Adams & Boyle, P.C. v. Herbert Slatery III

RECOMMENDED FOR PUBLICATION
Pursuant to Sixth Circuit I.O.P. 32.1(b)
File Name: 20a0127p.06

UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT

ADAMS & BOYLE, P.C. et al., ┐
Plaintiffs-Appellees, │
│
> No. 20-5408
v. │
│
HERBERT H. SLATERY III et al. │
Defendants-Appellants. │
┘

Appeal from the United States District Court
for the Middle District of Tennessee at Nashville.
No. 3:15-cv-00705—Bernard A. Friedman, District Judge.

Decided and Filed: April 24, 2020

Before: MOORE, WHITE, and THAPAR, Circuit Judges.
_________________
COUNSEL
ON MOTIONS AND REPLY: Sarah K. Campbell, Steven A. Hart, Alexander S. Rieger,
Matthew D. Cloutier, OFFICE OF THE TENNESSEE ATTORNEY GENERAL, Nashville,
Tennessee, for Appellants. ON RESPONSE: Thomas H. Castelli, AMERICAN CIVIL
LIBERTIES UNION FOUNDATION OF TENNESSEE, Nashville, Tennessee, Genevieve Scott,
Autumn Katz, Michelle Moriarty, CENTER FOR REPRODUCTIVE RIGHTS, New York, New
York, Maithreyi Ratakonda, PLANNED PARENTHOOD FEDERATION OF AMERICA, New
York, New York, Richard Muniz, PLANNED PARENTHOOD FEDERATION OF AMERICA,
Washington, D.C., Scott P. Tift, BARRETT JOHNSTON MARTIN & GARRISON, LLC,
Nashville, Tennessee, Michael J. Dell, KRAMER LEVIN NAFTALIS & FRANKEL LLP, New
York, New York, Julia Kaye, AMERICAN CIVIL LIBERTIES UNION FOUNDATION, New
York, New York, for Appellees. ON BRIEF: Edward L. White III, AMERICAN CENTER FOR
LAW & JUSTICE, Ann Arbor, Michigan, S. Chad Meredith, OFFICE OF THE KENTUCKY
ATTORNEY GENERAL, Frankfort, Kentucky, Laura Etlinger, OFFICE OF THE ATTORNEY
GENERAL OF NEW YORK, Albany, New York, Lisa T. Simpson, ORRICK, HERRINGTON &
SUTCLIFFE LLP, New York, New York, Kevin H. Theriot, ALLIANCE DEFENDING
FREEDOM, Scottsdale, Arizona, for Amici Curiae.

MOORE, J., delivered the opinion of the court in which WHITE, J., joined. THAPAR, J.
(pp. 23–33), delivered a separate dissenting opinion.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 2

_________________

OPINION
_________________

KAREN NELSON MOORE, Circuit Judge. This case arises at the intersection of two
essential constitutional rights: the right of a woman to control her pregnancy, on the one hand,
and the right of the state to exercise its “police power” during an emergency, on the other. More
specifically, we ask, does the Constitution permit a state to bar doctors from performing abortion
procedures for a three-week period—as part of a widespread temporary ban on “elective” and
“non-urgent” surgeries—based solely on the state’s assertion that such a bar is necessary to combat
effectively an ongoing public health crisis? The Governor of Tennessee thought so, and
accordingly adopted such a temporary ban on April 8, 2020, in response to the ongoing COVID-
19 global pandemic. The district court, however, disagreed, and accordingly issued a preliminary
injunction on April 17, enjoining Tennessee from enforcing its general ban on elective and non-
urgent surgeries against doctors performing abortion procedures. The State then filed this
emergency appeal, and also requested that we immediately stay the district court’s injunction
pending review.

We do not uphold an injunction against state action lightly, much less during a public health
crisis like the one our nation is experiencing now. It is imperative in such circumstances that
judges give legislatures and executives—the more responsive branches of government—the
flexibility they need to respond quickly and forthrightly to threats to the general welfare, even if
that flexibility sometimes comes at the cost of individual liberties. Affording flexibility, however,
is not the same as abdicating responsibility, especially when well-established constitutional rights
are at stake, as the right to an abortion most assuredly is. And, here, although we have great respect
for the challenges Tennessee faces as it responds to this novel public health crisis, we agree with
the district court that the State’s response, in this one respect, unduly curtailed constitutional
liberty, and that judicial intervention was thus warranted. By the same token, however, we also
conclude that, when it comes to the precise scope of the district court’s injunction, the district court
went too far in asserting its authority. Consequently, we AFFIRM the district court’s order issuing
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 3

a preliminary injunction but direct the district court to MODIFY the preliminary injunction in the
manner described below. We also DENY the State’s request for a stay pending appeal as MOOT.

I. BACKGROUND

Generally speaking, a Tennessee woman wishing to exercise her constitutional right to a
pre-viability1 abortion, in a legal manner, may do so in one of three ways: (1) receive a
“medication abortion” within the first 11 weeks from her last menstrual period (“LMP”);
(2) receive a “procedural abortion” within the first 20 weeks LMP, meaning either (a) an
“aspiration” abortion (which is a relatively quick clinical procedure, and can be performed up to
approximately 15 weeks LMP), or (b) a “dilation and evacuation” (“D&E”) abortion (which is a
more time-consuming procedure—albeit one that generally takes place in a clinical setting, too—
and is performed up to approximately 20 weeks LMP); or (3) travel to a state with more lenient
abortion regulations. See generally R.232-5 (Looney Dec.) (Page ID #5876–77).2 Tennessee law
also imposes a variety of other state-specific regulations, such as a 48-hour waiting period and
mandatory in-person visitation requirements. See, e.g., Tenn. Code Ann. §§ 39-15-202(a)–(h).
Moreover, if a Tennessee woman wishes (or needs) to have a procedural abortion in-state, there
are just a handful of providers in a handful of cities where she may do so. See R.232-6 (Terrell
Dec.) (Page ID #5908–09) (noting that “[a]ccess to abortion care in [Tennessee] is limited to begin
with, with only eight providers in four cities”). And of these clinics, only Planned Parenthood
performs abortions after 15 weeks LMP. See R.232-5 (Looney Dec.) (Page ID #5877).

Still, abortion in general, and procedural abortion in particular, remains relatively
commonplace in Tennessee, with hundreds of Tennessee women exercising their right to seek an
abortion in any given month. See, e.g., id. at Page ID #5878 (stating that, “[i]n January through
March 2020, [Planned Parenthood] performed 1,700 abortions in Tennessee, 917 of which were

1As the Supreme Court clarified in Planned Parenthood of Southeastern Pennsylvania v. Casey, the
constitutional right to an abortion ends (with some limited exceptions) once the fetus would be “viable” outside the
womb. 505 U.S. 833, 860, 870 (1992).
2For context, Tennessee bans abortion altogether at “viability,” which it presumes to occur at 24 weeks LMP.
See Tenn. Code Ann. § 39-15-211(b)(5) (setting this as a “rebuttable presumption”). Plaintiffs do not make clear,
however, if any recognized in-state clinics or doctors provide abortion services between 20 and 24 weeks LMP.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 4

procedural abortions and 536 of which occurred beyond eleven weeks LMP, when medication
abortion is not an option”).

With this background in mind, we now turn to the ongoing COVID-19 public health crisis,
an event with which all but the most secluded of readers should be familiar. Suffice it to say,
COVID-19 is the virus at the root of an ongoing global pandemic, which, in just a few short
months, has killed tens of thousands of people worldwide and infected hundreds of thousands
more. See, e.g., Friends of DeVito v. Wolf, --- A.3d ---, 2020 WL 1847100, at *2 (Pa. Apr. 13,
2020). The virus has also upended American economic and social life, causing schools and
businesses to shutter, and even the nominally unaffected to wear masks and stand six feet apart in
public.

Unsurprisingly, then, medical providers, including Tennessee’s abortion clinics, have had
to modify their way of doing business, for the safety of both staff and patients. As three of the
abortion providers involved in this litigation have attested, for instance, COVID-19 has caused
them to put at-risk staff on furlough, bar patients from bringing companions with them to the clinic,
cut back work days, curtail the number of personnel staffed on any given procedure, and eliminate
non-essential wellness appointments, among other social-distancing measures. See R.232-5
(Looney Dec.) (Page ID #5881–82) (Planned Parenthood of Tennessee and North Mississippi);
R.232-6 (Terrell Dec.) (Page ID #5911–12) (Memphis Center for Reproductive Health); R.232-7
(Rovetti Dec.) (Page ID #5922–23) (Knoxville Center for Reproductive Health).

