Court Opinion

ID: 2709065
Source: CourtListenerOpinion
Date Created: 2014-08-05 15:10:17.68907+00
Date Added: 2024-06-11T09:14:37.488534
License: Public Domain

In the

     United States Court of Appeals
                  For the Seventh Circuit
                     ____________________ 
No. 13‐2726 
PLANNED PARENTHOOD OF WISCONSIN, INC., et al., 
                                     Plaintiffs‐Appellees, 

                                 v. 

J.B. VAN HOLLEN, Attorney General of Wisconsin, et al., 
                                     Defendants‐Appellants. 
                     ____________________ 

        Appeal from the United States District Court for the 
                    Western District of Wisconsin. 
      No. 3:13‐cv‐00465‐wmc — William M. Conley, Chief Judge. 
                     ____________________ 

  ARGUED DECEMBER 3, 2013 — DECIDED DECEMBER 20, 2013 
               ____________________ 

   Before POSNER, MANION, and HAMILTON, Circuit Judges. 
    POSNER, Circuit Judge. On July 5 of this year, the Governor 
of  Wisconsin  signed  into  law  a  statute  that  the  Wisconsin 
legislature had passed the previous month. So far as relates 
to this appeal, the statute prohibits a doctor, under threat of 
heavy penalties if he defies the prohibition, from performing 
an  abortion  (and  in  Wisconsin  only  doctors  are  allowed  to 
perform  abortions,  Wis.  Stat.  § 940.15(5))  unless  he  has  ad‐
mitting  privileges  at  a  hospital  no  more  than  30  miles  from 
2                                                        No. 13‐2726 

the  clinic  in  which  the  abortion  is  performed.  Wis.  Stat. 
§ 253.095(2). 
    A  doctor  granted  admitting  privileges  by  a  hospital  be‐
comes  a member  of the hospital’s staff  and is authorized  to 
admit patients to that hospital and to treat them there; that is 
the meaning of “admitting privileges.” Of course any doctor 
(in  fact  any  person)  can  bring  a  patient  to  an  emergency 
room  to  be  treated  by  the  doctors  employed  there  (these 
days called “hospitalists”), and all Wisconsin abortion clinics 
already  have  transfer  agreements  with  local  hospitals  to 
streamline  the  process.  A  hospital  that  has  an  emergency 
room  is  obliged  to  admit  and  to  treat  a  patient  requiring 
emergency  care  even  if  the  patient  is  uninsured.  42  U.S.C. 
§ 1395dd(b)(1). 
    Planned Parenthood of Wisconsin and Milwaukee Wom‐
en’s Medical Services (also known as Affiliated Medical Ser‐
vices)—the only entities that operate abortion clinics in Wis‐
consin—filed  suit  (joined  by  two  physicians  affiliated  with 
these  clinics,  whom  we’ll  largely  ignore  in  an  effort  to  sim‐
plify  our  opinion)  challenging  the  constitutionality  of  the 
new  statute  under  42  U.S.C.  § 1983,  which  provides  a  tort 
remedy for violations of federal law by state employees. The 
suit  was  filed  promptly  on  July  5  and  simultaneously  with 
the filing the plaintiffs moved in the district court for a tem‐
porary  restraining  order.  The  court  granted  the  motion  on 
July  8  and  later  converted  it  to  a  preliminary  injunction 
against  enforcement  of  the  statute  pending  a  trial  on  the 
merits. The sparse evidentiary record ends on August 2, the 
day  the  preliminary  injunction  was  granted.  The  defend‐
ants—the Attorney General of Wisconsin and other state of‐
ficials  involved  in  enforcing  the  statute  (we  refer  to  the  de‐
No. 13‐2726                                                          3 

fendants  collectively  as  the  “state”)—have  appealed.  28 
U.S.C. § 1292(a)(1). 
    Discovery  is  continuing  in  the  district  court,  but  the 
judge  has  stayed  the  trial  (originally  set  for  November  25) 
pending  resolution  of  this  appeal.  The  stay  had  been  re‐
quested  by  the  defendants,  and  in  granting  it  the  judge  ex‐
plained that “(1) the stay will not prejudice plaintiffs; and (2) 
a  stay  may  simplify  or  clarify  the  issues  in  question  and 
streamline  the  case  for  trial.  Except  for  the  lingering  uncer‐
tainty  (which  will  not  be  eliminated  until  this  matter  is  re‐
solved through final appeal), plaintiffs are not prejudiced by 
the  stay  now  that  an  injunction  is  in  place.  As  plaintiffs 
acknowledge,  additional  time  may  allow  them  to  develop 
the record as to their ability to obtain admitting privileges at 
local hospitals. Furthermore, the Seventh Circuit’s review of 
the  preliminary  injunction  order  will  likely  provide  guid‐
ance to this court and the parties on the law and its applica‐
tion to the facts here. If anything, it would be inefficient for 
this court to address the merits of plaintiffs’ claims until ob‐
taining  this  guidance  from  the  Seventh  Circuit”  (citations 
omitted). 
     All we decide today is whether the district judge was jus‐
tified  in  entering  the  preliminary  injunction.  Evidence  pre‐
sented at trial may critically alter the facts found by the dis‐
trict judge on the basis of the incomplete record compiled in 
the first month of the suit, and recited by us. 
    Although signed into law on July 5, a Friday, the statute 
required compliance—the possession of admitting privileges 
at a hospital within a 30‐mile radius of the clinic at which a 
doctor  performs  abortions—by  July  8,  the  following  Mon‐
day. So there was only the weekend between the governor’s 
4                                                        No. 13‐2726 

signing  the  bill  and  the  deadline  for  an  abortion  doctor  to 
obtain  those  privileges.  There  was  no  way  the  deadline 
could have been met even if the two days hadn’t been week‐
end days. It is unquestioned that it takes a minimum of two 
or three months to obtain admitting privileges (often a hos‐
pital’s  credentials  committee,  which  decides  whether  to 
grant  admitting  privileges,  meets  only  once  a  month),  and 
often  it  takes  considerably  longer.  Moreover,  hospitals  are 
permitted rather than required to grant such privileges. 
    All  seven  doctors  in  Wisconsin  who  perform  abortions 
but as of July 8 did not have visiting privileges at a hospital 
within a 30‐mile radius of their clinic applied for such privi‐
leges  forthwith.  But  as  of  the  date  of  oral  argument  of  this 
appeal—five  months  after  the  law  would  have  taken  effect 
had it not been for the temporary restraining order—the ap‐
plication of one of the doctors had been denied and none of 
the other applications had been granted. Had enforcement of 
the  statute  not  been  stayed,  two  of  the  state’s  four  abortion 
clinics—one  in  Appleton  and  one  in  Milwaukee—would 
have  had  to  shut  down  because  none  of  their  doctors  had 
admitting  privileges  at  a  hospital  within  the  prescribed  30‐
mile radius of the clinics, and a third clinic would have lost 
the  services  of  half  its  doctors.  The  impossibility  of  compli‐
ance with the statute even by doctors fully qualified for ad‐
mitting privileges is a compelling reason for the preliminary 
injunction,  albeit  a  reason  that  diminishes  with  time.  There 
would be no quarrel with a one‐year deadline for obtaining 
admitting  privileges  as  distinct  from  a  one‐weekend  dead‐
line,  and  if  so  that  might  seem  to  argue  for  a  one‐year  (or 
even somewhat shorter) duration for the preliminary injunc‐
tion.  But  there  should  be  no  problem  in  getting  the  case  to 
trial and judgment well before July 8, 2014. The plaintiffs are 
No. 13‐2726                                                           5 

ready to go to trial. The defendants contemplate very limited 
discovery.  Furthermore  there  are  more  reasons  for  the  pre‐
liminary injunction than just the impossibility of compliance 
with the statute within the deadline set by the statute. 
     The stated rationale of the Wisconsin law is to protect the 
health  of  women  who  have  abortions.  Most  abortions—in 
Wisconsin  97  percent—are  performed  in  clinics  rather  than 
in hospitals, and proponents of the law argue that if a wom‐
an requires hospitalization because of complications from an 
abortion  she  will  get  better  continuity  of  care  if  the  doctor 
who  performed  the  abortion  has  admitting  privileges  at  a 
nearby hospital. The plaintiffs disagree. They argue that the 
statute would do nothing to improve women’s health—that 
its  only  effect  would  be  to  reduce  abortions  by  requiring 
abortion  doctors  to  jump  through  a  new  hoop:  acquiring 
admitting  privileges  at  a  hospital  within  30  miles  of  their 
clinic.  No  documentation  of  medical  need  for  such  a  re‐
quirement was presented to the Wisconsin legislature when 
the bill that became the law was introduced on June 4 of this 
year. The legislative deliberations largely ignored the provi‐
sion  concerning  admitting  privileges,  focusing  instead  on 
another provision—a requirement not challenged in this suit 
that a woman  seeking  an abortion  obtain an ultrasound ex‐
amination of her uterus first (if she hadn’t done so already), 
which might induce her to change her mind about having an 
abortion. Wis. Stat. § 253.10(3)(c)(1)(gm). 
    No  other  procedure  performed  outside  a  hospital,  even 
one as invasive as a surgical abortion (such as a colonoscopy, 
or  various  arthroscopic  or  laparoscopic  procedures),  and 
even  if  performed  when  the  patient  is  under  general  anes‐
thesia, and even though more than a quarter of all surgery in 
6                                                        No. 13‐2726 

the United States is now performed outside of hospitals, Ka‐
ren  A.  Cullen  et  al.,  “Ambulatory  Surgery  in  the  United 
States:  2006,”  Centers  for  Disease  Control  and  Prevention:  Na‐
tional  Health  Statistics  Reports  No.  11,  Sept.  4,  2009,  p.  5, 
www.cdc.gov/nchs/data/nhsr/nhsr011.pdf  (visited  Dec.  19, 
2013, as were the other websites cited in this opinion), is re‐
quired  by  Wisconsin  law  to  be  performed  by  doctors  who 
have admitting  privileges at hospitals within a specified, or 
indeed  any,  radius  of  the  clinic  at  which  the  procedure  is 
performed.  That  is  true  even  for  gynecological  procedures 
such as  diagnostic  dilation and  curettage (removal  of tissue 
from  the  inside  of  the  uterus),  hysteroscopy  (endoscopy  of 
the uterus), and surgical completion of miscarriage (surgical 
removal  of  fetal  tissue  remaining  in  the  uterus  after  a  mis‐
carriage,  which  is  to  say  a  spontaneous  abortion),  that  are 
medically similar to and as dangerous as abortion—or so at 
least  the  plaintiffs  argue,  without  contradiction  by  the  de‐
fendants.  These  procedures,  often  performed  by  the  same 
doctors who perform abortions, appear to be virtually indis‐
tinguishable from abortion from a medical standpoint. 
    An issue of equal protection of the laws is lurking in this 
case.  For  the  state  seems  indifferent  to  complications  from 
non‐hospital  procedures  other  than  surgical  abortion  (espe‐
cially  other  gynecological  procedures),  even  when  they  are 
more likely to produce complications. The rate of complica‐
tions resulting in hospitalization from colonoscopies, for ex‐
ample, appears to be three to six times the rate of complica‐
tions  from  abortions.  Compare  Cynthia  W.  Ko  et  al.,  “Seri‐
ous Complications Within 30 Days of Screening and Surveil‐
lance Colonoscopy Are Uncommon,” 8 Clinical Gastroenterol‐
ogy & Hepatology 166, 171–72 (2010), with two studies cited in 
an amicus curiae brief filed by the American College of Ob‐
No. 13‐2726                                                         7 

