RUST v. SULLIVAN
The national government provides funds for family planning services (Title X). The Department of Health and Human Services issued regulations limiting the ability of Title X fund recipients to engage in abortion-related activities. Title X funds were to be used only to support preventive family planning services.
Do the regulations violate the First and Fifth Amendment rights of clients and health providers?
Legal provision: 42 U.S.C. 1008
No. The intent of Congress in the enactment of Title X is ambiguous with regard to abortion counseling. Consequently, the Court will defer to the expertise of the administrative agency. The Court held that the "regulations promulgated by the Secretary [of HHS] do not raise the sort of 'grave and doubtful constitutional questions' that would lead us to assume Congress did not intend to authorize their issuance." Should government subsidize one protected right (family planning), as it does in this case, it does not follow that government must subsidize analogous counterpart rights (abortion services).
Argument of Laurence H. Tribe
Chief Justice Rehnquist: We'll hear argument first this morning in No. 89-1391, Irving Rust v. Louis W. Sullivan, and 89-1392, New York v. Louis W. Sullivan.
Mr. Tribe: Mr. Chief Justice, and may it please the Court:
We depend upon our doctors to tell us the whole truth, whoever is paying the medical bill... the patient or the government, whether in a Title X clinic or in the Bethesda Naval Hospital.
Especially when a medical test confirms a condition that we had worried about, we all, I think, rely on the doctor to level with us in a discussion that follows the diagnosis.
Unknown Speaker: Are doctors always involved in Title X programs?
Mr. Tribe: They supervise, Justice Kennedy.
They are not always the personal counselor, but under the Title X regulations they are responsible for supervision.
And the health care professionals to whom women speak, whether doctors or not, are ones that I think one would trust to tell one the truth.
And if the government were to play a role in the picture I think we would assume that its role is to make sure that nothing relevant is left out.
But if any of us were to discover that the government instead had arranged to have the doctor or the health care professional omit all information about one legally-available medical option and give you a referral list that is clearly tilted in the direction of the other option, regardless of what dangers there might be to your health, I would suppose that most of us would conclude that the government had used its bargaining power to betray a rather basic trust.
Its contract with the doctor, if that really were a fair description of the situation, would violate its more fundamental contract with all of us, including the First and Fifth Amendments.
By conditioning Title X grants on the regulations that we challenge in this case, the government, in the words of Judge Cardamone, concurring below, sets a trap for the unwary.
The reason, quite simply, is that under these regulations not even the petitioners' private funds, sometimes in excess of three times the size of the Federal grant, may be used to provide uncensored medical information to the patients enrolled in the petitioners' Title X family planning clinics.
Unknown Speaker: Excuse me.
I don't understand that to be the case, so long as those funds are not used in the Title X program.
The Title X program, by the way, is how much Federal money?
It's at least 90 percent, is it?
Mr. Tribe: Well, actually, Justice Scalia, the regulation makes reference to a 90-10 ratio, but, as the counsel for the Secretary explicitly conceded in oral argument in the First Circuit at footnote 59 of the Planned Parenthood brief, it's been a very long time since they have made any effort to live up with that.
The reason has been that as Federal funds have diminished and as the government, I think quite understandably, has not wanted to penalize clinics for growing, the norm now is that the Title X program project, as defined under 59.2 of the regs, is typically funded at a level of 50 percent or less, as the Secretary conceded in the First Circuit, of the Federal funds.
So that, for example, in the case of the clinics in this case, in Westchester-Rockland it's about 23 percent, in the case of the City of New York it's about 50.
Unknown Speaker: Where is the 90-10 pulled from?
Mr. Tribe: The 90-10 does have, actually, a statutory origin, and there is some confusion, I understand, about whether the statute has been properly construed by the Secretary of HHS in allowing the reach of the Federal hand to exceed this 10 percent Federal fisk.
But, in any event, there's no dispute that the entire program... the family planning program at the Hub in the Bronx, the family planning program, including, as the regs call it, the comprehensive coherent set of plans and program... including the private money, is encumbered by these regulations.
Unknown Speaker: I suppose we ought to evaluate the Federal statute and the regulations under the Federal statute on the basis of what Congress contemplated when it passed it, and Congress appears to have contemplated a program that is at least 90 percent Federal money.
Mr. Tribe: That has been argued in various courts.
It is still not resolved.
I would say that much of our argument is completely independent of whether the private funds are 10 percent or 50 percent, because we will be arguing that in this case the regulations are sufficiently viewpoint-based that it would not be permissible for the government to impose them, even as a condition of expending its own funds.
But when I reach that point, Justice Scalia, I think I will be adding a couple of thoughts about the way in which those arguments relate.
The government actually claims no general authority, even with its own money, to trick patients about their medical situation after they have come to trust a doctor in a government-assisted clinic, and they certainly don't affirmatively claim that with respect to private funds they have the power to do that.
Their basic claim is quite different.
Their claim is that once the client is diagnosed as pregnant the Title X program, the provision of services, is over, so that the further discussion that might be had about abortion is simply outside the scope of the program.
I think the fairest way to respond to that is simply to say that it just is not the case.
Much of section 59.8 of the regulations is expressly directed to post-conception services, with only abortion counseling and referral banned.
The section details the kind of information that a Title X client must be given once pregnancy is diagnosed, and indeed under the original version of the regulations it had said, and I quote,
"no medical services or counseling after pregnancy is diagnosed. "
would be allowed.
Unknown Speaker: Certainly the government in its brief, Mr. Tribe, and perhaps it is wrong, seems to take the position that this is basically a pre-pregnancy counseling program.
Mr. Tribe: That's right, Mr. Chief Justice.
We disagree with that.
We think that's incorrect.
Unknown Speaker: You say that that was not what Congress intended, or that's not what has happened in fact?
Mr. Tribe: I think neither.
That is, President Bush, when a Member of Congress, was one of the leading co-sponsors of this law, and he said that the health care service mechanism that he had in mind was not just a population control mechanism.
