Court Opinion

ID: 9429247
Source: CourtListenerOpinion
Date Created: 2023-08-02 23:26:11.30945+00
Date Added: 2024-06-11T17:23:18.300567
License: Public Domain

Justice Blackmun,
with whom Justice Brennan, Justice Marshall, and Justice Stevens join,
concurring in part and dissenting in part.
The Court’s decision today in Akron v. Akron Center for Reproductive Health, Inc., ante, p. 416, invalidates the city of Akron’s hospitalization requirement and a host of other provisions that infringe on a woman’s decision to terminate her pregnancy through abortion. I agree that Missouri’s hospitalization requirement is invalid under the Akron analysis, and I join Parts I and II of Justice Powell’s opinion in the present cases. I do not agree, however, that the remaining Missouri statutes challenged in these cases satisfy the constitutional standards set forth in Akron and the Court’s prior decisions.
I
Missouri law provides that whenever an abortion is performed, a tissue sample must be submitted to a “board eli*495gible or certified pathologist” for a report. Mo. Rev. Stat. §188.047 (Supp. 1982). This requirement applies to first-trimester abortions as well as to those performed later in pregnancy. Our past decisions establish that the performance of abortions during the first trimester must be left “‘free of interference by the State.’” Akron, ante, at 430, quoting Roe v. Wade, 410 U. S. 113, 163 (1973). As we have noted in Akron, this does not mean that every regulation touching upon first-trimester abortions is constitutionally impermissible. But to pass constitutional muster, regulations affecting first-trimester abortions must “have no significant impact on the woman’s exercise of her right” and must be “justified by important state health objectives.” Akron, ante, at 430; see ante, at 489-490.
Missouri’s requirement of a pathologist’s report is not justified by important health objectives. Although pathology examinations may be “useful and even necessary in some cases,” ante, at 487, Missouri requires more than a pathology examination and a pathology report; it demands that the examination be performed and the report prepared by a “board eligible or certified pathologist” rather than by the attending physician. Contrary to Justice Powell’s assertion, ibid., this requirement of a report by a pathologist is not in accord with “generally accepted medical standards.” The routine and accepted medical practice is for the attending physician to perform a gross (visual) examination of any tissue removed during an abortion. Only if the physician detects abnormalities is there a need to send a tissue sample to a pathologist. The American College of Obstetricians and Gynecologists (ACOG) does not recommend an examination by a pathologist in every case:
“In the situation of elective termination of pregnancy, the attending physician should record a description of the gross products. Unless definite embryonic or fetal parts can be identified, the products of elective interrup*496tions of pregnancy must be submitted to a pathologist for gross and microscopic examination.
“. . . Aspirated tissue should be examined to ensure the presence of villi or fetal parts prior to the patient’s release from the facility. If villi or fetal parts are not identified with certainty, the tissue specimen must be sent for further pathologic examination . . . .” ACOG, Standards for Obstetric-Gynecologic Services 52, 54 (5th ed. 1982).1
Nor does the National Abortion Federation believe that such an examination is necessary:
“All tissue must be examined grossly at the time of the abortion procedure by a physician or trained assistant and the results recorded in the chart. In the absence of visible fetal parts or placenta upon gross examination, obtained tissue may be examined under a low power microscope for the detection of villi. If this examination is inconclusive, the tissue should be sent to the nearest suitable pathology laboratory for microscopic examination.” National Abortion Federation Standards 6 (1981) (emphasis deleted).
As the Court of Appeals pointed out, there was expert testimony at trial that a nonpathologist physician is as capable of performing an adequate gross examination as is a pathologist, and that the “abnormalities which are of concern” are *497readily detectable by a physician. 655 F. 2d 848, 871, n. 37 (CA8 1981); see App. 135.2 While a pathologist may be better able to perform a microscopic examination, Missouri law does not require a microscopic examination unless “fetal parts or placenta are not identified.” 13 Mo. Admin. Code § 50-151.030(1) (1981). Thus, the effect of the Missouri statute is to require a pathologist to perform the initial gross examination, which is normally the responsibility of the attending physician and which will often make the pathologist’s services unnecessary.