stetricians  and  Gynecologists,  Tracy  A.  Weitz  et  al.,  “Safety 
of  Aspiration  Abortion  Performed  by  Nurse  Practitioners, 
Certified Nurse Midwives, and Physician Assistants Under a 
California  Legal  Waiver,”  103  Am.  J.  Public  Health  454,  457–
58  (2013),  and  Kelly  Cleland  et  al.,  “Significant  Adverse 
Events and Outcomes After Medical Abortions,” 121 Obstet‐
rics & Gynecology 166, 169 (2013). Wisconsin’s annual report 
on  abortions  suggests  a  higher  incidence  of  complications 
but it is unclear whether they all require hospitalization and 
it still is lower than the reported incidence of complications 
from  colonoscopies.  Wisconsin  Department  of  Health  Ser‐
vices,  “Reported  Induced  Abortions  in  Wisconsin,  2012” 
(Aug        2013),   www.dhs.wisconsin.gov/publications/p4/
p45360‐12.pdf. It is possible that because of widespread dis‐
approval of abortion, abortions and their complications may 
be underreported—some women who experience such com‐
plications and are hospitalized may tell the hospital staff that 
the complications are from a miscarriage. But as yet there is 
no evidence in the record of such undercounting. The state’s 
own report on abortions, just cited, lists (at table 9 of the re‐
port)  only  11  complications  out  of  the  6,692  abortions  of 
Wisconsin residents reported in 2012—a rate of less than 1.6 
tenths of 1 percent (1 per 608 abortions). And the report does 
not indicate how many of the complications involved hospi‐
talization  or  whether  6,692  was  an  undercount  of  the  num‐
ber of abortions. 
    We  asked  the  state’s  lawyer  at  oral  argument  what  evi‐
dence he anticipated producing at the trial on the merits. He 
did not mention evidence of alleged undercounting of abor‐
tions, but only that the state was looking for women in Wis‐
consin who had experienced complications from an abortion 
to testify. He did not mention any medical or statistical evi‐
8                                                          No. 13‐2726 

dence.  This may explain why the trial,  originally  scheduled 
for November 25, only four and a half months after the suit 
was filed, was expected to last only a couple of days. And it 
is why we think it most unlikely that the trial can’t be com‐
pleted well before the one‐year anniversary of the date of the 
statute’s enactment. 
     The  district  judge  said  in  a  footnote  in  his  opinion  that 
while he would “await trial on the issue, … the complete ab‐
sence of an admitting privileges requirement for clinical [i.e., 
outpatient] procedures including for those with greater risk 
is  certainly  evidence  that  Wisconsin  Legislature’s  only  pur‐
pose  in  its  enactment  was  to  restrict  the  availability  of  safe, 
legal abortion in this State, particularly given the lack of any 
demonstrable medical benefit for its requirement either pre‐
sented  to  the  Legislature  or  [to]  this  court”  (emphasis  in 
original).  A  fuller  enumeration  of  considerations  based  on 
purpose  would  include  the  two‐day  deadline  for  obtaining 
admitting  privileges,  the  apparent  absence  of  any  medical 
benefit  from  requiring  doctors  who  perform  abortions  to 
have  such  privileges  at  a  nearby  or  even  any  hospital,  the 
differential  treatment  of  abortion  vis‐à‐vis  medical  proce‐
dures that are at least as dangerous as abortions and proba‐
bly more so, and finally the strange private civil remedy for 
violations: The father or grandparent of the “aborted unborn 
child” is entitled to obtain damages, including for emotional 
and psychological distress, if the abortion was performed by 
a  doctor  who  violated  the  admitting‐privileges  provision. 
Wis. Stat. § 253.095(4)(a). Yet if the law is aimed only at pro‐
tecting the mother’s health, a violation of the law could harm 
the fetus’s father or grandparent only if the mother were in‐
jured as a result of her abortion doctor’s lacking the required 
admitting privileges. But no proof of such injury is required 
No. 13‐2726                                                           9 

to entitle the father or grandparent to damages if he proves a 
violation and resulting emotional or psychological injury to 
himself. 
    However, the purpose of the statute is not at issue in this 
appeal.  In  urging  affirmance  the  plaintiffs  reserve  the  issue 
for  trial,  arguing  to  us  only  that  the  law  discourages  abor‐
tions  without  medical  justification  and  imposes  an  undue 
burden on women. And the state on its side does not defend 
the statute  as protecting fetal  life but only  as protecting the 
health of women who have abortions. 
     Wisconsin’s  statute  is  not  unique.  Six  states  have  laws 
nearly  identical  to  Wisconsin’s:  Ala.  Code  § 26‐23E‐4;  Miss. 
Code. § 41‐75‐1(f); Mo. Stat. § 188.080; N.D. Cent. Code § 14‐
02.1‐04(1);  Tenn.  Code  § 39‐15‐202(h);  Tex.  Health  &  Safety 
Code  § 171.0031(a)(1).  Five  more  have  similar  though  less 
stringent  requirements  relating  to  admitting  privileges  for 
abortion  doctors:  Ariz.  Rev.  Stat.  § 36‐449.03(C)(3);  Fla.  Stat. 
§ 390.012(3)(c)(1);  Ind.  Code  § 16‐34‐2‐4.5;  Kan.  Stat.  § 65‐
4a09(d)(3);  Utah  Admin.  Code  R432‐600‐13(2)(a).  The  plain‐
tiffs argue that such laws, which are advocated by the right 
to  life  movement,  are  intended  to  hamstring  abortion.  The 
defendants deny this. We needn’t take sides. Discovering the 
intent behind a statute is difficult at best because of the col‐
lective character of a legislature, and may be impossible with 
regard to the admitting‐privileges statutes. Some Wisconsin 
legislators doubtless voted for the statute in the hope that it 
would  reduce  the  abortion  rate,  but  others  may  have  voted 
for  it  because  they  considered  it  a  first  step  toward  making 
invasive outpatient procedures in general safer. 
    As now appears (the trial may cast the facts in a different 
light), the statute, whatever the intent behind it (if there is a 
10                                                     No. 13‐2726 

single intent), seems bound  to have  a  substantial impact  on 
the  practical  availability  of  abortion  in  Wisconsin,  and  not 
only  because  of  the  unreasonably  tight  implementation 
deadline. Virtually all abortions in Wisconsin are performed 
at the plaintiffs’ four clinics; no other clinics in the state per‐
form  abortions  and  hospitals  perform  only  a  small  fraction 
of the state’s abortions; and a significant fraction of the clin‐
ics’  doctors  don’t  have  admitting  privileges  at  hospitals 
within 30‐mile radii of their clinics. 
    What is more, because few doctors in Wisconsin perform 
abortions, those who do often work at more than one clinic, 
so  that  the  statute  would  require  them  to  obtain  admitting 
privileges  at  multiple  hospitals.  And  whether  any  of  the 
hospitals  would  give  these  doctors  admitting  privileges  is 
unknown. It is true that federal law prohibits hospitals that 
receive  federal  funding,  including  Catholic  hospitals,  from 
denying  admitting  privileges  merely  because  a  doctor  per‐
forms  abortions.  42  U.S.C.  § 300a‐7(c)(1)(B)  (the  “Church 
Amendments”).  Yet  Wisconsin  State  Senator  Mary  Lazich, 
one  of  the  authors  of  the  admitting‐privileges  law,  was 
seemingly unaware of the Church Amendments, as were in‐
deed officials of the largest Catholic hospitals in Wisconsin, 
which  before  they  were  informed  of  the  amendments  were 
emphatic  that  their  religious  beliefs  would  preclude  their 
granting admitting privileges to doctors who perform abor‐
tions.  Akbar  Ahmed,  “Abortion  Ruling  Mired  in  Confu‐
sion,”  Milwaukee  Journal  Sentinel,  July  27,  2013,  p.  A1, 
www.jsonline.com/news/statepolitics/court‐file‐shows‐
confusion‐over‐wisconsin‐abortion‐regulation‐law‐
b9961373z1‐217196251.html#ixzz2mcyeJ5ba.  In  the  words  of 
the  chief  medical  officer  of  one  such  hospital,  “Wheaton 
Franciscan  Healthcare  is  a  ministry  of  the  Catholic  church. 
No. 13‐2726                                                      11 

… For that reason, if it’s known to us that a doctor performs 
abortions and that doctor applies for privileges at one of our 
hospitals, our hospital board would not grant privileges.” Id. 
    So not only would allowing the new law to go into effect 
on  July  8  have  wreaked  havoc  with  the  provision  of  abor‐
tions in Wisconsin because of the months it would have tak‐
en  for  the  doctors  who  perform  abortions  to  obtain  admit‐
ting privileges within the prescribed radii of their clinics; in 
addition  their  requests  for  such  privileges  would  have  en‐
countered  resistance  at  Catholic  hospitals—and  perhaps  at 
other  hospitals  as  well,  given  the  widespread  hostility  to 
abortion and the lack of any likely benefit to a hospital from 
granting such privileges to an abortion doctor. 
    The  criteria  for  granting  admitting  privileges  are  multi‐
ple, various, and unweighted. They include how frequently 
the physician uses the hospital (that is, the number of patient 
admissions), the quantity of services provided to the patient 
at the hospital, the revenue generated by the physician’s pa‐
tient  admissions,  and  the  physician’s  membership  in  a  par‐
ticular practice group or academic faculty (“closed staff” ar‐
rangements).  Barry  R.  Furrow  et  al.,  Health Law  § 14‐15,  pp. 
707–08  (2d  ed.  2000);  Elizabeth  A.  Weeks,  “The  New  Eco‐
nomic Credentialing: Protecting Hospitals from Competition 
by Medical Staff Members,” 36 J. Health L. 247, 249–52 (2003). 
The absence of definite standards for the granting of admit‐
ting privileges makes it difficult not only to predict who will 
be granted such privileges at what hospitals and when, but 
also to prove an improper motive for denial. Akbar Ahmed, 
“Hospitals  Can’t  Deny  Privileges,”  Milwaukee  Journal  Senti‐
nel,  Aug.  7,  2013,  p.  A1,  www.jsonline.com/news/
statepolitics/wisconsin‐attorney‐general‐says‐hospitals‐cant‐
12                                                     No. 13‐2726 

