Court Opinion

ID: 4234690
Source: CourtListenerOpinion
Date Created: 2018-01-05 20:00:24.000887+00
Date Added: 2024-06-11T14:16:05.960590
License: Public Domain

PUBLISHED

                             UNITED STATES COURT OF APPEALS
                                 FOR THE FOURTH CIRCUIT

                                          No. 16-2325

GREATER BALTIMORE CENTER FOR PREGNANCY CONCERNS,
INCORPORATED,
fiel
         Plaintiff - Appellee,

and

ST. BRIGID’S ROMAN CATHOLIC CONGREGATION INCORPORATED;
ARCHBISHOP EDWIN F. O’BRIEN, ARCHBISHOP OF BALTIMORE AND
HIS SUCCESSORS IN OFFICE, A CORPORATION SOLE,

               Plaintiffs,

v.

MAYOR AND CITY COUNCIL OF BALTIMORE; STEPHANIE RAWLINGS-
BLAKE, Mayor of Baltimore, in her Official Capacity; LEANA S. WEN, M.D., in
her official capacity as Baltimore City Health Commissioner,

               Defendants - Appellants,

and

OLIVIA FARROW, Esq., Acting Baltimore City Health Commissioner, in her
official capacity; BALTIMORE CITY HEALTH DEPARTMENT; OXIRIS
BARBOT,

               Defendants,

------------------------------

INTERNATIONAL MUNICIPAL LAWYERS ASSOCIATION; PUBLIC
HEALTH ADVOCATES; THE INFORMATION SOCIETY PROJECT AT YALE
LAW SCHOOL; NARAL PRO-CHOICE MARYLAND; NARAL PRO-CHOICE
AMERICA; CATHOLICS FOR CHOICE; BALTIMORE ABORTION FUND;
DC ABORTION FUND, (“DCAF”); NATIONAL ABORTION FEDERATION;
MARYLAND CHAPTER FOR THE NATIONAL ORGANIZATION FOR
WOMEN; PLANNED PARENTHOOD OF MARYLAND; RELIGIOUS
COALITION FOR REPRODUCTIVE CHOICE; WHOLE WOMAN’S HEALTH
OF BALTIMORE; WOMEN’S LAW CENTER OF MARYLAND,
INCORPORATED; THE HONORABLE CHRISTOPHER VAN HOLLEN, JR.;
THE HONORABLE ELIJAH CUMMINGS,

            Amici Supporting Appellant,

EBONY HARRIS; ETHAN TAYLOR; LINDA HOLLIDAY; NICOLE
HOWARD; DESTINIE JACKSON; JENNERA SMALLS; AMERICAN CENTER
FOR LAW AND JUSTICE; NATIONAL AND LOCAL PREGNANCY CARE
ORGANIZATIONS; DEMOCRATS FOR LIFE OF AMERICA;
INSTITUTIONAL RELIGIOUS FREEDOM ALLIANCE; CHRISTIAN LEGAL
SOCIETY; NATIONAL INSTITUTE OF FAMILY AND LIFE ADVOCATES;
HEARTBEAT INTERNATIONAL; NATIONAL LEGAL FOUNDATION;
STATE OF WEST VIRGINIA; STATE OF ALABAMA; STATE OF
ARKANSAS; STATE OF KANSAS; STATE OF MICHIGAN; STATE OF
NEBRASKA; STATE OF OHIO; STATE OF SOUTH CAROLINA; STATE OF
TEXAS; STATE OF UTAH; DR. KESTEN C. GREEN; LAW PROFESSORS;
ETHICS & RELIGIOUS LIBERTY COMMISSION; INTERNATIONAL
SOCIETY FOR KRISHNA CONSCIOUSNESS, INCORPORATED;
ARCHDIOCESE OF BALTIMORE,

            Amici Supporting Appellee.

Appeal from the United States District Court for the District of Maryland, at Baltimore.
Marvin J. Garbis, Senior District Judge. (1:10-cv-00760-MJG)

Argued: October 24, 2017                                      Decided: January 5, 2018

Before WILKINSON, DUNCAN, and AGEE, Circuit Judges.

Affirmed by published opinion. Judge Wilkinson wrote the opinion, in which Judge
Duncan and Judge Agee joined.