Still, to the Governor of Tennessee’s eye, voluntary measures like these were not enough
to limit effectively the spread of the virus; more compulsory measures were required. So, in
addition to instituting a variety of sweeping “shelter-in-place” orders throughout the month of
March, on April 8, 2020 the Governor issued a targeted directive to “[a]ll healthcare professionals
and healthcare facilities in the State of Tennessee,” requiring that they “postpone surgical and
invasive procedures that are elective and non-urgent,” at least until April 30, when the order would
expire on its own terms. R.240-20 (Order) (Page ID #6115–16). This Order, titled Executive
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 5

Order 25 (“EO-25”), had the twin goals of “preserving personal protective equipment [“PPE”]3 for
emergency and essential needs and preventing community spread of COVID-19 through
nonessential patient-provider interactions.” Id. at Page ID #6115. Its most relevant portion read
as follows:

All healthcare professionals and healthcare facilities in the State of Tennessee shall
postpone surgical and invasive procedures that are elective and non-urgent.
Elective and non-urgent procedures are those procedures that can be delayed until
the expiration of this Order because they are not required [1] to provide life
sustaining treatment, [2] to prevent death or risk of substantial impairment of a
major bodily function, or [3] to prevent rapid deterioration or serious adverse
consequences to a patient’s physical condition if the surgical or invasive procedure
is not performed, as reasonably determined by a licensed medical provider.

Id. at Page ID #6115–16 (alterations added).

The Order did not contain any provision specifically exempting abortion procedures, or
suggesting that medical professionals would have leeway to perform a procedure that, in their
clinical judgment, “would not deplete the hospital capacity or the [PPE] needed to cope with the
COVID-19 disaster.” Compare with In re Abbott, 954 F.3d 772, 780 (5th Cir. 2020) (describing
this “important” caveat contained in an analogous Texas COVID-19-related surgery ban).

Plaintiffs—more specifically, Adams & Boyle, P.C.; Memphis Center for Reproductive
Health; Planned Parenthood of the Greater Memphis Region; Planned Parenthood of Tennessee
and North Mississippi; Knoxville Center for Reproductive Health; and Dr. Kimberly Looney—
subsequently interpreted EO-25 as barring the performance of any procedural4 abortions between
April 8 and April 30 (and potentially beyond that, if the Order was extended), enforceable by
criminal sanction. See, e.g., R.232-7 (Rovetti Dec.) (Page ID #5921). And, as a result of this
understanding, Plaintiffs temporarily cancelled all procedural abortions scheduled for that period.
See, e.g., id. at Page ID #5924 (describing four “devastated,” “crying” clients scheduled for
procedural abortions on April 9 that the clinic had to turn away because of EO-25); R.232-6

3The Order defined PPE as “including, but not limited to, medical gowns, N95 masks, surgical masks,
TYVEK suits, boot covers, gloves, and/or eye protection.” Id. at Page ID #6116.
4The parties agree that EO-25 has no effect on medication abortions, which may continue to be performed.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 6

(Terrell Dec.) (Page ID #5915–16) (describing similar incident at a different clinic, and also noting
that the clinic had “156 patients scheduled for their mandatory [pre-abortion] in-person counseling
appointments between [April 13] and April 22”). At the same time, fearing that EO-25 might
cause their patients to lose their constitutional right altogether, or at least impose an “undue
burden” on that right, Casey, 505 U.S. at 876, as well as cause them (the providers) to face criminal
prosecution if they attempted to help their patients procure a procedural abortion, Plaintiffs sought
in the federal district court a “temporary restraining order and/or preliminary injunction,” barring
the State from enforcing “EO-25 as applied to procedural abortions.” R.232 (Pls.’ Preliminary Inj.
Br.) (Page ID #5782–83).5

Tennessee opposed the request. And notably, in its brief in opposition, the State appeared
to concede that EO-25 operated just as Plaintiffs thought it would: as a three-week criminal
prohibition on procedural abortions, albeit with the exception that the provider could perform an
abortion if it is required to “prevent rapid deterioration or serious adverse consequences to a
patient’s physical condition” (which the State did not explain in any greater detail). R.240 (Defs.’
Opp. Br.) (Page ID #6022).

The district court accordingly held an emergency telephonic conference, which lasted 90
minutes, and at which both sides explained the evidence undergirding their respective positions.

* * *

5Plaintiffs then highlighted the three groups of patients who most urgently needed protection:
(1) patients who, in the good faith professional judgment of the provider, will likely lose their ability to obtain
an abortion in Tennessee if their procedures are delayed until after April 30, 2020; (2) patients who, in the
good faith professional judgment of the provider, will likely be forced to undergo a lengthier and more
complex abortion procedure, which is only available at two clinics in Nashville and Memphis, if their
procedures are delayed until after April 30, 2020; [and] (3) patients who, in the good faith professional
judgment of the provider, will likely be forced to undergo a two-day procedure—which is only available at
two clinics in Nashville and Memphis, and which requires at least three separate visits to the provider—if
their procedures are delayed until April 30, 2020.
R.232 (Page ID #5783).
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 7

Plaintiffs’ evidentiary showing was as follows:

Harm to Patients. Plaintiffs first pointed out multiple ways in which their patients would
be harmed by even a three-week bar on procedural abortions, all turning on the basic fact that
pregnancy, unlike many other medical conditions, progresses on a rapid, and inevitable, timeline.
First, there were procedural abortion patients who would not be able to obtain an abortion at all,
either because their pregnancy would advance past 20 weeks LMP by April 30 (when Plaintiffs
could last provide the procedure), or because overburdened waiting lines following April 30 and/or
travel limitations would effectively prevent the patient from receiving the procedure. See, e.g.,
R.232-5 (Looney Dec.) (Page ID #5887–88). Second, there were procedural abortion patients who
would be forced against their will to undergo the more time-consuming, invasive, and expensive
D&E procedure because, by April 30, they would have “aged out” of the more common aspiration
procedure. See, e.g., id. at Page ID #5889. And, third, there were procedural abortion patients
who, even if ultimately able to obtain the same type of abortion procedure they would have sans
EO-25, would be forced either to travel out-of-state, and face the accordant COVID-19
transmission risks, see, e.g., id. at 5890, or maintain their pregnancy substantially longer than they
otherwise would have, and bear the resulting health risks, see, e.g., id. at Page ID #5888–89 (noting
that, “[w]hile abortion is extremely safe throughout pregnancy, the risks increase as pregnancy
progresses, and the later in pregnancy a patient accesses a procedural abortion the more likely she
is to experience a rare complication”). Plaintiffs further pointed out that their patients, like most
abortion patients nationwide, are predominantly “poor or low-income,” and hence “already
struggle to raise the money to afford an abortion, and to afford transportation, childcare, and lost
wages for missed work.” Id. at Page ID #5878, 5890–91.

Harm to the State. Plaintiffs also emphasized the corresponding lack of harm procedural
abortions posed to the State’s interests in preserving PPE and minimizing person-to-person
contact. For instance, Plaintiffs observed, because procedural abortions generally are performed
at clinics—not hospitals—and with limited personnel, they require “minimal” amounts of PPE and
interpersonal interaction. See, e.g., R.232-6 (Terrell Dec.) (Page ID #5913–14). Indeed, Plaintiffs
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 8

added, their staff do not even use the (much-coveted) N95 respirator masks.6 Id. If anything,
Plaintiffs continued, requiring a woman either to receive a D&E procedure instead of an aspiration
procedure, or carry her child all the way to pregnancy (with the accordant mandatory maternal care
visits), would result in far more PPE usage and interpersonal interaction than simply permitting
abortions to go forward at an appropriately maintained clinic. See, e.g., R.232-5 (Looney Dec.)
(Page ID #5882–83).

Statements from Medical Organizations. Plaintiffs also cited statements from prominent
medical organizations in which those organizations emphasized that, as serious a threat to public
health as COVID-19 presents, abortion nonetheless remains an “essential,” “time-sensitive service
for which a delay of several weeks, or in some cases days, may increase the risks [to patients] or
potentially make it completely unavailable.” Id. at Page ID #5879 (alteration in original) (citing
statement signed by the American College of Obstetricians and Gynecologists, among others).7

Likelihood that EO-25 Would Last Past April 30. Finally, Plaintiffs offered some evidence
that their fear that EO-25 would last past April 30—thus turning a three-week postponement of
procedural abortions into something more draconian—was warranted. See, e.g., R.232-5 (Looney
Dec.) (Page ID #5892) (citing statement from the Surgeon General saying that he expected social-
distancing measures to “be in place beyond April”).