It should include an annual physical examination, and the regulations themselves have contemplated and the statute has said from the beginning that one must provide more than just a kind of pregnancy kit and see you later.
And indeed the original version was objected to on the dramatic ground that it would permit no "counseling which discourages abortion".
The Secretary explained at 53 Federal Register 2926 that that is why the current version does not contain any language suggesting that the program finishes when pregnancy is diagnosed.
The aim was put very clearly in 52 Federal Register at 33.2.12, and I quote: "The express purpose"... and this is the purpose of the regulations about how the dialogue after diagnosis is to proceed...
"is to ensure Title X projects do not provide counseling relating to the issue of medical indication for abortion. "
That was the express purpose.
Unknown Speaker: I don't see where this argument is going.
I suppose where is lead is since the only prohibition in the statute is a prohibition on the use of funds in programs where abortion is a method of family planning, and since you say that the program doesn't just authorize family planning but authorizes medical treatment after a woman is pregnant, then there really is no prohibition even on the conduct of abortion.
Mr. Tribe: No, Justice Scalia.
I am sorry.
If I left that impression, I surely did not mean to.
Unknown Speaker: Well, it's where your argument leads.
I mean, it seems to me you are painting with a very broad brush when you say that the program is not just a program of family planning.
Mr. Tribe: No, I didn't say that, Justice Scalia.
The concept of family planning under the program is a somewhat broader concept than would be suggested by a kind of truck stop pregnancy test.
That is, many of these women are enrolled throughout their reproductive lives.
When they are diagnosed as pregnant, the statute and the regulations in fact do not authorize the provision to these women of the gynecological, obstetrical, prenatal and other services that they might need.
But the idea is that an important part of the program is not simply to put them out on the street without advice, without information.
It is at that point to have a discussion with them about the options available, and in that discussion the regulations are quite clear in specifically prohibiting even neutral discussion about one option, namely abortion, and at the same time mandating with respect to the other option in this mutually-exclusive pair of medical choices, mandating the provision of a prenatal list, a list of prenatal care centers, which under the regulations must include all prenatal care providers in the area, must exclude all clinics specializing in abortion, and must be limited to clinics that are committed to the welfare both of the unborn child and of the mother.
So that the message, quite plainly, of your doctor handing you, after a pregnancy diagnosis, a list of this sort and saying this is a list of places that will be concerned with you welfare and that of the unborn child is basically that your welfare is not endangered by the birth of the child, and the implicit message is that abortion needn't concern you.
And, indeed, if the woman asks she may be told that the project does not consider abortion an appropriate method of family planning.
So this is all quite obviously reassuring, but it is not a--
Unknown Speaker: But isn't the program permitted to respond to a question?
Aren't there some abortion agencies around?
Aren't they permitted to identify some in response to a question?
Mr. Tribe: --No, they are not, Justice White.
That is, what would be steering and referral in clear violation of the regulations.
They are allowed to say... they would be allowed to hand the woman a copy of the regulations, I suppose, although that might be said to be handing her material that could be encouraging of abortion.
I would hope not.
If they hand her that list... that is, the information on how the list is composed... she will understand that by coincidence there might be some abortion providers in the area, but even if they include a hospital which might, for example, provide abortion, the Federal Register 53 at page 29.38 says that the referral must be specifically made to its prenatal care service.
So that if the woman finds the needle in the haystack it's not going to be by the government's design.
Indeed, the Secretary, below, said it was designed to have no loopholes.
And, when asked below whether the woman could be told that maybe under A in the Yellow Pages she would find something that could be relevant to her, the government said no.
And two of the three judges below said that that would probably be, in their view, impermissible.
So this is not a neutral--
Unknown Speaker: Is your argument now suggesting that or arguing that the regulations are inconsistent with the statute?
Mr. Tribe: --Well, we have argued throughout that the regulations go way beyond the statute, but I'm now arguing that, even if they didn't, that a government command--
Unknown Speaker: You're making a constitutional argument now.
Mr. Tribe: --That's right.
And we're saying that--
Unknown Speaker: Even though perhaps we should deal with the statutory question first?
Mr. Tribe: --We'd be entirely happy to have you say that, to avoid the constitutional question.
Unknown Speaker: Or are you just following the ordinary rule that you're arguing your strongest point first?
Mr. Tribe: Well, I don't know whether that's the best rule.
One sometimes wants to wind up and finish with a bang.
But I think the point is that it's partly because of the constitutional doubt about these regulations that we would not suggest that the normal rules of Chevron in deferring to the HHS are appropriate.
And because of that we would suggest that if the constitutional cloud seems sufficiently ominous one might simply read the statute the way the Secretary himself read it for the first 11 years, simply to permit options to be presented to the woman and perhaps the way it's been read since '81, namely to require the neutral provision of options, but not the way these regs read it.
Unknown Speaker: Mr. Tribe, do you concede that the way the Secretary originally interpreted it is constitutional?
Mr. Tribe: We think in respect to that, Justice O'Connor, that permitting options to be presented is surely constitutional.
The part where I am not as certain... we were never in a position to challenge it because the clients that I represent, the City, the State of New York, and the various clinics do not themselves engage in encouraging or promoting abortion... but insofar as that was a viewpoint-based limitation I suppose an argument could be made that that part was not constitutional.
We do not make that argument here.
We do argue that when in respect to a binary choice about one's medical fate the government suppresses talk about one branch, even neutral talk, and mandates steering in the other direction, that that is the impermissible suppression of information.
Unknown Speaker: And why is that unconstitutional?
Mr. Tribe: Because, I guess, as Justice Rehnquist said in his concurring opinion in Bolger v. Youngs Drug, the central purpose of the First Amendment is to prevent the suppression of information.
Unknown Speaker: So this is a First Amendment argument?
Mr. Tribe: It's strictly a First Amendment argument.
Unknown Speaker: But is it peculiar to the medical situation here?
Because certainly if the government is talking about the Secretary of State hiring a press or public information officer or the press secretary at the White House, the press secretary or the public information officer are not free to say look, I want to tell the reporters everything I know, if the Secretary of State says you play this down.
