Planned Parenthood of Central Missouri v. Danforth
Docket: 74-1151
Court: Supreme Court of the United States; July 1, 1976; Federal Supreme Court; Federal Appellate Court
Mr. Justice Blackmun authored the Court's opinion in a case related to Roe v. Wade and Doe v. Bolton, addressing issues anticipated in those prior rulings. Following Roe and Doe, the Court remanded a Missouri case challenging the state's abortion laws, which resulted in a federal court declaring the statutes unconstitutional and granting injunctive relief. Shortly thereafter, Missouri enacted House Bill No. 1211, effective June 14, 1974, establishing a regulatory framework for abortions during all stages of pregnancy. Litigation commenced in the U.S. District Court for the Eastern District of Missouri three days after the Act took effect. The plaintiffs include Planned Parenthood of Central Missouri, along with Dr. David Hall, a prominent obstetrician, and Dr. Michael Freiman, both licensed in Missouri and involved in performing abortions. The defendants are the Missouri Attorney General and the Circuit Attorney of St. Louis, representing a class of local prosecutors. The plaintiffs seek to act on behalf of all licensed physicians performing abortions and their patients in Missouri.
Plaintiffs sought declaratory relief and an injunction against the enforcement of the Act, arguing that its provisions violated several constitutional rights. These included: the right to privacy in the physician-patient relationship; the right of physicians to practice medicine at the highest standards; the right of female patients to make decisions regarding childbirth; the right to life for patients due to risks associated with childbirth or alternative medical procedures to abortion; the right of patients to receive safe medical advice and treatment regarding pregnancy termination; the right under the Eighth Amendment to be free from cruel and unusual punishment by being coerced into carrying pregnancies; the potential bias in decision-making processes; and the right to due process under the Fourteenth Amendment.
The specific provisions of the Act challenged included: the definition of "viability"; requirements for written consent from the woman and her spouse for abortions within the first 12 weeks; parental consent for unmarried minors under 18; a mandate for physicians to preserve fetal life, under threat of manslaughter charges; classification of infants surviving attempted abortions as wards of the state, thus removing parental rights; a legislative finding that saline amniocentesis is harmful to maternal health; and requirements for reporting and record-keeping by health facilities and physicians performing abortions. The case was heard by a three-judge District Court, which determined that the physician-plaintiffs had standing based on the Act’s provisions linking noncompliance to criminal liability.
The court recognized the "obvious standing" of two physicians, rendering further determination of Planned Parenthood's standing unnecessary. The District Court ruled, mostly by a divided vote, that all sections of the Act were constitutional except for the first sentence of §6(1), which was deemed unconstitutionally overbroad for requiring physicians to exercise a standard of care for the fetus that included stages prior to viability. One judge partially concurred and partially dissented, agreeing with the majority on the constitutionality of several sections (definitions of viability, consent, and record maintenance) while dissenting on others related to spousal and parental consent and the termination of parental rights. The plaintiffs appealed the upholding of certain sections, while the Attorney General cross-appealed the ruling against §6(1). A stay of enforcement was granted pending appeal, and both appeals were noted for probable jurisdiction. The Supreme Court, in Roe v. Wade, affirmed that a woman's right to privacy encompasses her decision to terminate a pregnancy but emphasized that this right is not absolute and must be weighed against significant state interests, particularly concerning maternal health and potential human life. The Court acknowledged that the state's interest grows as the pregnancy progresses, necessitating a balance with the woman's privacy rights, informed by current medical knowledge.
The permissibility of state regulation of abortion is analyzed in three stages. In the first stage, prior to the end of the first trimester, the decision and execution of an abortion are to be made solely by the attending physician and the pregnant woman, without any state interference. After this stage, the state may reasonably regulate abortion procedures to protect maternal health. In the final stage, post-viability—determined flexibly based on medical expertise—the state can regulate abortions to protect fetal life, potentially prohibiting them unless necessary for the mother's life or health.
The physician-appellants have standing to challenge the Missouri Act, as the law directly affects them, similar to the physician's standing established in Doe v. Bolton. They should not have to face criminal prosecution before seeking relief. The court's focus will be on evaluating the challenged provisions of the Missouri abortion statute in light of prior rulings in Roe and Doe.
Specifically, the definition of "viability" in Section 2(2) of the Missouri Act is critiqued by the appellants for lacking a gestational time frame, incorporating the term "indefinitely," and imposing additional regulatory burdens. They argue it expands upon the definition established in Roe, which described viability as the point at which a fetus can live outside the womb, typically around seven months or 28 weeks, but possibly earlier. The court agrees with the District Court's conclusion that the Missouri Act's definition of viability does not conflict with Roe and reflects an attempt by the Missouri legislature to align with the guidance provided in Roe regarding viability. Furthermore, the appellant Hall indicated no significant issues with the statutory definition.