deny‐admitting‐privileges‐to‐abortion‐doctors‐b997046‐
218608951.html, points out for example that according to the 
Senior  Counsel  of  the  National  Women’s  Law  Center,  “in 
other  states  that  have  recently  passed  privileges  require‐
ments for abortion providers, religiously affiliated hospitals 
have  denied  the  doctors’  applications  by  citing  their  failure 
to meet other standards, such as admitting a certain number 
of patients per year. In Mississippi, a Baptist hospital did not 
provide doctors at an abortion clinic with an application for 
privileges  because  none  of  its  staff  would  write  letters  in 
support of the doctors, according to a court affidavit provid‐
ed  by  the  clinic’s  attorneys  at  the  Center  for  Reproductive 
Rights.” 
     Pretext aside, a common and lawful criterion for granting 
admitting  privileges  (though  it  has  been  criticized  by  the 
American  Medical  Association,  see  AMA,  “Opinion  4.07—
Staff  Privileges,”  www.ama‐assn.org/ama/pub/physician‐
resources/medical‐ethics/code‐medical‐ethics/
opinion407.page) is the number of patient admissions a doc‐
tor  can  be  expected  to  produce  for  the  hospital—the  more 
the  better,  as  that  means  more  utilization  of  hospital  em‐
ployees and resources and hence more fees for the hospital. 
But  the  number  of  patient  admissions  by  doctors  who  per‐
form abortions is likely to be negligible because there appear 
to  be  so  few  complications  from  abortions  and  only  a  frac‐
tion of those require hospitalization—probably a very small 
fraction. An even smaller fraction will still be near the hospi‐
tal  at  which  the  doctor  has  admitting  privileges  when  the 
complication  arises.  The  state  does  not  dispute  the  district 
court’s finding that “up to half of the complications will not 
present themselves until after the patient is home.” 
No. 13‐2726                                                        13 

    But what is certain  and also  not  disputed  by the  state  is 
that  banning  abortions  by  doctors  who  cannot  obtain  the 
requisite admitting privileges within the span of a weekend 
is bound to impede access to abortions. It would have creat‐
ed (had it not been for judicial intervention) a hiatus of un‐
known  duration  (but  duration  measured  in  months  rather 
than in weeks or days) in which a critical number of the few 
doctors  who  perform  abortions  in  Wisconsin  would  have 
been  forbidden  to  do  so,  under  threat  of  heavy  penalties  if 
they disobeyed. 
    There  cannot  have  been  a  felt  sense  of  urgency  on  the 
state’s  part  for  making  the  law  effective  too  abruptly  to  al‐
low  compliance  with  it.  It  has  been  40  years  since  Roe  v. 
Wade,  410  U.S.  113  (1973),  was  decided,  legalizing  (most) 
abortion throughout the United States, and it could not have 
taken  the  State  of  Wisconsin  all  this  time  to  discover  the 
supposed  hazards  of  abortions  performed  by  doctors  who 
do  not  have  admitting  privileges  at  a  nearby  hospital.  The 
state can without harm to its legitimate interests wait a few 
months more to implement its new law, should it prevail in 
this litigation. 
    One reason it can wait is that its expressed concern about 
the  hazards  resulting  from  abortions  performed  by  doctors 
who don’t have admitting privileges at a nearby hospital has 
intersected a movement in the hospital industry (an industry 
in  ferment,  as  everyone  now  knows)  to  restrict  admitting 
privileges on economic grounds. See Weeks, supra, at 248–49, 
252–53 (“for example, hospitals may refuse to grant initial or 
continuing  staff  privileges  to  physicians  who  own  or  have 
other financial interests in competing healthcare entities, re‐
fer patients to competing entities, have staff privileges at any 
14                                                         No. 13‐2726 

other area hospitals, or fail to admit some specified percent‐
age  of  their  patients  to  the  hospital”);  Peter  J.  Hammer  & 
William  M.  Sage,  “Antitrust,  Health  Care  Quality,  and  the 
Courts,” 102 Colum. L. Rev. 545, 567–68 and n. 58 (2002). The 
trend  in  the  hospital  industry  is  for  the  hospital  to  require 
the treating physician to hand over his patient who requires 
hospitalization  to  physicians  employed  by  the  hospital,  ra‐
ther than allowing the treating physician to continue partici‐
pating in the patient’s treatment in the hospital. Wisconsin is 
trying to buck that trend—but only with regard to abortions, 
though there is no evidence that the complications to which 
abortion  can  give  rise  require  greater  physician  continuity 
than  other  outpatient  procedures.  And  there  is  no  evidence 
that  women  who  have  complications  from  an  abortion  re‐
cover more quickly or more completely or with less pain or 
discomfort if their physician has admitting privileges at the 
hospital  to  which  the  patient  is  taken  for  treatment  of  the 
complications. 
    The state devotes most of its briefing in this court not to 
the merits but instead to arguing that the plaintiffs cannot be 
allowed  to  maintain  this  suit  because  their  rights  have  not 
been violated. The state does not deny that they may be in‐
jured  by  the  statute.  But  it  argues  that  no  rights  of  theirs 
have  been  violated  but  only  rights  of  their  patients,  if  it  is 
true (which of course the defendants deny) that the statute is 
a  gratuitous  interference  with  a  woman’s  right  to  an  abor‐
tion. 
   Yet the cases are legion that allow an abortion provider, 
such  as  Planned  Parenthood  of  Wisconsin  or  Milwaukee 
Women’s  Medical  Services,  to  sue  to  enjoin  as  violations  of 
federal  law  (hence  litigable  under  42  U.S.C.  § 1983)  state 
No. 13‐2726                                                          15 

laws  that  restrict  abortion.  See,  e.g.,  Isaacson  v.  Horne,  716 
F.3d 1213, 1221 (9th Cir. 2013) (“recognizing the confidential 
nature of the physician‐patient relationship and the difficul‐
ty  for  patients  of  directly  vindicating  their  rights  without 
compromising  their  privacy,  the  Supreme  Court  has  enter‐
tained both broad facial challenges and pre‐enforcement as‐
applied  challenges  to  abortion  laws  brought  by  physicians 
on  behalf  of  their  patients”);  Richard  H.  Fallon,  Jr.,  “As‐
Applied  and  Facial  Challenges  and  Third‐Party  Standing,” 
113 Harv. L. Rev. 1321, 1359–61 (2000). The reason for allow‐
ing such third‐party standing in the present case is different 
from  but  analogous  to  the  reason  that  persuaded  the  Su‐
preme  Court,  beginning  with  Roe  v.  Wade,  to  waive  the 
mootness defense to a suit by a pregnant woman challenging 
a state law restricting abortion. The suit could not be litigat‐
ed  to  judgment  before  she  gave  birth;  and  so  if  mootness 
were allowed as a defense, restrictions on abortion could not 
effectively be challenged by the persons whose rights the re‐
strictions  infringe.  That  was  a  practical  bar  to  insisting  on 
first‐party standing. The bar in this case is the extraordinary 
heterogeneity of the class likely to be affected by the statute. 
If  two  of  the  four  abortion  clinics  in  the  state  close  and  a 
third shrinks by half, some women wanting an abortion may 
experience  delay  in  obtaining,  or  even  be  unable  to  obtain, 
an abortion yet not realize that the new law is likely to have 
been  the  cause.  Those  women  are  unlikely  to  sue.  Other 
women may be able to find an abortion doctor who has ad‐
mitting  privileges  at  a  nearby  hospital,  yet  incur  costs  and 
delay  because  the  law  has  reduced  the  number  of  abortion 
doctors  and  hence  access.  The  heterogeneity  of  the  class  is 
likely to preclude class action treatment; and while one or a 
16                                                         No. 13‐2726 

handful of women might sue, the entire statute would be un‐
likely to be enjoined on the basis of such a suit. 
    The  principal  objection  to  third‐party  standing  is  that  it 
wrests  control  of  the  lawsuit  from  the  person  or  persons 
primarily concerned in it. See, e.g., MainStreet Organization of 
Realtors v. Calumet City, 505 F.3d 742, 746 (7th Cir. 2007); 13A 
Charles  A.  Wright,  Arthur  R.  Miller  &  Edward  H.  Cooper, 
Federal  Practice  &  Procedure  § 3531.9.3,  pp.  720–26  (3d  ed. 
2008).  For  an  extreme  example,  imagine  that  if  A  broke  his 
contract  with  B,  a  stranger  to  both  of  them  could  sue  A  for 
breach of contract, leaving B out in the cold. But that is not a 
problem in a case such as this. Wisconsin women who have 
or  want  to  have  an  abortion  are  not  seeking  damages  from 
the state, and so are not losing control over their legal rights 
as  a  result  of  litigation  by  clinics  and  doctors.  They  are  (or 
would be, if they were plaintiffs) seeking the same thing the 
clinics  are seeking  (with greater  resources): invalidating  the 
statute. 
    Anyway there is an alternative ground for standing, un‐
related  to  third‐party  standing,  in  this  case.  The  Supreme 
Court  held  in  Doe  v.  Bolton,  410  U.S.  179,  188  (1973)  (the 
companion  case  to  Roe  v.  Wade),  that  doctors  (two  of  the 
plaintiffs in this case are doctors) have first‐party standing to 
challenge  laws  limiting  abortion  when,  as  in  Doe  v.  Bolton 
and the present case as well, see Wis. Stat. §§ 253.095(3), (4), 
penalties for violation of the laws are visited on the doctors. 
See also Planned Parenthood of Southeastern Pennsylvania v. Ca‐
sey,  505  U.S.  833,  903–04,  909  (1992);  Planned  Parenthood  of 
Central  Missouri  v.  Danforth,  428  U.S.  52,  62  (1976);  Karlin  v. 
Foust,  188  F.3d  446,  456  n.  5  (7th  Cir.  1999);  Planned 
Parenthood  of  Wisconsin  v.  Doyle,  162  F.3d  463,  465  (7th  Cir. 
No. 13‐2726                                                              17 