Mr. Tribe: Some of them don't seem to realize that.
Unknown Speaker: Well, some of them may not realize it, but I think they'll soon learn.
Mr. Tribe: That's right.
Unknown Speaker: Would you agree that is not unconstitutional?
Mr. Tribe: Absolutely, Mr. Chief Justice.
The difference... it's not peculiar to the medical profession.
The real difference is that some people serve as mouthpieces for the state... speechwriters, spokespersons; other people serve as professionals in whom people place their trust.
That's at the other end of the spectrum.
And we suggest--
I didn't quite mean it that way.
The point really is that the people in Title X clinics look like doctors.
They are dressed like doctors.
They act like doctors.
And, therefore, when they try to speak like doctors the fact that the government has selectively shaped their speech has First Amendment significance that it wouldn't have if everyone looked at them and said, these are the Solicitor... I didn't mean the Solicitor General--
The Surgeon General of the United States.
In other words, these are not the Voice of America.
These are the voice of medical professionals.
Unknown Speaker: You don't challenge the statute, though, do you?
Mr. Tribe: No.
We think the statute would be unconstitutional only if it were written specifically to authorize these regulations; otherwise, excluding abortion from this funding I think is clearly permissible under Harris and under McRae.
Unknown Speaker: Under the Secretary's former interpretation, the one that you would like us to in effect go back to, suppose this medical care professional said, in our view, from your standpoint and your family situation, abortion is the recommended choice for family planning, and we urge you to have an abortion and here is the name of a place where you can obtain that.
Is that consistent with the statute?
Mr. Tribe: I think not, Justice Kennedy.
It seems to me that this statute is most plausibly implemented by maximizing the autonomy of the patient and by steering the patient in neither direction but by suppressing information in either direction.
That is, I would think that the most obviously constitutional way to implement it is to permit, as the Secretary did until 1981, or to require, as the Secretary did from 1981, the provision of a neutral set of options so that the person can make an intelligent choice.
Justice White I think--
Unknown Speaker: So that it's wrong to make a recommendation under the First Amendment?
Mr. Tribe: --It's not wrong to make a recommendation.
It is, however, consistent with a program designed to provide information and not designed to steer people toward any choice to insist that the professional stand back and play a more passive role.
Unknown Speaker: Well, I take it that a doctor could, under your view, under the statute as now interpreted or as previously interpreted, strongly recommend contraception.
Mr. Tribe: There's no doubt that the doctor could say... however, if the--
Unknown Speaker: So that's not viewpoint-neutral.
Mr. Tribe: --Total viewpoint neutrality in this area I have to concede is difficult to achieve because the very fact that these are professionals and that laws of informed consent surround this area means that they can be required to provide information without which an informed choice can't be made.
As Justice White suggested in his Thornburgh dissent, the average person has no one but his or her doctor to look to for these matters.
And that is why the American College of Obstetricians and Gynecologists and the American Medical Association have concluded that actually abiding by these regulations would be profoundly unethical, and that's why we believe it would be malpractice in a great many states.
That is, there are a great many situations generically in which a woman has no way of knowing when she comes into the clinic if abortion might be one of the things that would be medically relevant to her.
She might be quite opposed to it morally, and yet if, for example, she was using a contraceptive method like an IUD which, when left in place might create a risk of a spontaneous second trimester and possibly fatal abortion, surely that is something that she would be entitled to know.
And there a great many women like that.
There are, in addition to that, some 590,000 women who visited Title X clinics in 1988 who had some background medical complication... whether cancer or diabetes or hypertension or multiple sclerosis or chronic heart disease... who might have no idea, as most people do not, that these conditions can sometimes be induced to recur, can be aggravated by the continuation of a pregnancy.
Unknown Speaker: As a matter of public policy, that may not be a desirable thing, but the woman is in no worse position than she would have been in had the Title X clinic not existed.
So long as the clinic makes clear to her that we do not recommend abortion, we are not in that business... here is a list of providers, some of which providers, by the way, can provide abortion services... they are not excluded from referral, are they... only if their primary business is the--
Mr. Tribe: That's correct.
Justice Scalia, let me tell you why I think she is worse off.
It really goes back, in a way, to a point you made in Evans and Ulman.
On the question... well, let me why it struck me at the time as making a similar point, and I guess the court did it in Milcovitch.
It's really very hard for a disclaimer to undo the misimpression that can result from something... that is, the Evans and Novak column, with its factual misstatement, shrouded in a disclaimer saying this is opinion, or the Lorraine Daily Journal or Milcovitch, this is just opinion.
The fact is that if in the context there is something that might be injuriously misleading to the reader or to the listener, saying don't trust all of what I say, it may not be complete, may not be enough, partly because a woman will have come to rely on this doctor over the years... some of the women that I met in the clinics that I visited had gone there for a long time.
This is not just a one-stop thing.
Many of the clinics, by statutory design, induce reliance.
So a woman relies on the doctor for a period of time.
The doctor says I see you're eight weeks pregnant.
Here's a prenatal referral list.
The woman doesn't have any idea that her underlying medical condition might make that pregnancy turn into a really serious threat to her health.
The doctor isn't allowed to tell her that it might.
Under the regulations, that would be promoting the termination of the pregnancy.
She walks out of there with a prenatal referral and--
Unknown Speaker: --Excuse me.
Is it clear that the doctor can't tell her that, that the pregnancy may create a serious threat to her health?
Mr. Tribe: --Yes, I think it is clear, Justice Scalia.
The Secretary's explanation--
Unknown Speaker: Where is that?
Mr. Tribe: --Well, the Secretary's official explanation of the regulations said that they were designed to prevent any expression of medical indication for pregnancy, and I don't think there's anything in the regulations that would suggest that he could warn her in that way.
But, in any event, if she said, well, what should I do about that--
Unknown Speaker: You see, this is an important point you are on now.