On the record before us, I must conclude that the State has not “met its burden of demonstrating that [the pathologist requirement] further[s] important health-related State concerns.” Akron, ante, at 430.3 There has been no showing that tissue examinations by a pathologist do more to protect health than examinations by a nonpathologist physician. Missouri does not require pathologists’ reports for any other surgical procedures performed in clinics, or for minor surgery performed in hospitals. 13 Mo. Admin. Code § 50-20.030(3)(A)(7) (1977). Moreover, I cannot agree with Justice Powell that Missouri’s pathologist requirement has “no significant impact” ante, at 489, on a woman’s exercise of her right to an abortion. It is undisputed that this requirement may increase the cost of a first-trimester abortion by as much as $40. See 483 F. Supp. 679, 700, n. 48 (WD Mo. 1980). Although this increase may seem insignificant from the Court’s comfortable perspective, I cannot say that it is equally insignificant to every woman seeking an abortion. *498For the woman on welfare or the unemployed teenager, this additional cost may well put the price of an abortion beyond reach.4 Cf. Harper v. Virginia Board of Elections, 383 U. S. 663, 668 (1966) ($1.50 poll tax “excludes those unable to pay”); Burns v. Ohio, 360 U. S. 252, 255, 257 (1959) ($20 docket fee “foreclose^] access” to appellate review for indigents).
In Planned Parenthood of Central Missouri v. Danforth, 428 U. S. 52, 81 (1976), the Court warned that the minor recordkeeping requirements upheld in that case “perhaps approach[ed] impermissible limits.” Today in Akron, we have struck down restrictions on first-trimester abortions that “may in some cases add to the cost of providing abortions.” Ante, at 447-448; see ante, at 449-451. Missouri’s requirement of a pathologist’s report unquestionably adds significantly to the cost of providing abortions, and Missouri has not shown that it serves any substantial health-related purpose. Under these circumstances, I would hold that constitutional limits have been exceeded.
hH
In Missouri, an abortion may be performed after viability only if necessary to preserve the life or health of the woman. Mo. Rev. Stat. §188.030.1 (Supp. 1982). When a postviability abortion is performed, Missouri law provides that “there [must be] in attendance a [second] physician . . . who *499shall take control of and provide immediate medical care for a child born as a result of the abortion.” Mo. Rev. Stat. §188.030.3 (Supp. 1982). The Court recognized in Roe v. Wade, 410 U. S., at 164-165, that a State’s interests in preserving maternal health and protecting the potentiality of human life may justify regulation and even prohibition of postviability abortions, except those necessary to preserve the life and health of the mother. But regulations governing postviability abortions, like those at any other stage of pregnancy, must be “tailored to the recognized state interests.” Id., at 165; see H. L. v. Matheson, 450 U. S. 398, 413 (1981) (“statute plainly serves important state interests, [and] is narrowly drawn to protect only those interests”); Roe, 410 U. S., at 155 (“legislative enactments must be narrowly drawn to express only the legitimate state interests at stake”).
A
The second-physician requirement is upheld in these cases on the basis that it “reasonably furthers the State’s compelling interest in protecting the lives of viable fetuses.” Ante, at 486. While I agree that a second physician indeed may aid in preserving the life of a fetus born alive, this type of aid is possible only when the abortion method used is one that may result in a live birth. Although Missouri ordinarily requires a physician performing a postviability abortion to use the abortion method most likely to preserve fetal life, this restriction does not apply when this method “would present a greater risk to the life and health of the woman.” Mo. Rev. Stat. §188.030.2 (Supp. 1982).
The District Court found that the dilatation and evacuation (D&E) method of abortion entails no chance of fetal survival, and that it will nevertheless be the method of choice for some women who need postviability abortions. In some cases, in other words, maternal health considerations will preclude the use of procedures that might result in a live birth. 483 *500F. Supp., at 694.5 When a D&E abortion is performed, the second physician can do nothing to further the State’s compelling interest in protecting potential life. His presence is superfluous. The second-physician requirement thus is overbroad and “imposes a burden on women in cases where the burden is not justified by any possibility of survival of the fetus.” 655 F. 2d, at 865-866.
Justice Powell apparently believes that the State’s interest in preserving potential life justifies the State in requiring a second physician at all postviability abortions because some methods other than D&E may result in live births. But this fact cannot justify requiring a second physician to attend an abortion at which the chance of a live birth is nonexistent. The choice of method presumably will be made in advance,6 and any need for a second physician disappears when *501the woman’s health requires that the choice be D&E. Because the statute is not tailored to protect the State’s legitimate interests, I would hold it invalid.7
B