* * *

6Per the Food & Drug Administration, an “N95 respirator is a respiratory protective device designed to
achieve a very close facial fit and very efficient filtration of airborne particles.” N95 masks are not, however,
recommended for public usage, as they constitute “critical supplies that must continue to be reserved for health care
workers and other medical first responders.” See https://www.fda.gov/medical-devices/personal-protective-
equipment-infection-control/n95-respirators-and-surgical-masks-face-masks (last accessed Apr. 21, 2020).
7Moreover, after the onset of this appeal, over a dozen leading medical organizations—including the
American Public Health Organization and (again) the American College of Obstetricians and Gynecologists—signed
onto amicus briefs asserting, in no uncertain terms, (1) that abortion is an essential health service, and (2) that
restricting access to that service will not “save lives,” or otherwise meaningfully halt the spread of COVID-19. See
App. R. 30 (Amicus Br. for Am. Public Health Ass’n and Experts in Public Health); App. R. 42 (Amicus Br. for Am.
College of Obstetricians and Gynecologists and Other Nationwide Organizations of Medical Professionals); see also
Appellee Br. at 1 n.1 (citing similar guidance from the American College of Surgeons and the World Health
Organization).
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 9

The State, for its part, pointed to the following countervailing evidence in response:

Harm to the State. The State first emphasized that, as of April 14, 2020, there were nearly
6,000 cases of COVID-19 in Tennessee, along with 124 deaths, see R.240-1 (Apr. 14 Count) (Page
ID #6029), and that, given the intensely contagious nature of the virus, social distancing was
necessary to prevent those numbers from growing at an exponential rate, especially among
healthcare professionals themselves, see, e.g., R.240-11 (CDC Release) (Page ID #6076–77)
(discussing social distancing); R.240-12 (NYT Article) (Page ID #6079–82) (discussing risks to
health workers). The State also noted that, per guidance from the Centers for Disease Control and
Prevention (“CDC”), the State needed to preserve as much PPE for its front-line hospital
employees as possible, i.e., those dealing with COVID-19 patients, and that EO-25 was an essential
element of that plan. See, e.g., R.240-13 (CDC PPE Tips) (Page ID #6083–84). The State further
pointed out that, although there was evidence that its various social-distancing measures had
successfully lowered the virus’s growth rate, that evidence simply underscored the importance of
maintaining those measures to the maximum extent possible. See, e.g., R.240-7 (Vanderbilt Health
Policy COVID-19 Modeling for Tennessee) (Page ID #6059–65). And, in response to Plaintiffs’
contention that their PPE usage was minimal, the State observed that, even if procedural abortions
constituted a relatively small number of delayed medical procedures, and even if the resulting PPE
usage was “minimal,” “[e]very procedure that is postponed, and every item of PPE that is
preserved, furthers the State’s compelling interests in halting the spread of COVID-19 and
ensuring our healthcare system is equipped to treat—and prevent the death of—those who are
infected.” R.240 (Defs.’ Opp. Br.) (Page ID #6019–20).

Harm to Patients. In response to Plaintiffs’ statements that EO-25 would inhibit their
patients’ ability to obtain abortions, the State essentially attempted to show that Plaintiffs’
evidentiary showing was a paper tiger. The State first emphasized that, because Plaintiffs had
neither identified any “actual patient[s] who would be denied an abortion before the order expires
in two weeks,” nor “estimated what fraction of women could be allegedly denied an abortion by
operation of [EO-25],” there were presumably very few abortion patients who would be materially
harmed by the Order. Id. at Page ID #6022. The State then generally asserted that, to the extent
EO-25 posed any “serious adverse health consequences” to an abortion patient, the clinic could
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 10

perform that abortion “without delay” (although, again, without explaining what that exception
meant). Id.

Statements from Medical Organizations. The State did not cite any countervailing
statements suggesting that abortions procedures are not “essential” procedures, or that limiting
such procedures is necessary to fight COVID-19.

Likelihood that EO-25 Would Last Past April 30. Although the State repeatedly cited EO-
25’s limited duration as a reason injunctive relief was unnecessary, the State did not appear to offer
any assurances, in its brief or otherwise, that EO-25 would in fact end on April 30. If anything,
the general tone of the State’s evidentiary showing—which emphasized the severe consequences
portended by COVID-19—suggested the opposite.

* * *

The parties also provided the district court with thorough and thoughtful briefing, in which
they addressed not only the major abortion cases, such as Casey, but also Supreme Court precedent
concerning the expanded scope of a state’s police power during times of public health crisis, most
notably Jacobson v. Massachusetts, 197 U.S. 11 (1905) (affirming the state’s power to make
vaccination compulsory).

On Friday, April 17—just a few hours after the evidentiary hearing—the district court
issued a short, but thoughtful, order granting Plaintiffs’ request for a preliminary injunction.8 See
Adams & Boyle, P.C. v. Slatery, No. 3:15-cv-705, 2020 WL 1905147 (M.D. Tenn. Apr. 17, 2020).
In this order, the district court acknowledged that preliminary injunctions are “extraordinary
relief,” but ultimately found, after considering the evidence, that such an injunction was warranted
here. Id. at *4. Most importantly, the district court emphasized that because EO-25 was “likely”
to last past April 30, and because “[d]elaying a woman’s access to abortion even by a matter of
days can result in her having to undergo a lengthier and more complex procedure that involves
progressively greater health risks . . . or can result in her losing the right to obtain an abortion

8Although the district court’s order at times references Plaintiffs’ alternative request for a temporary
restraining order, read in context, the court clearly granted Plaintiffs a preliminary injunction. Indeed, neither party
argues to the contrary on appeal.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 11

altogether,” the Plaintiffs were likely to succeed on the merits of their constitutional claim, per the
Casey “undue burden” test. Id. at *5–6 (citation omitted). The district court also concluded that,
“[w]hile the stated goal of EO-25 to preserve PPE [was] unquestionably laudable,” the State
“presented no evidence that any appreciable amount of PPE would actually be preserved if EO-25
is applied to procedural abortions.” Id. at *6. To the contrary, the court noted, “procedural
abortion[s] use[] less PPE and involve[] significantly less patient interaction than carrying a
pregnancy to term and giving birth.” Id. The court further added that making women travel out-
of-state for abortion only increased the risks of person-to-person transmission of COVID-19, again
in contradiction of EO-25’s goals.

The district court accordingly concluded its opinion with the following, brief preliminary
injunction order: “Defendants are hereby immediately enjoined from enforcing EO-25 as applied
to procedural abortions.” Id. at *7. And, as a result of this order, Plaintiffs have presumably begun
providing, and scheduling, procedural abortions again.

In response, the State filed immediately with the district court a request that the court stay
its injunction pending appeal, followed by a notice of appeal. And, before the district court had a
chance to respond to the State’s stay request, the State filed a brief in this court entitled, “Combined
Emergency Motion for Stay Pending Appeal and Merits Brief,” in which the State requested that
we, as an initial matter, issue “a temporary administrative stay while [we] consider[] the stay
motion,” and then that we “grant an emergency stay of the preliminary injunction while [we]
consider[] the merits of the State’s appeal, and then reverse the district court.” Appellant Br. at 3
n.1, 27.

On Monday April 20, we denied the State’s request for an administrative stay (with one
judge dissenting), and asked the parties to provide expedited briefing so that we could consider the
issues raised in the State’s appeal with the benefit of argument from both sides. App. R. 9. 9 The
parties have now provided that briefing, and the question of whether the district court acted
properly in enjoining the State’s enforcement of EO-25 is ripe for our review.

9Two days after we issued this order the district court denied the State’s request for a stay. See R.252.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 12

II. DISCUSSION

Because the parties have sufficiently briefed the merits questions before us, and because
time is of the essence, we forgo consideration of the State’s stay request and instead proceed
straight to the preliminary injunction analysis.10

A.

A preliminary injunction is an “extraordinary remedy never awarded as of right.” Winter
v. Nat. Res. Def. Council, Inc., 555 U.S. 7, 24 (2008). Rather, the party seeking the injunction
must prove: (1) that they are likely to succeed on the merits of their claim, (2) that they are likely
to suffer irreparable harm in the absence of preliminary relief, (3) that the balance of equities tips
in their favor, and (4) that an injunction is in the public interest. Id. at 20. A court considering
whether to grant a preliminary injunction must therefore “balance the competing claims of injury
and must consider the effect on each party of the granting or withholding of the requested relief.”
Id. at 24 (quoting Amoco Prod. Co. v. Vill. of Gambell, 480 U.S. 531, 542 (1987)). Moreover,
when crafting an injunction, a district court must take care to “limit the solution to the problem,”
for example, by “enjoin[ing] only the unconstitutional applications of a [policy] while leaving
other applications in force.” Ayotte v. Planned Parenthood of N. New England, 546 U.S. 320,
328–29 (2006). We review a district court’s application of these principles for abuse of discretion.
Am. Civil Liberties Union Fund of Mich. v. Livingston Cty., 796 F.3d 636, 642 (6th Cir. 2015).

