Gretchen Stuart v. Paul Camnitz

PUBLISHED

UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT

No. 14-1150

GRETCHEN S. STUART, MD, on behalf of herself and her
patients seeking abortions; JAMES R. DINGFELDER, MD, on
behalf of himself and his patients seeking abortions; DAVID
A. GRIMES, MD, on behalf of himself and his patients
seeking abortions; AMY BRYANT, MD, on behalf of herself and
her patients seeking abortions; SERINA FLOYD, MD, on behalf
of herself and her patients seeking abortions; DECKER &
WATSON, INC., d/b/a Piedmont Carolina Medical Clinic;
PLANNED PARENTHOOD OF CENTRAL NORTH CAROLINA; A WOMAN'S
CHOICE OF RALEIGH, INC.; PLANNED PARENTHOOD HEALTH SYSTEMS,
INC.; TAKEY CRIST, on behalf of himself and his patients
seeking abortions; TAKEY CRIST, M.D., P.A., d/b/a Crist
Clinic for Women,

Plaintiffs - Appellees,

v.

PAUL S. CAMNITZ, MD, in his official capacity as President
of the North Carolina Medical Board and his employees,
agents and successors; ROY COOPER, in his official capacity
as Attorney General of North Carolina and his employees,
agents and successors; ALDONA ZOFIA WOS, in her official
capacity as Secretary of the North Carolina Department of
Health and Human Services and her employees, agents and
successors; JIM WOODALL, in his official capacity as
District Attorney ("DA") for Prosecutorial District ("PD")
15B and his employees, agents and successors; LEON STANBACK,
in his official capacity as DA for PD 14 and his employees,
agents and successors; DISTRICT ATTORNEY DOUGLAS HENDERSON,
in his official capacity as DA for PD 18 and his employees,
agents and successors; BILLY WEST, in his official capacity
as DA for PD 12 and his employees, agents and successors; C.
COLON WILLOUGHBY, JR., in his official capacity as DA for PD
10 and his employees, agents and successors; BENJAMIN R.
DAVID, in his official capacity as DA for PD 5 and his
employees, agents and successors; ERNIE LEE, in his official
capacity as DA for PD 4 and his employees, agents and
successors; JIM O'NEILL, in his official capacity as DA for
PD 21 and his employees, agents and successors,

Defendants - Appellants,

JOHN THORP,

Intervenor/Defendant,

FRANCIS J. BECKWITH, MJS, PhD; GERARD V. BRADLEY; TERESA S.
COLLETT; DAVID K. DEWOLF; RICK DUNCAN; EDWARD M. GAFFNEY;
STEPHEN GILLES; MICHAEL STOKES PAULSEN; RONALD J. RYCHLAK;
RICHARD STITH; RUTH SAMUELSON; PAT MCELRAFT; PAT HURLEY;
MARILYN AVILA; SUSAN MARTIN; CAROLYN M JUSTICE; RENA W.
TURNER; MICHELE D. PRESNELL; SARAH STEVENS; JACQUELINE
MICHELLE SCHAFFER; DEBRA CONRAD; MARK BRODY; CHRIS WHITMIRE;
ALLEN MCNEILL; DONNY LAMBETH; GEORGE CLEVELAND; LINDA
JOHNSON; DAVID CURTIS; JOYCE KRAWIEC; SHIRLEY RANDLEMEN; DAN
SOUCEK; NORMAN SANDERSON; WARREN DANIEL; BUCK NEWTON; KATHY
L. HARRINGTON; ANDREW BROCK,

Amici Supporting Appellant,

AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS;
AMERICAN MEDICAL ASSOCIATION; AMERICAN PUBLIC HEALTH
ASSOCIATION,

Amici Supporting Appellee.

Appeal from the United States District Court for the Middle
District of North Carolina, at Greensboro. Catherine C. Eagles,
District Judge. (1:11-cv-00804-CCE-LPA)

Argued: October 29, 2014 Decided: December 22, 2014

Before TRAXLER, Chief Judge, and WILKINSON and DUNCAN, Circuit
Judges.

2
Affirmed by published opinion. Judge Wilkinson wrote the
opinion, in which Chief Judge Traxler and Judge Duncan joined.

ARGUED: John Foster Maddrey, NORTH CAROLINA DEPARTMENT OF
JUSTICE, Raleigh, North Carolina, for Appellants. Julie
Rikelman, CENTER FOR REPRODUCTIVE RIGHTS, New York, New York,
for Appellees. ON BRIEF: Roy Cooper, Attorney General, Gary R.
Govert, Assistant Solicitor General, I. Faison Hicks, Special
Deputy Attorney General, NORTH CAROLINA DEPARTMENT OF JUSTICE,
Raleigh, North Carolina, for Appellants. Christopher Brook,
AMERICAN CIVIL LIBERTIES UNION OF NORTH CAROLINA LEGAL
FOUNDATION, Raleigh, North Carolina; Andrew D. Beck, AMERICAN
CIVIL LIBERTIES UNION FOUNDATION, New York, New York; Jennifer
Sokoler, CENTER FOR REPRODUCTIVE RIGHTS, New York, New York;
Walter Dellinger, Anton Metlitsky, Leah Godesky, O'MELVENY &
MYERS LLP, Washington, D.C.; Diana O. Salgado, New York, New
York, Helene T. Krasnoff, PLANNED PARENTHOOD FED. OF AMERICA,
Washington, D.C., for Appellees. Anna R. Franzonello, Mailee R.
Smith, William L. Saunders, Denise M. Burke, AMERICANS UNITED
FOR LIFE, Washington, D.C., for Amici Francis J. Beckwith, MJS,
PhD, Gerard V. Bradley, Teresa S. Collett, David K. Dewolf, Rick
Duncan, Edward M. Gaffney, Stephen Gilles, Michael Stokes
Paulsen, Ronald J. Rychlak, and Richard Stith. Scott W.
Gaylord, Jennings Professor, Thomas J. Molony, Associate
Professor of Law, ELON UNIVERSITY SCHOOL OF LAW, Greensboro,
North Carolina, for Amici Ruth Samuelson, Pat McElraft, Pat
Hurley, Marilyn Avila, Susan Martin, Carolyn M. Justice, Rena W.
Turner, Michele D. Presnell, Sarah Stevens, Jacqueline Michelle
Schaffer, Debra Conrad, Mark Brody, Chris Whitmire, Allen
McNeill, Donny Lambeth, George Cleveland, Linda Johnson, David
Curtis, Joyce Krawiec, Shirley Randlemen, Dan Soucek, Norman
Sanderson, Warren Daniel, Buck Newton, Kathy L. Harrington, and
Andrew Brock. Kimberly A. Parker, Alathea E. Porter, Thaila K.
Sundaresan, Tiffany E. Payne, WILMER CUTLER PICKERING HALE AND
DORR LLP, Washington, D.C., for Amici American College of
Obstetricians and Gynecologists and American Medical
Association. Shannon Rose Selden, Courtney M. Dankworth,
DEBEVOISE & PLIMPTON LLP, New York, New York, for Amicus
American Public Health Association.