                                           2
ARGUED: Suzanne Sangree, BALTIMORE CITY LAW DEPARTMENT, Baltimore,
Maryland, for Appellants. David William Kinkopf, GALLAGHER EVELIUS & JONES
LLP, Baltimore, Maryland, for Appellee. ON BRIEF: Molly R. Duane, Autumn C.
Katz, Stephanie Toti, CENTER FOR REPRODUCTIVE RIGHTS, New York, New
York, for Appellants. Peter J. Basile, FERGUSON, SHETELICH & BALLEW, PA,
Baltimore, Maryland; Steven G. Metzger, Anatoly Smolkin, GALLAGHER EVELIUS &
JONES LLP, Baltimore, Maryland; Mark L. Rienzi, THE BECKET FUND FOR
RELIGIOUS LIBERTY, Washington, D.C., for Appellee. Simona G. Strauss, P. Casey
Mathews, Palo Alto, California, Veronica R. Jordon-Davis, SIMPSON THACHER &
BARTLETT LLP, New York, New York, for Amicus Public Health Advocates. Douglas
W. Baruch, Washington, D.C., Janice Mac Avoy, Jennifer L. Colyer, Andrew B.
Cashmore, Leigh G. Rome, FRIED, FRANK, HARRIS, SHRIVER & JACOBSON LLP,
New York, New York, for Amicus International Municipal Lawyers Association.
Priscilla Joyce Smith, YALE LAW SCHOOL, Brooklyn, New York, for Amicus The
Information Society Project at Yale Law School. Kimberly A. Parker, Lesley Fredin,
Washington, D.C., Paloma Naderi, WILMER CUTLER PICKERING HALE AND
DORR LLP, Boston, Massachusetts, for Amici NARAL Pro-Choice Maryland, NARAL
Pro-Choice America, Baltimore Abortion Fund, Catholics for Choice, DC Abortion Fund,
Maryland Chapter for the National Organization for Women, National Abortion
Federation, Planned Parenthood of Maryland, Religious Coalition for Reproductive
Choice, Whole Woman’s Health of Baltimore, Incorporated, Women’s Law Center of
Maryland, The Honorable Christopher Van Hollen, Jr., and The Honorable Elijah
Cummings. Andrea Picciotti-Bayer, THE CATHOLIC ASSOCIATION, McLean,
Virginia; Jack Ryan Terziu, Baltimore, Maryland, for Amici Ebony Harris, Ethan Taylor,
Linda Holliday, Nicole Howard, Destinie Jackson, and Jennera Smalls. Edward L. White
III, Erik M. Zimmerman, Ann Arbor, Michigan, Frances J. Manion, Geoffrey R. Surtees,
AMERICAN CENTER FOR LAW AND JUSTICE, New Hope, Kentucky, for Amicus
American Center for Law and Justice. Anna F. Paprocki, Deanna M. Wallace,
AMERICANS UNITED FOR LIFE, Arlington, Virginia, for Amicus National and Local
Pregnancy Care Organizations. Thomas C. Berg, Religious Liberty Appellate Clinic,
UNIVERSITY OF ST. THOMAS SCHOOL OF LAW, Minneapolis, Minnesota;
Kimberlee Wood Colby, Christian Legal Society, CENTER FOR LAW AND
RELIGIOUS FREEDOM, Springfield, Virginia, for Amici Democrats for Life of
America, Institutional Religious Freedom Alliance, and Christian Legal Society. Kevin
H. Theriot, Elissa M. Graves, Scottsdale, Arizona, David A. Cortman, ALLIANCE
DEFENDING FREEDOM, Lawrenceville, Georgia, for Amici National Institute of
Family and Life Advocates and Heartbeat International. Frederick W. Claybrook, Jr.,
CLAYBROOK LLC, Washington, D.C.; Steven W. Fitschen, THE NATIONAL LEGAL
FOUNDATION, Virginia Beach, Virginia, for Amicus National Legal Foundation.
Patrick Morrisey, Attorney General, Elbert Lin, Solicitor General, Thomas M. Johnson,
Jr., Deputy Solicitor General, Erica N. Peterson, Assistant Attorney General, OFFICE OF
THE ATTORNEY GENERAL OF WEST VIRGINIA, Charleston, West Virginia, for

