some cases
   after the fifteen-week mark, though doing so would often be contrary to their
   preferences, medical judgment, and the patients’ best interests. This evi-
   dence is hardly so compelling as to allow only one possible reading regarding
   the feasibility of using suction alone to induce fetal demise after fifteen
   weeks’ gestation, and the plurality errs by abandoning its proper role as an
   appellate court in order to make a factual finding on the matter. See Swint,
   456 U.S. at 292 (“[F]actfinding is the basic responsibility of district courts,
   rather than appellate courts, and . . . the Court of Appeals should not have
   resolved in the first instance this factual dispute which had not been consid-
   ered by the District Court.” (quoting DeMarco v. United States, 415 U.S. 449,
   450 n.* (1974))).

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                                          2.
          The en banc plurality also argues that abortion providers can safely and
   effectively cause in utero fetal demise prior to the evacuation phase of a
   D&E—and thereby avoid criminal sanctions for violating SB8—by injecting
   the chemical digoxin into the fetus or amniotic fluid.
          The plurality relies heavily on the fact that some abortion providers
   have a policy of using digoxin to induce fetal demise when performing later-
   term abortions, typically after eighteen or twenty weeks’ gestation at the ear-
   liest. Plurality at 26. In its medical wisdom, the plurality seems to say that
   what is good for the goose is good for the gander; what is fit for some later-
   term D&Es must be suitable for all forceps-assisted D&Es at all gestational
   stages. But this point is not the coup de grâce the plurality believes.
          First, the plurality greatly overstates the prevalence of the technique;
   only two out of the twenty-one clinics in Texas have a policy of using digoxin
   for their later-term abortions, and in 2015, the injections were employed in
   less than 200 of the 3,150 Texas abortions that were performed after fifteen
   weeks’ gestation. Moreover, as the plurality fully acknowledges, the abortion
   providers that do use digoxin injections when performing later-term abor-
   tions frequently do so in order to fully ensure compliance with 18 U.S.C.
   § 1531, the federal law that prohibits performing a D&X abortion, which is a
   procedure that can be done inadvertently during a standard D&E if a
   woman’s cervix dilates more than anticipated. Plurality at 32-33; see Gonza-
   les, 550 U.S. at 154. The plurality posits that, “[s]urely, no reasonable abor-
   tion provider would subject women to ‘significant’ health risks from digoxin
   just to avoid their own federal liability,” Plurality at 33, but this underscores
   precisely why SB8 would impose such a large burden on women’s abortion
   access. As doctors testified to repeatedly in this case, many abortion provid-
   ers do not perform these later-term abortions, and more would stop providing

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   earlier term abortions if they were forced to include an additional risky, inva-
   sive, painful, and medically unnecessary step in the procedure that is contrary
   to their medical judgment regarding the patient’s best interest.
          And digoxin injections are all those things. The method requires a
   physician to insert a 3- to 4-inch surgical “spinal” needle either transabdom-
   inally (through the woman’s abdomen) or transvaginally (through the vaginal
   wall or the cervix). Obviously, the injection is invasive and painful, and it
   often requires the patient to receive an additional numbing injection or to un-
   dergo intravenous sedation. The plurality makes little effort to claim other-
   wise, stating only that anesthetic is available and, according to the reassur-
   ances one abortion provider gives in an effort to settle patients’ fears, the pain
   will fade quickly. Plurality at 27. As should be apparent, the administering
   of additional anesthetic and sedation can itself be quite painful and invasive,
   and it inherently imposes additional health risks.
          But the burdens imposed by digoxin injections are not limited to those
   associated with the immediate discomfort of the procedure. There was mul-
   titudinous evidence and expert testimony at trial that digoxin injections carry
   significant health risks as compared to a D&E procedure performed without
   the injections, including a heightened risk of infection, bleeding, tachycardia,
   nausea, vomiting, dizziness, fainting, and even extramural delivery—the un-
   expected and spontaneous expulsion of the fetus from the uterus while the
   woman is outside of a clinical setting and without the aid of a medical profes-
   sional. One study from the record found that the risk of hospitalization is six
   times greater when digoxin injections are administered than when a standard
   D&E is performed without the injections. One doctor testified that he had
   discontinued a policy of administering digoxin like the ones the en banc plu-
   rality cites specifically because of concern over the health risks associated
   with the unnecessary and nonbeneficial procedure. Digoxin injections are
   also contraindicated or outright impossible to administer to patients with