3
WILKINSON, Circuit Judge:

At issue here is a North Carolina statute that requires

physicians to perform an ultrasound, display the sonogram, and

describe the fetus to women seeking abortions. A physician must

display and describe the image during the ultrasound, even if

the woman actively “avert[s] her eyes” and “refus[es] to hear.”

N.C. Gen. Stat. § 90-21.85(b). This compelled speech, even

though it is a regulation of the medical profession, is

ideological in intent and in kind. The means used by North

Carolina extend well beyond those states have customarily

employed to effectuate their undeniable interests in ensuring

informed consent and in protecting the sanctity of life in all

its phases. We thus affirm the district court’s holding that

this compelled speech provision violates the First Amendment.

I.

In July 2011, the North Carolina General Assembly passed

the Woman’s Right to Know Act over a gubernatorial veto. The Act

amended Chapter 90 of the North Carolina General Statutes, which

governs medical and related professions, adding a new article

regulating the steps that must precede an abortion.

Physicians and abortion providers filed suit after the

Act’s passage but before its effective date, asking the court to

enjoin enforcement of the Act and declare it unconstitutional.

In October 2011, the district court issued a preliminary

4
injunction barring enforcement of one provision of the Act, the

Display of Real-Time View Requirement (“the Requirement”),

codified at N.C. Gen. Stat. § 90-21.85. J.A. 143-44. The court

subsequently allowed the plaintiffs to amend their complaint.

The Third Amended Complaint asserted that the Display of Real-

Time View Requirement violated the physicians’ First Amendment

free speech rights and the physicians’ and the patients’

Fourteenth Amendment due process rights. J.A. 282. 1

The Display of Real-Time View Requirement obligates doctors

(or technicians) to perform an ultrasound on any woman seeking

an abortion at least four but not more than seventy-two hours

before the abortion is to take place. N.C. Gen. Stat. § 90-

21.85(a)(1). The physician must display the sonogram so that the

woman can see it, id. § 90-21.85(a)(3), and describe the fetus

in detail, “includ[ing] the presence, location, and dimensions

of the unborn child within the uterus and the number of unborn

children depicted,” id. § 90-21.85(a)(2), as well as “the

presence of external members and internal organs, if present and

viewable,” id. § 90-21.85(a)(4). The physician also must offer

1
The Third Amended Complaint also challenged both the
Display of Real-Time View Requirement and the Informed Consent
to Abortion provision, N.C. Gen. Stat. § 90-21.82, as
unconstitutionally vague. J.A. 281. The parties and the district
court agreed on savings constructions so that the Act was not
void for vagueness, and the plaintiffs did not appeal that
ruling. Stuart v. Loomis, 992 F. Supp. 2d 585, 611 (M.D.N.C.
2014) (district court opinion).

5
to allow the woman to hear the fetal heart tone. Id. § 90-

21.85(a)(2). The woman, however, may “avert[] her eyes from the

displayed images” and “refus[e] to hear the simultaneous

explanation and medical description” by presumably covering her

eyes and ears. Id. § 90-21.85(b).

The Act provides an exception to these requirements only in

cases of medical emergency. Id. § 90-21.86. Physicians who

violate the Act are liable for damages and may be enjoined from

providing further abortions that violate the Act in North

Carolina. Id. § 90-21.88. Violation of the Act also may result

in the loss of the doctor’s medical license. See id. § 90-

14(a)(2) (The North Carolina Medical Board may impose

disciplinary measures, including license revocation, upon a

doctor who “[p]roduc[es] or attempt[s] to produce an abortion

contrary to law.”).

Not at issue in this appeal are several other informed

consent provisions to which physicians, independently of the

Display of Real-Time View Requirement, are subject. The first is

the informed consent provision of the Act itself. Id. § 90-

21.82. It requires that, at least twenty-four hours before an

abortion is to be performed, a doctor or qualified professional

explain to the woman seeking the abortion the risks of the

procedure, the risks of carrying the child to term, “and any

adverse psychological effects associated with the abortion.” Id.

6
§ 90-21.82(1)(b), (d). The physician must also convey the

“probable gestational age of the unborn child,” id. § 90-

21.82(1)(c), that financial assistance for the pregnancy may be

available, that the father of the child is obligated to pay

child support, and that there are alternatives to abortion, id.

§ 90-21.82(2)(a)-(d). Furthermore, the doctor must inform the

woman that she can view on a state-sponsored website materials

published by the state which describe the fetus. The doctor must

also give or mail the woman physical copies of the materials if

she wishes, and must “list agencies that offer alternatives to

abortion.” Id. § 90-21.82(2)(e).

Before this Act, physicians were still subject to North

Carolina’s general informed consent requirements when conducting

abortions. See id. § 90-21.13(a); 10A N.C. Admin. Code

14E.0305(a); Appellees’ Br. 6. Prior to its enactment, the

physicians challenging the Act claim they were “inform[ing] each

patient about the nature of the abortion procedure, its risks

and benefits, and the alternatives available to the patient and

their respective risks and benefits” and “counsel[ing] the

patient to ensure that she was certain about her decision to

have an abortion.” Appellees’ Br. 6.

Both parties moved for summary judgment. Applying

heightened, intermediate scrutiny, Stuart v. Loomis, 992 F.

