Court Opinion

ID: 8975148
Source: CourtListenerOpinion
Date Created: 2022-11-27 10:53:02.55922+00
Date Added: 2024-06-11T17:10:31.976324
License: Public Domain

CARDAMONE, Circuit Judge,
concurring:
I concur in Judge Winter’s thorough opinion to affirm because I agree that the regulations promulgated by the Secretary are permissible under Title X, and are not constitutionally infirm. If experience under the regulations proves otherwise, a challenge may later be raised and resolved. I write separately to express two concerns.
The first concern is directed at the regulation requiring the Secretary to consider “[t]he existence of separate personnel” as a factor in determining the “objective integrity and independence [from abortion-related facilities]” of Title X facilities. See 42 C.F.R. § 59.9(c) (1988). This factor allows the Secretary in allocating Title X funding to consider whether Title X health-care providers perform or counsel abortions outside of their employment. The concern this raises is whether the Secretary may withhold funding from health-care providers based upon their exercise of First Amendment rights outside the scope of their Title X employment; a course of action explicitly found unconstitutional in Perry v. Sindermann, 408 U.S. 593, 597, 92 S.Ct. 2694, 2697, 33 L.Ed.2d 570 (1972); see also Webster v. Reproductive Health Servs., — U.S. —, 109 S.Ct. 3040, 3052 n. 8, 106 L.Ed.2d 410 (1989) (“This case might ... be different if the State barred doctors who performed abortions in private facilities from the use of public facilities_”).
Despite my concerns under Perry, I do not believe § 59.9(c) is constitutionally unsound. The regulation’s plain language indicates that the Secretary will consider the existence of separate personnel in conjunction with several other factors: the maintenance of distinct accounting records, the physical separation of facilities, and the degree to which signs and other written indicia denote the two as separate facilities. Thus, “[w]here sharing of personnel exists, but the project can demonstrate on an overall basis that it is objectively separated from prohibited activities, the Department will determine that the project is in compliance. ...” 53 Fed.Reg. 2922, 2941 (1988). In addition, there is no evidence in the record before us that the Secretary has relied or intends to rely upon the non-Title X employment activities of personnel in determining whether to grant a facility Title X status.
*415The second concern relates to the regulations insofar as they do not permit Title X attending physicians to provide the Yellow Pages found in an ordinary telephone book to a patient requesting information about health-care providers who perform and counsel patients regarding abortions. The Secretary’s oral and written interpretations of the regulations state that Title X grantees may “keep[]” but not “provide]” the Yellow Pages. See 53 Fed.Reg. 2922, 2942 (1988). In addition, the plain language of § 59.8(a)(3) prohibits the inclusion of “health care providers whose principal business is the provision of abortions” in referral lists given to patients. Because such facilities are listed in the Yellow Pages, this regulation bars their use as a reference source for Title X patients.
Under the regulations, a Title X physician’s hands are tied with respect to the response he or she may give to a patient seeking abortion information. Crafting the regulations in this fashion constitutes a trap for the mostly unsophisticated and unwary patients,1 and jeopardizes the ability of Title X physicians to safeguard the health of those seeking their expert advice. For example, a Title X grantee must refer patients to facilities that do not perform or counsel abortions, see 42 C.F.R. § 59.8(a)(3) & (b)(4) (1988), regardless of whether the grantee believes the facility is sound medically or not. Moreover, the list must include all such facilities because the Secretary has ruled that excluding any such provider is inappropriate under Title X. The dilemma that comes to mind occurs when the Title X grantee knows that a health-care provider that does not perform or counsel abortions is — in the physician’s opinion — not medically of high quality, but must nonetheless list that facility as a proper reference to a patient seeking the grantee’s advice.
When faced with a somewhat analogous predicament, the Supreme Court, addressing the issue of what information must be supplied by a physician to facilitate a patient’s “informed consent,” declined to define the information provided by the physician narrowly. Rather, the Court required only that the physician indicate “what would be done and ... its consequences” because a more detailed definition “might well confine the attending physician in an undesired and uncomfortable straitjacket in the practice of his profession.” Planned Parenthood v. Danforth, 428 U.S. 52, 67 n. 8, 96 S.Ct. 2831, 2840 n. 8, 49 L.Ed.2d 788 (1976).
It strikes me that a regulation allowing the Yellow Pages to be “kept” but not “provided” is a small and petty contrivance, inconsistent with our nation’s high principles. Hence, although I vote to affirm because the subject regulations meet the letter of the law, I must say that in my view they fall woefully short of the tolerant spirit that gave birth to and should continue to animate our constitutional system.

. It has been said that Title X, as the single largest federally-funded family planning program, serves 4.3 million people: its targeted population consists of an estimated 14.5 million women at risk of unintended pregnancy, including 5 million adolescents between the ages of 15 and 19, and 9.5 million adult women between the ages of 20 and 44, all of whom have an income 150 percent below the poverty level. Note, The Title X Family Planning Gag Rule: Can the Government Buy Up Constitutional Rights?, 41 Stan.L.Rev. 401, 408 (1989).