900 F.3d 1310
11th Cir.2018Background
- Alabama enacted the Unborn Child Protection from Dismemberment Abortion Act, which prohibits dismembering a living unborn child but permits dismembering after the child has been killed; it includes a narrow health exception and criminal penalties for violations.
- The only clinics in Alabama that perform most post-15-week (second-trimester) abortions are the West Alabama Women’s Center and the Alabama Women’s Center; ~99.6% of Alabama abortions occur in outpatient clinics and ~93% occur before 15 weeks.
- Plaintiffs (the two clinics and their medical directors) sued, and the district court held an evidentiary hearing, found the State’s proposed methods to cause fetal demise (potassium chloride injection, umbilical cord transection, digoxin injection) were not safe, effective, and available in the outpatient-clinic context, and entered a permanent as-applied injunction.
- The district court found those methods pose significant health risks, require specialized training not available to clinic practitioners, and would increase time, travel, and cost burdens—especially for low-income patients.
- Alabama appealed; the Eleventh Circuit reviewed de novo legal conclusions and clear-error factual findings and affirmed the district court’s permanent injunction.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the Act imposes an undue burden on pre-viability abortion rights | The Act is an undue burden because the State’s proposed fetal-demise workarounds are not safe, effective, or available in Alabama clinics and thus substantially obstruct access | The State says fetal-demise methods (KCl, cord transection, digoxin) are feasible; any increased risk is not "significant" or is a matter of medical uncertainty for the legislature to resolve | Held: Act imposes an undue burden; proposed methods are not safe, effective, and available in the clinics and thus the injunction is affirmed |
| Whether potassium chloride injection is a feasible alternative | KCl is unsafe, technically demanding, unavailable for clinic practitioners, and increases risk (e.g., cardiac arrest, uterine injury) | State: KCl is a recognized method to cause fetal demise | Held: KCl infeasible in outpatient-clinic context (not safe, not available, requires extensive training) |
| Whether umbilical cord transection or the Act’s intent requirement avoids constitutional problems | Cord transection is technically unworkable, increases hemorrhage/infection risk, visualization is poor after sac rupture, and the intent defense and health exception are inadequate to ensure practicable access | State: Cord transection can be performed; intent standard shields accidental mistakes; health exception protects patient safety | Held: Cord transection infeasible; intent requirement and health exception do not cure the burden and would deter practitioners |
| Whether digoxin injection is a feasible, nonburdensome alternative | Digoxin is unreliable (10–15% failure), unstudied at 15–18 weeks, poses infection/extramural-delivery risks, may require additional visits/doses, and would be effectively experimental for many patients | State: Digoxin is a viable, less technically demanding option | Held: Digoxin not sufficiently safe, effective, or reliable for the relevant gestational window; logistical burdens (extra visits/delay/cost) contribute to undue burden |
Key Cases Cited
- Roe v. Wade, 410 U.S. 113 (establishing constitutional right to abortion)
- Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833 (adopting the undue burden standard)
- Stenberg v. Carhart, 530 U.S. 914 (invalidating a ban that could cover dismemberment abortions and lacked a health exception)
- Gonzales v. Carhart, 550 U.S. 124 (upholding a partial-birth abortion ban where it did not cover dismemberment and discussing legislative deference under medical uncertainty)
- Whole Woman’s Health v. Hellerstedt, 136 S. Ct. 2292 (Courts must weigh evidence and may not defer to legislature on medical uncertainty; regulations imposing substantial obstacles are invalid)
- Grupo Mexicano de Desarrollo S.A. v. Alliance Bond Fund, 527 U.S. 308 (preliminary injunction mootness when a permanent injunction issues)
- Anderson v. City of Bessemer City, 470 U.S. 564 (clear-error standard for appellate review of district-court factual findings)