In addition, I would hold that the statute’s failure to provide a clear exception for emergency situations renders it unconstitutional. As Justice Powell recognizes, ante, at 485, n. 8, an emergency may arise in which delay could be dangerous to the life or health of the woman. A second physician may not always be available in such a situation; yet the statute appears to require one. It states, in unqualified terms, that a postviability abortion “shall be performed . . . only when there is in attendance” a second physician who “shall take control of” any child born as a result of the abortion, and it imposes certain duties on “the physician required by this section to be in attendance.” Mo. Rev. Stat. §188.080.3 (Supp. 1982) (emphasis added). By requiring the attendance of a second physician even when the resulting delay may be harmful to the health of the pregnant woman, the statute im-permissibly fails to make clear “that the woman’s life and *502health must always prevail over the fetus’ life and health when they conflict.” Colautti v. Franklin, 439 U. S. 379, 400 (1979).
Justice Powell attempts to cure this defect by asserting that the final clause of the statute, requiring the two physicians to “take all reasonable steps ... to preserve the life and health of the viable unborn child; provided that it does not pose an increased risk to the life or health of the woman,” could be construed to permit emergency postviability abortions without a second physician. Ante, at 485, n. 8. This construction is contrary to the plain language of the statute; the clause upon which Justice Powell relies refers to the duties of both physicians during the performance of the abortion, but it in no way suggests that the second physician may be dispensed with.
Moreover, since Justice Powell’s proposed construction is not binding on the courts of Missouri,8 a physician performing an emergency postviability abortion cannot rely on it with any degree of confidence. The statute thus remains imper-missibly vague; it fails to inform the physician whether he may proceed with a postviability abortion in an emergency, or whether he must wait for a second physician even if the woman’s life or health will be further imperiled by the delay. This vagueness may well have a severe chilling effect on the physician who perceives the patient’s need for a postviability abortion. In Colautti v. Franklin, we considered a statute that failed to specify whether it “require[d] the physician to make a ‘trade-off’ between the woman’s health and additional percentage points of fetal survival.” 439 U. S., at 400. The Court held there that “where conflicting duties of this magnitude are involved, the State, at the least, must proceed with greater precision before it may subject a physician to possible *503criminal sanctions.” Id., at 400-401.9 I would apply that reasoning here, and hold Missouri’s second-physician requirement invalid on this ground as well.10
I — I
Missouri law prohibits the performance of an abortion on an unemancipated minor absent parental consent or a court order. Mo. Rev. Stat. § 188.028 (Supp. 1982).
Until today, the Court has never upheld “a requirement of a consent substitute, either parental or judicial,” ante, at 491. In Planned Parenthood of Central Missouri v. Danforth, 428 U. S., at 74, the Court invalidated a parental-consent requirement on the ground that “the State does not have the constitutional authority to give a third party an absolute, and possibly arbitrary, veto over the decision of the physician and his patient to terminate the patient’s pregnancy, regardless of the reason for withholding the consent.” In Bellotti v. Baird, 443 U. S. 622 (1979) (Bellotti II), eight Justices *504agreed that a Massachusetts statute permitting a judicial veto of a mature minor’s decision to have an abortion was unconstitutional. See id., at 649-650 (opinion of Powell, J.); id., at 654-656 (opinion of Stevens, J.). Although four Justices stated in Bellotti II that an appropriately structured judicial-consent requirement would be constitutional, id., at 647-648 (opinion of Powell, J.), this statement was not necessary to the result of the case and did not command a majority. Four other Justices concluded that any judicial-consent statute would suffer from the same flaw the Court identified in Danforbh: it would give a third party an absolute veto over the decision of the physician and his patient. 443 U. S., at 655-656 (opinion of Stevens, J.).
I continue to adhere to the views expressed by Justice Stevens in Bellotti II:
“It is inherent in the right to make the abortion decision that the right may be exercised without public scrutiny and in defiance of the contrary opinion of the sovereign or other third parties. ... As a practical matter, I would suppose that the need to commence judicial proceedings in order to obtain a legal abortion would impose a burden at least as great as, and probably greater than, that imposed on the minor child by the need to obtain the consent of the parent. Moreover, once this burden is met, the only standard provided for the judge’s decision is the best interest of the minor. That standard provides little real guidance to the judge, and his decision must necessarily reflect personal and societal values and mores whose enforcement upon the minor — particularly when contrary to her own informed and reasonable decision— is fundamentally at odds with privacy interests underlying the constitutional protection afforded to her decision.” Ibid, (footnote omitted).
Because Mo. Rev. Stat. §188.028 (Supp. 1982) permits a parental or judicial veto of a minor’s decision to obtain an abortion, I would hold it unconstitutional.