Viability is defined as a medical judgment that varies with each pregnancy, and it is not appropriate for the legislature or courts to set a specific gestational point for viability. The definition in §2(2) of the Act aligns with Roe v. Wade, as it maintains the flexibility of the viability concept without infringing on established limitations on state regulation. The appellees agree that viability determination lies with the attending physician’s professional judgment.
Regarding consent, §3(2) mandates that a woman must provide written consent prior to an abortion during the first 12 weeks, ensuring that her consent is informed and voluntary, free from coercion. Appellants argue this creates an additional regulatory burden and is vague. However, the District Court found that this requirement does not uniquely target abortion but applies broadly to medical procedures, reinforcing the woman's control over her healthcare decisions. The majority opinion concluded that the consent requirement is not overly burdensome or chilling, serving a legitimate state interest in ensuring the decision is made by the woman herself. The District Court's ruling on §3(2) was upheld, recognizing that while no similar requirement exists for other surgical procedures in Missouri, the written consent for abortion is not unconstitutional.
The decision to undergo an abortion is recognized as significant and stressful, necessitating that the woman make it with complete understanding of its implications. The State can constitutionally require prior written consent for various surgeries, including abortions, without violating constitutional rights. However, Section 3(3) of the Missouri Act mandates that a woman seeking an abortion within the first 12 weeks obtain her spouse's written consent, except when the abortion is deemed essential to preserve the mother's life. The rationale for this requirement is grounded in the view of marriage as a joint decision-making institution, with historical precedents for spousal consent in various legal contexts, such as adoption and sterilization.
Appellees argue that mutual consent is a logical requirement for significant changes in family status. Conversely, appellants contend that this provision effectively gives husbands unilateral veto power over abortions, violating established precedents such as Roe and Doe. They also highlight practical issues, such as situations where a husband cannot be located, and criticize the provision as vague and overbroad. Ultimately, the court concludes that the State cannot constitutionally require spousal consent for abortions during the first trimester, affirming that the State may not delegate a veto power to a spouse that it is prohibited from exercising itself during this period.
The Court acknowledges the deep concern a husband has regarding his wife's pregnancy and recognizes the significance of the marital relationship. However, it asserts that the State cannot grant a husband unilateral authority to prevent his wife from terminating her pregnancy, especially when the State itself lacks that right. The Court emphasizes that, ideally, both partners should agree on such a critical decision, but granting the husband veto power would undermine the mutuality and trust essential to marriage. The Court highlights that the wife, who bears the child, should have the predominant say in this decision, as established in Roe v. Wade. Consequently, the Court finds §3(3) of the Missouri Act unconstitutional for conflicting with these principles.
Regarding parental consent, §3(4) mandates that unmarried minors under 18 must obtain written consent from a parent or guardian to have an abortion within the first 12 weeks of pregnancy, except when necessary to preserve the mother's life. The law is defended on the grounds that minors may be subject to stricter regulations than adults, with references to legal precedents and Missouri statutes aimed at protecting minors’ welfare.
Certain decisions are deemed beyond a minor’s capacity to act in their own or the public's best interest, as evidenced by laws prohibiting the sale of firearms, certain literature, and alcohol to minors without parental consent. Testimony indicates that children as young as 10 and 11 have sought abortions, leading to the conclusion that allowing a minor to obtain an abortion without adult guidance would neglect the State's duty to protect minors' welfare. Parental discretion is upheld against undue State interference, citing landmark cases like Meyer v. Nebraska and Wisconsin v. Yoder. The statute §3(4) does not impose new burdens on physicians, as parental consent was already required for minor abortions. However, the appellants argue that Missouri law allows minors to consent to medical services for pregnancy (excluding abortion), venereal disease, and drug abuse without parental consent. The statute prioritizes parental authority over the minor's wishes. The District Court acknowledged the State's interest in family authority but noted that the safeguard of marriage is not relevant to §3(4). A dissenting view argued for a minor's right to self-determination, similar to adult women, provided the minor is mature enough to understand the procedure. Previous court rulings have questioned the constitutionality of blanket parental consent requirements for minors seeking abortions, asserting that the State cannot grant third parties an absolute veto over a physician's and patient's decision regarding abortion. Thus, the imposition of such consent requirements, particularly during the first 12 weeks of pregnancy, is deemed unconstitutional.