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   certain conditions who collectively account for a large portion of the popula-
   tion, including those with heart conditions, certain fetal or uterine anatomy,
   and even obesity and fibroids. The plurality dismisses these latter concerns
   by stating that a D&E itself might be unsafe for women with these conditions,
   citing a passage from an abortion provider’s documentation that states these
   are “special conditions requiring special evaluation and management.” Plu-
   rality at 27 n.19. But that special measures may need to be employed to per-
   form a D&E safely on women with these conditions has no bearing on
   whether this procedure—digoxin injections—can ever be safely administered
   to these women. The plurality reverses the district court’s factual finding
   that the use of digoxin carries “significant health risk” not simply on the basis
   of conflicting evidence, which we are not supposed to do, but against the
   overwhelming weight of the evidence in the record.
          Digoxin, moreover, fails to actually induce fetal demise about 5-10% of
   the time, with its effectiveness dependent on variables such as uterine anat-
   omy and fetal positioning. The plurality hand waves away this fact—that as
   many as one-in-ten digoxin injections expose a woman to a painful, invasive,
   and risky technique without even accomplishing the central goal of the pro-
   cedure. Plurality at 27-28. Doctors can simply try again with a second injec-
   tion, the Plurality states. But the plurality fails to acknowledge that, in addi-
   tion to the pain and health risks normally associated with an initial digoxin
   injection, there is no documented testing regarding the efficacy and safety of
   administering a second injection; in fact, every abortion provider who testi-
   fied in this case stated that, because of this unknown risk, they do not employ
   a second digoxin injection if the first one fails. Instead, they currently simply
   proceed with a standard D&E when a digoxin injection does not induce fetal
   demise, a fallback measure that SB8 criminalizes. In a sizable number of
   cases, then, SB8 would require doctors to undertake a wholly experimental

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   second digoxin injection that they presently deem too dangerous to adminis-
   ter.
          Similarly, as the district court observed, nearly every study in the rec-
   ord concerning the safety and efficacy of digoxin injections included only
   pregnancies at or after eighteen weeks’ gestation, with only a few studies in-
   cluding cases at seventeen weeks. No study considered the efficacy, dosage,
   or safety of injecting digoxin into women before seventeen weeks’ gestation.
   Indeed, that no abortion providers administer digoxin prior to eighteen
   weeks’ gestation is a testament to how risky and untested the procedure is at
   these earlier stages, for many of the same § 1531-compliance concerns that
   exist after eighteen weeks’ gestation also exist before that point. In light of
   the lack of evidence regarding its safety, the district court found that requir-
   ing digoxin injections before eighteen weeks of pregnancy would subject
   women to an arguably experimental procedure without any counterbalancing
   medical benefit.
          The plurality calls these well-supported findings error, relying on
   statements in Gonzales that state legislatures enjoy substantial latitude to reg-
   ulate abortion where there is scientific uncertainty. Plurality at 30-32 (citing
   550 U.S. at 161-62, 166-67). First, the plurality once again repeats the mis-
   takes of the past. In Hellerstedt, the Supreme Court rebuked our court for
   relying on these same passages from Gonzales to declare that “medical un-
   certainty underlying a statute is for resolution by legislatures, not the
   courts.” 136 S. Ct. at 2309 (quoting Whole Woman’s Health v. Cole, 790 F.3d
   563, 587 (5th Cir. 2015)). A majority of the Supreme Court held this “artic-
   ulation of the relevant standard is incorrect,” and stated clearly that courts
   should not defer to legislatures or refrain from making findings based on con-
   flicting scientific evidence when Constitutional rights are at issue: “The
   statement that legislatures, and not courts, must resolve questions of medical
   uncertainty is also inconsistent with this Court’s case law,” the Court