10We acknowledge the State’s alternative argument that Plaintiffs do not have proper “third-party standing”
to bring this suit on behalf of their patients. Appellant Br. at 22. But because Plaintiffs unquestionably have standing
to sue on their own behalf (because EO-25 potentially threatens them with criminal prosecution) we need not address
third-party standing. See In re Abbott, 954 F.3d at 782 n.17 (“[The plaintiff abortion providers] have standing to sue
on their own behalf because [the at-issue Executive Order] ‘directly operates’ against them.” (citing Planned
Parenthood of Cen. Mo. v. Danforth, 428 U.S. 52, 62 (1976))).
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 13

1.

We begin by asking whether Plaintiffs have shown that they are likely to succeed on the
merits of their constitutional claim. We conclude that they are.

In Roe v. Wade, 410 U.S. 113 (1973), the Supreme Court held that the provision of the
Fourteenth Amendment establishing that no state “shall . . . deprive any person of life, liberty, or
property, without due process of law,” includes within it a substantive guarantee of reproductive
liberty, that is, a promise that no state shall prevent a woman from terminating her pregnancy if
she so chooses (subject to certain limitations, depending on the trimester of pregnancy). The Court
then narrowed this right in Planned Parenthood of Southeastern Pennsylvania v. Casey, clarifying
that states could ban abortion after “viability,” see supra n.1, and could also regulate the practice
of abortion before then, so long as those regulations did not impose an “undue burden,” which the
Court defined as a “provision of law” whose “purpose or effect [was] to place a substantial obstacle
in the path of a woman seeking an abortion.” 505 U.S. at 878. Still, the Casey court was careful
to distinguish between regulation and prohibition, emphasizing that, “[r]egardless of whether
exceptions are made for particular circumstances, a State may not prohibit any woman from
making the ultimate decision to terminate her pregnancy before viability.” Id. at 879.

Casey’s undue burden framework, and the accordant distinction between regulation and
prohibition, has not always been easy to apply. See, e.g., Whole Woman’s Health v. Hellerstedt,
136 S. Ct. 2292, 2309–10 (2016) (discussing differing interpretations). But in the context of “time
regulations” like the three-week measure at issue here, courts appear to have readily distinguished
between the imposition of a short waiting period, see, e.g., Casey, 505 U.S. at 885–86 (upholding
state law requiring 24-hour waiting period prior to abortion); Cincinnati Women’s Servs., Inc. v.
Taft, 468 F.3d 361, 372–73 (6th Cir. 2006) (same), and the outright curtailment of the abortion
right, see, e.g., Jackson Women’s Health Org. v. Dobbs, 945 F.3d 265 (5th Cir. 2019) (rejecting
state law prohibiting abortions, with limited exceptions, after 15 weeks LMP); McCormack v.
Herzog, 788 F.3d 1017 (9th Cir. 2015) (same, with respect to a law prohibiting abortions after
20 weeks LMP). And, notably, although Casey upheld a 24-hour waiting period, the Court
described the question as “close[],” and noted that the potential of such a policy to prevent low-
income women from seeking an abortion at all was “troubling.” 505 U.S. at 885–86.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 14

Were there no public health crisis, then, the analysis would be relatively straightforward:
by banning all procedural abortions for a three-week period—limited by only a vague, undefined
exception for women who needed the abortion to avoid facing “serious adverse health
consequences”—EO-25 placed “a substantial obstacle in the path of” Tennessee women
attempting to obtain a procedural abortion during that time period, and thus constituted an undue
burden. Casey, 505 U.S. at 878. Indeed, as the evidence presented in the district court elucidated,
depending on the stage of a woman’s pregnancy, EO-25 functioned not just as a “delaying
regulation,” the likes of which are generally reviewed under Casey’s undue burden standard, but
also as an outright ban on pre-viability abortion, which would unquestionably be verboten under
Casey and Roe. And if that weren’t enough, the women affected by EO-25 (and the Plaintiff
providers) do not know if EO-25 will even end on April 30, thus making the burden of “planning
ahead”—a necessity for a time-sensitive procedure like abortion—all the more crushing. Suffice
it to say, in normal times there is no way that a measure like EO-25 would pass constitutional
muster.11

But, of course, we are not living in normal times; we are living in pandemic times. And so
the State points us to Jacobson v. Massachusetts, 197 U.S. 11 (1905), a century-old case in which
the Supreme Court held that a city faced with the risk of a viral outbreak could require all of its
adult residents to be vaccinated against that virus. See Appellant Br. at 12 (contending that
“Jacobson establishes the legal framework for judicial review of the State’s exercise of its police
power during public-health emergencies”). Jacobson is an important case, and it is unfortunate
that the district court did not address it until it issued its order denying Tennessee’s request for a
stay. See R.252 at Page ID #6267–68 (analyzing Jacobson in denying stay). But we are not
convinced that this matters because even if Jacobson’s more state-friendly standard of review is

11True, the Supreme Court has long permitted states to enact parental consent regulations, which can
sometimes have the effect of delaying an abortion for a weeks-long period. See, e.g., Garza v. Hargan, 874 F.3d 735,
755 (D.C. Cir. 2017) (en banc) (Kavanaugh, J., dissenting) (making this point). But to the extent parental consent
laws have a delaying effect, that is for reasons outside a state’s control. The permissibility of such regulations in no
way suggests that the Supreme Court would countenance a state-mandated three-week delay period, at least in
ordinary circumstances.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 15

the test we should be applying here—rather than the usual Roe/Casey standard—we still think that
Plaintiffs are likely to succeed on the merits of their constitutional claim.

In Jacobson, the Supreme Court affirmed the imposition of a five-dollar criminal fine12 on
a Cambridge, Massachusetts resident who refused to comply with the city’s mandatory vaccination
regime, which Cambridge had enacted in response to a smallpox outbreak. The resident then
appealed his conviction to the Supreme Court, arguing that the mandatory vaccination statute was
unconstitutional. Although the Court acknowledged that the statute unquestionably impinged on
the resident’s individual autonomy, cf. Guertin v. State, 912 F.3d 907, 918–22 (6th Cir. 2019)
(discussing the Fourteenth Amendment right to bodily integrity), the Court ultimately found that
the statute was justified on public health grounds, and emphasized that the safety and importance
of vaccines “[w]hile not accepted by all,” were “accepted by the mass of the people, as well as by
most members of the medical profession.” 197 U.S. at 34 (citation omitted). And in explaining
the standard of review courts should employ when confronted with such a public health measure,
the Court held as follows:

If there is any such power in the judiciary to review legislative action in respect of
a matter affecting the general welfare, it can only be when that which the legislature
has done comes within the rule that, if a statute purporting to have been enacted to
protect the public health, the public morals, or the public safety, has no real or
substantial relation to those objects, or is, beyond all question, a plain, palpable
invasion of rights secured by the fundamental law, it is the duty of the courts to so
adjudge, and thereby give effect to the Constitution.

Id. at 31 (emphasis added).

Leave aside the myriad factual differences between this case and Jacobson—asking a
person to get a vaccination, on penalty of a small fine, is a far cry from forcing a woman to carry
an unwanted fetus against her will for weeks, much less all the way to term—and the challenge of
reconciling century-old precedent with the Supreme Court’s more recent constitutional
jurisprudence. The bottom line is that, even accepting Jacobson at face value, it does not
substantially alter our reasoning here. As of today, a woman’s right to a pre-viability abortion is

12Approximately $140, adjusted for inflation.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 16

a part of “the fundamental law.” And, for the reasons set forth above, EO-25, at least in some
applications—most notably, those that would prevent a woman from exercising her right in-state
altogether, or would require her to undergo a more invasive and costlier procedure that she
otherwise would have—constitutes “beyond question, a plain, palpable invasion of rights secured
by [that] fundamental law.”

More still, although mandatory vaccination clearly had a “real” and “substantial” relation
to the state’s public health goals in Jacobson—indeed, as the Supreme Court emphasized, the
importance of vaccination was widely accepted by the medical community—it is much harder to
discern that relation here, given the paltry amount of PPE saved, and limited amount of in-person
contact avoided, by halting procedural abortions for a three-week period (not to mention the lack
of expert medical opinion in support of the State’s position). And although the State cites language
in Jacobson stating, “[i]t is no part of the function of a court or a jury to determine which one of
two [responses] [is] likely to be most effective for the protection of the public against disease,” id.
at 30—and suggests that this means we must defer uncritically to the State’s ipse dixit that a three-
week bar on procedural abortions is necessary to save critical PPE and preclude risky interpersonal
contact, see supra at 9—neither Jacobson in particular, nor Supreme Court abortion precedent in
general, requires such abdication. See, e.g., Jacobson, 197 U.S. at 34–38 (discussing the
voluminous medical evidence in support of vaccination); Hellerstedt, 136 S. Ct. at 2310 (noting
that uncritical deference to a legislature’s factual findings regarding abortion is inappropriate).