Supp. 2d 585, 600-01 (M.D.N.C. 2014), the district court held

7
that the Display of Real-Time View Requirement violated the

physicians’ First Amendment rights to free speech. Id. at 607-

09. It thus granted the plaintiffs’ motion for summary judgment

and entered a permanent injunction. Id. at 610-11. The court

declined to reach the merits of the due process claim, finding

it moot in light of the court’s ruling on the First Amendment

claim. Id. at 611. 2

We review a grant of summary judgment de novo. S.

Appalachian Mountain Stewards v. A & G Coal Corp., 758 F.3d 560,

562 (4th Cir. 2014). In so doing, we view the facts in the light

most favorable to the state. Moore-King v. Cnty. of

Chesterfield, Va., 708 F.3d 560, 566 (4th Cir. 2013).

II.

A.

“Congress shall make no law . . . abridging the freedom of

speech.” U.S. Const. amend. I. This concept sounds simple, but

proves more complicated on closer inspection. Laws that impinge

upon speech receive different levels of judicial scrutiny

depending on the type of regulation and the justifications and

purposes underlying it. On the one hand, regulations that

2
After the district court’s order granting the preliminary
injunction, several individuals and pregnancy counseling centers
moved to intervene as defendants. The district court denied the
motion, Stuart v. Huff, 2011 WL 6740400 (M.D.N.C. Dec. 22,
2011), and this court affirmed, Stuart v. Huff, 706 F.3d 345
(4th Cir. 2013).

8
discriminate against speech based on its content “are

presumptively invalid,” R.A.V. v. City of St. Paul, Minn., 505

U.S. 377, 382 (1992), and courts usually “apply the most

exacting scrutiny,” Turner Broad. Sys., Inc. v. FCC, 512 U.S.

622, 642 (1994); see also United States v. Playboy Entm’t Grp.,

Inc., 529 U.S. 803, 814 (2000). On the other hand, “area[s]

traditionally subject to government regulation,” such as

commercial speech and professional conduct, typically receive a

lower level of review. Cent. Hudson Gas & Elec. Corp. v. Pub.

Serv. Comm’n of N.Y., 447 U.S. 557, 562-63 (1980) (regulation of

commercial speech); see also Keller v. State Bar of Cal., 496

U.S. 1, 13-16 (1990) (regulation of legal profession).

We thus must first examine the type of regulation at issue

to determine the requisite level of scrutiny to apply. Turner,

512 U.S. at 637 (explaining that “because not every interference

with speech triggers the same degree of scrutiny under the First

Amendment, we must decide at the outset the level of scrutiny

applicable”). As we do, we are mindful of “the First Amendment’s

command that government regulation of speech must be measured in

minimums, not maximums.” Riley v. Nat’l Fed’n of the Blind of

N.C., Inc., 487 U.S. 781, 790 (1988).

The physicians urge us to find that the regulation must

receive strict scrutiny because it is content-based and

ideological. See Appellees’ Br. 36-40. The state counters that

9
the Requirement must be treated as a regulation of the medical

profession in the context of abortion and thus subject only to

rational basis review. See Appellants’ Br. 7-15, 20-28. The

district court chose a different path. Recognizing that the

Requirement both compelled speech and regulated the medical

profession, the court applied neither strict scrutiny nor

rational basis review, but rather the intermediate scrutiny

standard normally used for certain commercial speech

regulations. See Stuart v. Loomis, 992 F. Supp. 2d 585, 598-601

(M.D.N.C. 2014). For the reasons outlined below, we agree with

the district court that the Requirement is a content-based

regulation of a medical professional’s speech which must satisfy

at least intermediate scrutiny to survive.

B.

The Display of Real-Time View Requirement regulates both

speech and conduct. The physician must convey the descriptions

mandated by the statute in his or her own voice. The sonogram

display is also intimately connected with the describing

requirement. The two are thus best viewed as a single whole. In

deciding whether an activity “possesses sufficient communicative

elements to bring the First Amendment into play, we have asked

whether ‘[a]n intent to convey a particularized message was

present, and [whether] the likelihood was great that the message

would be understood by those who viewed it.’” Texas v. Johnson,

10
491 U.S. 397, 404 (1989) (quoting Spence v. Washington, 418 U.S.

405, 410–11 (1974)). The state’s avowed intent and the

anticipated effect of all aspects of the Requirement are to

discourage abortion or at the very least cause the woman to

reconsider her decision. See Appellants’ Br. 29-32. The clear

import of displaying the sonogram in this context -- while the

woman who has requested an abortion is partially disrobed on an

examination table -- is to use the visual imagery of the fetus

to dissuade the patient from continuing with the planned

procedure. If the state’s intent is to convey a distinct

message, the message does not lose its expressive character

because it happens to be delivered by a private party. Whether

one agrees or disagrees with the state’s approach here cannot be

the question. In this context, the display of the sonogram is

plainly an expressive act entitled to First Amendment

protection. See, e.g., John Doe No. 1 v. Reed, 561 U.S. 186,

194-95 (2010) (recognizing First Amendment protections for

signing a referendum petition); Joseph Burstyn, Inc. v. Wilson,

343 U.S. 495, 501-02 (1952) (commercial film).

The First Amendment not only protects against prohibitions

of speech, but also against regulations that compel speech.

“Since all speech inherently involves choices of what to say and

what to leave unsaid, one important manifestation of the

principle of free speech is that one who chooses to speak may

11
also decide what not to say.” Hurley v. Irish-Am. Gay, Lesbian &

Bisexual Grp. of Bos., 515 U.S. 557, 573 (1995) (citations

omitted) (internal quotation marks omitted); see also Wooley v.

Maynard, 430 U.S. 705, 714 (1977) (“[T]he First Amendment . . .

includes both the right to speak freely and the right to refrain

from speaking at all.”). A regulation compelling speech is by

its very nature content-based, because it requires the speaker

to change the content of his speech or even to say something

where he would otherwise be silent. Riley, 487 U.S. at 795

(“Mandating speech that a speaker would not otherwise make

necessarily alters the content of the speech.”); Centro Tepeyac

v. Montgomery Cnty., 722 F.3d 184, 189 (4th Cir. 2013) (en banc)

(same). Compelled speech is particularly suspect because it can

directly affect listeners as well as speakers. Listeners may

have difficulty discerning that the message is the state’s, not

the speaker’s, especially where the “speaker [is] intimately

connected with the communication advanced.” Hurley, 515 U.S. at

576.