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    explained. Id. at 2310. Such deference wrongly “equate[s] the judicial re-
    view applicable to the regulation of a constitutionally protected personal lib-
    erty with the less strict review applicable where, for example, economic leg-
    islation is at issue.” Id. at 2309. Instead, “[c]ourt[s] retain[] an independent
    constitutional duty to [make and] review factual findings where constitu-
    tional rights are at stake.” 8 Id. at 2310 (quoting Gonzales, 550 U.S. at 165).
    That is exactly what the district court did here, finding that the wholly un-
    known risks associated with the digoxin protocols the State advocates would
    be a burden to the health and well-being of women who seek abortions.
            Moreover, the situation we are presented with is materially different
    from Gonzales. As the plurality states, the record in Gonzales contained con-
    flicting expert testimony and other evidence about the safety of D&X abor-
    tions and available alternatives. Plurality at 30 (citing 550 U.S. at 161). Here,
    the record contains no evidence about the safety of employing a second di-
    goxin injection or administering digoxin prior to seventeen weeks’ gestation,
    and a plethora of evidence stating that doctors currently refrain from doing
    so because of the risks associated with performing an untested procedure.
    Indeed, the only evidence the plurality can point to is one expert’s mention
    of a study that the author has since publicly acknowledged contained incor-
    rect information regarding the gestation age at which digoxin was used. Plu-
    rality at 32 & n. 22. Aside from this information that the plurality concedes
    is erroneous, the plurality offers only one expert’s comment that he knows of
    doctors who have employed digoxin before eighteen weeks, which is not re-
    motely probative of whether it is in fact safe and effective to do so.

            8
               For this same reason, the plurality and concurrence’s contentions regarding the
    possibility that SB8 guards against fetal pain are misplaced. The majority of the scientific
    literature and expert testimony in the record indicates that fetal pain is not possible at these
    early stages of development, and the district court was well within its rights to so find.

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           The plurality further faults the district court’s well-supported finding
    that employing a digoxin injection generally adds a day to what is typically a
    one-day procedure, again doing its own fact finding to imagine various sce-
    narios where this might not be the case. Plurality at 28-29. It further states
    that it was error for the district court to even consider this matter as a burden
    on abortion access, citing the Supreme Court’s upholding of mandatory wait-
    ing periods and other regulations that by their nature cause a delay in a
    woman receiving an abortion. Plurality at 29 (citing Casey, 505 U.S. at 885-
    86). But this misses the point. The delay occasioned by requiring digoxin
    injections is only one of the burdens on abortion access that would result from
    requiring the technique. The district court did not err by holding that, when
    this delay is considered together with the increased travel and other financial
    costs it leads to, and in conjunction with the painful and invasive nature of
    the procedure, its significant health risks, and its lack of consistent efficacy,
    the burdens add up to a substantial obstacle—particularly when viewed in
    light of the total absence of medical benefit associated with the technique.
           Based on the pain and invasiveness of the procedure, the delay in care
    and logistical difficulties it necessitates, its unreliability, the unknown risks
    for women before eighteen weeks’ gestation, and the known heightened risk
    of complication in all instances, the district court found that digoxin is not a
    safe and viable method of inducing fetal demise before the evacuation phase
    of a D&E abortion. These findings, along with those regarding the unfeasi-
    bility of other methods of inducing fetal demise, are all very well supported
    by the record, and the plurality errs by substituting its own findings for those
    of the district court. See Anderson, 470 U.S. at 574 (stating that, as an appel-
    late court, even if we disagree with the findings below, we cannot reverse
    them so long as they are based on a “permissible view[ ] of the evidence”).

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                                                C.
            Lastly, the plurality contests the district court’s large-fraction analy-
    sis, variously claiming that the court “bungl[ed]” and “botched” the evalu-
    ation. Plurality at 3, 33. But the plurality’s analysis is itself riddled with er-
    rors and predicated on its unsupported assumptions and faulty factual find-
    ings.
            The Supreme Court held in Casey that an abortion regulation is fa-
    cially unconstitutional if “it will operate as a substantial obstacle to a
    woman’s choice to undergo an abortion” in “a large fraction of the cases in
    which [it] is relevant.” 505 U.S. at 895. The Court reaffirmed and clarified
    that standard in Hellerstedt, in which it held that the phrase refers to a large
    fraction of “those women for whom the provision is an actual rather than an
    irrelevant restriction.” 136 S. Ct. at 2320 (alterations omitted) (quoting Ca-
    sey, 505 U.S. at 895). That category is narrower “than all women, pregnant
    women, or even women seeking abortions[.]” Id. (internal quotation marks
    omitted).
            Thus, the appropriate denominator—the number of women for whom
    SB8 is an actual rather than irrelevant restriction—is not “all women with
    fetuses in the gestational age of 15-22 weeks” as the plurality claims. Plural-
    ity at 34. For a great many of those women, SB8 is a totally “irrelevant re-
    striction.” Id. The vast majority are not seeking abortions, 9 and of that small