I read the regulations as preventing any referral of abortion or even reference to abortion as a means of family planning, but I think they draw a clear line between abortion as a means of family planning and abortion as a medical necessity.
There is a specific reference to ectopic pregnancy in one of the exammples that they give.
Mr. Tribe: --Yes.
It's made clear at 33.2.12 of the Federal Register, Volume 52, that the point of the ectopic pregnancy example is simply to say that if there is an imminent threat to life they cannot refer her to someone who might do an abortion, but to an emergency room.
But the reference to abortion as a method of family planning, Justice Scalia, the words "family planning" I think have no meaning under the government's reading of the statute or ours, in this sense.
If a therapeutic abortion, an abortion for reasons of health, were not encompassed within that concept, then there'd be nothing in the statute that would even prevent the use of Federal funds directly for the performance of abortion to protect the woman's health.
And it seems to me that that's clearly not what the regulations mean.
That is, the regulations are clearly designed not to in any way, as 59.10 says, promote or encourage abortion.
And to tell her that if you remain pregnant it might hurt your health is surely to promote or encourage abortion.
Let me add, though, that--
Unknown Speaker: Suppose, Professor, that the doctor gives neutral advice or is permitted to give this neutral advice and provide all the information and then the patient says, well, look, I've been coming to you.
I usually want your opinion.
What should I do about this?
You say that the statute may constitutionally prevent the doctor from answering that question?
Mr. Tribe: --I guess answering truthfully what his opinion is in a way that does not steer or encourage her... these are lines that are terribly hard to draw, which is why the government oughtn't to be in the business of editing these dialogues... I think is beyond what the government could forbid.
But what it tries to forbid here--
Unknown Speaker: Well, the statute would forbid it.
Mr. Tribe: --Well, I suppose you might--
Unknown Speaker: I thought you said the statute was... you weren't challenging the statute.
Mr. Tribe: --The statute would forbid encouraging or promoting, not necessarily when pressed saying his own truthful--
Unknown Speaker: You don't think saying my opinion is you should have an abortion is promoting?
Mr. Tribe: --Justice White, I must say that I think there is no easy way to figure out where to draw that line, and insofar as the statute is read to control speech it raises a profound problem in any event.
But the worst problem is created when the regulations are as viewpoint-based as these are.
That is, these regulations draw a sharp distinction between advocacy and literature distribution which is pro-choice and which is pro-life.
The combined effect of 59.9 and 59.50 is that it is permissible with the Title X project, quite apart from this dialogue, to engage in vigorous advocacy and legislative lobbying in favor of the pro-life position, not in favor of the pro-choice position.
Unknown Speaker: Mr. Tribe, have you made a complete answer to Justice Kennedy's question of why wouldn't it not be equally viewpoint-neutral for these people to advise the use of contraceptives?
Mr. Tribe: Why it would not be viewpoint-neutral to advise?
Unknown Speaker: Yes, to take the position that it's appropriate for the people that visit the clinics to use contraceptives.
Isn't that advocating a viewpoint, too?
Mr. Tribe: Well, the point isn't that the professional cannot advocate a viewpoint.
It's that the government cannot suppress a particular kind of information in the dialogue, and that it cannot create a viewpoint-based tilt, even in the expenditure of its money.
And in this case, if I might remind the Court, given how much private money is also burdened, the case is very like League of Women Voters.
Unknown Speaker: Well, don' the regulations prevent the hiring of advice-givers who say the only form of family planning you should use is natural birth control?
You should not use artificial birth control.
Isn't that forbidden by the regulations?
Mr. Tribe: Well, the regulations do suggest that the full range of options--
Unknown Speaker: More than suggest.
It has to provide a broad range of--
Mr. Tribe: --But that's like informed consent, Justice Scalia.
Unknown Speaker: --Why is it like informed consent?
It's saying you can only give one advice.
You cannot advise the person to use only natural family planning.
Mr. Tribe: It's that you must provide the person with the full range of options.
It is not that you cannot, if asked, tell the person what you think would be best, but you are not supposed to--
Unknown Speaker: I think the full range of options is not best.
I think you should only use one.
You are not allowed to provide that kind of advice.
You have to provide the full range of options.
Mr. Tribe: --If the Court had before it a challenge, there is under the statute a conscientious exemption.
That is, someone cannot be forced under these regulations to give advice that violates his or her conscience or religion.
But it's true that any program that has programmatic requirements will exclude some possible providers.
A drug counseling program plainly is going to exclude people whose opinion is that there should be no drug counseling and that everyone should take drugs.
But here it is not as though a plausibly neutral line has been drawn in terms of the purposes of the program.
What's happened is that truthful information that may be relevant is being deliberately withheld from people who have every reason to expect it and that, on top of that, with respect to advocacy, with respect to the preparation and distribution of literature, with respect to the leaflets that are left in the waiting room, there is a censor overseeing the entire process, saying that if they advocate abortion or in any way enhance its accessibility or its availability, the regulations have been violated.
Unknown Speaker: You say the First Amendment prevents the government from refusing to fund pamphlets that promote abortion?
Mr. Tribe: It's not that the government has an obligation to fund them.
But if the government said--
Unknown Speaker: Well, I thought you just said pamphlets in the waiting room that advocated abortion.
Mr. Tribe: --Paid for by private funds, Mr. Chief Justice.
But in TWR, for example, when you wrote that the line that was drawn by the government with respect to lobbying was acceptable because veterans and non-veterans are distinguishable without regard to viewpoint, imagine in that case if they had said we will subsidize pro-life lobbying but not pro-choice lobbying.
Now the government does not have the power, the Court has said and held in Speiser v. Randall, to make a financial benefit available, even if it's a government subsidy, based on the viewpoint expressed.
It's particularly not permissible for the government, as it does here, to say that all of the literature and all of the material, even if paid for, as in the case of many of these clinics, fully by non-Federal funds, must be expelled from the project.
Unknown Speaker: Well, does it make any difference in constitutional terms whether these pamphlets in the waiting room are paid for by private funds or paid for by Federal funds?