Constitutional rights are inherent and do not depend on reaching the age of majority; both minors and adults are entitled to constitutional protections. However, states have broader authority to regulate minors' activities. The legitimacy of requiring parental consent for a minor's abortion is questioned, particularly regarding its impact on family unity and parental authority, especially in cases of conflict between the minor and the non-consenting parent. The court finds that the interests of the parent in this context do not outweigh the minor's right to privacy concerning her pregnancy decision. The specific provision requiring parental consent is deemed invalid as it unjustifiably restricts a minor's ability to terminate a pregnancy.
Additionally, Section 9 of the statute prohibits saline amniocentesis for abortions after the first 12 weeks, citing maternal health risks as justification. This method is commonly used, and its prohibition effectively limits abortion access after the first trimester, as alternative methods are more dangerous. The court must assess whether this prohibition reasonably relates to protecting maternal health per established legal precedents, noting that the appellees assert it is supported by substantial medical evidence.
The District Court majority concluded that the maternal mortality rate during childbirth exceeds that associated with saline amniocentesis, allowing for the potential upholding of §9 only if there were safe alternatives for abortion after the first 12 weeks. The majority identified hysterotomy, hysterectomy, mechanical induction, and prostaglandin injection as alternatives, asserting that the latter two were safer than saline. However, significant factors were overlooked in this analysis. The majority failed to consider that saline amniocentesis is widely accepted, utilized in 68% to 80% of post-first-trimester abortions. Limitations on the availability of prostaglandin at the trial's time were also ignored, as it was only experimental and not widely practiced in Kentucky or Missouri. Furthermore, the statute's language potentially bans future effective methods, including prostaglandin. The majority did not acknowledge the inconsistency in §9, which prohibits saline yet permits techniques with higher maternal mortality rates. This oversight suggests that the state's ban on saline is unreasonable and arbitrary, undermining maternal health and effectively restricting access to safe abortion methods. Consequently, this regulation does not withstand constitutional scrutiny. Additionally, Sections 10 and 11 of the Act impose recordkeeping requirements for abortion-related health facilities and physicians, regardless of pregnancy stage.
Facilities and physicians performing abortions are required to use specific forms aimed at preserving maternal health and compiling medical data related to abortions, with the intent to ensure compliance with legal provisions. The information collected is confidential, intended solely for statistical purposes, and can be accessed by public health officials. Records must be maintained for seven years at the health facility where the abortion occurred. Appellants argue that these reporting and recordkeeping requirements create an additional regulatory burden applicable at all pregnancy stages. However, the District Court judges considered them essential for advancing medical knowledge without restricting abortion decisions or medical judgment.
While acknowledging the conflicting interests surrounding recordkeeping, the court emphasized that such records can aid in maternal health preservation but noted that during the first stage of pregnancy, the state cannot impose restrictions on the physician's medical judgment regarding abortion. After this stage, reasonable regulations aimed at protecting maternal health are permissible. Ultimately, the court found that the recordkeeping provisions, although potentially bordering on impermissibility, do not violate constitutional rights. The requirements for confidentiality and a seven-year retention period are deemed appropriate, and the provisions are expected to be enforced in a manner consistent with the court's rulings on other aspects of the law. The state cannot enforce invalidated spousal or parental consent requirements.
Individuals performing or inducing an abortion are required to exercise a level of professional skill and care to protect the fetus's life and health equivalent to that required for any fetus intended for birth. Failure to do so, resulting in the death of the fetus, constitutes manslaughter, and the responsible party may face civil liability. The District Court ruled the initial sentence of §6(1) unconstitutional for being overly broad, as it did not limit its applicability to pregnancies post-viability. The Attorney General contends this interpretation is incorrect, asserting that the standard of care applies only after a live birth occurs. In contrast, the appellants argue that the statute imposes this standard regardless of the viability stage, effectively prohibiting abortion. The court agrees with the District Court's assessment, stating that §6(1) imposes obligations on the physician to protect the fetus at any pregnancy stage. The subsequent sentence regarding criminal penalties does not limit this duty. The appellees suggest that if the first sentence is unconstitutional, the second could remain valid and severable. However, the court finds that both sentences are interdependent, thus invalidating the entire §6(1). The ruling affirms that any failure to protect a liveborn infant would be prosecutable under Missouri's criminal laws.
The District Court's judgment is partially affirmed and partially reversed, with the case remanded for further proceedings. The document includes House Bill No. 1211 from Missouri, which aims to regulate abortion in line with U.S. Supreme Court decisions. Key definitions include:
1. **Abortion**: Intentional destruction of an embryo or fetus or termination of pregnancy for reasons other than to ensure a live birth or address a dead or dying fetus.
2. **Viability**: The stage when an unborn child's life can be sustained outside the womb.