                                          3
Amicus State of West Virginia. Steven T. Marshall, Attorney General, OFFICE OF THE
ATTORNEY GENERAL OF ALABAMA, Montgomery, Alabama, for Amicus State of
Alabama.     Leslie Rutledge, Attorney General, OFFICE OF THE ATTORNEY
GENERAL OF ARKANSAS, Little Rock, Arkansas, for Amicus State of Arkansas.
Derek Schmidt, Attorney General, OFFICE OF THE ATTORNEY GENERAL OF
KANSAS, Topeka, Kansas, for Amicus State of Kansas. Bill Schuette, Attorney
General, OFFICE OF THE ATTORNEY GENERAL OF MICHIGAN, Lansing,
Michigan, for Amicus State of Michigan. Douglas J. Peterson, Attorney General,
OFFICE OF THE ATTORNEY GENERAL OF NEBRASKA, Lincoln, Nebraska, for
Amicus State of Nebraska. Michael DeWine, Attorney General, OFFICE OF THE
ATTORNEY GENERAL OF OHIO, Columbus, Ohio, for Amicus State of Ohio. Alan
Wilson, Attorney General, OFFICE OF THE ATTORNEY GENERAL OF SOUTH
CAROLINA, Columbia, South Carolina, for Amicus State of South Carolina. Ken
Paxton, Attorney General, OFFICE OF THE ATTORNEY GENERAL OF TEXAS,
Austin, Texas, for Amicus State of Texas. Sean D. Reyes, Attorney General, OFFICE
OF THE ATTORNEY GENERAL OF UTAH, Salt Lake City, Utah, for Amicus State of
Utah. Blaine H. Evanson, Daniel Nowicki, GIBSON, DUNN & CRUTCHER LLP, Los
Angeles, California, for Amicus Dr. Kesten C. Green. C. Kevin Marshall, David T.
Raimer, Catherine Maggio Schmucker, JONES DAY, Washington, D.C., for Amici Law
Professors. Daniel P. Collins, Adam P. Barry, MUNGER, TOLLES & OLSON LLP, Los
Angeles, California, for Amici Ethics & Religious Liberty Commission, International
Society for Krishna Consciousness, Incorporated, and Archdiocese of Baltimore.

                                        4
WILKINSON, Circuit Judge:

       A Baltimore City ordinance requires pregnancy clinics that do not offer or refer

for abortions to disclose that fact through signs posted in their waiting rooms. The district

court held that the law, as applied to appellee, the Greater Baltimore Center for

Pregnancy Concerns, Inc., violates the First Amendment’s Free Speech Clause. We

affirm. The City has considerable latitude in regulating public health and deceptive

advertising. But Baltimore’s chosen means here are too loose a fit with those ends, and in

this case compel a politically and religiously motivated group to convey a message

fundamentally at odds with its core beliefs and mission.

                                             I.

                                             A.

       The Greater Baltimore Center for Pregnancy Concerns is a non-profit Christian

organization committed to “providing alternatives to abortion to women who find

themselves in the midst of an unplanned pregnancy.” J.A. 360. Operating from rent-free

space provided by a Catholic Church, the Center provides pregnant women with free

services, including counseling, bible study, pregnancy tests, sonograms, and education on

child care, life skills, and abstinence. It also provides free prenatal vitamins, diapers,

clothing, books, and other assistance. The Center does not charge for its goods or

services. In keeping with its religious mission, the Center does not provide or refer for

abortions. That fact is clearly stated in a “Commitment of Care” pamphlet available in the

Center’s waiting room. J.A. 362, 375.

                                             5
       The Center advertises its pregnancy-related services, but does not expressly

broadcast its religious opposition to abortion in those ads. For example, a 2010 campaign

on Baltimore buses touted “FREE Abortion Alternatives,” “FREE Confidential Options

Counseling,” “FREE Pregnancy Tests,” and “FREE Services.” J.A. 698. A 2013 spread

in the local Penny Saver advertised, among other things, “Pre-natal development

information,” “Information about procedures and risks of abortion,” “Bible Study,” and

“Post Abortion Counseling & Education.” J.A. 693. The Center is also affiliated with two

pro-life umbrella organizations, Care Net and Heartbeat International, which refer women

to their affiliates through national call centers and websites.

       Concerned that women seeking abortions might be misled into visiting pro-life

pregnancy centers and delaying the abortion, the Mayor and City Council of Baltimore

enacted Ordinance 09-252 on December 4, 2009. The ordinance requires any “limited-

service pregnancy center” to post a disclaimer in its waiting room notifying clients that it

“does not provide or make referral for abortion or birth-control services.” See Balt. City

Health Code §§ 3-501 to 3-506 (2010). Under the ordinance, a “limited-service

pregnancy center” means any entity “whose primary purpose is to provide pregnancy-

related services” and which “provides information about pregnancy-related services,” but

“does not provide or refer for” abortions or “nondirective and comprehensive” birth

control. Id. at § 3-501. The required signs must be “conspicuously posted” and “easily

readable” in English and Spanish. Id. at § 3-502(b).

       In the event of a violation, the ordinance authorizes Baltimore City’s Health

Commissioner to issue a notice directing an offending pregnancy center to correct the

                                              6
violation. Id. at § 3-503. Failure to comply is punishable by the issuance of a $150

citation. Id. at § 3-506; Balt., Md. City Code Art. I, §§ 40-14, 41-14.