1998);  13A  Wright,  Miller  &  Cooper,  supra,  pp.  748–50.  The 
state  argues  that  none  of  these  precedents  governs  because 
none  of  them  “grapple[d]  with  whether  [42  U.S.C.]  § 1983 
creates  a  cause  of  action  for  abortion  providers  or  clinics  to 
assert  the  rights  of  their  patients.”  But  nearly  all  the  cited 
cases  in  which  doctors  and  abortion  clinics  were  found  to 
have  had  standing  had  been  filed  pursuant  to  section  1983, 
and the justiciability of such cases is not in question. 
    Apart from the issue of standing just discussed, the legal 
principles  applicable  to  our  consideration  of  the  appeal  are 
not in contention between the parties. The task of the district 
court asked to grant a preliminary injunction is “to estimate 
the likelihood that the plaintiff will prevail in a full trial and 
which of the parties is likely to be harmed more by a ruling, 
granting or denying a preliminary injunction, in favor of the 
other party, and combine these findings in the manner sug‐
gested in such cases as Abbott Laboratories v. Mead Johnson & 
Co.,  971  F.2d  6,  12  (7th  Cir.  1992):  ‘the  more  likely  it  is  the 
plaintiff  will  succeed  on  the  merits,  the  less  the  balance  of 
irreparable harms need weigh towards its side; the less like‐
ly it  is  the  plaintiff  will succeed, the  more the balance  need 
weigh  towards  its  side.’”  Kraft  Foods  Group  Brands  LLC  v. 
Cracker  Barrel  Old  Country  Store,  Inc.,  735  F.3d  735,  740  (7th 
Cir.  2013); see  also  NLRB  v.  Electro–Voice, Inc.,  83  F.3d  1559, 
1568 (7th Cir. 1996); Grocery Outlet Inc. v. Albertson’s Inc., 497 
F.3d  949,  951  (9th  Cir.  2007)  (per  curiam);  O  Centro  Espirita 
Beneficiente Uniao Do Vegetal v. Ashcroft, 389 F.3d 973, 1028–29 
(10th Cir. 2004) (en banc) (per curiam), affirmed, 546 U.S. 418 
(2006);  Novartis  Consumer  Health,  Inc.  v.  Johnson  &  Johnson–
Merck  Consumer  Pharmaceuticals  Co.,  290  F.3d  578,  597  (3d 
Cir. 2002). This formulation is a variant of, though consistent 
with, the Supreme Court’s recent formulations of the stand‐
18                                                         No. 13‐2726 

ard,  in  such  cases  as  Winter  v.  National  Resources  Defense 
Council, Inc., 555 U.S. 7, 20 (2008): “A plaintiff seeking a pre‐
liminary injunction must establish that he is likely to succeed 
on  the  merits,  that  he  is  likely  to  suffer  irreparable  harm  in 
the absence of preliminary relief, that the balance of equities 
tips in his favor, and that an injunction is in the public inter‐
est.” 
    Because of the uncertainty involved in balancing the con‐
siderations that bear on the decision whether to grant a pre‐
liminary  injunction—an  uncertainty  amplified  by  the  una‐
voidable haste with which the district judge must strike the 
balance—we  appellate  judges  review  his  decision  deferen‐
tially. 
    The state concedes that its only  interest  pertinent  to  this 
case  is  in  the  health  of  women who  obtain  abortions.  But  it 
has  neither  presented  evidence  of  a  health  benefit  (beyond 
an inconclusive affidavit by one doctor concerning one abor‐
tion  patient  in  another  state,  as  we’ll  see),  or  rebutted  the 
plaintiffs’ evidence that the statute if upheld will harm abor‐
tion providers and their clients and potential clients. 
   And  it  is  beyond  dispute  that  the  plaintiffs  face  greater 
harm irreparable by the entry of a final judgment in their fa‐
vor  than  the  irreparable  harm  that  the  state  faces  if  the  im‐
plementation of its statute is delayed. For if forced to comply 
with  the  statute,  only  later  to  be  vindicated  when  a  final 
judgment  is  entered,  the  plaintiffs  will  incur  in  the  interim 
the  disruption  of  the  services  that  the  abortion  clinics  pro‐
vide.  With  the  closure  of  two  and  a  half  of  the  state’s  four 
abortion clinics if their doctors fail to obtain admitting privi‐
leges, including one clinic responsible for half the abortions 
performed  in  the  state,  their  doctors’  practices  will  be  shut 
No. 13‐2726                                                       19 

down completely unless and until the doctors obtain visiting 
privileges  at  nearby  hospitals.  Patients  will  be  subjected  to 
weeks  of  delay  because  of  the  sudden  shortage  of  eligible 
doctors—and delay in obtaining an abortion can result in the 
progression  of  a  pregnancy  to  a  stage  at  which  an  abortion 
would be less safe, and eventually illegal. 
    Some  patients  will  be  unable  to  afford  the  longer  trips 
they’ll  have  to  make  to  obtain  an  abortion  when  the  clinics 
near  them  shut  down—60  percent  of  the  clinics’  patients 
have incomes below the federal poverty line. One of the clin‐
ics that will close is Planned Parenthood’s clinic in Appleton, 
which, as shown in the accompanying map, is in the approx‐
imate  center of the state.  The remaining  abortion clinics are 
in  Madison  or  Milwaukee,  about  100  miles  south  of  Apple‐
ton.  A  woman  who  lives  north  of  Appleton  who  wants  an 
abortion may (unless she lives close to the Minnesota border 
with  Wisconsin  and  not  far  from  an  abortion  clinic  in  that 
state) have to travel up to an additional 100 miles each way 
to obtain it. And that is really 400 miles—a nontrivial burden 
on  the  financially  strapped  and  others  who  have  difficulty 
traveling long distances to obtain an abortion, such as those 
who already have children. For Wisconsin law requires two 
trips to the abortion clinic (the first for counseling and an ul‐
trasound)  with  at  least  twenty‐four  hours  between  them. 
Wis. Stat. § 253.10(3)(c). When one abortion regulation com‐
pounds the effects of another, the aggregate effects on abor‐
tion rights must be considered. 
20                                                       No. 13‐2726 

                                                                    
     The  state  has  made  no  attempt  to  show  an  offsetting 
harm from a delay of a few months in the implementation of 
its  new  law  (should  it  be  upheld  after  a  trial).  States  that 
have passed  similar laws have allowed much longer imple‐
mentation  time  than  a  weekend—for  example,  Mississippi 
has  allowed  76  days,  Alabama  114  days,  Texas  103,  and 
North Dakota 128. See 2012 Miss. Gen. Laws 331 (H.B. 1390), 
enjoined, Jackson Women’s Health Org. v. Currier, 940 F. Supp. 
2d  416,  424  (S.D.  Miss.  2013); 2013  Ala.  Legis.  Serv.  2013‐79 
(H.B. 57), enjoined, Planned Parenthood Southeast, Inc. v. Bent‐
ley,  No.  2:13cv405‐MHT,  2013  WL  3287109,  at  *8  (M.D.  Ala. 
June 28, 2013); 2013 Tex. Sess. Law Serv. 2nd Called Sess. Ch. 
No. 13‐2726                                                          21 

1  (H.B.  2),  permanent  injunction  stayed  pending  appeal, 
Planned Parenthood of Greater Texas Surgical Health Services v. 
Abbott, 734 F.3d 406 (5th Cir. 2013); 2013 North Dakota Laws 
Ch. 118 (S.B. 2305), enjoined, MKB Management Corp. v. Bur‐
dick, No. 1:13‐cv‐071, 2013 WL 3779740, at *2 (D.N.D. July 22, 
2013). 
     Is  there  such  urgency  to  implementing  the  law,  because 
Wisconsin  is  rife  with  serious  complications  from  abortion 
and requiring admitting privileges to hospitals within short 
distances  of  abortion  clinics  is  essential  to  preventing  such 
complications?  As  noted  earlier,  the  state  has  presented  no 
evidence of either reason for the weekend deadline. Compli‐
cations of abortion are estimated to occur in only one out of 
111  physician‐performed  aspiration  abortions  (the  most 
common  type  of  surgical  abortion);  and  96  percent  of  com‐
plications are “minor.” Weitz et al., supra, p. 457; cf. Cleland 
et  al.,  supra.  The  official  Wisconsin  figure,  cited  earlier,  is 
much  lower:  one  complication  per  608  abortions.  Few  com‐
plications require hospitalization; studies cited earlier found 
that  only  1  in  1,915  aspiration  abortions  (0.05%)  and  1  in 
1,732  medical  abortions  (0.06%)  result  in  complications  re‐
quiring hospitalization. Weitz et al., supra, p. 459; Cleland et 
al., supra, p. 169 table 2. 
    What  fraction  of  these  hospitalizations  go  awry  because 
the doctor who performed the abortion did not have admit‐
ting privileges at the hospital to which the woman was taken 
is another unknown in a case in which thus far the state has 
been chary in the presentation of evidence. True, one doctor, 
who said he’s been treating complications from abortions for 
29 years, furnished the defendants with an affidavit describ‐
ing a case in which, he opines, a woman with a complication 
22                                                      No. 13‐2726 

from an abortion might have avoided a hysterectomy had her 
abortion  doctor,  who  did  not  have  admitting  privileges,  re‐
mained in closer touch with her. That is the only evidence in 
the  record  that  any  woman  whose  abortion  results  in  com‐
plications  has  ever,  anywhere  in  the  United  States,  been 
made  worse  off  by  being  “handed  over”  by  her  abortion 
doctor to a gynecologist employed by the hospital to which 
she’s taken. One (doubtful) case in 29 years is not impressive 
evidence  of  the  medical  benefits  of  the  Wisconsin  statute. 
And we note that as a protection for Wisconsin women who 
have  abortions,  abortion  clinics—uniquely,  it  appears, 
among  outpatient  providers  of  medical  services  in  Wiscon‐
sin—are required to adopt the transfer protocols, mentioned 
earlier, which are intended to assure prompt hospitalization 
of any abortion patient who experiences complications seri‐
ous  enough  to  require  hospitalization.  See  Wis.  Admin. 
Code Med. § 11.04(g). 
    The defendants argue that obtaining admitting privileges 
operates as a kind of Good Housekeeping Seal of Approval 
of a physician. But that benefit does not require that the hos‐
pital  in  which  he  obtains  the  privileges  be  within  a  30‐mile 
radius of the clinic. Cf. Women’s Health Center of West County, 
Inc.  v.  Webster,  871  F.2d  1377,  1378–81  (8th  Cir.  1989)  (up‐
holding  an  admitting  privileges  requirement  with  no  geo‐
graphic  restriction).  Several  abortion  doctors  in  Wisconsin 
who  lack  admitting  privileges  at  hospitals  within  30  miles 
have them at hospitals beyond that radius. Yet they are not 
excused by the statute from having to obtain the same privi‐
leges from a hospital within 30 miles. 
   Furthermore,  nothing in the statute requires an abortion 
doctor  who  has  admitting  privileges  to  care  for  a  patient 
No. 13‐2726                                                          23 