            9
               The plurality seems to acknowledge that these women are unaffected by SB8,
    stating in a footnote that “SB8 affects only abortions between 15 and 22 weeks[.]” Plurality
    at 33 n.23 (emphasis added). The plurality also misrepresents the district court’s finding
    on this matter, which was not that SB8 affected “only women with fetuses at the gestational
    age of 15-20 weeks.” Plurality at 33. Rather, the district court found that “the class of
    women here consists of all women in Texas who are 15 to 20 weeks pregnant and seek an
    outpatient second-trimester D & E abortion.” Whole Woman’s Health, 280 F. Supp. 3d at 952
    (emphasis added). At most, the district court’s formulation was slightly underinclusive in
    that some D&E abortions performed prior to fifteen weeks’ and from twenty to twenty-two

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    portion who are, some would undergo a procedure that would comply with
    SB8 in any event, even were the law not in effect. That is because, as the
    plurality relies on elsewhere in its opinion, some D&Es are currently per-
    formed through suction aspiration alone after fifteen weeks’ gestation and
    some D&Es are currently performed with digoxin injections after eighteen
    weeks’ gestation.
            Instead, the appropriate denominator is the class of women actually
    affected by SB8, which is composed of only those women who would undergo
    a forceps-assisted D&E in Texas without their doctors’ first inducing fetal
    demise in the absence of SB8. These are the only women “for whom the
    provision is an actual . . . restriction,” because these are the only women for
    whom SB8 mandates a change in the procedure they would otherwise un-
    dergo. Cf. Jackson Women’s Health Org, 945 F.3d at 276 (“The only women
    to whom the Act is an actual restriction, then, are those who seek abortions
    before 20 weeks; the Act is redundant of existing Mississippi law as to all
    abortions after that point.”). The plurality errs by defining the class far more
    broadly to include many women whose lives will never be the least bit im-
    pacted by SB8, regardless of whether the law goes into effect.
            The question, then, becomes what portion of the women who would
    otherwise receive SB8-noncompliant abortions are unduly burdened by the
    statute. As I have stated, under controlling precedent, this is the number of
    those women for whom the burdens SB8 imposes outweigh any benefits re-
    sulting from the law. Hellerstedt, 136 S. Ct. at 2300, 2309-10, 2312, 2318. In
    light of the district court’s well-supported findings that the fetal demise

    weeks’ gestation do not already comply with SB8 and slightly overinclusive in that some
    D&E abortions performed from fifteen to twenty weeks’ gestation are already SB8 compli-
    ant. But the district court’s analysis was far closer to the mark than the plurality’s, which
    includes a majority of women for whom SB8 is a wholly irrelevant restriction.

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    measures that these women must undergo to comply with SB8 expose the
    woman to risky, painful, invasive, and untested procedures; have no medical
    benefit for the patient; cause needless delay and increased financial costs; and
    only marginally advance the State’s interest in protecting and providing dig-
    nity to potential human life, it is clear that SB8’s burdens far outweigh its
    benefits in every such case. Cf. Jackson Women’s Health Org., 945 F.3d at
    276 (“Here, the Act is invalid as applied to every Mississippi woman seeking
    an abortion for whom the Act is an actual restriction, never mind a large frac-
    tion of them.”).
           The plurality declares that the district court erred by concluding the
    fraction of women for whom SB8 is both an actual restriction and an undue
    burden was 1/1. Plurality at 33. But when the matter is properly framed and
    the district court’s findings are given the appropriate deference, no other
    conclusion is possible.
                                          ***
           The plurality concludes its opinion by relisting the litany of mistakes
    it wrongfully attributes to the district court, none of which in fact occurred.
    Plurality at 37. And, underscoring its abdication of the role of an appellate
    court, it declines to order the remedy that would be proper if the district court
    had in fact misstepped in its analysis, which would be a remand for reconsid-
    eration in light of our clarification of the pertinent legal principles. The plu-
    rality instead renders judgment, stating that its view of the evidence is the
    only possible logical conclusion. For the above reasons, the plurality is
    wrong.
           The tendency of our court to eschew settled legal principles when
    abortion is involved has been documented and discussed elsewhere, see, e.g.,
    June Medical Services, L.L.C., 905 F.3d at 834-35 (Higginbotham, J. dissent-
    ing) (“[W]hen abortion shows up, application of the rules of law grows