                                             B.

       The Center filed suit against the City Council, Mayor Stephanie Rawlings-Blake,

and acting Health Commissioner Olivia Farrow in the District of Maryland on March 29,

2010. The suit, brought under 42 U.S.C. § 1983, sought to enjoin enforcement of the

ordinance for violating the Center’s First Amendment rights to free speech, assembly,

and free religious exercise; the Fourteenth Amendment’s guarantee of equal protection;

and Maryland law’s so-called “conscience clause,” Md. Code Ann., Health-Gen. § 20-

214. The Center filed a motion for partial summary judgment on First Amendment

grounds supported by an affidavit from its executive director, and the City responded

with a motion to dismiss for failure to state a claim. The City also filed a Rule 56(f)

affidavit informing the district court that it believed additional discovery was necessary to

resolve the case.

       The district court granted summary judgment for the Center. It held that the

ordinance violated the Free Speech Clause because it was not narrowly tailored to

accomplish a compelling government interest. O’Brien v. Mayor & City Council of

Baltimore, 768 F. Supp. 2d 804, 808 (D. Md. 2011). A panel of this court affirmed that

decision on appeal. Greater Baltimore Ctr. for Pregnancy Concerns, Inc. v. Mayor &

City Council of Baltimore, 683 F.3d 539 (4th Cir. 2012).

       Rehearing the case en banc, the court vacated the district court’s judgment and

remanded for further proceedings. Greater Baltimore Ctr. for Pregnancy Concerns, Inc.

                                              7
v. Mayor & City Council of Baltimore, 721 F.3d 264 (4th Cir. 2013) (en banc). The court

concluded that discovery was needed to determine the Center’s economic motivation, the

scope and content of its advertisements, the effect of the ordinance, and “evidence

substantiating the efficacy of the Ordinance in promoting public health, as well as

evidence disproving the effectiveness of purported less restrictive alternatives to the

Ordinance’s disclaimer.” Id. at 285-88.

          On remand, the parties conducted extensive discovery and filed cross-motions for

summary judgment. The City objected to some discovery limitations below, but does not

raise that issue on appeal. As it acknowledges, “[t]he evidence that the City was able to

gather through discovery is more than sufficient” to decide this case. Appellant Opening

Br. 17.

          The district court held that the ordinance, as applied to the Center, violated the

First Amendment right to freedom of speech. J.A. 1243. First, it concluded “that the

Ordinance is a content-based regulation that regulates noncommercial speech, or, at the

least, that the Center’s commercial and professional speech is intertwined with its

noncommercial speech, and [the ordinance] is thus subject to strict scrutiny.” J.A. 1256.

Second, the district court determined that the record failed to demonstrate that the

ordinance furthers a compelling government interest because “there is insufficient

evidence to demonstrate that deception actually takes place and that health harms are in

fact being caused by delays resulting from deceptive advertising.” J.A. 1280. Finally, the

court concluded that the ordinance is not narrowly tailored because it applies to

                                              8
pregnancy centers “regardless of whether they advertise nonfraudulently or do not

advertise at all.” J.A. 1286.

       This appeal followed. We review the grant of a motion for summary judgment de

novo. See Desmond v. PNGI Charles Town Gaming, L.L.C., 564 F.3d 688, 691 (4th Cir.

2009). Summary judgment is appropriate where there is no genuine dispute of material

fact and “the moving party is entitled to judgment as a matter of law.” Couch v. Jabe, 679

F.3d 197, 200 (4th Cir. 2012).

                                            II.

       We must first consider what level of scrutiny applies to the ordinance.

       In general, “[l]aws that compel speakers to utter or distribute speech bearing a

particular message are subject to . . . rigorous scrutiny.” Turner Broad. Sys., Inc. v.

F.C.C., 512 U.S. 622, 642 (1994). However, the City contends that a relatively relaxed

level of scrutiny applies because the regulation is a routine exercise of the state’s police

power that targets commercial speech, or alternatively that targets professional speech.

                                            A.

       The ordinance, as applied to the Center, does not regulate commercial speech.

       As we explained in our prior en banc decision, “commercial speech is ‘usually

defined as speech that does no more than propose a commercial transaction.’” Greater

Baltimore Ctr., 721 F.3d at 284 (quoting United States v. United Foods, Inc., 533 U.S.

405, 409 (2001)). However, because “application of this definition is not always a simple

matter,” Adventure Commc’ns, Inc. v. Ky. Registry of Election Fin., 191 F.3d 429, 440

(4th Cir. 1999), some speech outside this “core notion” may also be deemed commercial.