who has complications from an abortion. He doesn’t have to 
accompany her to the hospital, treat her there, visit her, call 
her,  or  indeed  do  anything  that  a  doctor  employed  by  the 
hospital might not do for the patient. 
    Also  the  statute  does  not  distinguish  between  surgical 
and medical abortions. The latter term refers to an abortion 
induced by a pill given to the patient by her doctor: she takes 
one  pill  in  the  clinic,  goes  home,  and  takes  a  second  pill  a 
few days later to complete the procedure. (The first pill ends 
the  fetus’s  life,  the  second  induces  the  uterus  to  expel  the 
remains.)  Her  home  may  be  far  from  any  hospital  within  a 
30‐mile  radius  of  her  doctor’s  clinic,  but  close  to  a  hospital 
outside that radius. If she calls an ambulance, the paramed‐
ics are likely to take her to the nearest hospital—a hospital at 
which  her  doctor  is  unlikely  to  have  admitting  privileges. 
Likewise  in  the  case  of  surgical  abortions  when  complica‐
tions occur not at the clinic, during or immediately after the 
abortion, but after the patient has returned home: because of 
distance  she may  no longer have ready access  to  the hospi‐
tals  near  the  clinic  at  which  the  abortion  was  performed, 
even though she may live near a hospital at which the doctor 
who performed her abortion does not have admitting privi‐
leges. 
    The cases that deal with abortion‐related statutes sought 
to be justified on medical grounds require not only evidence 
(here lacking as we have seen) that the medical grounds are 
legitimate  but  also  that  the  statute  not  impose  an  “undue 
burden” on women seeking abortions. Planned Parenthood of 
Southeastern Pennsylvania v. Casey, supra, 505 U.S. at 874, 877, 
900–01  (plurality  opinion);  Stenberg  v.  Carhart,  530  U.S.  914, 
930, 938 (2000); cf. Mazurek v. Armstrong, 520 U.S. 968, 972–73 
24                                                      No. 13‐2726 

(1997)  (per  curiam).  The  feebler  the  medical  grounds,  the 
likelier the burden, even if slight, to be “undue” in the sense 
of  disproportionate  or  gratuitous.  It  is  not  a  matter  of  the 
number of women likely to be affected. “[A]n 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.” 
Planned  Parenthood  of  Southeastern  Pennsylvania  v.  Casey,  su‐
pra, 505 U.S. at 877 (plurality opinion). In this case the medi‐
cal  grounds  thus  far  presented  (“thus  far”  being  an  im‐
portant qualification given the procedural setting—a prelim‐
inary‐injunction proceeding) are feeble, yet the burden great 
because  of  the  state’s  refusal  to  have  permitted  abortion 
providers a reasonable time within which to comply. 
     And so the district judge’s grant of the injunction must be 
upheld.  But  given  the  technical  character  of  the  evidence 
likely  to  figure  in  the  trial—both  evidence  strictly  medical 
and  evidence  statistical  in  character  concerning  the  conse‐
quences both for the safety of abortions and the availability 
of abortion in Wisconsin—the district judge may want to re‐
consider appointing a neutral medical expert to testify at the 
trial, as authorized by Fed. R. Evid. 706, despite the parties’ 
earlier objections.  Given the passions that swirl  about abor‐
tion rights and their limitations there is a danger that  party 
experts  will  have  strong  biases,  clouding  their  judgment. 
They will still be allowed to testify if they survive a Daubert 
challenge,  but  a court‐appointed  expert  may  help  the  judge 
to  resolve  the  clash  of  the  warring  party  experts.  And  the 
judge may be able to procure a genuine neutral expert simp‐
ly by directing the party experts to confer and agree on two 
or  three  qualified  neutrals  among  whom  the  judge  can 
choose  with  confidence  in  their  competence  and  neutrality. 
No. 13‐2726                                                         25 

If either side’s party experts stonewall in the negotiations for 
the  compilation  of  the  neutral  list,  the  judge  can  take  disci‐
plinary action; we doubt that will be necessary. 
    We  emphasize  in  conclusion  that  the  trial  on  the  merits 
may cast the facts we have recited, based as they are on the 
record  (by  no  means  slim,  however,  though  entirely  docu‐
mentary) of the preliminary‐injunction proceeding, in a dif‐
ferent light. That record—all we have—requires that the dis‐
trict  judge’s  grant  of  the  preliminary  injunction  be,  and  it 
hereby is, 
                                                           AFFIRMED. 
26                                                   No. 13-2726

   MANION, Circuit Judge, concurring in part and in the
judgment.
    I agree with the court that the temporary restraining order
and the subsequent preliminary injunction were appropriate.
The Wisconsin law at issue requires abortion doctors to obtain
admitting privileges at a hospital no more than 30 miles from
the clinic in which the abortion is performed. 2013 Wis. Act 37,
§ 1 (codified at Wis. Stat. § 253.095(2)). As I explain below, the
legislature had a rational basis to enact the law. However, the
law was signed by the governor on a Friday and took effect the
following Monday. The law’s immediate effective date made
it impossible for the doctors employed at the various clinics
providing abortion services to seek and obtain admitting
privileges at a nearby hospital. The injunctive relief has now
been in place for nearly half a year, so abortion doctors have
had plenty of time to secure admitting privileges. However, in
this appeal, Wisconsin has only argued that the original entry
of the injunction was error, so whether the injunction remains
appropriate will be decided on remand. I also agree with the
court about third-party standing. There is no need for the
parties to dwell on this issue.
    As the court notes, at this juncture, “the Seventh Circuit’s
review of the preliminary injunction order will likely provide
guidance to the court and the parties on the law and its
application to the facts here.” Maj. Op. at 3. The court has
expressed rather extensive guidance for the district court on
remand. At this point, I hope to offer some of my own observa-
tions on the legitimate interests that are furthered by the
requirements of Wisconsin Act 37 and the nature of the
No. 13-2726                                                    27

burdens that the requirements may impose on access to
abortion.
           The Two-Part Test for Laws Regulating the
                  Provision of Abortions
    “Where it has a rational basis to act, and it does not impose
an undue burden, the State may” regulate the provision of
abortions. Gonzales v. Carhart, 550 U.S. 124, 158 (2007). Thus,
legislation regulating abortions must past muster under
rational basis review and must not have the “practical effect of
imposing an undue burden” on the ability of women to obtain
abortions. See Karlin v. Foust, 188 F.3d 446, 481 (7th Cir. 1999);
Planned Parenthood of Greater Tex. Surgical Health Servs. v.
Abbott, 734 F.3d 406, 411 (5th Cir. 2013), application to vacate
stay of injunction denied, 134 S. Ct. 506 (Nov. 19, 2013).
Step 1: Rational Basis
    At the first step, we must presume that the admitting-
privileges requirement is constitutional, and uphold it so long
as the requirement is rationally related to Wisconsin’s legiti-
mate interests. See St. John’s United Church of Christ v. City of
Chicago, 502 F.3d 616, 637–38 (7th Cir. 2007) (quoting City of
Cleburne, Tex. v. Cleburne Living Ctr., 473 U.S. 432, 440 (1985)).
Wisconsin asserts that its admitting-privileges requirement
furthers its legitimate interests in protecting the health of
mothers and in maintaining the professional standards
applicable to abortion doctors. Carhart, 550 U.S. at 157; Planned
Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 846 (1992). The
question, then, is whether Wisconsin’s adoption of the
admitting-privileges requirement is rationally related to these
interests. “Under rational basis review, ‘the plaintiff has the
28                                                    No. 13-2726

burden of proving the government’s action irrational,’ and
“[t]he government may defend the rationality of its action on
any ground it can muster, not just the one articulated at the
time of decision.’” RJB Props., Inc. v. Bd. of Educ. of Chicago, 468
F.3d 1005, 1010 (7th Cir. 2006) (quoting Smith v. City of Chicago,
457 F.3d 643, 652 (7th Cir. 2006)).
    The court suggests that Wisconsin must come forward with
medical evidence that the admitting-privileges requirement
furthers the State’s legitimate interests. Maj. Op. at 23. But,
under rational basis review, Wisconsin’s legislative choice
“may be based on rational speculation unsupported by
evidence or empirical data.” F.C.C. v. Beach Commc’ns, Inc., 508
U.S. 307, 315 (1993). States have “broad latitude” to regulate
abortion doctors, “even if an objective assessment might
suggest that” the regulation is not medically necessary.
Mazurek v. Armstrong, 520 U.S. 968, 973 (1997) (quotation marks
and emphasis omitted). Thus, the Supreme Court has rejected
as misguided arguments that an abortion law is unconstitu-
tional because the medical evidence contradicts the claim that
the law has any medical basis. Id.; see also Greenville Women’s
Clinic v. Bryant, 222 F.3d 157, 169 (4th Cir. 2000) (“[T]here is no
requirement that a state refrain from regulating abortion
facilities until a public-health problem manifests itself. In
Danforth, for example, the [Supreme] Court upheld health
measures that ‘may be helpful’ and ‘can be useful.’” (quoting
Planned Parenthood of Cent. Mo. v. Danforth, 428 U.S. 52, 80–81
(1976))). In sum, Wisconsin need offer only “a ‘conceivable
state of facts that could provide a rational basis’ for requiring
abortion physicians to have hospital admission privileges.”
Abbott, 734 F.3d at 411 (quoting F.C.C., 508 U.S. at 313).
No. 13-2726                                                                29

    The Medical Professions’ Support for Admitting Privileges
    In 2003, the American College of Surgeons issued a state-
ment on patient-safety principles that reflected a consensus in
the surgical community “on a set of 10 core principles that
states should examine when moving to regulate office-based
procedures.”1 These principles were based on a document that
was unanimously agreed to by medical associations of every
stripe, including the American Medical Association and the
American College of Obstetricians and Gynecologists. Core
Principle #4 provides that “[p]hysicians performing
office-based surgery must have admitting privileges at a
nearby hospital, a transfer agreement with another physician
who has admitting privileges at a nearby hospital, or maintain
an emergency transfer agreement with a nearby hospital.”
Unsurprisingly, the National Abortion Federation has specifi-
cally recommended that “[i]n the case of emergency, the doctor
should be able to admit patients to a nearby hospital (no more
than 20 minutes away).” National Abortion Federation, Having
an Abortion? Your Guide to Good Care (2000) (pamphlet),
available at http://web.archive.org/web/20000619200916/http://
www.prochoice.org/pregnant/goodcare.htm (internet archive
of NAF website on June 19, 2000) (hereinafter, “NAF Guide to
Good Care”). This should be sufficient to establish that Wiscon-

