Court Opinion

ID: 9428060
Source: CourtListenerOpinion
Date Created: 2023-08-02 23:22:39.896014+00
Date Added: 2024-06-11T17:23:11.484006
License: Public Domain

Mr. Justice Brennan,
with whom Mr. Justice Marshall and Mr. Justice Blackmun join, dissenting.*
I agree entirely with my Brother Stevens that the State’s interest in protecting the potential life of the fetus cannot justify the exclusion of financially and medically needy women from the benefits to which they would otherwise be entitled solely because the treatment that a doctor has concluded is medically necessary involves an abortion. See post, at 351-352. I write separately to express my continuing disagreement 1 with the Court’s mischaracterization of the nature of the fundamental right recognized in Roe v. Wade, 410 U. S. 113 (1973), and its misconception of the manner in which that right is infringed by federal and state legislation withdrawing all funding for medically necessary abortions.
Roe v. Wade held that the constitutional right to personal privacy encompasses a woman’s decision whether or not to *330terminate her pregnancy. Roe and its progeny2 established that the pregnant woman has a right to be free from state interference with her choice to have an abortion — a right which, at least prior to the end of the first trimester, absolutely prohibits any governmental regulation of that highly personal decision.3 The proposition for which these cases stand thus is not that the State is under an affirmative obligation to ensure access to abortions for all who may desire them; it is that the State must refrain from wielding its enormous power and influence in a manner that might burden the pregnant woman’s freedom to choose whether to have an abortion. The Hyde Amendment’s denial of public funds for medically necessary abortions plainly intrudes upon this constitutionally protected decision, for both by design and in effect it serves to coerce indigent pregnant women to bear children that they would otherwise elect not to have.4
*331When viewed in the context of the Medicaid program to which it is appended, it is obvious that the Hyde Amendment is nothing less than an attempt by Congress to circumvent the dictates of the Constitution and achieve indirectly what Roe v. Wade said it could not do directly.5 Under Title XIX of the Social Security Act, the Federal Government reimburses participating States for virtually all medically necessary services it provides to the categorically needy. The sole limitation of any significance is the Hyde Amendment’s prohibition against the use of any federal funds to pay for the *332costs of abortions (except where the life of the mother would be endangered if the fetus were carried to term). As my Brother Stevens persuasively demonstrates, exclusion of medically necessary abortions from Medicaid coverage cannot be justified as a cost-saving device. Rather, the Hyde Amendment is a transparent attempt by the Legislative Branch to impose the political majority’s judgment of the morally acceptable and socially desirable preference on a sensitive and intimate decision that the Constitution entrusts to the individual. Worse yet, the Hyde Amendment does not foist that majoritarian viewpoint with equal measure upon everyone in our Nation, rich and poor alike; rather, it imposes that viewpoint only upon that segment of our society which, because of its position of political powerlessness, is least able to defend its privacy rights from the encroachments of state-mandated morality. The instant legislation thus calls for more exacting judicial review than in most other cases. “When elected leaders cower before public pressure, this Court, more than ever, must not shirk its duty to enforce the Constitution for the benefit of the poor and powerless.” Beal v. Doe, 432 U. S. 438, 462 (1977) (Marshall, J., dissenting). Though it may not be this Court’s mission “to decide whether the balance of competing interests reflected in the Hyde Amendment is wise social policy,” ante, at 326, it most assuredly is our responsibility to vindicate the pregnant woman’s constitutional right to decide whether to bear children free from governmental intrusion.
Moreover, it is clear that the Hyde Amendment not only was designed to inhibit, but does in fact inhibit the woman’s freedom to choose abortion over childbirth. “Pregnancy is unquestionably a condition requiring medical services. . , . Treatment for the condition may involve medical procedures for its termination, or medical procedures to bring the pregnancy to term, resulting in a live birth. ‘[A]bortion and childbirth, when stripped of the sensitive moral arguments surrounding the abortion controversy, are simply two alter*333native medical methods of dealing with pregnancy. . . .’” Beal v. Doe, supra, at 449 (Brennan, J., dissenting) (quoting Roe v. Norton, 408 F. Supp. 660, 663, n. 3 (Conn. 1975)). In every pregnancy, one of these two courses of treatment is medically necessary, and the poverty-stricken woman depends on the Medicaid Act to pay for the expenses associated with that procedure. But under the Hyde Amendment, the Government will fund only those procedures incidental to childbirth. By thus injecting coercive financial incentives favoring childbirth into a decision that is constitutionally guaranteed to be free from governmental intrusion, the Hyde Amendment deprives the indigent woman of her freedom to choose abortion over maternity, thereby impinging on the due process liberty right recognized in Roe v. Wade.
The Court’s contrary conclusion is premised on its belief that “[t]he financial constraints that restrict an indigent woman’s ability to enjoy the full range of constitutionally protected freedom of choice are the product not of governmental restrictions on access to abortions, but rather of her indigency.” Ante, at 316. Accurate as this statement may be, it reveals only half the picture. For w.hat the Court fails to appreciate is that it is not simply the woman’s indigency that interferes with her freedom of choice, but the combination of her own poverty and the Government’s unequal subsidization of abortion and childbirth.