                                             9
Bolger v. Youngs Drug Prods. Corp., 463 U.S. 60, 66 (1983). Courts rely on three factors

to identify such commercial speech: “(1) is the speech an advertisement; (2) does the

speech refer to a specific product or service; and (3) does the speaker have an economic

motivation for the speech.” Greater Baltimore Ctr., 721 F.3d at 285 (citing U.S.

Healthcare, Inc. v. Blue Cross of Greater Phila., 898 F.2d 914, 933 (3d Cir. 1990)).

       Because of the “difficulty of drawing bright lines that will clearly cabin

commercial speech,” the inquiry is fact-intensive. City of Cincinnati v. Discovery

Network, Inc., 507 U.S. 410, 419 (1993). It is also one in which “context matters.”

Greater Baltimore Ctr., 721 F.3d at 286. That is why this court remanded this case for

discovery to determine, among other things, “evidence concerning the Center’s economic

motivation (or lack thereof) and the scope and content of its advertisements.” Id.

       The ordinance, as applied to the Center, does not regulate speech that “propose[s]

a commercial transaction.” United Foods, 533 U.S. at 409. Nothing in the record suggests

that the Center proposes any transactions in the waiting room where the disclaimer would

appear. Even if pregnancy-related services are discussed there, the Center collects no

remuneration of any kind, including referral fees from physicians. A morally and

religiously motivated offering of free services cannot be described as a bare “commercial

transaction.”

       The City contends that the ordinance regulates commercial speech because the

Center advertises its services, some of which have commercial value in other contexts.

But that fact alone does not suffice to transform the Center’s ideological and religious

advocacy into commercial activity.

                                            10
       First, it is not clear that the ordinance directly regulates the Center’s

“advertisement.” Greater Baltimore Ctr., 721 F.3d at 285. The City analogizes this case

to First Resort, Inc. v. Herrera, 80 F. Supp. 3d 1043 (N.D. Cal. 2015), aff’d, 860 F.3d

1263 (9th Cir. 2017), and Fargo Women’s Health Org., Inc. v. Larson, 381 N.W.2d 176

(N.D. 1986), in which courts applied commercial speech doctrine to suits involving

allegedly misleading advertisements by pregnancy centers. But both those suits involved

laws that directly regulated misleading advertising itself. See First Resort, 80 F. Supp. 3d

at 1047 (applying an ordinance that “prohibit[ed] the use of false or misleading

advertising”); Larson, 381 N.W.2d at 177 (applying “the North Dakota false advertising

law, Chapter 51–12, N.D.C.C.”). While motivated by similar concerns, the ordinance

here requires a waiting-room disclosure without any effect on advertising qua

advertising. Indeed, the Baltimore ordinance applies to pregnancy centers regardless of

whether they advertise at all.

       Second, the record gives no indication that the Center harbors an “economic

motivation.” Greater Baltimore Ctr., 721 F.3d at 285. Again, the Center is a non-profit

organization whose clearest motivation is not economic but moral, philosophical, and

religious. It provides free services and collects no fees. And after extensive discovery, the

only evidence the City can muster in support of its contention that the Center is

economically motivated is its assertion that the Center’s “fundraising efforts . . . depend

on its ability to attract clients.” Appellant Opening Br. 29. That may or may not be true.

But the City’s evidence is speculative at best. Without more, the relationship here

                                             11
between clinic patronage and fundraising is too attenuated to amount to “economic

motivation.”

       We do not foreclose the possibility that another facility in different circumstances

could engage in commercial speech. But with a “fully developed record” now before us,

Greater Baltimore Ctr., 721 F.3d at 286, we agree with the district court. The ordinance,

as applied to this Center, does not regulate commercial speech.

                                             B.

       Nor does the ordinance, as applied to the Center, regulate professional speech. 1

       “The power of government to regulate the professions is not lost whenever the

practice of a profession entails speech.” Lowe v. SEC, 472 U.S. 181, 228 (1985) (White,

J., concurring in the judgment). But at the same time, “individuals [do not] simply

abandon their First Amendment rights when they commence practicing a profession.”

Stuart v. Camnitz, 774 F.3d 238, 247 (4th Cir. 2014). Thus, “[w]hen the First

Amendment rights of a professional are at stake, the stringency of review . . . slides along

a continuum from public dialogue on one end to regulation of professional conduct on the

other.” Id. at 248 (internal quotation marks omitted).