1
  See American College of Surgeons, Statement on Patient Safety Principles for
Office-based Surgery Utilizing Moderate Sedation/Analgesia, Deep Seda-
tion/Analgesia, or General Anesthesia, Bulletin of the American College of
Surgeons, Vol. 89, No. 4 (Apr. 2004), available at http://www.facs.org/
fellows_info/statements/st-46.html (last visited on Dec. 12, 2013, as were the
other websites cited in this opinion).
30                                                            No. 13-2726

sin’s admitting-privileges requirement is reasonably designed
to promote the state’s legitimate interest in women’s health.
And, as the court recognizes, Wisconsin is one of twelve states
adopting such a requirement. Maj. Op. at 9.
     The Benefits of Admitting Privileges in an Emergency Situation
   Further, the parties agree that at least a small number of
abortions result in complications that require hospitalization.2
Wisconsin offers doctors’ declarations establishing that the
admitting-privileges requirement expedites the admission
process and avoids mis-communications between the patient
and the hospital in situations where swift treatment is critical.
See J.A. 149–50, ¶¶ 12–19 (Decl. of Dr. James Anderson);
175–76, ¶ 14 (Decl. of Dr. Matthew Lee); 184, ¶ 9 (Decl. of Dr.
Linn); 237–38, ¶¶ 6–12 (Decl. of Dr. David C. Merrill); 332–33,
¶¶ 25–31 (Decl. of Dr. John Thorp); see also Darrell J. Solet, MD,
et al., Lost in Translation: Challenges and Opportunities to
Physician-to-Physician Communication During Patient Handoffs,
80 Academic Medicine 1094, 1097 (Dec. 2005) (observing, in the

2
  The exact percentage is in dispute, but at least .3% of abortions result in
complications requiring hospitalization. In Wisconsin, this amounts to a
woman requiring hospitalization as a result of an abortion or attempted
abortion every 16 days. As the court recognizes, however, this percentage
is likely artificially low due to under-reporting. Maj. Op. at 7. When a
woman is admitted to a hospital without a request for admission from an
abortion doctor, the social stigmas associated with abortion will likely cause
her to report her complications as arising from a miscarriage or other
mishap rather than a botched abortion. See also Abbott, 734 F.3d at 412
(quoting Dr. John Thorp regarding “the ‘unique nature of an elective
pregnancy termination and its likely under-reported morbidity and
mortality’”); J.A. 183, ¶ 6 & n.1 (Decl. of Dr. Linn).
No. 13-2726                                                                 31

context of patient transfers, that “poor communication in
medical practice turns out to be one of the most common
causes of error”). After all, the abortion doctor is better
acquainted with his patient’s medical history and is in a better
position to quickly diagnose complications resulting from the
procedure. See J.A. 238, ¶ 12 (Decl. of Dr. Merrill); 332, ¶ 25
(Decl. of Dr. Thorp). Additionally, the admitting-privileges
requirement ensures “that a physician will have the authority
to admit his patient into a hospital whose resources and
facilities are familiar to him … .” Women’s Health Ctr. of W.
Cnty., Inc. v. Webster, 871 F.2d 1377, 1381 (8th Cir. 1989)
(quotation marks omitted).
    The Oversight Function of the Admitting-Privileges Requirement
   Moreover, “[t]he requirement that physicians performing
abortions must have hospital admitting privileges helps to
ensure that credentialing of physicians beyond initial licensing
and periodic license renewal occurs.”3 Abbott, 734 F.3d at 411.
Thus, Wisconsin’s admitting-privileges requirement adds an
extra layer of protection for all of the patients of abortion

3
   The court expresses doubts about this justification because Wisconsin
requires that the hospital be within 30 miles of the clinic at which the doctor
performs the abortions. “Under rational basis review, however, the
[selected means] need not be the most narrowly tailored means available to
achieve the desired end.” Zehner v. Trigg, 133 F.3d 459, 463 (7th Cir. 1997);
see also American College of Surgeons, supra note 1 (“Physicians performing
office-based surgery must have admitting privileges at a nearby hospital, a
transfer agreement with another physician who has admitting privileges at
a nearby hospital, or maintain an emergency transfer agreement with a
nearby hospital.”) (emphasis added); NAF Guide to Good Care (recommend-
ing admitting privileges at a hospital “no more than 20 minutes away”).
32                                                    No. 13-2726

doctors. Indeed, every circuit to address the issue has held that
admitting-privileges requirements further states’ legitimate
interests. Abbott, 734 F.3d at 412 (“We have little difficulty in
concluding that, with regard to the district court’s rational
basis determination, the State has made a strong showing that
it is likely to prevail on the merits.”); Greenville Women’s Clinic
v. Comm’r, S.C. Dep’t of Health & Envtl. Control, 317 F.3d 357,
363 (4th Cir. 2002) (“These requirements of having admitting
privileges at local hospitals and referral arrangements with
local experts are so obviously beneficial to patients.”); Webster,
871 F.2d at 1381 (Missouri’s admitting-privileges requirement
“furthers important state health objectives.”).
     Admitting Privileges and Other Outpatient Surgeries
   The court emphasizes the fact that Wisconsin has not
imposed an admitting-privileges requirement on doctors who
perform outpatient procedures other than abortion. But the
plaintiffs bear the burden of proof and have offered no
evidence that doctors in those other fields have a lack of
admitting privileges—as do abortion doctors—which would
necessitate a legislative response. Moreover, there is no
mandate that state legislatures uniformly regulate medical
procedures—or regulate medical procedures with higher or
even the highest incidents of complications. States “may select
one phase of one field and apply a remedy there, neglecting the
others.” Williamson v. Lee Optical of Okla. Inc., 348 U.S. 483, 489
(1955). Finally, Wisconsin had a perfectly good reason for
addressing abortion first—namely, the Gosnell scandal.
No. 13-2726                                                                 33

    The Dr. Kermit Gosnell Scandal
    There has been no high-profile exposure of substandard
care by doctors who perform outpatient procedures other than
abortion. However, just a few weeks prior to the enactment of
Wisconsin’s admitting-privileges requirement, there was a
shocking revelation of terrible conditions and procedures at an
abortion clinic that received nationwide attention. On May 13,
2013, a Philadelphia abortion doctor, Dr. Kermit Gosnell, was
convicted of three counts of first-degree murder for the death
of three infants delivered alive but subsequently killed at his
clinic. The record in this appeal contains articles extensively
discussing the egregious health care practices at Dr. Gosnell’s
clinic leading up to his conviction. These include bloody floors
and unlicensed employees conducting gynecological examina-
tions and administering painkillers, resulting in the death of a
patient. See J.A. 154 (Joann Loviglio, Abortion Doctor Suspended
After Philadelphia Raid: ‘Deplorable’ Conditions Reported At Kermit
Gosnell’s Office, The Huffington Post, Feb. 23, 2010, http://
www.huffingtonpost.com/2010/02/23/abortion-doctor-
suspended_n_473963.html). In addition, media reports
circulated that, among other things, Dr. Gosnell physically
assaulted and performed a forced abortion on a minor and left
fetal remains in a woman’s uterus causing her excruciating
pain.4 Although these details were first publicized after Dr.
Gosnell’s arrest in 2011, the case did not garner national

4
  Jessica Hopper, Alleged Victim Calls Philadelphia Abortion Doc Kermit Gosnell
a ‘Monster’, ABC News, Jan. 25, 2011, http://abcnews.go.com/US/alleged-
victim-calls-philadelphia-abortion-doctor-kermit-gosnell/story?
id=12731387&singlePage=true
34                                                           No. 13-2726

attention until his trial in March 2013. Unsurprisingly, the case
provoked shock and outrage, prompting a heightened concern
for the health of women seeking abortions. In addition to Dr.
Gosnell’s case, Wisconsin identifies numerous other examples
of egregious and substandard care by abortion providers and
clinics. See Appendix to the Concurrence; J.A. 154–56.
    On June 4, 2013, Wisconsin Act 37, which contained the
admitting-privileges requirement at issue in this appeal and
also contained an ultrasound requirement, was introduced in
the Wisconsin Senate. On June 12, the Act passed in the Senate.
On June 13, the Act passed in the Assembly, where it was
returned to the Senate and presented to the governor for his
signature on July 3. On July 5, the Act was signed into law by
the governor. This timeline demonstrates that Wisconsin
legislators promptly responded to their constituents’ concerns.
Wisconsin Act 37 was a response to the dangers (graphically
illustrated by Dr. Gosnell’s case) to women’s health and the
right to freely exercise their choice.
          The Interaction Between the Act’s Admitting-Privileges
                    and Ultrasound Requirements
    In addition, the admitting-privileges requirement furthers
the Act’s ultrasound requirement. See Wis. Stat. § 253.10(3)(c).
Performing an ultrasound allows an abortion doctor to get a
clear picture of the woman’s pregnancy—including the
gestational age and size of the unborn child, whether there are
twins, whether the heart is beating,5 and the orientation of the

5
    Detecting a heartbeat enables the abortion doctor to determine whether
                                                              (continued...)
No. 13-2726                                                               35

unborn child within the uterus—which allows the doctor to
anticipate any likely complications. The law requires that,
absent an emergency, the woman receive an ultrasound at the
clinic or elsewhere. Accordingly, regardless of where the
ultrasound is performed, important and easily determinable
facts about the pregnancy are available to the abortion doctor.
Additionally, the ultrasound must be explained to the woman
so that she can exercise her right to choose while fully in-
formed.6 These benefits conferred by the ultrasound require

5
  (...continued)
the unborn child is still alive—a serious concern in light of the prevalence
of miscarriages. See National Institute of Health, National Library of
Medicine, Miscarriage, http://www.nlm.nih.gov/medlineplus/ency/article/
001488.htm (“Among women who know they are pregnant, the miscarriage
rate is about 15-20%.”). Determining whether there is a beating heart is a
crucial component to ensuring that a woman receives quality care. For
example, if more than seven weeks have passed since the last menstrual
cycle (“LMC”), and there is no fetal heartbeat, then the unborn child is
almost certainly naturally deceased—although a pregnancy test will
continue to generate a positive result. In that situation, the woman must be
fully informed about whether an abortion is still necessary because state-
subsidized private health insurance and Medicaid—which in most cases do
not cover an abortion—will generally cover the procedure for removing the
remains. See Wis. Stat. Ann. § 632.8985 (prohibiting coverage of abortions
by health plans offered through health benefit exchanges); Wis. Stat. Ann.
§ 20.927 (prohibiting state or municipal subsidies for the performance of
abortions).

