Court Opinion

ID: 9733681
Source: CourtListenerOpinion
Date Created: 2023-08-26 17:14:02.712251+00
Date Added: 2024-06-11T18:26:43.548900
License: Public Domain

LAWRENCE G. CRAHAN, Judge,
concurring.
I concur fully in the per curiam opinion of the court. The opinion quite properly does not address the constitutionality of the Act. That issue will be determined by the federal district court when this case is finally resolved. The briefs of both parties, however, reflect the implicit assumption that the absence of a health exception will render the Act unconstitutional under Stenberg v. Carhart, 580 U.S. 914, 120 S.Ct. 2597, 147 L.Ed.2d 743 (2000). I write separately to explain why Stenberg is based on an implicit assumption that the record in this case at least suggests may not be true.
Stenberg struck down a Nebraska statute that the court found banned both the rarely-performed D & X procedure and the more commonly performed D & E procedure. Id. at 938, 120 S.Ct. 2597. The trial court in this case found and the parties do not dispute that Missouri’s Act “does not apply to the performance, by a licensed physician, ... of a dismemberment or “nonintact” dilation (dilatation) and evacuation (D & E) abortion.”
The Supreme Court further held that Nebraska had failed to demonstrate that banning the D & X procedure without a health exception may not create significant health risks for women because the record before it showed that significant medical authority supports the proposition that in some circumstances, D & X would be the safest procedure. Id. at 932, 120 S.Ct. 2597.1 Curiously, however, after enumerating these perceived benefits of intact *66extraction of the fetus, the Court never addresses the more fundamental question presented by Missouri’s (and arguably Nebraska’s) Act: Why is it necessary or desirable to perform the procedure on a fetus that is still alive? Or, to state the issue in constitutional terms: What, if any, risk is presented to the health of the mother by requiring her physician to take steps to humanely bring about the demise of the fetus before undertaking intact extraction from the uterus? By failing to discuss this issue, the Stenberg opinion at least implicitly assumes either that there is some medical benefit to the fetus being alive during extraction from the uterus or that taking steps to humanely cause the demise of the fetus before extraction would pose some appreciable additional health risk to the mother. It is not at all clear, however, that the Court had any factual basis for either assumption.
The trial court expressly found and the parties do not dispute that Missouri’s Act “does not apply to the performance, by a licensed physician, ... of any abortion pri- or to the time that a fetal heartbeat is detectable, nor does it apply to an abortion at any time when the fetus has no detectable heartbeat.” Thus, Missouri’s Act clearly permits intact extraction of a fetus from the uterus, with all of its perceived benefits identified by the Supreme Court in Stenberg. It merely requires that the physician take steps to humanely bring about the demise of the fetus before performing the procedure.
We have no record of the debates leading up to the enactment of Missouri’s Act and thus do not know for certain what precise concerns led to its enactment. However, Dr. Cook’s testimony at the trial of this case identifies one of the more likely concerns. Dr. Cook testified that in his opinion, the D & X procedure was needlessly cruel because the infant was still alive and capable of feeling pain. The basis for Dr. Cook’s opinion that the fetus can suffer pain as a result of the D & X procedure was not explored further because it was not the focus of the proceeding below. 'Whether a fetus can, in fact, experience pain is apparently a matter of some dispute. In Women’s Medical Professional Corp. v. Voinovich, 911 F.Supp. 1051, 1072-74 (S.D.Ohio 1995), the court recounted testimony by two neurosurgeons who generally agreed that a fetus at the age of twenty to twenty-four weeks will react to noxious stimuli, but neither could state with certainty that the fetus experiences a conscious awareness of pain. It is indeed difficult to imagine how this could ever be conclusively established. But if there is uncertainty as to whether the fetus can experience pain as a result of the D & X procedure (or, for that matter the non-intact D & E, which involves actual dismemberment of the fetus), must a State sit. idly by and tolerate potential cruelty when there are humane alternatives that may pose no appreciable additional risk to the mother’s health?
In Stenberg, the Supreme Court somewhat cryptically made reference to an AMS report which states that, after twenty weeks, “[s]ome physicians use intrafetal potassium chloride or digoxin to induce fetal demise prior to a late D & E (after twenty weeks), to facilitate evacuation.” 530 U.S. at 924, 120 S.Ct. 2597 (citing American Medical Association, Report of Board of Trustees on Late-Term Abortion, pp. 491-92). Although it was not the focus of the hearing below, Dr. Crist’s and Dr. Stubblefield’s testimony both suggest that cutting the umbilical cord would also bring about fetal demise, thus ensuring the fetus *67would not experience pam during the process of extraction from the uterus. Dr. Stubblefield also testified that all abortions performed after seventeen weeks at Boston Medical Center, where he chairs the department of obstetrician and gynecology,, are done by labor induction and only after the introduction of a saline solution into the amniotic sac, which causes the demise of the fetus.
I cite this testimony because it at least suggests that there are safe and humane measures that can be employed by a physician without appreciable additional health risks to the mother that will cause the painless demise of the fetus prior to extraction from the uterus. I readily acknowledge that this was not the subject or focus of the hearing below and that there may well be other considerations not explored in the limited record before us. I do respectfully submit, however, that a complete examination of this subject is both necessary and appropriate in any proceeding to determine the constitutionality of Missouri’s Act.

. Citing the findings of the district court, the advantages of the D & X procedure were identified as (1) it permits the fetus to pass through the cervix with a minimum of instrumentation; (2) it reduces operating time, blood loss and risk of infection; (3) it reduces complications from bony fragments; (4) it reduces instrument inflicted damage to the uterus and cervix; (5) it prevents the most common causes of maternal mortality (DIC *66and amniotic fluid embolus); and (6) it eliminates the possibility of "horrible complications” arising from retained fetal parts. Id.