3. **Physician**: A person licensed to practice medicine in Missouri.
The bill stipulates that no abortion may occur in the first twelve weeks of pregnancy unless performed by a licensed physician with the woman's informed, written consent, and, in certain cases, spousal or parental consent is also required. After twelve weeks, abortions can only be performed in hospitals and under similar consent conditions, except when necessary to protect the mother's life or health.
Additionally, the bill mandates that a physician must certify that the fetus is not viable before performing an abortion not needed for the mother's health. It establishes that failure to exercise adequate care in preserving the fetus's life may lead to manslaughter charges, while intentionally killing a viable, prematurely aborted infant is classified as second-degree murder.
No fetus or premature infant aborted alive may be used for scientific, research, or experimental purposes, except to protect the life and health of the infant. If a live infant results from an abortion not intended to save the mother's life or health, the infant becomes a ward of the state, and the parents lose all parental rights, similar to a termination of rights under section 211.411, RSMo. The attending physician must notify the juvenile court of the live birth. Women seeking abortions must be verbally informed of these provisions and certify in writing that they have been informed.
The act prohibits the saline amnio*87centesis abortion method after the first twelve weeks of pregnancy due to its harmful effects on maternal health. Health facilities and physicians must use state-provided forms to collect maternal health data and monitor compliance with the law, ensuring confidentiality for patient information, which can only be accessed by public health officers.
Medical records related to abortions must be kept for seven years. Health professionals who knowingly violate the law may face revocation of their licenses. Those breaching confidentiality face misdemeanor charges, as do individuals who perform or assist in unlawful abortions. Non-licensed individuals performing abortions face felony charges and imprisonment. The act does not exempt individuals from civil liability for medical malpractice.
Immediate state action is deemed necessary to regulate abortions for the protection of public health, safety, and welfare, thereby classifying this act as an emergency measure effective upon passage and approval on June 14, 1974. If any part of the Act is found invalid, the remaining provisions will still apply, as they are declared severable. Viability is generally recognized at about seven months but can occur earlier, with the act specifically addressing circumstances when a live-born infant results from an attempted abortion not performed for the mother’s health. In such cases, the infant is declared an abandoned ward of the state, and the parents lose all parental rights and obligations.
The physician-appellants do not contest the imposition of obligations from this section nor claim sufficient interest to establish standing to challenge it, leading to the conclusion that they lack standing. The District Court did not determine whether Planned Parenthood has standing to challenge the Act, as it focused on the physician-appellants’ standing concerning the entire Act. The matter of the constitutionality of the section related to state wardship is left undecided for the District Court to reconsider on remand.
The excerpt emphasizes that viability assessments should be made by physicians on a case-by-case basis, acknowledging the variability in determining when a fetus is viable due to individual patient factors and medical advancements. A referenced Minnesota statute was criticized for its unreasonable definition of viability during gestation.
Testimony indicates that obtaining prior written consent for surgery is a customary practice in some parts of Missouri, but it is not universally recognized across the medical profession. The appellants raise concerns regarding the vagueness of the term "informed consent," questioning its precise meaning. The three-judge District Court interpreted "informed consent" as the provision of information to the patient about the procedure and its consequences, avoiding a restrictive definition that could hinder physicians' practices. The excerpt highlights the right to privacy, which predates the Bill of Rights and emphasizes the sacred nature of marriage as a partnership of two individuals, each with distinct perspectives. It asserts that the right of privacy encompasses the individual's freedom from unwarranted government interference in personal decisions, such as childbearing. The text critiques a specific state provision that prioritizes a husband’s interest in continuing a pregnancy over a wife’s right to terminate it, asserting that this undermines the constitutional protections established by Roe v. Wade. Additionally, the dissenting opinion is noted to overlook the broader implications of this issue. It addresses Justice White’s argument regarding the availability of the prostaglandin method for abortion in Missouri, asserting that the record does not provide evidence supporting this claim and that until January 1974, this method was only used experimentally at select medical centers.
At the time the Missouri General Assembly enacted legislation restricting the sale of saline, prostaglandin was primarily distributed to approximately twenty medical centers nationwide, indicating limited availability. Consequently, the burden was on the appellees to demonstrate that prostaglandin was accessible during the 1974 trial, which they failed to do. The expert witness relied upon by the dissenting opinion only acknowledged that prostaglandin had limited use prior to the trial and speculated that it might have been more accessible at that time. This speculative assertion did not establish meaningful availability or accessibility for individuals in Missouri. Additionally, it is highlighted that Missouri physicians are required to report births, deaths, and communicable diseases, and their use of controlled substances is strictly regulated by state law.