The Requirement is quintessential compelled speech. It

forces physicians to say things they otherwise would not say.

Moreover, the statement compelled here is ideological; it

conveys a particular opinion. The state freely admits that the

purpose and anticipated effect of the Display of Real-Time View

Requirement is to convince women seeking abortions to change

12
their minds or reassess their decisions. See Appellants’ Br. 29-

32.

It may be true, as the Fifth Circuit has noted, that “the

required disclosures . . . are the epitome of truthful, non-

misleading information.” Tex. Med. Providers Performing Abortion

Servs. v. Lakey, 667 F.3d 570, 577-78 (5th Cir. 2012). But an

individual’s “right to tailor [his] speech” or to not speak at

all “applies . . . equally to statements of fact the speaker

would rather avoid.” Hurley, 515 U.S. at 573; see also Sorrel v.

IMS Health Inc., 131 S. Ct. 2653, 2667 (2011); Turner, 512 U.S.

at 645; Riley, 487 U.S. at 797-98. While it is true that the

words the state puts into the doctor’s mouth are factual, that

does not divorce the speech from its moral or ideological

implications. “[C]ontext matters.” Greater Balt. Ctr. for

Pregnancy Concerns, Inc. v. Mayor of Balt., 721 F.3d 264, 286

(4th Cir. 2013) (en banc). Of course we need not go so far as to

say that every required description of a typical fetus is in

every context ideological. But this Display of Real-Time View

Requirement explicitly promotes a pro-life message by demanding

the provision of facts that all fall on one side of the abortion

debate -- and does so shortly before the time of decision when

the intended recipient is most vulnerable.

The state protests that the Requirement does not dictate a

specific script and that the doctor is free to supplement the

13
information with his own opinion about abortion. Reply Br. 14-

16. That is true; the state does not demand that the doctor use

particular words. But that does not mean that the Requirement is

“not designed to favor or disadvantage speech of any particular

content.” Turner, 512 U.S. at 652. In fact, the clear and

conceded purpose of the Requirement is to support the state’s

pro-life position. That the doctor may supplement the compelled

speech with his own perspective does not cure the coercion --

the government’s message still must be delivered (though not

necessarily received).

Content-based regulations of speech typically receive

strict scrutiny. Id. at 642. The state, however, maintains that

the Requirement is merely a regulation of the practice of

medicine that need only satisfy rational basis review. We turn

now to that contention. 3

C.

The state’s power to prescribe rules and regulations for

professions, including medicine, has an extensive history. See

3
Plaintiffs seem to suggest that the Display of Real-Time
View Requirement constitutes viewpoint discrimination and that
we should strike the provision down on that basis. See
Appellees’ Br. 2, 54. Because we find that the Requirement fails
even intermediate scrutiny, infra Part III, it is unnecessary
for us to definitively determine whether the compelled speech
here requires strict scrutiny. See Greater Balt., 721 F.3d at
288 (cautioning against “precipitately concluding that the
[provision] is an exercise of viewpoint discrimination”).

14
Dent v. West Virginia, 129 U.S. 114, 122 (1889) (“[I]t has been

the practice of different states, from time immemorial, to exact

in many pursuits a certain degree of skill and learning upon

which the community may confidently rely.”). Licensing and

regulation by the state “provide clients with the confidence

they require to put their health or their livelihood in the

hands of those who utilize knowledge and methods with which the

clients ordinarily have little or no familiarity.” King v. Gov.

of N.J., 767 F.3d 216, 232 (3d Cir. 2014). The state may

establish licensing qualifications, Dent, 129 U.S. at 122,

oblige the payment of dues to a professional organization for

purposes such as “disciplining members” and “proposing ethical

codes,” Keller, 496 U.S. at 16, and even set standards for the

conduct of professional activities, Barsky v. Bd. of Regents of

Univ. of State of N.Y., 347 U.S. 442, 449-50 (1954). In the

medical context, the state may require the provision of

information sufficient for patients to give their informed

consent to medical procedures, see Canterbury v. Spence, 464

F.2d 772, 781 (D.C. Cir. 1972), and patients may seek damages

when doctors fail to follow statutory and professionally

recognized norms, see, e.g, N.C. Gen. Stat. § 90-21.88. Simply

put, “[t]he power of government to regulate the professions is

not lost whenever the practice of a profession entails speech.”

15
Lowe v. SEC, 472 U.S. 181, 228 (1985) (White, J., concurring in

the judgment).

But that does not mean that individuals simply abandon

their First Amendment rights when they commence practicing a

profession. See Planned Parenthood of Se. Pa. v. Casey, 505 U.S.

833, 884 (1992) (plurality opinion) (“[T]he physician’s First

Amendment rights not to speak are implicated.” (emphasis

added)); Lowe, 472 U.S. at 229-30 (White, J., concurring in the

judgment) (“But the principle that the government may restrict

entry into professions and vocations through licensing schemes

has never been extended to encompass the licensing of speech per

se or of the press.”). To the contrary, “speech is speech, and

it must be analyzed as such for purposes of the First

Amendment.” King, 767 F.3d at 229. There are “many dimensions”

to professionals’ speech. Fla. Bar v. Went For It, Inc., 515

U.S. 618, 634 (1995). And “[t]here are circumstances in which we

will accord speech by attorneys on public issues and matters of

legal representation the strongest protection our Constitution

has to offer.” Id. With all forms of compelled speech, we must

look to the context of the regulation to determine when the

state’s regulatory authority has extended too far. Riley, 487

U.S. at 796.

When the First Amendment rights of a professional are at

stake, the stringency of review thus slides “along a continuum”

16
from “public dialogue” on one end to “regulation of professional

conduct” on the other. Pickup v. Brown, 740 F.3d 1208, 1227,

1229 (9th Cir. 2013) (emphasis in original). Other circuits have

recently relied on the distinction between professional speech

and professional conduct when deciding on the appropriate level

of scrutiny to apply to regulations of the medical profession.

See King, 767 F.3d at 224-29, 233-37; Wollschlaeger v. Gov. of

Fla., 760 F.3d 1195, 1217-25 (11th Cir. 2014).