Mr. Tribe: I think it makes a difference, Mr. Chief Justice, whether they attempt to extend their quite limited power to assure how Federal dollars are spent.
That is, otherwise it could have been said in League of Women Voters that because the parent organization could always go off and put the same editorial on CBS or could publish it somewhere else with its own money that its private money was therefore not encumbered.
But this Court did not take that view.
I had meant to save some time for rebuttal.
Unknown Speaker: But you haven't.
Mr. Tribe: Thank you.
Unknown Speaker: Thank you, Mr. Tribe.
Argument of Kenneth W. Starr
Mr. Starr: Thank you, Mr. Chief Justice, and may it please the Court:
In light of what we have heard this morning, let me begin with a few very brief points of clarification.
First, the context.
This case involves a Federal program that is specialized.
It is not Medicaid.
It is not community health services.
It is a family planning program and which the Secretary views, consistent with Congress's intent, as being a term of art.
It means, as the conference committee report suggested, preventive services, preconceptional services.
It does not mean counseling or treating a pregnant woman, other than as part of her transition out of the family planning project, the Title X project, to another health care provider.
That is what these regulations were designed to do in response to criticisms leveled at the program by the General Accounting Office, by the Inspector General, and then pursuant... and I think this is important in terms of the orderliness of the procedure.
There was a notice and comment rulemaking here which was responsive to the very kinds of concerns that had been identified by the General Accounting Office.
That is to say the Secretary, among other things, had proceeded in a very informal way.
There had never been regulations.
There had only been informal memoranda from the Office of General Counsel which were responding to ad hoc requests for essentially a no-action kind of letter or advice and the like.
Guidelines were finally promulgated in 1981.
Those guidelines themselves represented a shift in the agency's position.
Frankly, there had been, prior to the notice and comment rulemaking, great uncertainty and confusion and indeed I don't overstate it by saying chaos in the system as to precisely what was permitted and what was not.
And in the notice of proposed rulemaking and throughout the Secretary made it very clear that this program was limited.
Professor Tribe has quoted from the Federal Register.
Let me share one very brief quote as well.
The Secretary said... this is at 52 Federal Register 33.
"as clearly contemplated by Title X and its legislative history, family planning is meant to address plans and methods for facilitating or preventing pregnancy, not for terminating it. "
"As such, medical services or counseling relating to pregnancy care after pregnancy diagnosis or any services relating to abortion as a method of family planning are outside the scope of activity supported by Title X funds. "
Unknown Speaker: General Starr, do you take the position that the way the program was being run before these current regulations went into effect somehow did not meet the requirements of the statute?
Mr. Starr: I think the answer to that is yes in this sense, Justice O'Connor.
The Secretary did come to the view that the kind of counseling that was going on was not in fact consistent with the Secretary's reading of section 1008, and at a minimum with the purpose.
What the Secretary saw as the purpose was not to encourage or promote abortion, and that was being done.
Unknown Speaker: Well, you take the position that compliance with the memos that had been sent in prior years in response to questions about providing neutral information was itself in violation of the statute?
Mr. Starr: I don't think at the time, Justice O'Connor, for this reason.
Unknown Speaker: It would be now, but not then?
Is that what you are saying?
Mr. Starr: I think so.
As odd as that may seem, I think so in light of the notice and comment rulemaking and the General Accounting Office report because, Justice O'Connor, those--
Unknown Speaker: Suppose a different rule had been adopted, one in accordance with the prior memos?
Would that be invalid under the terms of the statute, in your view?
Mr. Starr: --If it had had the effect of promoting or encouraging abortion, then I believe it would.
We would owe a deference to the Secretary.
Unknown Speaker: I'm not sure that's responsive.
Mr. Starr: I'm sorry.
Unknown Speaker: Because the prior memos at least purported to say viewpoint-neutral information may be given.
Mr. Starr: That is exactly right.
It was thought that non-directive counseling could in fact be consistent with the mandate, as those early memos, if you look at our footnote 3, the Carol Conrad memorandum said very clearly that promotion and encouragement of abortion is forbidden.
We believe, speaking on behalf of the General Counsel in this informal setting... this is not the Secretary speaking; this is not through a notice and comment rulemaking; this is an important lawyer's opinion... it was her opinion that non-directive counseling was consistent with that goal.
The Secretary, after a notice and comment rulemaking, after GAO criticism, after an Inspector General criticism, said that is not so.
And what we want to do is to return to what this program is about, which is preventive care.
Unknown Speaker: But could the Secretary have taken the position of that earlier response and been within the meaning of the statute?
Mr. Starr: I think that's problematic.
I have, frankly, serious doubts that the Secretary could have, but I don't think we have to resolve that definitively here, and reasonable minds may differ on that.
Unknown Speaker: Well, not if experience had shown that viewpoint-neutral information really wasn't consistent with the statute.
Mr. Starr: Well, especially, Justice White, and getting back to what this statute is all about, what the Secretary saw is that this is a statute about preventive pre-conceptional services, that is to say providing pregnancy care goes beyond the statute.
Unknown Speaker: General Starr, can I ask you, on that very point, the regulations, at least as quoted in the briefs, say that once a client served by a Title X project is diagnosed as pregnant, she must be referred for appropriate prenatal and/or social services by furnishing a list of available providers that promote the welfare of the mother and the unborn child.
Is that provision authorized by the statute?
Mr. Starr: Yes, I think so.
The Secretary has long felt that the program must be administered in a humane, compassionate way that in fact attends to the health needs of the individual and to refer that person to an appropriate provider of medical care.
Unknown Speaker: So the statute does require some post-pregnancy counseling?
Mr. Starr: In the sense of transition, transitional referral, and providing, I think the regulation goes on, Justice Stevens, to say--
Unknown Speaker: Never mind the regulation.
Where does the statute require that or authorize that, for that matter?
Mr. Starr: --I don't think it requires it.
I think that the Secretary, in his discretion, has determined that as a matter of common sense interpretation there must be a transition out of Title X to protect... in essence to maintain the status quo until the referral appointment can be kept.