A poor woman in the early stages of pregnancy confronts two alternatives: she may elect either to carry the fetus to term or to have an abortion. In the abstract, of course, this choice is hers alone, and the Court rightly observes that the Hyde Amendment “places no governmental obstacle in the path of a woman who chooses to terminate her pregnancy.” Ante, at 315. But the reality of the situation is that the Hyde Amendment has effectively removed this choice from the indigent woman’s hands. By funding all of the expenses associated with childbirth and none of the expenses incurred in terminating pregnancy, the Government literally makes an *334offer that the indigent woman cannot afford to refuse. It matters not that in this instance the Government has used the carrot rather than the stick. What is critical is the realization that as a practical matter, many poverty-stricken women will choose to carry their pregnancy to term simply because the Government provides funds for the associated medical services, even though these same women would have chosen to have an abortion if the Government had also paid for that option, or indeed if the Government had stayed out of the picture altogether and had defrayed the costs of neither procedure.
The fundamental flaw in the Court’s due process analysis, then, is its failure to acknowledge that the discriminatory distribution of the benefits of governmental largesse can discourage the exercise of fundamental liberties just as effectively as can an outright denial of those rights through criminal and regulatory sanctions. Implicit in the Court’s reasoning is the notion that as long as the Government is not obligated to provide its citizens with certain benefits or privileges, it may condition the grant of such benefits on the recipient’s relinquishment of his constitutional rights.
It would belabor the obvious to expound at any great length on the illegitimacy of a state policy that interferes with the exercise of fundamental rights through the selective bestowal of governmental favors. It suffices to note that we have heretofore never hesitated to invalidate any scheme of granting or withholding financial benefits that incidentally or intentionally burdens one manner of exercising a constitutionally protected choice. To take but one example of many, Sherbert v. Verner, 374 U. S. 398 (1963), involved a South Carolina unemployment insurance statute that required recipients to accept suitable employment when offered, even if the grounds for refusal stemmed from religious convictions. Even though the recipients possessed no entitlement to compensation, the Court held that the State could not cancel the *335benefits of a Seventh-Day Adventist who had refused a job requiring her to work on Saturdays. The Court’s explanation is particularly instructive for the present case:
“Here not only is it apparent that appellant’s declared ineligibility for benefits derives solely from the practice of her religion, but the pressure upon her to forego that practice is unmistakable. The ruling forces her to choose between following the precepts of her religion and forfeiting benefits, on the one hand, and abandoning one of the precepts of her religion in order to accept work, on the other hand. Governmental imposition of such a choice puts the same kind of burden upon the free exercise of religion as would a fine imposed against appellant for her Saturday worship.
“Nor may the South Carolina court’s construction of the statute be saved from constitutional infirmity on the ground that unemployment compensation benefits are not appellant’s ‘right’ but merely a ‘privilege.’ It is too late in the day to doubt that the liberties of religion and expression may be infringed by the denial of or placing of conditions upon a benefit or privilege. . . . [T]o condition the availability of benefits upon this appellant’s willingness to violate a cardinal principle of her religious faith effectively penalizes the free exercise of her constitutional liberties.” Id., at 404-406.
See also Frost & Frost Trucking Co. v. Railroad Comm’n, 271 U. S. 583 (1926); Speiser v. Randall, 357 U. S. 513 (1958); Elfbrandt v. Russell, 384 U. S. 11 (1966); Goldberg v. Kelly, 397 U. S. 254 (1970); U. S. Dept. of Agriculture v. Moreno, 413 U. S. 528 (1973); Southeastern Promotions, Ltd. v. Conrad, 420 U. S. 546 (1975). Cf. Shapiro v. Thompson, 394 U. S. 618 (1969); Memorial Hospital v. Maricopa County, 415 U. S. 250 (1974).
The Medicaid program cannot be distinguished from these other statutory schemes that unconstitutionally burdened *336fundamental rights.6 Here, as in Skerbert, the government withholds financial benefits in a manner that discourages the exercise of a due process liberty: The indigent woman who chooses to assert her constitutional right to have an abortion can do so only on pain of sacrificing health-care benefits to which she would otherwise be entitled. Over 50 years ago, Mr. Justice Sutherland, writing for the Court in Frost & Frost Trucking Co. v. Railroad Comm’n, supra, at 593-594, made the following observation, which is as true now as it was then:
“It would be a palpable incongruity to strike down an act of state legislation which, by words of express divestment, seeks to strip the citizen of rights guaranteed by the federal Constitution, but to uphold an act by *337which the same result is accomplished under the guise of a surrender of a right in exchange for a valuable privilege which the state threatens otherwise to withhold. It is not necessary to challenge the proposition that, as a general rule, the state, having power to deny a privilege altogether, may grant it upon such conditions as it sees fit to impose. But the power of the state in that respect is not unlimited; and one of the limitations is that it may not impose conditions which require the relinquishment of constitutional rights. If the state may Compel the surrender of one constitutional right as a condition of its favor, it may, in like manner, compel a surrender of all. It is inconceivable that guaranties embedded in the Constitution of the United States may thus be manipulated out of existence.”
I respectfully dissent.