The Display of Real-Time View Requirement resides somewhere

in the middle on that sliding scale. It is a regulation of

medical treatment insofar as it directs doctors to do certain

things in the context of treating a patient. In that sense, the

government can lay claim to its stronger interest in the

regulation of professional conduct. But that is hardly the end

of the matter. The government’s regulatory interest is less

potent in the context of a self-regulating profession like

medicine. Moore-King v. Cnty. of Chesterfield, Va., 708 F.3d

560, 570 (4th Cir. 2013). Moreover, the Requirement is a clearly

content-based regulation of speech; it requires doctors to “say”

as well as “do.” As the district court found, the confluence of

these factors points toward borrowing a heightened intermediate

scrutiny standard used in certain commercial speech cases.

Stuart, 992 F. Supp. 2d at 600. Thus, we need not conclusively

determine whether strict scrutiny ever applies in similar

17
situations, because in this case “the outcome is the same

whether a special commercial speech inquiry or a stricter form

of judicial scrutiny is applied.” Sorrel, 131 S. Ct. at 2667.

D.

Insofar as our decision on the applicable standard of

review differs from the positions taken by the Fifth and Eighth

Circuits in cases examining the constitutionality of abortion

regulations under the First Amendment, we respectfully disagree.

Both courts relied heavily on a single paragraph in Casey:

All that is left of petitioners' argument is an
asserted First Amendment right of a physician not to
provide information about the risks of abortion, and
childbirth, in a manner mandated by the State. To be
sure, the physician's First Amendment rights not to
speak are implicated, see Wooley v. Maynard, 430 U.S.
705 (1977), but only as part of the practice of
medicine, subject to reasonable licensing and
regulation by the State, cf. Whalen v. Roe, 429 U.S.
589, 603 (1977). We see no constitutional infirmity in
the requirement that the physician provide the
information mandated by the State here.

505 U.S. at 884; see also Lakey, 667 F.3d at 574-76; Planned

Parenthood Minn., N.D., S.D. v. Rounds, 686 F.3d 889, 893 (8th

Cir. 2012) (en banc) (“Rounds II”); Planned Parenthood Minn.,

N.D., S.D. v. Rounds, 530 F.3d 724, 733-35 (8th Cir. 2008) (en

banc) (“Rounds I”). That is the sum of the First Amendment

analysis in Casey.

In considering an ultrasound display-and-describe

requirement similar to the one at issue here, the Fifth Circuit

18
interpreted Casey as employing “the antithesis of strict

scrutiny.” Lakey, 667 F.3d at 575. It further noted that in

Gonzales v. Carhart, the Supreme Court “upheld a state’s

‘significant role . . . in regulating the medical profession.’”

Lakey, 667 F.3d at 575-76 (quoting Gonzales v. Carhart, 550 U.S.

124, 157 (2007)). Therefore, the Lakey court reasoned,

provisions such as the one at issue here -- that is, laws that

“require truthful, nonmisleading, and relevant disclosures,” id.

at 576 -- “do not fall under the rubric of compelling

‘ideological’ speech that triggers First Amendment strict

scrutiny,” id. The Eighth Circuit similarly drew from Casey and

Gonzales the rule that the First Amendment permits the state to

“use its regulatory authority to require a physician to provide

truthful, non-misleading information relevant to a patient’s

decision to have an abortion.” Rounds I, 530 F.3d at 734-35; see

also Rounds II, 686 F.3d at 893.

With respect, our sister circuits read too much into Casey

and Gonzales. The single paragraph in Casey does not assert that

physicians forfeit their First Amendment rights in the

procedures surrounding abortions, nor does it announce the

proper level of scrutiny to be applied to abortion regulations

that compel speech to the extraordinary extent present here. The

plurality opinion stated that the medical profession is “subject

to reasonable licensing and regulation by the State” and that

19
physicians’ speech is “part of the practice of medicine.” Casey,

505 U.S. at 884. But the plurality did not hold sweepingly that

all regulation of speech in the medical context merely receives

rational basis review. Rather, having noted the physicians’

First Amendment rights and the state’s countervailing interest

in regulating the medical profession, the plurality simply

stated that it saw “no constitutional infirmity in the

requirement that the physician provide the information mandated

by the State here.” Id. (emphasis added). That particularized

finding hardly announces a guiding standard of scrutiny for use

in every subsequent compelled speech case involving abortion.

Furthermore, the Fifth and Eighth Circuits’ reliance on

Gonzales seems inapposite. Gonzales was not a First Amendment

case; the plaintiffs there did not bring free speech claims. See

Carhart v. Ashcroft, 331 F. Supp. 2d 805, 814 (D. Neb. 2004);

Planned Parenthood Fed’n of Am. v. Ashcroft, 320 F. Supp. 2d

957, 967 (N.D. Cal. 2004). Thus Gonzales does not elucidate the

First Amendment standard applied in Casey. Gonzales provides

valuable insight into the relationship between the state and the

medical profession and the role the state may play in ensuring

that women are properly informed before making what is

indisputably a profound choice with permanent and potentially

harmful impacts. See infra Part III. But it says nothing about

the level of scrutiny courts should apply when reviewing a claim

20
that a regulation compelling speech in the abortion context

violates physicians’ First Amendment free speech rights. The

fact that a regulation does not impose an undue burden on a

woman under the due process clause does not answer the question

of whether it imposes an impermissible burden on the physician

under the First Amendment. A heightened intermediate level of

scrutiny is thus consistent with Supreme Court precedent and

appropriately recognizes the intersection here of regulation of

speech and regulation of the medical profession in the context

of an abortion procedure. 4

III.

Under an intermediate standard of scrutiny, the state bears

the burden of demonstrating “at least that the statute directly

advances a substantial governmental interest and that the

measure is drawn to achieve that interest.” Sorrel v. IMS Health

Inc., 131 S. Ct. 2653, 2667-68 (2011). This formulation seeks to

“ensure not only that the State's interests are proportional to

the resulting burdens placed on speech but also that the law

4
The state’s amici insist that the decision we reach today
will permit future litigants to use the First Amendment “as a
‘trump card’ in a multitude of challenges to abortion
regulations, allowing abortion proponents to provoke a ‘back-
door,’ strict scrutiny approach” that will override Casey’s
undue burden standard. Law Professors’ Br. 27. We think this
concern is overdrawn. The great majority of abortion regulations
do not compel anyone’s speech, and the great majority of
litigants do not raise First Amendment concerns.