The dissent disagrees with us on this last point, arguing that the State’s three-week bar on
procedural abortions does have a “real and substantial relationship to the current pandemic,” and,
indeed, that, if we don’t allow that bar to go into effect, “doctors, nurses, and first responders will
die . . . .” Dissent at 29, 31. But the dissent roots these bold assertions in nothing more than the
State’s say-so. The Center for Disease Control and Prevention (“CDC”) webpage the dissent cites
certainly does not support the State’s position. That webpage simply recommends that U.S.
healthcare facilities preserve PPE and cancel “elective and non-urgent procedures/appointments”;
it says absolutely nothing about abortion. Id. at 29. And the State has never, at any point in this
litigation, attempted to support its policy choice with expert or medical evidence. See supra at 10.
This is unsurprising because, as far as we can tell, every serious medical or public health
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 17

organization to have considered the issue has said the opposite. See, e.g., supra at 8 n.7 (citing
statements signed by over a dozen leading medical organizations). So, in our view, the dissent’s
position is not so much deference as it is abdication.

Of course, we do not mean to suggest that abortion rights during a public health crisis are
identical to abortion rights during normal times. If Jacobson teaches us anything, it is that context
matters. And as noted in Section B, infra, we have tried to accommodate for that context here.
What we will not countenance, however, is the notion that COVID-19 has somehow demoted Roe
and Casey to second-class rights, enforceable against only the most extreme and outlandish
violations. Such a notion is incompatible not only with Jacobson, but also with American
constitutional law writ large. See generally, e.g., Ex Parte Milligan, 71 U.S. 2, 76 (1866) (“The
Constitution of the United States is a law for rulers and people, equally in war and peace, and
covers with the shield of its protection all classes of men, at all times, and under all
circumstances.”).

We conclude by acknowledging that orders analogous to EO-25 have generated a flood of
litigation the past few weeks, and that judges across the country have reached differing conclusions
as to the orders’ legality. Compare, e.g., In re Rutledge, No. 20-1791 (8th Cir. Apr. 22, 2020); In
re Abbott, ---F.3d ---, 2020 WL 1911216 (5th Cir. Apr. 20, 2020); In re Abbott, 954 F.3d 772 (5th
Cir. 2020), with Robinson v. Attorney General, --- F.3d ---, 2020 WL 1952370 (11th Cir. Apr. 23,
2020); In re Abbott, 2020 WL 1911216, at *18–30 (Dennis, J., dissenting); In re Rutledge, No. 20-
1791, slip op. at 24 (Loken, J., dissenting); South Wind Women’s Ctr., LLC v. Stitt, 2020 WL
1932900 (W.D. Okla. Apr. 20, 2020) (Goodwin, J.). Given the speed at which this issue is
developing, we decline to address these other opinions in detail; suffice it to say, it is clear that
there exists profound, but good faith, disagreement as to the constitutional questions involved. We
will note, however, that the Texas executive order underlying the recent Fifth Circuit decision—a
decision the State cites repeatedly in its brief here—is fundamentally different than EO-25. This
is because the Texas order contains an important caveat permitting doctors to perform procedures
that, in their clinical judgment, “would not deplete the hospital capacity or the [PPE] needed to
cope with the COVID-19 disaster.” In re Abbott, 954 F.3d at 780; see also In re Abbott, 2020 WL
1911216, at *30 (Dennis, J., dissenting) (noting that the plaintiff abortion providers there had
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 18

“represented that all of their abortion care will fall” under this exception). EO-25, by contrast,
contains no such caveat, other than the “serious adverse health consequences” exception
mentioned above. But because a woman could plainly have her right to an abortion undermined
without her suffering “serious adverse health consequences”—indeed, if a woman is forced to
undergo an unwanted, but otherwise healthy, pregnancy as a result of EO-25 she would
presumably fall outside the exception’s scope—this narrow provision does not save EO-25’s
constitutionality.

In sum, Plaintiffs are likely to succeed on the merits of their constitutional claim.

2.

We now address the remaining three preliminary injunction factors, in turn.

Irreparable Harm. This is not a case that can be remedied with money damages, or a post-
hoc apology. Rather, if Tennessee is allowed to enforce EO-25 in the sweeping manner that it
desires, any woman in Tennessee who wishes to have a procedural abortion during the relevant
time period stands at risk of losing her constitutional rights, or at least of incurring substantial
physical, emotional, and financial harms en route to exercising those rights; this is especially so
for the low-income women who disproportionately seek out abortions and who have been
disproportionately harmed by the economic downturn generated in COVID-19’s wake. And
Plaintiffs are at risk of criminal prosecution if they attempt to help their patients exercise that
right.13

13To be sure, as the State emphasized in the district court, and as the dissent hammers home here, Plaintiffs
have not pointed to specific patients who would be irreparably harmed by EO-25. But cf. R.248-1 (Chism Aff.) (Page
ID #6168–72) (affidavit filed after the district court issued its injunction, in which a Knoxville woman who was
13 weeks LMP at the time EO-25 went into effect explained how she risked losing her ability to obtain any abortion
in Tennessee as a result of the Order). But given the rapid timeline under which Plaintiffs were operating, and the
obvious reality that any Tennessee woman who would like to have a procedural abortion during the month of April
would be impacted by EO-25, we can forgive Plaintiffs for not being hyper-specific. And, in any event, Plaintiffs
provided evidence that hundreds of women in any given month seek procedural abortions because they are past the
point where medication abortion is an option, and that they (Plaintiffs) had to cancel specific procedural abortion
appointments because of EO-25, including some where the woman was literally at the clinic. See supra at 3–4, 5–6.
All of this is to say, there is no reason to think that, in April 2020, Tennessee women suddenly stopped deciding to
have procedural abortions. Moreover, as Plaintiffs’ amici make clear, the medical risks at stake are anything but
speculative. See, e.g., Br. of Am. Public Health Ass’n at 2–7.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 19

Balance of Harms. That Plaintiffs have pointed to concrete threats to constitutional liberty
and bodily autonomy does not guarantee them an injunction, of course. Rather, we must “balance
the competing claims of injury and must consider the effect on each party of the granting or
withholding of the requested relief.” Winter, 555 U.S. at 24 (emphasis added) (quoting Amoco,
480 U.S. at 542). Here, though, we find the “competing claims of injury” cited by the State to be
speculative and abstract; they do not outweigh the tangible harms EO-25 risks wrecking on
Plaintiffs and their patients.

Most potently, the State raises the specter of further COVID-19 contamination—and the
accordant risk of yet more Tennesseans dying from the disease—saying that such harms are
“certain to occur” if procedural abortions are allowed to take place. Appellant’s Br. at 24; see also
R.240 (Defs.’ Opp. Br.) (Page ID #6019–20) (“Every procedure that is postponed, and every item
of PPE that is preserved, furthers the State’s compelling interests in halting the spread of COVID-
19 and ensuring our healthcare system is equipped to treat—and prevent the death of—those who
are infected.”). We cannot gainsay the threat posed by COVID-19; as we stated at the outset of
the opinion, these are extraordinary times calling for extraordinary measures. But, with respect to
just those procedural abortions affected by the district court’s injunction (as modified below), the
State’s proffered harm is purely speculative. As the district court noted, the State presented “no
evidence that any appreciable amount of PPE would actually be preserved if EO-25 is applied to
procedural abortions,” and the State has not remedied that shortcoming on appeal. Adams & Boyle,
P.C., 2020 WL 1905147, at *6; see also supra at 16–17 (further discussing the lack of medical
evidence in support of the State’s position).

In response, the State suggests that if we permit this one exemption, surely the joint-
replacement surgeons, the cataract-removal specialists, and every other medical provider affected
by EO-25’s bar on elective procedures will follow, with similar “minimal impact” arguments in
tow. Cf. Pre-Term Cleveland v. Attorney General of Ohio, 2020 WL 1673310, at *4 (6th Cir. Apr.
6, 2020) (Bush, J., concurring) (deeming this “a serious free rider” problem). But this contention
fails to appreciate that abortion is fundamentally different than a hip replacement or a cataract
removal: not only is abortion entitled to explicit constitutional protection, but also, as the district
court appropriately recognized, it is a uniquely “time-sensitive procedure,” both as a biological
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 20

matter and a regulatory matter. Adams & Boyle, P.C., 2020 WL 1905147, at *6. After all, how
many other elective procedures have mandatory 48-hour waiting periods beforehand, and are
available in only four cities state-wide? So if there is a slippery slope here, we fail to see it.