They will assist in keeping the referral appointment.
And to ensure that the status quo is maintained the individual is given necessary information to protect the health of the mother and of the unborn child.
Unknown Speaker: Well, then why would it prohibit giving necessary health information in that rare case in which abortion might be medically indicated?
I don't understand the distinction.
Mr. Starr: If there is an emergency, then it can be.
Unknown Speaker: No, it's not an emergency, but it's the better of two options just from a purely medical point of view, not for any family planning reason... just for the health of the mother.
Why can you say in the one case it's appropriate to have post-pregnancy advice and the other it's not appropriate... under the statute only?
I'm not talking constitutionally.
Mr. Starr: Post-pregnancy advice is terribly limited.
It's terribly limited because of the humanity of the situation.
The individual needs to get to an appropriate provider of health care.
She has, as it were, graduated from Title X.
If the individual is going into detailed options counseling, providing Spock on baby care and the like, showing baby care materials and the like, that is beyond the scope of Title X.
Unknown Speaker: But this is not?
Mr. Starr: I don't think so, and certainly they have not challenged the fact that the individual should be given enough information to maintain the status quo until that short period... and we hope it would be a very short period... until she could see a physician who is in fact outside of the Title X program.
Unknown Speaker: I don't understand what you mean by the status quo.
The status quo is she is pregnant.
She doesn't need advice to stay pregnant.
Mr. Starr: You are quite right.
My choice of terms is infelicitous.
To maintain the circumstances so that she can in fact get... that is to say, if she needs information.
You are pregnant.
You should now in fact see an appropriate provider of medical care.
Here is information that you need to know.
I'm scheduled to go to a party tomorrow night, and I tend to be a heavy drinker.
It is completely appropriate for the physician... and of course this is typically, the counseling is typically done... and I think our colleagues on the other side realize this... by health care practitioners, by nurses and nurse practitioners, are entitled to say here's a list of appropriate care providers, but at that party don't drink at all because you may damage your health, you may damage the health of the unborn child.
That is appropriate, the Secretary has determined, in his interpretation of the statute.
There is no constitutional problem here by virtue of the Secretary following the very path that was laid down by the court in FCC v. League of Women Voters.
That is what the program integrity requirements are all about.
So that to maintain the abortion neutrality of the Title X program, to keep abortion out of that program entirely, the Secretary, through the 59.9 integrity regulations, permits the establishment of a separate vehicle.
Unknown Speaker: It isn't an abortion neutrality.
It is the one thing that is singled out that shall not be used as a means of family planning.
Mr. Starr: It certainly tilts against abortion.
There is no question about that.
But what the program integrity requirements permit is complete non-neutrality.
That is to say, the grantee... that is why the Secretary was quite precise in drawing the line between the Title X program or project and the grantee.
The grantee is at liberty to have an abortion services clinic and the like to provide abortion-related information, to provide abortion counseling.
And that is exactly what this Court said in League of Women Voters was in fact permissible, following the lead of what the Court indicated in Reagan v. Taxation with Representation.
Unknown Speaker: But not as part of this program.
Mr. Starr: Exactly, Justice Kennedy.
That is the precise point.
This is a limited program.
The prohibition runs only to the program, and that is what takes this out of the unconstitutional conditions line of cases.
Unknown Speaker: Suppose the medical care provider in the Title X program ascertains that the woman is pregnant.
That provider has a regular practice of engaging in performing therapeutic abortions.
Can he say I want you to make an appointment with me tomorrow at my other office, and I am going to give you some advice?
Mr. Starr: Not if in that latter capacity that provider's principal purpose or principal business is the providing of abortions.
Unknown Speaker: Then you are saying that this Title X grantee can still engage in abortion.
It's really meaningless.
This woman might find them out.
She might not.
Mr. Starr: But the list that can be provided, Justice Kennedy, I wouldn't focus on that one provider.
The list is to be in fact a global list, leaving out only one kind of entity, and that is entities whose principal business is the providing of abortions.
There can in fact be providers on that list who do provide abortions, in response to Justice White's question.
Unknown Speaker: Well, the lady asks the doctor in one of these Federally-funded organizations, asks the doctor, well, could you tell me where I can get an abortion.
And he says no, I can't tell you where to get an abortion.
But I'll tell you I'm going to refer you, give you a list of health care providers, and some of those people can answer questions that I can't answer.
Is that all right?
Mr. Starr: That is correct.
That is entirely correct.
In fact, part of the theme that we have heard, Justice White, is that there is distortion, there is trickery.
There should be none at all.
If the program is proceeding with integrity, as it should, it will be up front with the clients of the Title X project and say we do not counsel with respect to abortion as a method of family planning.
We do not refer to clinics whose principal business is the providing of abortions.
What we are going to give you, now that you have been diagnosed as pregnant, is a comprehensive list and on this list are appropriate providers of medical care to protect the health of the mother and the unborn child.
And on that list there can in fact be providers who do provide abortions.
Unknown Speaker: General, what do you say the statute and the regs permit in a situation in which the object is not simply to preserve the status quo but the situation in which the Title X physician in the course of his consulting or examination concludes that the mother is pregnant and in fact is in some imminent danger to health?
In that case, do you take the position that either the statute or the regs permit the Title X physician to say you are in danger to health as a result of your pregnancy and one appropriate response to that would be to have an abortion and I will refer you to a hospital or a physician who can provide it?
Would that place the program in violation of either the statute or the regs?
Mr. Starr: Part B does, Part A does not.
To say in Part A of your hypothetical your health is in danger, you do need treatment, that is absolutely fine, and to refer the person to an emergency provider of medical services is fine.
To actually go forward, as I understand the hypothetical, and to counsel you need an abortion is beyond the mandate.
And the person can say, the health care provider can say, I'm not going to trick you.
I'm not going to deceive you.
This is important.
Here is a list.
In fact, I need to get you over for emergency care, but I am not at liberty to be counseling with respect to the appropriate medical treatment.