21
does not seek to suppress a disfavored message.” Id. at 2668.

The court can and should take into account the effect of the

regulation on the intended recipient of the compelled speech,

especially where she is a captive listener. See Hill v.

Colorado, 530 U.S. 703, 716-18 (2000); Va. State Bd. of Pharmacy

v. Va. Citizens Consumer Council, Inc., 425 U.S. 748, 756-57

(1976); Greater Balt. Ctr. For Pregnancy Concerns, Inc. v. Mayor

of Balt., 721 F.3d 264, 286 (4th Cir. 2013) (en banc); cf. Lee

v. Weisman, 505 U.S. 577, 598 (1992).

The protection of fetal life, along with the companion

interests of protecting the pregnant woman’s psychological

health and ensuring that “so grave a choice is well informed,”

Gonzales, 550 U.S. at 159, is undeniably an important state

interest. The Supreme Court has repeatedly affirmed the state’s

“important and legitimate interest” in preserving, promoting,

and protecting fetal life. Roe v. Wade, 410 U.S. 113, 162 (1973)

(quoted in Casey, 505 U.S. at 871); see also Gonzales, 550 U.S.

at 145. We shall presume for the purpose of this appeal that

this statute protects fetal life by increasing the likelihood

that a woman will not follow through on the decision to have an

abortion. Nonetheless, the means used to promote a substantial

state interest must be drawn so as to directly advance the

interest without impeding too greatly on individual liberty

interests or competing state concerns. Sorrel, 131 S. Ct. at

22
2667-68. The means employed here are far-reaching -- almost

unprecedentedly so -- in a number of respects and far outstrip

the provision at issue in Casey. See Casey, 505 U.S. at 881.

This statutory provision interferes with the physician’s right

to free speech beyond the extent permitted for reasonable

regulation of the medical profession, while simultaneously

threatening harm to the patient’s psychological health,

interfering with the physician’s professional judgment, and

compromising the doctor-patient relationship. We must therefore

find the Display of Real-Time View Requirement unconstitutional.

A.

Before addressing the provision’s constitutional

infirmities, it is well worth identifying briefly the various

state interests at stake in this case. As we noted above, the

Supreme Court has forcefully reiterated that the state’s

interest in protecting fetal life is important and profound.

This interest derives from the state’s general interest in

protecting and promoting respect for life, and has been

recognized in abortion decisions without number. See, e.g.,

Gonzales, 550 U.S. at 158; Casey, 505 U.S. at 871; Greenville

Women’s Clinic v. Bryant, 222 F.3d 157, 165-66 (4th Cir. 2000).

We do not question the substantial state interest at work here.

As part of its general interest in promoting the health of

its citizens, the state also has an interest in promoting the

23
psychological health of women seeking abortions. Appellants’ Br.

17. The state may seek to protect women both from the

psychological harm of “com[ing] to regret their choice,”

Gonzales, 550 U.S. at 159, as well as the psychological harm

from the process of obtaining an abortion itself. The Supreme

Court has also recognized a state interest in maintaining “the

integrity and ethics of the medical profession,” which includes

promoting a healthy doctor-patient relationship, Washington v.

Glucksberg, 521 U.S. 702, 731 (1997); see also Gonzales, 550

U.S. at 157, and respecting physicians’ professional judgment,

see Casey, 505 U.S. at 884.

However, that important state interests are implicated in

the abortion context is only the starting point for our

analysis. Though physicians and other professionals may be

subject to regulations by the state that restrict their First

Amendment freedoms when acting in the course of their

professions, professionals do not leave their speech rights at

the office door. See Lowe v. SEC, 472 U.S. 181, 229-30 (1985)

(White, J., concurring in the judgment). Any state regulation

that limits the free speech rights of professionals must pass

the requisite constitutional test. The Display of Real-Time View

Requirement must directly advance an important state interest in

a manner that is drawn to that interest and proportional to the

burden placed on the speech. See Sorrel, 131 S. Ct. at 2667-68.

24
 B.

North Carolina contends that the Display of Real-Time View

Requirement is merely “reasonable . . . regulation by the State”

of the medical profession that does not violate the physicians’

First Amendment rights any more than informed consent

requirements do. Appellants’ Br. 22-25 (quoting Tex. Med.

Providers Performing Abortion Servs. v. Lakey, 667 F.3d 570, 575

(5th Cir. 2012) (quoting Casey, 505 U.S. at 882)). The

requirements the provision imposes on physicians, however,

resemble neither traditional informed consent nor the variation

found in the Pennsylvania statute at issue in Casey. The North

Carolina statute goes much further, imposing additional burdens

on the physicians’ free speech and risking the compromise of

other important state interests.

Traditional informed consent requirements derive from the

principle of patient autonomy in medical treatment. Grounded in

self-determination, obtaining informed consent prior to medical

treatment is meant to ensure that each patient has “the

information she needs to meaningfully consent to medical

procedures.” Am. Coll. of Obstetricians & Gynecologists & the

Am. Med. Ass’n (“ACOG & AMA”) Br. 5; see also AMA, Op. 8.08 –

Informed Consent (2006). As the term suggests, informed consent

consists of two essential elements: comprehension and free

consent. ACOG & AMA Br. 7; ACOG, Comm. Op. No. 439 - Informed

25
Consent, at 2 (2012). Comprehension requires that the physician

convey adequate information about the diagnosis, the prognosis,

alternative treatment options (including no treatment), and the

risks and likely results of each option. ACOG & AMA Br. 7; ACOG,

Comm. Op. No. 439, at 3, 5; see also J.A. 359 (declaration of

Dr. Anne Drapkin Lyerly); Canterbury v. Spence, 464 F.2d 772,

780-81 (D.C. Cir. 1972). Physicians determine the “adequate”

information for each patient based on what a reasonable

physician would convey, what a reasonable patient would want to

know, and what the individual patient would subjectively wish to

know given the patient’s individualized needs and treatment

circumstances. ACOG, Comm. Op. No. 439, at 5. Free consent, as

it suggests, requires that the patient be able to exercise her

autonomy free from coercion. Id. at 3, 5. It may even include at

times the choice not to receive certain pertinent information

and to rely instead on the judgment of the doctor. Id. at 7;

ACOG & AMA Br. 8. The physician’s role in this process is to

inform and assist the patient without imposing his or her own

personal will and values on the patient. J.A. 359-60

(declaration of Dr. Anne Drapkin Lyerly); ACOG, Comm. Op. No.