Tennessee also emphasizes that a state’s “sovereignty is irreparably harmed anytime action
taken by its democratically elected leaders is enjoined,” and argues that we should take account of
that harm here. Appellant Br. at 24 (citing Abbott v. Perez, 138 S. Ct. 2305, 2324 (2018)). But as
we stressed at the outset of this opinion, we have taken that harm into account. And, in the
particular circumstances of this case, we find that the affront the Governor of Tennessee will suffer
from having one small part of a limited-duration executive order enjoined (which itself is just one
piece of a much more comprehensive state policy) is far outweighed by the harm the individual
Tennessee women affected by that order will suffer if it is given full effect.

The Public Interest. We need not say much on this point. As the district court correctly
observed, “it is always in the public interest to prevent violation of a party’s constitutional rights.”
Deja Vu of Nashville, Inc. v. Metro Gov’t of Nashville & Davidson Cty., Tenn., 274 F.3d 377, 400
(6th Cir. 2001) (quoting G & V Lounge, Inc. v. Mich. Liquor Control Comm’n, 23 F.3d 1071, 1079
(6th Cir. 1994)).

* * *

For these reasons, the district court did not abuse its discretion in granting a preliminary
injunction.

B.

This leaves one final matter: the scope of the district court’s injunction. As noted above,
the district court’s order is just one sentence long: “Defendants are hereby immediately enjoined
from enforcing EO-25 as applied to procedural abortions.” The State argues that this perfunctory
order is overbroad, and that the district court failed to “tailor its injunctive relief” to the
burdensome situations actually identified by Plaintiffs. Appellant Br. at 21; compare with, e.g.,
Robinson, 2020 WL 1952370, at *8 (in the course of denying state’s request for a stay on appeal,
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 21

citing with approval the district court’s “narrowly tailored” preliminary injunction); cf. Pre-Term
Cleveland, 2020 WL 1673310, at *1 (similar conclusion, in TRO context).

On this point, we agree with the State. As explained earlier, because a preliminary
injunction is an extraordinary remedy, a district court must be careful to “limit the solution to the
problem.” Ayotte, 546 U.S. at 328–29. And, here, the undue burden problem identified by
Plaintiffs encompassed three classes of patients, which Plaintiffs helpfully identified in their
district court brief seeking injunctive relief:

(1) patients who, in the good faith professional judgment of the provider,
will likely lose their ability to obtain an abortion in Tennessee if their
procedures are delayed until after April 30, 2020;
(2) patients who, in the good faith professional judgment of the provider,
will likely be forced to undergo a lengthier and more complex abortion
procedure, which is only available at two clinics in Nashville and
Memphis, if their procedures are delayed until after April 30, 2020;
[and]
(3) patients who, in the good faith professional judgment of the provider,
will likely be forced to undergo a two-day procedure—which is only
available at two clinics in Nashville and Memphis, and which requires
at least three separate visits to the provider—if their procedures are
delayed until April 30, 2020.
R.232 (Pls.’ Preliminary Inj. Br.) (Page ID #5783).

Consequently, we direct the district court to modify its injunction so that it enjoins the State
from enforcing EO-25 against Plaintiffs to the extent they provide procedural abortions to these
three categories of patients. And, to be clear, this second category of patients includes women
who, in the good faith professional judgment of the provider, will likely be forced to undergo a
D&E procedure instead of an aspiration procedure if their procedures are delayed until after April
30, 2020.

To the extent that Plaintiffs work with patients who can safely delay their procedural
abortions past EO-25’s April 30 expiration date, in a manner commensurate with the
aforementioned criteria, however, Plaintiffs must comply with EO-25 and delay those particular
procedures. To rule otherwise would be to grant Plaintiffs a wholesale exemption from the public
health dictates of EO-25, which, per our earlier discussion, Jacobson cautions against.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 22

III. CONCLUSION

For these reasons, we AFFIRM the district court order issuing a preliminary injunction
but direct the district court to MODIFY the preliminary injunction in the manner set forth above.
We leave it to the district court to address any further developments in the first instance.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 23

_________________

DISSENT
_________________

THAPAR, Circuit Judge, dissenting. Even in ordinary times, the district court’s injunction
in this case would be deeply flawed. But these are no ordinary times. In the midst of a once-in-a-
century pandemic, the district court broadly enjoined the State of Tennessee from enforcing a
measure at the heart of the State’s response. In doing so, the court committed numerous legal
errors, made hardly any factual findings, issued an overly broad injunction, and brazenly
substituted its own policy views for those of the elected officials who are actually fighting the
pandemic. All because the district court thought that a three-week delay for certain abortions
might prevent some unidentified person from having an abortion. Most cases of judicial
aggrandizement have costs. But in few are the potential costs so great. I would reverse.

I.

Two weeks ago, the Governor of Tennessee issued an executive order—based on guidance
from various medical organizations—in response to the COVID-19 pandemic. The Governor’s
order explains the critical importance of conserving what’s known as “personal protective
equipment” (e.g., face masks, gloves, protective clothing) and therefore directs “[a]ll healthcare
professionals and healthcare facilities” in the State to “postpone surgical and invasive procedures
that are elective and non-urgent.” The order defines “elective and non-urgent” procedures as those
that “are not required to provide life sustaining treatment, to prevent death or risk of substantial
impairment of a major bodily function, or to prevent rapid deterioration or serious adverse
consequences to a patient’s physical condition if the surgical or invasive procedure is not
performed, as reasonably determined by a licensed medical provider.” The order will expire just
after midnight on April 30, 2020—less than six days from now and exactly three weeks after it
took effect.

Within days of the Governor’s announcement, the plaintiffs in this case—abortion
providers in Tennessee—moved to “supplement” a five-year old complaint (six months after trial)
to seek a temporary restraining order or preliminary injunction. The plaintiffs argued that the
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 24

executive order prohibits most “surgical abortions” in the state and thus will prevent their clients
from obtaining an abortion.

A mere four days later, the district court granted the motion to supplement and entered a
preliminary injunction, enjoining the enforcement of the executive order as to all surgical abortions
in Tennessee. The court’s analysis of why the plaintiffs were likely to succeed on the merits
consisted of two paragraphs. The State then appealed. (Despite the breadth of its ruling, the district
court recently denied a stay pending appeal.)

II.

The State now asks us to stay the district court’s decision pending appeal and ultimately to
reverse the preliminary injunction. Both requests involve the same basic factors: (1) who is likely
to prevail on the merits; (2) whether the moving party is likely to suffer irreparable harm in the
interim; (3) what is the balance of harms; and (4) where does the public interest lie. See Fowler v.
Benson, 924 F.3d 247, 256 (6th Cir. 2019); Serv. Emps. Int’l Union Local 1 v. Husted, 698 F.3d
341, 343 (6th Cir. 2012) (per curiam). The plaintiffs’ failure to show a likelihood of success on
the merits would itself warrant reversal. See, e.g., Fowler, 924 F.3d at 259–60. But the other
factors counsel the same outcome. And even if the district court was correct to grant a preliminary
injunction (it was not), these same factors show that the injunction was much broader than
permitted under the law.

Success on the Merits. Start with the plaintiffs’ likelihood of success on the merits. The
basic question is whether the executive order places an “undue burden” on a woman’s ability to
have an abortion. Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 874 (1992). As the
modifier “undue” suggests, not just any “incidental effect . . . making it more difficult or more
expensive” to have an abortion will do. Id. Rather, the state regulation must create a “substantial
obstacle” for women seeking an abortion. Id. at 877. But importantly, we do not consider any
burden in isolation. Instead, we must consider “the burdens a law imposes on abortion access
together with the benefits those laws confer” and then “weigh[] the asserted benefits against the
burdens.” Whole Woman’s Health v. Hellerstedt, 136 S. Ct. 2292, 2309, 2310 (2016) (emphasis
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 25

added). In short, the plaintiffs must show that the order imposes a burden and that this burden
outweighs the order’s asserted benefits.

Given this framework, the district court committed two fundamental errors. First, it failed
to make the necessary factual findings to show that the executive order imposes a burden on
anyone’s rights. Second, the court failed even to acknowledge the benefits of the executive order
and thus necessarily failed to balance its speculative burden against these benefits. Either error
would warrant reversal. Together, they certainly do.