6
  Wisconsin may also hope that a woman who sees the ultrasound picture
of her unborn child and hears the heart beating will choose to carry the
unborn child to term. But because the ultrasound requirement is not
challenged in this case, Wisconsin does not assert its legitimate interest in
                                                              (continued...)
36                                                             No. 13-2726

ment are secured by the oversight function of the admitting-
privileges requirement. Specifically, hospitals extending
admitting privileges are given a role in ensuring that the new
requirements for the protection of women’s health and choice
are observed by abortion doctors—to prevent a substandard
abortion care crisis in Wisconsin.
    Additionally, many abortion-seeking patients face uniquely
challenging circumstances not faced by other surgery patients.
Many are young and vulnerable. Some may be pressured by
angry, disappointed parents or by a putative father shirking
responsibility. And, as the court remarks, there is wide-spread
social disapproval of abortion. Maj. Op. at 7. So the woman is
likely seeking absolute privacy and has had little or no external
consultation or advice. A legislature could rationally speculate
that a surgical procedure commonly undergone by young and
vulnerable patients under the influence of either direct or
social pressures is in greater need of regulation.
    In summary, “[t]he State ‘may regulate the abortion
procedure to the extent that the regulation reasonably relates
to the preservation and protection of maternal health.’” City of
Akron v. Akron Ctr. for Reprod. Health, 462 U.S. 416, 430–31
(1983) (quoting Roe v. Wade, 410 U.S. 113, 163 (1973)). That is
what Wisconsin has done in this case, and its decision to do so
by means of an admitting-privileges requirement is certainly
rational.

6
   (...continued)
fetal life here. See Carhart, 550 U.S. at 145 (recognizing “that the government
has a legitimate and substantial interest in preserving and promoting fetal
life” pre-viability).
No. 13-2726                                                                37

Step 2: Undue Burden
    The court also suggests that the admitting-privileges
requirement imposes significant burdens on women’s ability
to obtain abortions. At this second step, we must determine
“whether the [admitting privileges requirement has] the
practical effect of imposing an undue burden” on women’s
abortion rights. Karlin, 188 F.3d at 481. We cannot find the
requirement unconstitutional unless the plaintiffs can show
that the requirement “will have the likely effect of preventing
a significant number of women for whom the regulation is
relevant from obtaining abortions.” Id. In this case, because the
requirement applies to all abortion doctors in the state, it
affects all Wisconsin women who may seek abortions.7 See
Abbott, 734 F.3d at 414. Therefore, the question is whether the
requirement prevents “a significant number of” women from
obtaining abortions. At this step too, the plaintiffs have the
burden of proof. See Karlin, 188 F.3d at 485; Bryant, 222 F.3d at
171.
    In suggesting that Wisconsin’s admitting-privileges
requirement imposes an undue burden, the court emphasizes
that it will temporarily force two abortion clinics to stop
providing abortions and another clinic to cut the number of
doctors by half, which could cause delays for women seeking
abortions. Of course, this effect will only last until the doctors
at these clinics obtain admitting privileges in accordance with

7
  Thus, the district court erred because it limited its review to women living
in the areas near the clinics that may be closed.
38                                                            No. 13-2726

the law.8 Regardless, more than 70% of women in Wisconsin
who seek abortions live in the southern counties near Milwau-
kee and Madison, where clinics will continue operating. See
J.A. 292. Thus, to the extent the remaining clinics are unable to
quickly adjust for the decreased supply of legally qualified
abortion doctors, most Wisconsin women seeking abortions
can travel to clinics in Illinois. Indeed, women living in the
northern part of Wisconsin can seek abortions in Minnesota.
For example, both Minneapolis and Duluth have abortion
clinics.9 Thus, the admitting-privileges requirement itself will
likely not prevent any woman from obtaining an abortion if
she wishes to do so. See Bryant, 222 F.3d at 163, 170–72 (holding
that “increased costs, delays in the ability to obtain abortions,
decreased availability of abortion clinics, [and] increased
distances to travel to clinics” do not constitute an undue
burden). Any delays are merely the incidental effects of

8
  The undue burden analysis is not concerned with any burden the law
may place on abortion doctors, except insofar as the law burdens women’s
ability to obtain abortions. Any burden on women will vanish once abortion
doctors obtain admitting privileges.

9
  The district court thought that the availability of abortions in cities near
the Wisconsin border was irrelevant. Although the Wisconsin law does not
affect doctors performing abortions in Minnesota, the availability of near-
but-out-of-state abortions at least speaks to whether the admitting-
privileges requirement has the “practical effect” of preventing a “significant
number” of women from obtaining abortions. In our economy, crossing
state lines to obtain services at a nearby urban center is common. Thus, state
lines are unlikely to affect a woman’s decision about where to get an
abortion and the availability of abortion at out-of-state clinics should be
considered in the undue burden analysis.
No. 13-2726                                                              39

abortion doctors’ obligation to come into compliance with the
admitting-privileges requirement. The fact that the require-
ment “has the incidental effect of making it more difficult or
more expensive to procure an abortion cannot be enough to
invalidate it.” Casey, 505 U.S. at 874. And here, we are affirm-
ing the district court’s decision to give abortion doctors a
reasonable amount of time to obtain admitting privileges.10
    The court is also concerned by the fact that (because of
Wisconsin’s 24-hour waiting law) some Wisconsin women live
around 100 miles from the closest abortion clinic—namely,
those living in north-eastern Wisconsin—and consequently,
will have to traverse that distance four times to obtain abor-
tions (if they cannot afford to spend the night at a local hotel).11

10
   Now that some months have passed, Wisconsin abortion doctors have
had sufficient time to come into compliance with the admitting-privileges
requirement. The court suggests that disapproval for abortion may interfere
with abortion doctors’ abilities to obtain admitting privileges at sectarian
hospitals. Maj. Op. at 10–11. However, “Lutheran and Jewish hospitals in
Milwaukee allow abortions.” J.A. 185, ¶ 13 (Decl. of Dr. James G. Linn).
Furthermore, “[w]hile Catholic hospitals do not permit abortions to be
performed at their facilities, they do allow abortion providers staff
membership.” Id. (“I know for a fact that Catholic hospitals in Milwaukee
have or have had abortion providers on their medical staffs.”). Although
federal law prohibits sectarian hospitals from discriminating against
abortion doctors when awarding admitting privileges, it seems reasonable
that—in light of Catholic social teaching—Catholic hospitals would wish to
grant admitting privileges to abortion doctors so that women injured by
abortions would have better access to the compassionate medical care
needed in that delicate circumstance.

11
     The number of women who seek abortions living in the areas near the
                                                           (continued...)
40                                                           No. 13-2726

The court suggests that the time and costs of that travel will
prevent a “significant number” of Wisconsin women from
obtaining abortions. But the costs of traveling up to 100 miles
on four different occasions pale in comparison to the cost of an
abortion. The costs of travel are undoubtedly inconvenient, but
an inconvenience—even a “severe inconvenience”—“is not an
undue burden.” Karlin, 188 F.3d at 481; see also Casey, 505 U.S.
at 874 (“The 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.”); Bryant, 222 F.3d
at 163, 170–72.
    Moreover, in reversing a district court’s decision to prelimi-
narily enjoin Texas’s admitting-privileges requirement, the
Fifth Circuit recently held that “[a]n increase in travel distance
of less than 150 miles for some women is not an undue burden
on abortion rights.” Abbott, 734 F.3d at 415. Texas also imposes
a 24-hour waiting requirement (which applies to any woman
who lives within 100 miles of the clinic). See Tex. Health &
Safety Code § 171.012(a)(4). Thus, under Abbott, Texas women
could face an increase in travel distance of almost 400 miles. If
an increase in travel distance of almost 400 miles is not an
undue burden, it is difficult to see how a total travel distance of

11
   (...continued)
closed clinics is apparently very small compared to those living near the
clinics that will continue to operate. Thus, the admitting-privileges
requirement likely only will compel a few rural women to drive longer
distances. So it is far from clear that a “significant number” of women will
be prevented from obtaining abortions.
No. 13-2726                                                      41

about 400 miles could be. See also Bryant, 222 F.3d at 170–71
(finding that admitting-privileges requirement imposed no
undue burden where, inter alia, an abortion clinic was still
operating “some 70 miles away”); Women’s Med. Prof’l Corp. v.
Baird, 438 F.3d 595, 605 (6th Cir. 2006) (concluding, in an as-
applied challenge to abortion regulation, that an increase in
travel distance of 45 to 55 miles is not an undue burden).
    In summary, the plaintiffs “have not demonstrated that the
[admitting-privileges requirement] would be unconstitutional
in a large fraction of relevant cases.” Carhart, 550 U.S. at 167-68.
The other circuits to address this issue have reached the same
conclusion. See Abbott, 734 F.3d at 416, 419; Bryant, 222 F.3d at
159, 173.
                           Conclusion
    The decision to have an abortion is, for many women, “the
most difficult decision they will ever make.” Lizz Winstead,
Abortion Is a Medical Procedure, The Huffington Post, Nov. 11,
2012, http://www.huffingtonpost.com/lizz-winstead/abortion-
is-a-medical-procedure_b_2064176.html. Therefore, when a
woman enters an abortion clinic, she has a right to expect
excellent care from a qualified doctor. One key component of
quality care is the use of an ultrasound, which furnishes the
abortion doctor with important and easily determinable facts
about the pregnancy related to the woman’s health and
exercise of her free choice. For example, an ultrasound allows
a determination of whether there is a fetal heartbeat, the
gestational age and size of the unborn child, and whether there
42                                                            No. 13-2726

are twins.12 An ultrasound is also material to the costs of the
procedure inasmuch as it may reveal that an abortion is no
longer necessary (if the unborn child is no longer alive) and
because clinics base the cost of the abortion procedure on the
unborn child’s gestational age.
    The admitting-privileges requirement has an indisputable
benefit when emergency care is needed. If serious complica-
tions arise, then the woman should be able to call her clinic and
speak with the doctor who treated her. If that physician has
admitting privileges, he or she can direct the woman to the
hospital and meet her there, or at least contact the hospital and
notify the proper admitting personnel to describe the possible
causes of the woman’s symptoms. Then, upon arrival at the
hospital, the woman would be able to receive immediate care.
And, if necessary, the hospital’s doctor could contact the
abortion doctor to confidentially obtain further details. Indeed,
by requiring abortion doctors to commit to continued care, the
admitting-privileges requirement prevents a situation where
a hospital doctor is not fully aware of medical concerns
because the patient does not wish to disclose that she had an
abortion. Relatedly, the ability to obtain any followup care
from same doctor furthers a patient’s interest in privacy—a
significant concern given the social stigma associated with
abortion. Moreover, the admitting-privileges requirement
furthers the state’s interest in preventing crises of substandard

12
    If the ultrasound reveals twins, this result may cause a woman to
reconsider or at least reflect on an unexpected circumstance. In either case,
the ultrasound furthers her health and ability to make a fully informed
decision.
No. 13-2726                                                                 43

care. By entrusting hospitals with an oversight function, the
requirement guards against worst-case scenarios.
    The notion that abortion doctors will be unable to obtain
admitting privileges is a fiction. Some already have them.13
Even sectarian hospitals, apart from their legal duties, are
interested in providing compassionate care to women who
need it. Some hospitals may not allow elective or discretionary
abortions to be performed on their premises, but even these
hospitals have every reason to grant admitting privileges to
abortion doctors in order to ensure that women in need receive
adequate—as well as compassionate—medical care.
    At trial, testimony from a technician who routinely per-
forms ultrasounds on pregnant women—those who anticipate
and look forward to having a baby as well as those who are
considering terminating an unwanted pregnancy—would be
beneficial. A neutral technician could explain the value an
ultrasound provides for women’s health in order to further
illustrate the oversight benefit of the admitting-privileges
requirement.