439, at 3. The informed consent process typically involves a

conversation between the patient, fully clothed, and the

physician in an office or similar room before the procedure

begins. ACOG & AMA Br. 8, 23; ACOG, Comm. Op. No. 439, at 4.

26
Once the patient has received the information she needs, she

signs a consent form, and treatment may proceed. See, e.g., N.C.

Gen. Stat. § 90-21.13(b).

The Pennsylvania statute challenged in Casey prescribes a

modified form of informed consent for abortions. To provide

informed consent, the statute first requires the physician to

orally inform the woman of the nature of the abortion procedure,

the “risks and alternatives to the procedure . . . that a

reasonable patient would consider material to the decision”

whether to have an abortion, the risks of carrying the child to

term, and the “probable gestational age of the unborn child”

when the abortion is to be performed. 18 Pa. Cons. Stat.

§ 3205(a)(1). The physician must give this information at least

twenty-four hours prior to the abortion. Id. Aside from the

gestational age of the fetus, this information is the same type

that would be required under traditional informed consent for

any medical procedure.

The statute continues on, however, to require that the

physician must inform the woman, at least twenty-four hours in

advance, that the state prints materials that describe the

unborn child, and a copy must be provided to her if she wants

it. 18 Pa. Cons. Stat. § 3205(a)(2)-(3). Finally, the statute

requires the physician to provide some additional information

about financial and other assistance that may be available from

27
the state and the father. 18 Pa. Cons. Stat. § 3205(a)(2). These

provisions deviate only modestly from traditional informed

consent. They also closely resemble the informed consent

provisions of North Carolina’s Woman’s Right to Know Act that

are not under challenge in this appeal. N.C. Gen. Stat. § 90-

21.82(1)-(2). The challenged Display of Real-Time View

Requirement, N.C. Gen. Stat. § 90-21.85, however, reaches beyond

the modified form of informed consent that the Court approved in

Casey. In so doing, it imposes a virtually unprecedented burden

on the right of professional speech that operates to the

detriment of both speaker and listener.

C.

The burdens trace in part from deviations from the

traditions of informed consent. The most serious deviation from

standard practice is requiring the physician to display an image

and provide an explanation and medical description to a woman

who has through ear and eye covering rendered herself

temporarily deaf and blind. This is starkly compelled speech

that impedes on the physician’s First Amendment rights with no

counterbalancing promotion of state interests. The woman does

not receive the information, so it cannot inform her decision.

In fact, “[t]he state’s own expert witness agrees that the

delivery of the state’s message in these circumstances does not

provide any information to the patient and does not aid

28
voluntary and informed consent.” Stuart v. Loomis, 992 F. Supp.

2d 585, 602 (M.D.N.C. 2014). And while having to choose between

blindfolding and earmuffing herself or watching and listening to

unwanted information may in some remote way influence a woman in

favor of carrying the child to term, forced speech to unwilling

or incapacitated listeners does not bear the constitutionally

necessary connection to the protection of fetal life. Moreover,

far from promoting the psychological health of women, this

requirement risks the infliction of psychological harm on the

woman who chooses not to receive this information. She must

endure the embarrassing spectacle of averting her eyes and

covering her ears while her physician -- a person to whom she

should be encouraged to listen -- recites information to her. We

can perceive no benefit to state interests from walling off

patients and physicians in a manner antithetical to the very

communication that lies at the heart of the informed consent

process.

The constitutional burden on the physicians’ expressive

rights is not lifted by having a willing listener. The

information the physician had to convey orally in Casey was no

more than a slight modification of traditional informed consent

disclosures. The information conveyed here in the examining room

more closely resembles the materials that in Casey were provided

by the state in a pamphlet. Casey, 505 U.S. at 881. A physician

29
in Pennsylvania need only inform the patient that such

information is available and, if requested, provide her with a

copy of the state-issued pamphlet. 18 Pa. Cons. Stat.

§ 3205(a)(2)(i) & (a)(3). Informing a patient that there are

state-issued materials available is not ideological, because the

viewpoint conveyed by the pamphlet is clearly the state’s -- not

the physician’s. It is no wonder then that the Casey court found

no First Amendment infirmities in that requirement. By contrast,

the North Carolina statute compels the physician to speak and

display the very information on a volatile subject that the

state would like to convey. See N.C. Gen. Stat. § 90-

21.85(a)(2)-(4). The coercive effects of the speech are

magnified when the physician is compelled to deliver the state’s

preferred message in his or her own voice. This Requirement

treads far more heavily on the physicians’ free speech rights

than the state pamphlet provisions at issue in Casey.

Though the information conveyed may be strictly factual,

the context surrounding the delivery of it promotes the

viewpoint the state wishes to encourage. As a matter of policy,

the state may certainly express a preference for childbirth over

abortion, Webster v. Reprod. Health Servs., 492 U.S. 490, 511

(1989), and use its agents and written materials to convey that

message. However the state cannot commandeer the doctor-patient

relationship to compel a physician to express its preference to

30
the patient. As the district court noted, “[b]y requiring

providers to deliver this information to a woman who takes steps

not to hear it or would be harmed by hearing it, the state has

. . . moved from ‘encouraging’ to lecturing, using health care

providers as its mouthpiece.” Stuart, 992 F. Supp. 2d at 609.

Transforming the physician into the mouthpiece of the state

undermines the trust that is necessary for facilitating healthy

doctor-patient relationships and, through them, successful

treatment outcomes. See Am. Pub. Health Ass’n (“APHA”) Br. 9-10.

The patient seeks in a physician a medical professional with the

capacity for independent medical judgment that professional

status implies. The rupture of trust comes with replacing what

the doctor’s medical judgment would counsel in a communication

with what the state wishes told. It subverts the patient’s

expectations when the physician is compelled to deliver a state

message bearing little connection to the search for professional

services that led the patient to the doctor’s door.