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    opaque, a phenomenon not unique to this court.” (footnote omitted)), and
    there seems little need to reprise that debate now, for the matter speaks for
    itself. The district court’s legal rulings were correct, and its factual findings
    were not clearly erroneous. And while the plurality laments the amount of
    time SB8 has been enjoined, that is time in which women in Texas were
    shielded from the ill effects of a law that is clearly unconstitutional in light of
    Stenberg, 530 U.S. at 938-39, and the great burdens the statute places on abor-
    tion access with exceedingly few reciprocal benefits. That the shield is with-
    drawn today and that women in Texas will be forced to undergo invasive and
    unsafe techniques to exercise their constitutional right to an abortion—if it
    does not prevent their exercising that right altogether—is a devastating blow
    to their self-determination. I hope only that this opinion gives voice to a mod-
    icum of their frustration, anger, and pain. Once again, I respectfully but em-
    phatically dissent.

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    Stephen A. Higginson, Circuit Judge, joined by Costa, Circuit
    Judge, dissenting:
            I write separately to make two observations.
            First, given our court’s plurality opinion’s conclusion that the district
    court erred because it assessed SB8 under a “balancing test,” without the
    benefit of Chief Justice Roberts’ “narrower version (only burdens) of the
    plurality’s test (benefits and burdens),” 1 we should do no more than remand
    to the district court, confident that it will perform its role finding and
    applying facts to rules of law we clarify. This leaves us in our lane, not
    arrogating to ourselves the job district judges perform: above all weighing
    witness testimony, especially expert witness testimony, elicited by talented,
    opposing counsel during a week-long trial. Indeed, a circuit decision the
    plurality cites favorably, Hopkins v. Jegley, 968 F.3d 912, 916 (8th Cir. 2020),
    did just that—and we should do no more.
            Second, our court’s plurality opinion’s separate conclusion that the
    district court erred “under all of the Supreme Court’s precedents”—a
    contention I think is wrong—should be further reason for us to stay in our
    lane—i.e., error correction. 2 We should explain our distinguishing

            1
              This issue currently divides courts. Compare EMW Women’s Surgical Ctr., P.S.C.
    v. Friedlander, 978 F.3d 418, 433 (6th Cir. 2020) (“[T]he Chief Justice’s position is the
    narrowest under Marks. His concurrence therefore constitutes June Medical Services’
    holding and provides the governing standard here.” (cleaned up)), with Planned Parenthood
    of Ind. & Ky., Inc. v. Box, 991 F.3d 740, 748 (7th Cir.), petition for cert. filed, No. 20-1375
    (Mar. 29, 2021) (“[T]he Marks rule tells us that June Medical did not overrule Whole
    Woman’s Health.”).
            2
              I regret our court’s plurality opinion’s characterization of the district judge’s
    efforts—including that our colleague “disregarded and distorted the record,” “copied and
    pasted” the facts section of the court’s opinion, “failed to apprehend” the evidence before
    it, and “botched” a portion of its legal analysis. We weaken what we exaggerate. See
    Jean-Francois de La Harpe, Mélanie act 1, sc. 1 (1778).

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    interpretation of Supreme Court doctrine and, with rules of law clarified,
    return the case to the district court for it to perform its work applying facts
    assessed at trial to law we have clarified. Stated otherwise, what we should
    not do is what we recently were admonished not to do in June Medical Services
    v. Russo, 140 S. Ct. 2103, 2121, (2020): reweigh facts and witness credibility
    ourselves, here relying selectively on unspecified portions of transcripts from
    a five-day bench trial where plaintiffs’ expert testimony was heard, and
    credited or discredited, by a district judge present to observe witness
    demeanor. 3 See generally Aransas Project v. Shaw, 774 F.3d 324, 325-26, 331
    (5th Cir. 2014) (Prado, J., dissenting from denial of rehearing en banc).
    Regardless of the sensitivity and consequence of any issue that comes to us,
    our commitment must be to layered judicial responsibilities, where co-equal
    judges in courts of original jurisdiction adjudicate facts and we do our best
    not to do so but just to discern error under existing Supreme Court law.
            It goes without saying that our layer of responsibility starts and finishes
    with the primacy of the only Court the Framers contemplated, whose rulings
    we must unerringly follow. Especially when presented with facts we dislike,
    it can be tempting to arrogate to ourselves the task of constitutional revision,
    fractionally stepping ahead of, or nudging, the Supreme Court. 4                            The
    imperative, however, is the one followed by this district judge 5 and every