       Because the state has a strong interest in supervising the ethics and competence of

those professions to which it lends its imprimatur, this sliding-scale review applies to

       1
          Contrary to the Center’s arguments, the City did not forfeit this argument by
failing to advance a professional speech theory earlier. The professional speech issue was
fully briefed, analyzed, and decided on remand to the district court. There is no bar to
considering it here.

                                            12
traditional occupations, such as medicine or accounting, which are subject to

comprehensive state licensing, accreditation, or disciplinary schemes. See e.g., Stuart,

774 F.3d 238 (doctors); Accountant’s Soc’y of Va. v. Bowman, 860 F.2d 602 (4th Cir.

1988) (accountants). More generally, the doctrine may apply where “the speaker is

providing personalized advice in a private setting to a paying client.” Moore-King v. Cty.

of Chesterfield, Va., 708 F.3d 560, 569 (4th Cir. 2013).

       The Center fits none of these characteristics of a professional speaker. In

Maryland, pregnancy centers are not required to be licensed or otherwise subject to a

state regulatory scheme. 2 There is no medical or professional board that certifies the

Center’s employees, nor any disciplinary panel that regulates their conduct. Although the

Center has a volunteer “medical director” who is a licensed physician, she is “very

rarely” on site and does not meet directly with clients. J.A. 921. Simply put, no one in the

Greater Baltimore Center is practicing a “profession” in the traditional sense

contemplated by our First Amendment jurisprudence.

       Nor does the Center fit the more general criteria laid out in Moore-King. Although

the Center “provid[es] personalized advice in a private setting,” 708 F.3d at 569, and

       2
        The lack of a licensing scheme distinguishes this case from a recent Ninth Circuit
decision analyzing a California clinic disclosure law under the rubric of professional
speech. See Nat’l Inst. of Family & Life Advocates v. Harris, 839 F.3d 823 (9th Cir.
2016), cert. granted sub nom., Nat’l Inst. of Family & Life Advocates v. Becerra, No. 16-
1140 (U.S. Nov. 13, 2017). In that case, the court applied the professional speech
doctrine only to compelled disclosures in clinics licensed by the state. Id. at 839. The
Ninth Circuit did not reach the question of whether the doctrine applied to disclosures
required in unlicensed pregnancy centers like the one at issue here. Id. at 843.

                                            13
describes its patrons as “clients,” J.A. 827, none of those clients are “paying,” 708 F.3d at

569. Again, the Center does not charge for its services. “The mere fact that [a pregnancy

center] provides its program participants with the promise of confidentiality does not

transform its message into professional speech.” Tepeyac v. Montgomery Cty., 5 F. Supp.

3d 745, 761 (D. Md. 2014).

       With no record of comprehensive state regulation or paying clients before us, we

cannot say that the ordinance regulates professional speech.

                                             C.

       Because the commercial speech and professional speech doctrines are inapplicable

in this case, the Baltimore ordinance’s compulsion “to utter or distribute speech bearing a

particular message” receives heightened scrutiny. Turner Broad. Sys., 512 U.S. at 642.

As a result, the ordinance calls for more searching review than the relaxed standards

advocated by the City.

       The essentially factual nature of the compelled disclaimer does not diminish the

need for rigorous review. Because a statement’s factuality “does not divorce the speech

from its moral or ideological implications,” Stuart, 774 F.3d at 246, a person’s right to

refrain from speaking “applies . . . equally to statements of fact the speaker would rather

avoid,” Hurley v. Irish-Am. Gay, Lesbian & Bisexual Grp. of Boston, 515 U.S. 557, 573

(1995).

       The compelled speech at issue here raises particularly troubling First Amendment

concerns. At bottom, the disclaimer portrays abortion as one among a menu of morally

equivalent choices. While that may be the City’s view, it is not the Center’s. The message

                                             14
conveyed is antithetical to the very moral, religious, and ideological reasons the Center

exists. Its avowed mission is to “provid[e] alternatives to abortion.” J.A. 360. Its “pro-life

Christian beliefs permeate all that the Center does.” J.A. 354. Its staff and volunteers are

trained “in encouraging women not to have an abortion.” J.A. 366. Of course, this

mission gives the Center no license at all to lie to women, and, indeed, there is no such

suggestion here. But it does provide some latitude in how to broach a sensitive topic. The

Center currently explains its opposition to abortion in its “Commitment of Care”

pamphlets. But it does so on its own terms. None of that changes the fact that the

ordinance forces the Center to utter in its own waiting room words at odds with its

foundational beliefs and with the principles of those who have given their working lives

to it.