Begin with the burden. The district court failed to make specific findings about whether
the executive order creates a “substantial obstacle” for women seeking an abortion. See Casey,
505 U.S. at 874. At most, the district court pointed out that the executive order will delay certain
abortions for three weeks. But that doesn’t take the plaintiffs very far. Both the Supreme Court
and our court have upheld laws that have the effect of delaying abortions for days or even weeks.
See, e.g., Ohio v. Akron Ctr. for Reprod. Health, 497 U.S. 502, 514 (1990) (up to three-week
delay); Cincinnati Women’s Servs., Inc. v. Taft, 468 F.3d 361, 366, 372–74 (6th Cir. 2006) (up to
two-week delay). Indeed, for the last forty years, the Supreme Court has “repeatedly upheld a
wide variety of abortion regulations that entail some delay in the abortion.” Garza v. Hargan, 874
F.3d 735, 755–56 (D.C. Cir. 2017) (en banc) (Kavanaugh, J., dissenting) (collecting cases). The
district court failed to grapple with any of these precedents. Its silence speaks volumes.

(For its part, the majority tries to distinguish these cases by saying those delays were
outside the state’s control. It doesn’t offer any support for this distinction. But more importantly,
the distinction seems to assume that a once-in-a-century pandemic is within a state’s control.)

To be clear, the district court enjoined a version of the order that didn’t exist. It acted as if
the State had banned most pre-viability abortions. But that’s just not the case. Tennessee law
generally allows women to seek an abortion until the twentieth week of their pregnancy. See Tenn.
Code Ann. §§ 39-15-211, -212. So any woman who was less than seventeen-weeks pregnant when
the order went into effect would still have time to seek an abortion after the order expires.

The plaintiffs speculate that there might be women out there who were more than
seventeen-weeks pregnant when the order was issued and who will now be unable to obtain an
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 26

abortion in Tennessee. (Or who otherwise would be unable to obtain an abortion for some reason.)
But speculation usually doesn’t count for much. See, e.g., Mazurek v. Armstrong, 520 U.S. 968,
972–74 (1997) (per curiam). And there’s no reason it should have counted for so much here. Make
no mistake—the burden was on the plaintiffs to bring forward concrete evidence (1) that such
women exist, (2) that they want an abortion, and (3) that they would be unable to obtain one. See
Winter v. Nat. Res. Def. Council, Inc., 555 U.S. 7, 20 (2008). The majority claims a snippet of
evidence supports this concern—an affidavit that vaguely states that “some patients” will be
prevented from obtaining an abortion under the executive order. R. 232-5, Pg. ID 5887. But the
district court didn’t make any factual findings on this front. Nor do the plaintiffs even cite this
evidence on appeal.

Not only that. No one—not the plaintiffs, not the district court, not even the majority—
has made any effort to quantify how this hypothetical pool of women relates to the broader pool
of women affected by the order—as binding precedent requires. See Gonzales v. Carhart, 550
U.S. 124, 167–68 (2007); Cincinnati Women’s Servs., 468 F.3d at 367–68 (explaining that courts
must consider whether a restriction will operate as a “substantial obstacle” in “a large fraction of
the cases in which the abortion restriction is relevant” (cleaned up)). In fact, the State points out
that the vast majority of abortions in Tennessee occur before the seventeenth week of pregnancy.
The plaintiffs haven’t offered any evidence in response. So even if speculation were the stuff of
winning legal claims, plaintiffs still haven’t made the proper showing.

But we aren’t even done with speculation. The plaintiffs (and now the majority) say that
the Governor of Tennessee might extend the executive order beyond the current three-week period.
This is a smart move—it makes a short, finite burden look like an indefinite one, exaggerating its
severity. The problem is that the Governor hasn’t said he will impose any restrictions on medical
procedures after April 30, which is when the order in this case expires. If the Governor issues a
new order limiting surgeries beyond that date, it is possible that he will extend the existing
restrictions—but it is just as likely that the new order will contain a different and perhaps more
tailored set of restrictions. The majority simply assumes it will be the former. Based on what?
The plaintiffs and majority point to a statement by the Surgeon General of the United States about
extending certain public-health measures. But in this country, federal officials don’t speak on
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 27

behalf of state leaders. And again, the plaintiffs haven’t pointed to any evidence about what the
Governor of Tennessee will do. As the crisis facing our country continues to develop, so too will
government responses. And those who have problems with those responses must wait until actual
and imminent harms arise. See, e.g., D.T. v. Sumner Cty. Schs., 942 F.3d 324, 327 (6th Cir. 2019).
Federal courts are not in the business of issuing advisory opinions, let alone advisory injunctions.

All that is reason enough to reverse. But the district court also committed another
fundamental error: it entirely failed to balance these purported burdens against the executive
order’s benefits. See Whole Woman’s Health, 136 S. Ct. at 2309. The court didn’t even mention
the benefits of the order in its “undue burden” analysis. That flatly contradicts Supreme Court
precedent, which “requires that courts consider the burdens a law imposes on abortion access
together with the benefits those laws confer.” Id. Count that as another error warranting reversal.

Perhaps the district court didn’t perform this balance because it couldn’t do so. How does
one balance a harm to some unspecified number of people? The district court didn’t tell us and
the majority doesn’t either.

One could stop there. But in fact, Tennessee’s interests in protecting its citizens from the
pandemic cannot be overstated. All agree that these are far from ordinary times. Over the past
few weeks, our entire nation has come together to combat a generation-defining crisis. Many have
done so at great personal sacrifice.

In Tennessee, as in so many other states, the Governor has taken extraordinary steps to
fight the pandemic. He declared a state of emergency, required all residents to remain at home
except in limited circumstances, and ordered the closure of most businesses. As part of that effort,
he also signed the generally applicable order at issue here. The Governor’s order allowed the state
to conserve valuable personal protective equipment for those fighting the coronavirus. The order
protects those who have undertaken perhaps the greatest personal sacrifice in protecting the
citizens of Tennessee. There’s no reason to doubt that the Governor took these measures because
“the safety of the general public” demanded it. Jacobson v. Commonwealth of Massachusetts,
197 U.S. 11, 29 (1905).
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Our law has long-protected just these types of decisions from judicial interference based
on purported violations of substantive due process. In times of emergency, elected officials need
room to do what they were elected to do—to govern. Sometimes their actions will incidentally
impact a person’s liberty interests. But the Supreme Court has upheld such actions anyway,
explaining that “[r]eal liberty for all could not exist under the operation of a principle which
recognizes the right of each individual person to use his own [person or property], . . . regardless
of the injury that may be done to others.” Id. at 26. And there’s no abortion exception to this well-
settled principle. To the contrary, the Supreme Court has made clear from the beginning that the
ability to obtain an abortion is neither “absolute” nor “unlimited.” Roe v. Wade, 410 U.S. 113,
154 (1973) (citing Jacobson, 197 U.S. 11).

Of course, this does not mean that the courts should rubber stamp emergency measures—
far from it. See Jacobson, 197 U.S. at 28–29. But it does mean that judges should act with care
during such times, recognizing the limits of our knowledge, institutional capacity, and lawful
authority. See id. at 30–31; cf. Gonzales, 550 U.S. at 163 (explaining that the Supreme Court has
“given state and federal legislatures wide discretion to pass legislation in areas where there is
medical and scientific uncertainty”).

Remarkably, the district court failed to acknowledge—let alone apply—these principles
before it granted the injunction. Nor did it acknowledge the State’s heightened interests during
times of emergency. Based on its decision, one might think that the executive order would be
unconstitutional no matter how many lives it could save and no matter how few—if any—
abortions it might prevent. Even the majority calls this omission “unfortunate.”

In a subsequent order denying a stay pending appeal, the district court seems to have
recognized that it erred by ignoring the State’s primary legal authority for its position, Jacobson
v. Commonwealth of Massachusetts, 197 U.S. 11 (1905). But rather than correct its mistake, the
court doubled down, finding the facts of Jacobson to be readily “distinguishable” from the facts
of this case. In doing so, the district court overlooked the basic principle of Jacobson: that states
may respond to emergencies in the face of substantive-due-process rights, so long as they act
reasonably and don’t single out specific rights or persons for disfavored treatment. See id. at 28–
30.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 29

No one claims that the State of Tennessee has singled out specific rights or persons in its
response to the current pandemic. The executive order in this case applies to all non-essential
medical procedures. And again, the Governor has issued several other orders that apply to all
persons and that affect every aspect of daily life across the state.