Unknown Speaker: Even in that case he's not counseling for the purposes of family planning.
He is in fact acting as a physician for the purpose of preventing an imminent risk or removing an imminent risk to the patient's health.
Why does that violate the statute or the regs?
Mr. Starr: The problem is the context, that that advice is being given in the context of a Title X family planning program.
And in fact the Secretary reasonably reads the 1008 prohibition that the goal that Congress had in what was inherently a controversial program is let's not bring abortion and the abortion controversy into the program.
We have made the decision to bring contraceptives in.
Unknown Speaker: But isn't he going a step further?
Isn't he saying, if he follows the position that you have just outlined, isn't he saying that in fact if a Title X physician sees a professional, a standard professional need or obligation to give advice for the purpose of protecting the health of his patient from imminent danger, and in giving that advice he is not giving it for the purposes of family planning but simply for those traditional purposes, that too is forbidden?
Doesn't that go beyond the statute and the regs?
Mr. Starr: I don't think so, Your Honor, because at that point the person, the physician in your hypothetical... I think it is an extreme hypothetical, but accepting it and facing it... I think in that hypothetical the physician has transcended the boundaries of Title X.
His Title X hat, family planning services, is on.
Once he steps out of that hat and begins treating the individual's pregnancy, he is providing a different kind of medical care beyond the scope of Title X, quite apart from abortion.
Unknown Speaker: The Secretary requires him to do that, as Justice Stevens' question earlier demonstrated.
I mean, it's the Secretary that says you have to provide this kind of medical care in the regs.
Mr. Starr: That you have to provide medical care that is needed during that interim period... I won't use status quo... during the interim period when an appointment is to be made.
The key is make an appointment, and that's what I think the regulations suggest.
Make an appointment with an emergency provider of services, and you can assist the person in making sure that that emergency appointment is in fact kept.
Unknown Speaker: But in my hypothetical the interim period may be extraordinarily short.
For all we know, the high blood pressure is going to result in a stroke within the next hour, and it seems to me that you are telling us that in those circumstances... to be sure that is not what Title X was concerned with, but in those circumstances... the physician cannot perform a normal professional responsibility which is outside of the object of Title X funding, even though that responsibility does not violate the prohibition against using abortion counseling for family planning.
I think you are telling us that in that circumstance, simply because it is outside the object of Title X, the Secretary in effect may preclude professional speech.
Mr. Starr: I don't think that the program is prescribing professional speech, if I accept your hypothetical as not in fact permitting what the Secretary contemplated to take place.
Here is what the Secretary contemplated... that in cases in which emergency care is required... that's, I think, what we are dealing with... a Title X project shall be required only to refer the client immediately to an appropriate provider of emergency medical services.
Unknown Speaker: It's one thing to say it may be required only to do that.
It's another thing to say that he may be precluded, the physician may be precluded from something else, even though it does not violate the condition that Title X may not use abortion for family planning.
Mr. Starr: That may very well be.
That may very well be.
Unknown Speaker: May I expand on that?
Supposing the case is not one of emergency at the time of the conference but in the doctor's professional judgment unless steps are taken within 30 days there is a danger of an emergency, and he thinks the appropriate way of avoiding that danger is to at least consider abortion as an option.
What is he supposed to do under the regulations?
Mr. Starr: I'm sorry.
I missed the last part of the hypothetical.
Unknown Speaker: What is the doctor's... how much freedom does the doctor have to explain to the patient that in the next 30 days you ought to have some tests to see whether or not it's appropriate to have an abortion, because that may be the only way to avoid a risk that is not today an emergency but may become an emergency in three weeks?
Mr. Starr: I think that the physician is at liberty to provide medical information that is necessary, and so I think that the physician in that hypothetical could respond, provide that physician's best medical judgment, as long as the physician does not in fact steer the patient in the direction of an abortion, but, rather, steers the patient in the direction of an appropriate care provider.
Unknown Speaker: Well, but may the physician... I don't want to use the word "steer"... may the physician, as a part of his or her explanation of the problem, say that the reason I want you to see some other professional is I think it may be appropriate to avoid this danger by getting an abortion?
Mr. Starr: I think that, in my judgment, that goes beyond what is permitted under Title X.
Unknown Speaker: Well, is it permitted for him to give any other medical judgment?
Is he permitted to do anything but refer?
I mean, suppose he... is he permitted to give the judgment, in my opinion, you should have the following course of treatment?
Mr. Starr: He should not in fact, Justice Scalia, be in the business of treating pregnancy and caring for the person in her pregnant condition.
Unknown Speaker: I thought he can only refer.
Mr. Starr: Exactly right.
Unknown Speaker: And in the event of an emergency of the sort Justice Souter was referring to he can refer even to, as I read the regulations, even to an agency whose principal business is abortion.
Mr. Starr: I don't think that the regulations by their terms rule that out.
It simply says emergency and an appropriate provider of emergency services.
At that point, the health of and welfare of the mother are paramount, and the physician must in fact make the appropriate referral to an emergency provider.
Unknown Speaker: Let me ask one other question.
Again assuming it is not an immediate emergency but a concern about 30 days from now, could the doctor say I just happened to notice this, I think you ought to have your tonsils taken out?
I'm serious about that.
Mr. Starr: Yes.
I think that the physician can in fact alert the individual to a potential medical problem.
Unknown Speaker: And suggest the proper solution, in his or her judgment?
Mr. Starr: I think at that point the physician may very well be going beyond what Title X is all about.
As an enforcement matter, as a practical matter--
Unknown Speaker: It's no longer family planning, but is it something that the statute would prohibit the doctor from doing?
Mr. Starr: --I think it goes beyond the terms of the statute.
Whether an enforcement action would be brought is quite another thing.
Unknown Speaker: That's not my question.
Do you think the statute would prohibit the doctor from giving medical advice that is not specifically authorized by the statute or contemplated within the notion of family planning?
He just sees a problem with the patient and says, look, I think this is what you should do.
My understanding is he can give any medical advice he wants to, except that he cannot say that I think an abortion is indicated.