         The classic First Amendment violation has always been thought to involve an

outright prohibition by the state of certain speech. See, e.g., Cohen v. California, 403

U.S. 15 (1971) (holding that a state may not prosecute someone for wearing a jacket

bearing the words “Fuck the Draft”); Near v. Minnesota, 283 U.S. 697 (1931) (holding

that a state may not exercise a prior restraint on publishing a newspaper). But over time,

adjunct First Amendment rights have emerged, which in their own way have become as

significant for expressive liberty as the right not to be silenced by a disapproving public

entity. One of those adjunct rights is the right to listen. See Rossignol v. Voorhaar, 316

F.3d 516, 522 (4th Cir. 2003) (observing that the First Amendment “protects both a

speaker’s right to communicate information and ideas to a broad audience and the

intended recipients’ right to receive that information and those ideas”). Another is the

                                             15
right to express oneself through conduct. See Tinker v. Des Moines Indep. Cmty. Sch.

Dist., 393 U.S. 503 (1969) (holding that a public school may not, without evidence of

substantial disruption, punish students for wearing armbands protesting the Vietnam

War). Yet another is the right not to utter political and philosophical beliefs that the state

wishes to have said. See W. Virginia State Bd. of Educ. v. Barnette, 319 U.S. 624, 642

(1943) (holding that a public school cannot compel students to perform the pledge of

allegiance). These adjunct rights have become crucial to speech freedoms because,

without them, states can bend individuals to their own beliefs and use compelled speech

as a weapon to run its ideological foes into the ground. Preserving some distance between

the state and the message is thus the aim of preventing banned speech and compelled

speech alike, and it is what gives the right in this case its fundamental character.

                                             III.

       We now consider whether the Baltimore ordinance satisfies heightened scrutiny.

“[E]xacting First Amendment scrutiny” requires that compelled disclosures be “narrowly

tailored” to achieve a “weighty” government interest. Riley v. Nat’l Fed’n of the Blind of

N. Carolina, Inc., 487 U.S. 781, 798 (1988). “A statute is narrowly tailored if it targets

and eliminates no more than the exact source of the ‘evil’ it seeks to remedy.” Frisby v.

Schultz, 487 U.S. 474, 485 (1988).

       The City’s interests are plainly important. Baltimore’s stated goals in enacting the

ordinance were to address allegedly deceptive advertising and to prevent health risks that

can accompany delays in seeking to end a pregnancy. States must have ample room to

regulate deceptions and health risks. Courts have long recognized those sorts of aims as

                                             16
weighty. See, e.g., Maryland v. Universal Elections, Inc., 729 F.3d 370, 376-77 (4th Cir.

2013) (“promoting disclosure to avoid misleading [consumers]”); Varandani v. Bowen,

824 F.2d 307, 311 (4th Cir. 1987) (“assuring safe health care for the public”). Where

there is solid evidence of such dangers, courts will not hesitate to give government the

deference it is due.

       However, as the district court found, “there is insufficient evidence to demonstrate

that deception actually takes place and that health harms are in fact being caused by

delays resulting from deceptive advertising.” J.A. 1280. The City’s only support for its

contention that women might have read a bus ad mentioning “abortion alternatives” to

mean “abortion services” is a reported increase in phone calls to the Center’s hotline from

“abortion minded callers.” J.A. 705. After seven years of litigation and a 1,295-page

record before us, the City does not identify a single example of a woman who entered the

Greater Baltimore Center’s waiting room under the misimpression that she could obtain

an abortion there. What the record does show is affirmative advocacy of abortion

alternatives by a lawful non-profit group. None of the public advocacy of alternatives,

however, suggests that the Center would provide help or assistance in obtaining an

abortion. Truthful affirmative assertions are not, without more, misleading.

       Additionally, scrutiny of means creates difficulties with the City’s view. It is

scrutiny of means that helps identify the point on the spectrum where valid disclosures

slip silently into the realm of impermissible compelled speech. Particularly troubling in

this regard is (1) that the ordinance applies solely to speakers who talk about pregnancy-

related services but not to speakers on any other topic; and (2) that the ordinance compels

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speech from pro-life pregnancy centers, but not other pregnancy clinics that offer or refer

for abortion. It is well established that “[t]he government may not regulate . . . based on

hostility—or favoritism—towards the underlying message expressed.” R.A.V. v. City of

St. Paul, Minn., 505 U.S. 377, 386 (1992). A speech edict aimed directly at those

pregnancy clinics that do not provide or refer for abortions is neither viewpoint nor

content neutral. Especially in this context, content-based regulation “raises the specter

that the government may effectively drive certain ideas or viewpoints from the

marketplace.” Simon & Schuster, Inc. v. Members of New York State Crime Victims Bd.,

502 U.S. 105, 116 (1991). We do not begrudge the City its viewpoint. But neither may

the City disfavor only those who disagree.