13
   According to the plaintiffs, Planned Parenthood’s Milwaukee-Jackson
clinic would be able to remain open even if the admitting-privileges
requirement went into effect. Thus, at least one abortion doctor at that clinic
must have admitting privileges at a nearby hospital. But Affiliated Medical
Services’ clinic, which will allegedly close for lack of abortion doctors with
admitting privileges, is only 1.3 miles away from Planned Parenthood’s
Milwaukee-Jackson clinic. So any claim that abortion doctors at AMS will
be unable to obtain admitting privileges because of recalcitrant local
hospitals is all but meritless.
44                                                  No. 13-2726

    Wisconsin’s admitting-privileges requirement is rationally
related to the State’s legitimate interests and should not create
an undue burden to Wisconsin women’s right to abortion. But
Wisconsin’s failure to include a reasonable time for compliance
merited a preliminary injunction. Therefore, I concur in part
and concur in the judgment.
No. 13-2726                                                   45

                  Appendix to the Concurrence

    Dr. Soleiman Soli in Pennsylvania. See Mark Scolforo, Two
Abortion Clinics Closed After Reports, The Washington Times,
Mar. 10, 2011, http://www.washingtontimes.com/news/2011/
mar/10/2-abortion-clinics-closed-after-reports/ (two abortion
clinics shut down when inspection revealed expired drugs,
uncalibrated medical equipment, and untrained personnel; a
network of abortion care providers described the clinics as
“women exploiters” ).

    Dr. Andrew Rutland in California. See C. Perkes, Abortion
Doctor Gives Up License Over Death, Orange County Register,
Jan. 25, 2011, http://www.ocregister.com/articles/rutland-
285561-death-license.html (woman died where clinic “was not
equipped to handle emergencies” and the abortion doctor
“failed to recognize [an allergic] reaction, adequately attempt
resuscitation or promptly call 911.” The doctor had previously
given up his license “after allegations of . . . scaring patients
into unnecessary hysterectomies, botching surgeries, lying to
patients, falsifying medical records, over-prescribing painkill-
ers and having sex with a patient in his office.”).

   Dr. Albert Dworkin in Delaware. See Steven Ertelt, Hearing:
Delaware Abortionist Helped Kermit Gosnell Avoid Law, LifeNews,
Mar. 16, 2011, http://www.lifenews.com/2011/03/16/hearing-
delaware-abortionist-helped-kermit-gosnell-avoid-law/ (doctor
46                                                    No. 13-2726

complicit in Kermit Gosnell’s violations has license suspended).

    Dr. James Pendergraft in Florida. See Steven Ertelt, Abortion
Practitioner James Pendergraft Loses Florida License a Fourth Time,
LifeNews, Jan. 1, 2009, http://www.lifenews.com/2009/01/01/
state-5339/ (abortion doctor’s license suspended for fourth time
for entrusting drug administration to unlicensed employee,
previous suspensions included a botched abortion that
resulted in the unborn child being shoved into the abdominal
cavity and requiring that the woman receive a hysterectomy).

    The Gentilly Medical Clinic for Women and the Hope
Medical Group for Women in Louisiana. See Steven Ertelt,
Abortion Business in Louisiana Loses License for Poor Health, Safety
Standards, LifeNews, Jan. 20, 2010, http://www.lifenews.com/
2010/01/20/state-4743/ (clinic lost license for operating without
trained nurse or proper drug license); P. J. Smith, Louisiana
Abortion Clinic Shut Down for Ignoring “Most Basic” Medical
Practices, LifeNews, Sep. 7, 2011, http://www.lifesitenews.com/
news/archive/ldn/2010/sep/10090707 (clinic’s operations
suspended for failing to observe “the most basic medical
practices” including “provid[ing] women a physical examina-
tion prior to abortions” or “follow[ing] necessary protocols for
the administration of anesthesia and monitoring their clients’
vital signs”).

   Drs. Romeo Ferrer, George Shepard, Leroy Carhart, and
Nicola Riley in Maryland. See, respectively, Steven Ertelt,
No. 13-2726                                                      47

Pro-Lifers Want Maryland Practitioner Disciplined, Killed Woman
in Botched Abortion, LifeNews, June 1, 2010, http://
www.lifenews.com/2010/06/01/state-5145/ (“Board of Physi-
cian’s Peer Reviewers concluded the woman’s death resulted
from Ferrer’s failure to meet the standard of quality care in
violation of state law.”); Steven Ertelt, Troubled Abortion Biz Sees
Two Practitioners Lose Medical Licenses, LifeNews, Sept. 3, 2010,
http://www.lifenews.com/2010/09/03/state-5416/ (transfer of
patient of botched abortion in a rental car to a clinic in another
state leads to the discovery, and suspension, of two doctors
circumventing state law); Authorities: Woman Died from Abortion
Complications, June 12, 2013, http://www.usatoday.com/story/
news/nation/2013/02/21/woman-late-term-abortion-bled-
todeath/1935799/ (Dr. Carhart is under investigation for the
death of Jennifer Morbelli, a 29 year-old school teacher who
underwent a late-term abortion); The order is available at
http://abortiondocs.org/wp-content/uploads/2013/05/
Nicola-Riley-MD-Permanent-Revocation-May-6-2013.pdf
(order permanently revoking Dr. Nicola Riley’s medical license
Maryland after she failed to call for emergency help for a
critically injured abortion patient and transported her to the
hospital in the backseat of a rental car).

   Dr. Steven Brigham in Maryland, New Jersey, and Pennsyl-
vania. See N.J. Targets Abortion Doctor Steven Brigham’s License,
Lehigh Valley Live, Sept. 9, 2010, http://www.lehighvalleylive.
com/phillipsburg/index.ssf/2010/09/nj_targets_abortion_
doctor_ste.html (New Jersey seeks to take doctor’s license after
Maryland already took his license for risky interstate abortion
scheme).
48                                                  No. 13-2726

    Dr. Rapin Osathanondh in Massachusetts. See Denise
Lavoie, Doctor Gets 6 Months in Abortion Patient Death, Associ-
ated Press, Sep. 14, 2010, http://www.msnbc.msn.com/id/
39177186/ns/us_news-crime_and_courts/t/doctor-gets-months-
abortion-patientdeath/ (doctor sentenced to six months in jail
for involuntary manslaughter because “he failed to monitor
[abortion patient] while she was under anesthesia, delayed
calling emergency services when her heart stopped, and later
lied to try to cover up his actions.”).

    Dr. Alberto Hodari in Michigan. See Schuette Files Suit to
Close Unlicensed Abortion Clinic, Office of the Attorney General,
State of Michigan, Mar. 29, 2011, http://www.michigan.gov/ag/
0,4534,7-164--253426--,00.html (Michigan Attorney General
sues to close abortion clinic for failing to comply with health
and safety rules applicable to surgical outpatient facilities).

    Drs. Salomon Epstein and Robert Hosty in New York. See
Steven Ertelt, Practitioner Denies He Botched Legal Abortion That
Killed Hispanic Woman, LifeNews, Mar. 1, 2010, http://
www.lifenews.com/2010/03/01/state-4858/ (New York police
investigate doctor after 37-year-old patient dies in botched
abortion); http://operationrescue.org/pdfs/Hosty%20
revocation.pdf (eventually, responsibility for the death Dr.
Epstein was investigated for was attributed to another doctor
at the clinic, Dr. Hosty, whose license was revoked in this
order); Southwestern Women’ Options in New Mexico, see
Jeremy Kryn, New 911 Call from New Mexico Abortion Clinic
Exposes Pattern of Emergencies, LifeNews, Oct. 20, 2011, http://
No. 13-2726                                                      49

www.lifesitenews.com/news/new-911-call-from-new-mexico-
abortion-clinic-exposes-pattern-of-emergencies (“A recording
of a 911 call . . . highlights the continuing danger [at] an
Albuquerque abortion clinic . . . . The call is the eleventh
emergency call [from the clinic] in less than two years . . . .” it
was transcribed as follows, “‘Uh, we have a 31-year-old female
who underwent an abortion today. She’s continuing to bleed.
We need to transfer her to the hospital, please’ . . . . ‘The
bleeding is persistent. It will not stop.’”).

    Dr. Tami Lynn Holst Thorndike in North Dakota. See
Denise Burke, North Dakota Abortionist Practices With Expired
License, Americans United for Life, Nov. 8, 2010, http://
www.aul.org/2010/11/north-dakota-abortionist-practices-with-
expired-license/ (“[A] North Dakota abortionist is being
investigated for practicing with an expired license.”).

    Drs. Robert E. Hanson Jr., Margaret Kini, Douglas Karpen,
Pedro J. Kowalyszyn, Sherwood C. Lynn Jr., Alan Molson,
Robert L. Prince, H. Brook Randal, Franz Theard, and William
W. West, Jr. of Whole Women’ Health in Texas. See Steven
Ertelt, Tenth Texas Abortion Practitioner Under State Investigation,
LifeNews, Aug. 24, 2011, http://www.lifenews.com/2011/08/24/
tenth-texas-abortion-practitioner-under-state-investigation/
(abortion center investigated for “illegal dumping of patient
records and medical waste”).
50                                                   No. 13-2726

    Dr. Thomas Walter Tucker II in Alabama and Mississippi.
See Abortion Doctor Suspended for Improper Drug Storage,
Orlando Sentinel, Apr. 24, 1994, http://articles.orlandosentinel.
com/1994-04-24/news/9404240462_1_abortion-doctor-tucker
-licensing (Dr. Tucker lost his medical license for drug-storage
violations, and was subsequently found liable for $10 million
in a medical malpractice case involving the death of an
abortion patient. See Former Abortion Doctor Ordered to Pay $10
Million, Sun Herald, Dec. 8, 1996, 1996 WLNR 256209).

   Dr. Mi Yong Kim in New York and Virginia. See Operation
Rescue, Troubled Virginia Abortion Clinic Puts Bleeding Botched
Abortion Patient in Hospital, LifeSiteNews, Apr. 20, 2012, http://
www.lifesitenews.com/news/troubled-virginia-abortion-clinic-
puts-bleeding-botched-abortion-patient-in/ (patient put in
hospital after abortion at clinic run by a doctor whose license
had been surrendered. The surrender order available at http://
abortiondocs.org/wp-content/uploads/2012/04/Kim-VA-
License-Surrender05182007.pdf.).