 See Maher v. Roe, 432 U. S. 464, 482-490 (1977) (Brennan, J., dissenting).

 E. g., Doe v. Bolton, 410 U. S. 179 (1973); Planned Parenthood of Central Missouri v. Danforth, 428 U. S. 52 (1976); Singleton v. Wulff, 428 U. S. 106 (1976); Bellotti v. Baird, 443 U. S. 622 (1979); cf. Carey v. Population Services International, 431 U. S. 678 (1977).

 After the first trimester, the State, in promoting its interest in the mother’s health, may regulate the abortion procedure in ways that are reasonably related to that end. And even after the point of viability is reached, state regulation in furtherance of its interest in the potentiality of human life may not go so far as to proscribe abortions that are necessary to preserve the life or health of the mother. See Roe v. Wade, 410 U. S. 113, 164-165 (1973).

 My focus throughout this opinion is upon the coercive impact of the congressional decision to fund one outcome of pregnancy — childbirth— while not funding the other — abortion. Because I believe this alone renders the Hyde Amendment unconstitutional, I do not dwell upon the other disparities that the Amendment produces in the treatment of rich and poor, pregnant and nonpregnant. I concur completely, however, in my Brother Stevens’ discussion of those disparities. Specifically, I agree that the congressional decision to fund all medically necessary procedures except for those that require an abortion is entirely irrational either as a means of allocating health-care resources or otherwise serving legitimate social welfare goals. And that irrationality in turn exposes the Amend*331ment for what it really is — a deliberate effort to discourage the exercise of a constitutionally protected right.
It is important to put this congressional decision in human terms. Nonpregnant women may be reimbursed for all medically necessary treatments. Pregnant women with analogous ailments, however, will be reimbursed only if the treatment involved does not happen to include an abortion. Since the refusal to fund will in some significant number of cases force the patient to forgo medical assistance, the result is to refuse treatment for some genuine maladies not because they need not be treated, cannot be treated, or are too expensive to treat, and not because they relate to a deliberate choice to abort a pregnancy, but merely because treating them would as a practical matter require termination of that pregnancy. Even were one of the view that legislative hostility to abortions could justify a decision to fund obstetrics and child delivery services while refusing to fund nontherapeutic abortions, the present statutory scheme could not be saved. For here, that hostility has gone a good deal farther. Its consequence is to leave indigent sick women without treatment simply because of the medical fortuity that their illness cannot be treated unless their pregnancy is terminated. Antipathy to abortion, in short, has been permitted not only to ride roughshod over a woman’s constitutional right to terminate her pregnancy in the fashion she chooses, but also to distort our Nation’s health-care programs. As a means of delivering health services, then, the Hyde Amendment is completely irrational. As a means of preventing abortions, it is concededly rational— brutally so. But this latter goal is constitutionally forbidden.

 Cf. Singleton v. Wulff, supra, at 118-119, n. 7:
“For a doctor who cannot afford to work for nothing, and a woman who cannot afford to pay him, the State’s refusal to fund an abortion is as effective an 'interdiction’ of it as would ever be necessary.”

 The Court rather summarily rejects the argument that the Hyde Amendment unconstitutionally penalizes the woman’s exercise of her right to choose an abortion with the comment that “[a] refusal to fund protected activity, without more, cannot be equated with the imposition of a ‘penalty’ on that activity.’’ Ante, at 317, n. 19. To begin with, the Court overlooks the fact that there is “more” than a simple refusal to fund a protected activity in this case; instead, there is a program that selectively funds but one of two choices of a constitutionally protected decision, thereby penalizing the election of the disfavored option.
Moreover, it is no answer to assert that no “penalty” is being imposed because the State is only refusing to pay for the specific costs of the protected activity rather than withholding other Medicaid benefits to which the recipient would be entitled or taking some other action more readily characterized as “punitive.” Surely the Government- could not provide free transportation to the polling booths only for those citizens who vote for Democratic candidates, even though the failure to provide the same benefit to Republicans “represents simply a refusal to subsidize certain protected conduct,” ibid., and does not involve the denial of any other governmental benefits. Whether the State withholds only the special costs of a disfavored option or penalizes the individual more broadly for the manner in which she exercises her choice, it cannot interfere with a constitutionally protected decision through the coercive use of governmental largesse.