 See also ACOG, Standards for Obstetric-Gynecologic Services 66 (1982):
“Tissue removed should be submitted to a pathologist for examination. ... An exception to the practice may be in elective terminations of pregnancy in which definitive embryonic or fetal parts can be identified. In such instances, the physician should record a description of the gross products. Unless definite embryonic or fetal parts can be identified, the products of elective interruptions of pregnancy must be submitted to a pathologist for gross and microscopic examination.”

 The District Court made no findings on this point, noting only that some witnesses for the State had testified that “pathology should be done” for every abortion. 483 F. Supp. 679, 700, n. 49 (WD Mo. 1980).

 Justice Powell appears to draw support from the facts that “questionable practices” occur at some abortion clinics, while at others “the standards of medical practice . . . may not be the highest.” Ante, at 489, n. 12. There is no evidence, however, that such questionable practices occur in Missouri.

 A $40 pathologist’s fee may increase the price of a first-trimester abortion by 20% or more. See 655 F. 2d 848, 869, n. 35 (1981) (cost of first-trimester abortion at Reproductive Health Services is $170); F. Jaffe, B. Lindheim, & P. Lee, Abortion Politics: Private Morality and Public Policy 36 (1981) (cost of first-trimester clinic abortion ranges from approximately $185 to $235); Henshaw, Freestanding Abortion Clinics: Services, Structure, Fees, 14 Family Planning Perspectives 248, 255 (1982) (average cost of first-trimester clinic abortion is $190); National Abortion Federation Membership Directory 18-19 (1982/1983) (NAF clinics in Missouri charge $180 to $225 for first-trimester abortion).

 The District Court relied on the testimony of Doctors Robert Crist and Richard Schmidt. Doctor Crist testified that in some instances abortion methods other than D&E would be “absolutely contraindicated” by the woman’s health condition, 3 Record 438-439, giving the example of a recent patient with hemolytic anemia that would have been aggravated by the use of prostaglandins or other labor-inducing abortion methods, id., at 428. Doctor Schmidt testified that “[t]here very well may be” situations in which D&E would be used because other methods were contraindicated. 5 Record 836. Although Doctor Schmidt previously had testified that a postviability D&E abortion was “almost inconceivable,” this was in response to a question by the State’s attorney regarding whether D&E would be used “[a]bsent the possibility that there is extreme contraindication for the use of prostaglandins or saline, or of hysterotomy.” Id., at 787. Any inconsistencies in Doctor Schmidt’s testimony apparently were resolved by the District Court in the plaintiffs’ favor.
The Court of Appeals upheld the District Court’s factual finding that health reasons sometimes would require the use of D&E for postviability abortions. 655 F. 2d, at 865. Absent the most exceptional circumstances, we do not review a District Court’s factual findings in which the Court of Appeals has concurred. Branti v. Finkel, 445 U. S. 507, 512, n. 6 (1980).

 In addition to requiring the physician to select the method most likely to preserve fetal life, so long as it presents no greater risk to the pregnant woman, Missouri requires that the physician “certify in writing the avail*501able method or techniques considered and the reasons for choosing the method or technique employed.” Mo. Rev. Stat. § 188.030.2 (Supp. 1982). This ensures that the choice of method will be a reasoned one.

 The State argues that its second-physician requirement is justified even when D&E is used, because “[i]f the statute specifically excepted D&E procedures, abortionists would be encouraged to use it more frequently to avoid the expense of a second physician, to ensure a dead fetus, to prevent the presence of a second professional to observe malpractice or the choice of a questionable procedure from a safety viewpoint, a fetus-destroying procedure, or to avoid their own awakening to concern for the newborn.” Brief for Petitioners in No. 81-1623, p. 44. The Court rejected this purported justification for a second physician in Doe v. Bolton, 410 U. S. 179, 199 (1973): “If a physician is licensed by the State, he is recognized by the State as capable of exercising acceptable clinical judgment. If he fails in this, professional censure and deprivation of his license are available remedies. Required acquiescence by co-practitioners has no rational connection with a patient’s needs and unduly infringes on the physician’s right to practice.”

 “Only the [Missouri] courts can supply the requisite construction, since of course ‘we lack jurisdiction authoritatively to construe state legislation.’” Gooding v. Wilson, 405 U. S. 518, 520 (1972), quoting United States v. Thirty-seven Photographs, 402 U. S. 363, 369 (1971).

 A physician who fails to comply with Missouri’s second-physician requirement faces criminal penalties and the loss of his license. Mo. Rev. Stat. §§ 188.065, 188.075 (1978 and Supp. 1982).

 Because I would hold the statute unconstitutional on these grounds, I do not reach the question whether Missouri’s second-physician requirement impermissibly interferes with the doctor-patient relationship. I note, however, that Missouri does not require attendance of a second physician at any other medical procedure, including a premature birth. There was testimony at trial that a newborn infant, whether the product of a normal birth or an abortion, ordinarily remains the responsibility of the woman’s physician until he turns its care over to another. App. 133; see ACOG, Standards for Obstetric-Gynecologic Services 31 (5th ed., 1982) (“The individual who delivers the baby is responsible for the immediate post-delivery care of the newborn until another person assumes this duty”).
This allocation of responsibility makes sense. Consultation and teamwork are fundamental in medical practice, but in an operating room a patient’s life or health may depend on split-second decisions by the physician. If responsibility and control must be shared between two physicians with the lines of authority unclear, precious moments may be lost to the detriment of both woman and child.