            3
             Notably, whereas our court’s plurality opinion gives repeated assurances about
    SB8’s limited impact, as well as assurances about permissible abortion alternatives, the
    Texas legislature set forth no such findings, indeed, it set forth no legislative findings at all.
            4
                Cf. Ruth Bader Ginsburg, Four Louisiana Giants in the Law, 48 Loy. L. Rev.
    253, 264 (2002) (applauding Judge Rubin’s vision and confidence that “courts need not
    follow . . . outgrown dogma,” yet acknowledging that only the Supreme Court may revise
    its interpretation of the Constitution).
            5
               Cf. Alvin B. Rubin, Views from the Lower Court, 23 UCLA L. Rev. 448, 452
    (1976) (“[A]n understandable desire to decide today’s case in accordance with the
    proclivities of the panel now sitting seems to lead to opinions that fail to accord to prior

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    court to have considered legislation like SB8. 6 He, they, and we are bound
    by existing Supreme Court law. Our court’s plurality opinion goes to pains
    to perceive nuance in Supreme Court precedent twice confirming that bans
    like SB8 are invalid, 7 as well as to subordinate to one final footnote
    acknowledgment of contrary circuit law. Suffice it to say, I agree with the
    consensus of courts that apply Supreme Court law to invalidate similar bans,
    leaving several judges on those courts free to regret the state of that law. 8
    Indeed, Justices themselves confirm and apply, as to this issue, that law even
    as they critique it 9—and we cannot do more.

    decisions the willing acceptance and wholehearted enforcement that trial judges are
    expected to accord appellate decisions.”).
            6
              EMW Women’s Surgical Ctr., P.S.C. v. Friedlander, 960 F.3d 785, 793 (6th Cir.
    2020) (affirming injunction and noting that “in every challenge brought to date [as to ten
    states’ similar laws], the court has enjoined the law, finding that it indeed unduly
    burdens”); W. Ala. Women’s Ctr. v. Williamson, 900 F.3d 1310, 1327 (11th Cir. 2018)
    (affirming injunction, also noting that “every court to consider the issue has ruled that laws
    banning dismemberment abortions are invalid and that fetal demise methods are not a
    suitable workaround”), cert. denied sub nom. Harris v. W. Ala. Women’s Ctr., 139 S. Ct. 2606
    (2019).
            7
              See Gonzales v. Carhart, 550 U.S. 124, 147, 150 (2007); Stenberg v. Carhart, 530
    U.S. 914 (2000).
            8
               E.g., W. Ala. Women’s Ctr. v. Williamson, 900 F.3d 1310, 1314 (11th Cir. 2018),
    cert. denied sub nom. Harris v. W. Ala. Women’s Ctr., 139 S. Ct. 2606 (2019) (Carnes, C.J.,
    writing for the majority) (“Some Supreme Court Justices have been of the view that there
    is constitutional law and then there is the aberration of constitutional law relating to
    abortion. If so, what we must apply here is the aberration.”); id. at 1329-30 (“In our judicial
    system, there is only one Supreme Court, and we are not it. . . . The primary factfinder is
    the district court, and we are not it. Our role is to apply the law the Supreme Court has laid
    down to the facts the district court found.”); id. at 1330 (Dubina, J., concurring) (“I am not
    on the Supreme Court, and as a federal appellate judge, I am bound by my oath to follow all
    of the Supreme Court’s precedents, whether I agree with them or not.”).
            9
              Harris v. W. Ala. Women’s Ctr., 139 S. Ct. 2606, 2607 (2019) (Thomas, J.,
    concurring in certiorari denial as to the Eleventh Circuit’s adherence to Stenberg and the

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    undue burden test to invalidate similar legislation while still offering sharp critique: “[W]e
    cannot continue blinking the reality of what this Court has wrought.”).

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