       Further, there are serious questions here as to narrow tailoring. First, we are

unpersuaded that the City could not pursue its goals through less restrictive means. As the

Supreme Court has noted in compelled speech cases, the government itself may

“communicate the desired information to the public without burdening a speaker with

unwanted speech.” Riley, 487 U.S. at 800. In this case, that would mean informing

citizens about the scope of services offered at various facilities through a public

advertising campaign. See Evergreen Ass’n, Inc. v. City of N.Y., 740 F.3d 233, 250 (2d

Cir. 2014) (noting that “the City can communicate this message through an advertising

campaign”); Centro Tepeyac v. Montgomery Cty., 722 F.3d 184, 190 (4th Cir. 2013) (en

banc) (stating that the government had “several options less restrictive than compelled

speech,” such as “launch[ing] a public awareness campaign” (internal quotation marks

omitted)). The City could also pursue its goals through the direct application of laws

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against misleading advertising. See First Resort, 80 F. Supp. 3d at 1047; Larson, 381

N.W.2d at 177; cf. Riley, 487 U.S. at 800 (“Alternatively, the State may vigorously

enforce its antifraud laws . . . .”).

       Second, and more fundamentally, there is only a loose fit between the compelled

disclosure at issue and the purported ills identified by the government. “[W]hen [laws]

affect First Amendment rights they must be pursued by means that are neither seriously

underinclusive nor seriously overinclusive.” Brown v. Entm’t Merchants Ass’n, 564 U.S.

786, 805 (2011). Baltimore seeks to combat deceptive advertising and consequent delays

in abortion services. In that respect the ordinance is quite overinclusive. It applies to

pregnancy centers without regard to whether their advertising is misleading, or indeed

whether they advertise at all. As illustrated by Larson and First Resort, the direct

application of laws prohibiting misleading advertising might provide a better fit for the

problems about which the City is concerned. See First Resort, 80 F. Supp. 3d 1043;

Larson, 381 N.W.2d 176.

       There are, in short, too many problems with the City’s case. The dangers of

compelled speech in an area as ideologically sensitive and spiritually fraught as this one

require that the government not overplay its hand. Without proving the inefficacy of less

restrictive alternatives, providing concrete evidence of deception, or more precisely

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targeting its regulation, the City cannot prevail. The Baltimore ordinance, as applied to

the Center, fails to satisfy heightened First Amendment scrutiny. 3

                                            IV.

       The abortion debate in our country has a long and bitter history. Vast disagreement

on the merits has led both sides to retributive speech restrictions and compulsions. See,

e.g., Stuart, 774 F.3d at 242. To be sure, states must have room for reasonable regulation.

But there is a limit to how much they can dictate core beliefs. This court has in the past

struck down attempts to compel speech from abortion providers. Id. And today we do the

same with regard to compelling speech from abortion foes. We do so in belief that earnest

advocates on all sides of this issue should not be forced by the state into a corner and

required essentially to renounce and forswear what they have come as a matter of deepest

conviction to believe.

       Weaponizing the means of government against ideological foes risks a grave

violation of one of our nation’s dearest principles: “that no official, high or petty, can

prescribe what shall be orthodox in politics, nationalism, religion, or other matters of

       3
          Our holding does not conflict with the Ninth Circuit’s decision in Harris. See
839 F.3d 823, cert. granted, No. 16-1140 (U.S. Nov. 13, 2017). The law at issue in that
case involved two compelled disclosures. First, the law in Harris required licensed clinics
to post a notice informing women of the availability of state-sponsored services,
including abortion, and a phone number to call for more information. Id. at 830. The
content of that disclaimer—and, because it only applied to licensed facilities, the scrutiny
which it received—was markedly different from the Baltimore ordinance. Second, the
law in Harris required unlicensed pregnancy centers to post a notice stating that their
facilities are not licensed by the state. Id. Because the compelled message did not
mention abortion, the burden on the speaker—and therefore the First Amendment
analysis—was different in kind.

                                            20
opinion or force citizens to confess by word or act their faith therein.” Barnette, 319 U.S.

at 642. It may be too much to hope that despite their disagreement, pro-choice and pro-

life advocates can respect each other’s dedication and principle. But, at least in this case,

as in Stuart, it is not too much to ask that they lay down the arms of compelled speech

and wield only the tools of persuasion. The First Amendment requires it.

       For the foregoing reasons, the judgment of the district court is

                                                                               AFFIRMED.

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