Furthermore, by failing to include a therapeutic privilege

exception, the Display of Real-Time View Requirement interferes

with the physician’s professional judgment and ethical

obligations. The absence of a therapeutic exception means that

the state has sought not only to control the content of the

physician’s speech, but to dictate its timing. Under the

Requirement, the physician must display and describe the fetus

31
simultaneously with the ultrasound procedure, and he must do

this at least four and not more than seventy-two hours prior to

the abortion procedure. See N.C. Gen. Stat. § 90-21.85(a).

Therapeutic privilege, however, permits physicians to decline or

at least wait to convey relevant information as part of informed

consent because in their professional judgment delivering the

information to the patient at a particular time would result in

serious psychological or physical harm. ACOG, Comm. Op. 439, at

7. It is an important privilege, albeit a limited one to be used

sparingly. See id. It protects the health of particularly

vulnerable or fragile patients, and permits the physician to

uphold his ethical obligations of benevolence.

The Casey court found it relevant that the Pennsylvania

statute contained a therapeutic exception so that it “does not

prevent the physician from exercising his or her medical

judgment.” 505 U.S. at 883-84. North Carolina by contrast

requires the physician to “[d]isplay the images” and “[p]rovide

a simultaneous explanation of what the display is depicting”

along with “a medical description of the images,” with no

exception. N.C. Gen. Stat. § 90-21.85(a)(2)-(4). The lack of a

provision similar to Pennsylvania’s in North Carolina’s statute

runs contrary to the state’s interest in “protecting the

integrity and ethics of the medical profession,” Gonzales, 550

U.S. at 157, and more generally to its interest in the

32
psychological and physical well-being of the affected women.

Particularly for women who have been victims of sexual assaults

or whose fetuses are nonviable or have severe, life-threatening

developmental abnormalities, having to watch a sonogram and

listen to a description of the fetus could prove psychologically

devastating. See J.A. 332-33 (declaration of Dr. Gretchen S.

Stuart); Appellees’ Br. 12-13; APHA Br. 8-9. Requiring the

physician to provide the information regardless of the

psychological or emotional well-being of the patient, see N.C.

Gen. Stat. §§ 90-21.85 & 90-21.86, can hardly be considered

closely drawn to those state interests the provision is supposed

to promote.

In sum, though the State would have us view this provision

as simply a reasonable regulation of the medical profession,

these requirements look nothing like traditional informed

consent, or even the versions provided for in Casey and in N.C.

Gen. Stat. § 90-21.82. As such, they impose an extraordinary

burden on expressive rights. The three elements discussed so far

-- requiring the physician to speak to a patient who is not

listening, rendering the physician the mouthpiece of the state’s

message, and omitting a therapeutic privilege to protect the

health of the patient -- markedly depart from standard medical

practice.

D.

33
 Other aspects of the Requirement are equally unusual. As

described above, informed consent frequently consists of a

fully-clothed conversation between the patient and physician,

often in the physician’s office. It is driven by the “patient’s

particular needs and circumstances,” J.A. 388 (declaration of

Dr. Amy Weil), so that the patient receives the information he

or she wants in a setting that promotes an informed and

thoughtful choice.

This provision, however, finds the patient half-naked or

disrobed on her back on an examination table, with an ultrasound

probe either on her belly or inserted into her vagina.

Appellees’ Br. 13; APHA Br. 8. Informed consent has not

generally been thought to require a patient to view images from

his or her own body, ACOG & AMA Br. 7, much less in a setting in

which personal judgment may be altered or impaired. Yet this

provision requires that she do so or “avert[] her eyes.” N.C.

Gen. Stat. § 90-21.85(a)(3), (b). Rather than engaging in a

conversation calculated to inform, the physician must continue

talking regardless of whether the patient is listening. See

Stuart, 992 F. Supp. 2d at 590 & 602 n.34. The information is

provided irrespective of the needs or wants of the patient, in

direct contravention of medical ethics and the principle of

patient autonomy. “[F]orcing this experience on a patient over

her objections” in this manner interferes with the decision of a

34
patient not to receive information that could make an

indescribably difficult decision even more traumatic and could

“actually cause harm to the patient.” J.A. 330 (declaration of

Dr. Gretchen S. Stuart). And it is intended to convey not the

risks and benefits of the medical procedure to the patient’s own

health, but rather the full weight of the state’s moral

condemnation. Though the state is plainly free to express such a

preference for childbirth to women, it is not the function of

informed consent to require a physician to deliver the state’s

preference in a setting this fraught with stress and anxiety.

There are few absolutes in the difficult area of

professional regulation and professional expression. But there

do exist constraints on the permissible interference with the

doctor-patient relationship; there are limits on state attempts

to compel physicians to deliver its message, especially when

that message runs counter to the physician’s professional

judgment and the patient’s autonomous decision about what

information she wants. Though states may surely enact

legislation to ensure that a woman’s choice is informed and

thoughtful when she elects to have an abortion, states cannot so

compromise physicians’ free speech rights, professional

judgment, patient autonomy, and other important state interests

in the process. The means here exceed what is proper to promote

the undeniably profound and important purpose of protecting

35
fetal life. See, e.g., Sorrel, 131 S. Ct. at 2667-68, 2670

(holding that Vermont statute unconstitutionally burdened speech

because “[w]hile Vermont’s stated policy goals may be proper,

§ 4631(d) does not advance them in a permissible way” under

intermediate scrutiny).

IV.

“The right to speak and the right to refrain from speaking

are complementary components of the broader concept of

‘individual freedom of mind.’” Wooley v. Maynard, 430 U.S. 705,

714 (1977) (quoting W. Va. State Bd. of Educ. v. Barnette, 319

U.S. 624, 637 (1943)). Regulations which compel ideological

speech “pose the inherent risk that the Government seeks not to

advance a legitimate regulatory goal, but to suppress unpopular

ideas or information or manipulate the public debate through

coercion rather than persuasion.” Turner Broad. Sys., Inc. v.

FCC, 512 U.S. 622, 641 (1994). Abortion may well be a special

case because of the undeniable gravity of all that is involved,

but it cannot be so special a case that all other professional

rights and medical norms go out the window. While the state

itself may promote through various means childbirth over

abortion, it may not coerce doctors into voicing that message on

behalf of the state in the particular manner and setting

attempted here. The district court did not err in concluding

that § 90-21.85 of the North Carolina General Statutes violates

36
the First Amendment and in enjoining the enforcement of that

provision. Its judgment is in all respects affirmed.

AFFIRMED

37