Mr. Starr: I disagree with that.
On your tonsils example, it seems to me that under a de minimis approach that is unobjectionable.
With respect to--
Unknown Speaker: Well, say it's appendix or say it's major surgery, you ought to have a bypass operation.
There are a lot of things that are... if it's important, can he do it and unimportant not?
Is that your notion?
Mr. Starr: --No.
I think that the physician is simply going beyond what Title X is all about.
Unknown Speaker: I understand he's going beyond what's been authorized.
I'm asking if it violates either the statute or the regulations to give that kind of medical advice.
Mr. Starr: I think it will violate the terms of the grant, because the grant is in fact... they are funding this physician to provide Title X services.
Unknown Speaker: So if he gave that kind of medical advice you could withdraw the grant for the future?
Mr. Starr: In terms of what... oh, I didn't say that at all.
Unknown Speaker: Suppose I thought--
Mr. Starr: Not at all.
There may have been... there are all kinds of violations.
Unknown Speaker: --What are the consequences if violating the regulation about abortion?
What can happen to the doctor for doing that?
Mr. Starr: The program may be the subject of an audit and then appropriate action taken, which could include not renewing the grant.
Unknown Speaker: Could the same action be taken if he gave advice to have a tonsillectomy, and, if not, why not?
Mr. Starr: Well, it might, because the individual is at that point transcending Title X.
Unknown Speaker: I presume you would certainly terminate the grant if indeed that were the regular practice, that people were coming in to get family planning advice simply because at the end of it the doctor said, by the way, while you're here, let me look at your tonsils.
And they were regularly treating people or giving advice about all sorts of medical conditions.
You would probably terminate the program in that event, I would assume.
Mr. Starr: That is precisely why I was suggesting the possibility of a de minimis exception.
That is to say there is no rule that--
Unknown Speaker: With respect to abortion consultation, that is much more likely to happen regularly than is advice about tonsils.
Mr. Starr: --Individuals are coming in, exactly, for the purpose of receiving family planning.
Unknown Speaker: Well, does it happen regularly that when a pregnant person comes in that there's a medical need unrelated to family planning problems?
I thought you said that was the rare exception.
Mr. Starr: Well, the individual can again be referred out.
I think we're talking about here is what you should do.
In your hypothetical, Justice Stevens, as I understand it, the physician is saying I am here as a Title X physician, but I am telling you to go have your tonsils out.
The individual is, it seems to me, at that point practicing beyond the scope of the program.
Unknown Speaker: Just if a doctor sees a medical problem, is the doctor permitted to tell the patient about the existence of the problem, with the normal recommended, what his professional advice is.
I guess you are saying no, that he cannot.
Mr. Starr: He certainly is able to say I have spotted a tonsils problem and you should go have it attended to.
It is not the purpose of this project to tell you exactly what you should do, but we will assist you in finding an appropriate health care provider.
Last point that I would like to make on the unconstitutional conditions point.
Much has been said about Perry against Sindermann and the line of cases that suggest that the government cannot in fact require someone to give up a liberty as a condition for a particular kind of benefit... Speiser against Randall and the like.
That, as I was saying before the colloquy, about what the regulations permit, is exactly why the Secretary has the program integrity requirements, to permit these kinds of services to be permitted through a separate vehicle, and by virtue of that there is in fact no extension of the prohibition beyond the program itself.
The prohibition is entirely program-specific, and by virtue of that there is no unconstitutional condition that is being mounted or imposed upon these individuals and on these clinics.
Above all, as this Court has said time and again, the law assumes a robust common sense, and a robust sense that individuals are in fact free to determine whether to participate in a government program or not.
The Secretary fashioned a program that was true to Congress's intent, as reflected in 1008 and in the statements of legislators and the conference committee report, that this program, to have integrity, must in fact be a preventive services preconceptional program.
I thank the Court.
Chief Justice Rehnquist: Thank you, General Starr.
The case is submitted.
Argument of Chief Justice Rehnquist
Mr. Tribe: I have the opinions of the Court to announce in three cases.
The first is No. 89-1391, Rust against Sullivan with a companion case.
Title X of the Public Health Service Act provides federal funding for preconception for family planning services.
Section 1008 of the Act specifies that none of the funds appropriated for family-planning services shall be used in programs where abortion is a method of family planning.
In 1988, the Secretary promulgated new regulations designed to provide clear and operational guidance to Title X grantees about how to preserve the distinction between Title X programs and abortion as a method of family planning.
These regulations prohibit Title X projects from engaging in counseling concerning referrals for and activities advocating abortion as a method of family planning and requires such projects to maintain an objective integrity and independence from the prohibited abortion activities by use of separate facilities, personnel, and accounting record.
Before the regulations could be put into effect, they were challenged by the petitioners in this case.
They were upheld in the lower courts but the other Courts of Appeals held otherwise so we granted certiorari to resolve the difference of opinion.
In an opinion filed with the clerk today, we uphold the Secretary's regulations and affirm the judgment of the Court of Appeals.
We hold the regulations are a permissible construction of Title X because Section 1008 is ambiguous and that it does not speak directly to the issue of abortion counseling referral and advocacy, the Secretary's construction must be afforded substantial deference as the interpretation of the agency charged with administering the statute.
We also find that the regulations do not violate the First Amendment free speech rights of private Title X, recipients, their staffs or their patients, by impermissibly imposing viewpoint-discriminatory conditions on government subsidies.
There is no question but that Section 1008 itself is constitutional and the government is not required to fund the activities which are constitutionally protected.
We also hold that the regulations do not violate a woman's Fifth Amendment right to choose whether to terminate her pregnancy.
The government, as we have held before, has no constitutional obligation to subsidies an activity merely because it is constitutionally protected.
Justice Blackmun has filed a dissenting opinion in which Justice Marshall joins and part 1 of which, Justice O'Connor joins, and in parts 2 and 3 of which, Justice Stevens joins; Justice Stevens and Justice O'Connor have also filed separate dissenting opinion.