Nor have the plaintiffs shown that the State has acted unreasonably in requiring its residents
to postpone non-essential medical procedures for a three-week period. Just contrast this case with
the facts of Jacobson, where the Supreme Court upheld a state’s authority to forcibly vaccinate
individuals. See id. at 27–30. If the State can physically invade a person’s body in response to an
emergency, then it surely may require people to delay certain medical procedures for the same
purpose.

On these points the majority, for its part, is conclusory: it does little more than assert that
the executive order “is, beyond all question, a plain, palpable invasion of rights secured by the
fundamental law.” Jacobson, 197 U.S. at 31. Given that plaintiffs haven’t established a
constitutional violation in the first place, they certainly haven’t done so “beyond all question.”

The majority also dismisses the State’s interests on the ground that the executive order has
no “real” and “substantial” relationship to the current pandemic. Id. That claim is remarkable
given that the order follows recommendations from our nation’s leading public-health institution.
See Centers for Disease Control and Prevention, Coronavirus Disease 2019 (COVID-19):
Strategies to Optimize the Supply of PPE and Equipment (last visited Apr. 24, 2020),
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html (explaining that
equipment “shortages are currently posing a tremendous challenge to the US healthcare system”
and recommending the cancellation of “elective and non-urgent procedures/appointments”). Plus,
Jacobson clearly tells us that it’s “no part of the function of a court or a jury to determine which
one of two modes [is] likely to be the most effective for the protection of the public against
disease.” 197 U.S. at 30. The majority doesn’t explain why our court is an exception to that rule.
And the amicus briefs the majority cites to discredit the State’s rationale for the executive order
“are more formidable by their number than by their inherent value.” Id. One need only open a
newspaper to appreciate the importance of preserving medical equipment at this time. So if
nothing else, Jacobson forecloses the plaintiffs’ claim.
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Irreparable Harm. Consider next what (if any) irreparable harm the plaintiffs will suffer
without an injunction. To be clear, the plaintiffs don’t claim that they themselves will suffer any
irreparable harm. Rather, the plaintiffs assert that the women they purport to represent will suffer
irreparable harm without an injunction. But cf. Gee v. June Med. Servs. L.L.C., 140 S. Ct. 35
(2019) (Mem.) (granting certiorari to consider whether traditional third-party standing rules apply
in abortion cases).

The district court reasoned that the plaintiffs had established an irreparable injury because
it thought that the executive order would prevent some women in Tennessee from having an
abortion. But again the district court failed to make any factual findings showing that the order
would prevent any particular woman from obtaining an abortion. To satisfy the irreparable-injury
requirement, parties must demonstrate “likely” harm. Winter, 555 U.S. at 22. And the plaintiffs
offer only speculation.

The district court also asserted that delays in the provision of abortions might irreparably
harm some women by making their abortions more dangerous. But this argument stands in stark
contrast with the claim that “[a]bortion is one of the safest medical procedures performed in the
United States.” Whole Woman’s Health, 136 S. Ct. at 2320 (Ginsburg, J., concurring) (citation
omitted). In fact, the plaintiffs themselves say that “abortion is extremely safe throughout
pregnancy.” Plaintiffs Br. at 5. Is it an irreparable injury for a medical procedure to be only
“extremely safe”? But again the district court addressed none of these facts on its way to its
destination.

Meanwhile, the executive order allows doctors to perform an abortion when a woman
would suffer “serious adverse consequences to [her] physical condition” without the surgery “as
reasonably determined by a licensed medical provider.” The plaintiffs haven’t made any effort to
explain why this exception (which contains built-in deference to medical professionals) would not
give them the flexibility they need during this time of national crisis. And again, it was the
plaintiffs’ burden to show that the executive order (with its exception) causes an irreparable injury.
They failed to do so.
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Balance of Harms. Consider also the irreparable harms created by the district court’s
injunction. Of course, a state always suffers irreparable injury when it’s wrongfully enjoined from
enforcing one of its laws. See Abbott v. Perez, 138 S. Ct. 2305, 2324 & n.17 (2018); Maryland v.
King, 567 U.S. 1301, 1303 (2012) (Roberts, C.J., in chambers). But that’s far from the only harm
here. The Governor issued the executive order to preserve critical medical equipment. Every
piece of equipment used for something besides the pandemic response could cost a life—the life
of someone who acts selflessly to help others in a time of crisis. Simply put: doctors, nurses, and
first responders will die without proper equipment. And that’s to say nothing of their family
members, whose lives will be put at risk too. Given the twin risks of exponential community
spread and hospital overload, every additional infection among first responders represents a
significant threat to public health. It’s hard to imagine a scenario in which the harm imposed by
an injunction would be greater.

The district court brushed off these concerns, saying the plaintiffs have already taken
measures to reduce their use of medical equipment during surgical abortions. The district court
apparently thought that the State would be harmed only if surgical abortions used an “appreciable
amount” of medical equipment. (The Majority seems to think the same.) But neither the district
court nor the Majority is in any position to second-guess the Governor’s judgment as to the amount
of equipment that is really necessary to keep healthcare workers alive.

The district court also asserted that the executive order would be counterproductive for
various policy reasons. Again the district court’s (and now the majority’s) willingness to
constitutionalize its own policy judgments—in the midst of a national emergency no less—is
remarkable. If anything has remained constant over the past hundred years of constitutional law,
it’s that courts aren’t supposed to second guess policymakers based on their own subjective
judgments of what makes for good policy. See, e.g., Perry v. Perez, 565 U.S. 388, 394 (2012) (per
curiam) (noting that courts must exercise care not to displace “legitimate state policy judgments
with the court’s own preferences”). All the more when our elected officials are tasked with making
difficult decisions under conditions of uncertainty, risk, and imperfect information. See Jacobson,
197 U.S. at 30–31.
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 32

The district court and majority also note that some women might travel to other states to
have an abortion and that this might further aggravate the current pandemic. But neither the
plaintiffs nor the district court nor the majority have pointed to a single person who said she would
need to travel to another state to get an abortion. So again this is nothing more than speculation.

Public Interest. This factor points in the same direction. See Nken v. Holder, 556 U.S.
418, 435–36 (2009); Winter, 555 U.S. at 24–26. Plainly the public interest is served by a state’s
ability to enforce a regulation whose purpose and effect is to save the lives of healthcare workers.
The district court and majority assert that the public interest favors a preliminary injunction
because it’s always in the public interest to prevent the violation of constitutional rights. See, e.g.,
Dodds v. U.S. Dep’t of Educ., 845 F.3d 217, 222 (6th Cir. 2016) (per curiam). That reasoning
would have more force if the plaintiffs or district court had shown that the regulation actually
violates any constitutional rights. But again the majority’s reasoning is only conclusory.

Scope of the Injunction. Finally, the district court plainly erred in defining the injunction’s
scope. Preliminary injunctions are an “extraordinary remedy.” Winter, 555 U.S. at 24. That
means courts that shouldn’t grant them based on speculative harms, which is what the district court
did here; and that “the scope of relief should be strictly tailored to accomplish only that which the
situation specifically requires.” Sharpe v. Cureton, 319 F.3d 259, 273 (6th Cir. 2003) (citation
omitted). As the Supreme Court put it, “[i]t is neither our obligation nor within our traditional
institutional role to resolve questions of constitutionality with respect to each potential situation
that might develop.” Gonzales, 550 U.S. at 168. And an injunction’s proper scope becomes all
the more important in cases involving government officials—and especially in cases where, as
here, federal courts enjoin them. See Rizzo v. Goode, 423 U.S. 362, 378–80 (1976); see also
Gonzales, 550 U.S. at 168 (“It would indeed be undesirable for [courts] to consider every
conceivable situation which might possibly arise in the application of complex and comprehensive
legislation.” (cleaned up)).

But again the district court disregarded these well-settled legal principles. The district
court’s injunction doesn’t just apply to women who might lose their ability to have an abortion
before Tennessee’s twenty-week deadline; it applies to all women who seek a surgical abortion—
 No. 20-5408 Adams & Boyle, P.C. et al. v. Slatery et al. Page 33

no matter their ability to obtain an abortion after the order expires. Injunctions should be aimed
with rifle-scope precision. The district court here used a twelve-gauge.

The majority does acknowledge at least this error and tries to remedy it on appeal. But in
doing so, the majority doesn’t fix the problem and also creates a problem of its own: it creates
three “classes” of women—all of them amorphous, and thus likely to sow confusion going
forward. In effect, the majority has certified a class under Rule 23(b)(2) without any request to do
so or any effort to comply with the Federal Rules. Nor does the majority explain why the executive
order unduly burdens most of the putative class. It simply announces that the injunction will apply
to them.

The district court’s errors here are not unprecedented: Two other circuits have recently
encountered similar district court decisions, and both circuits promptly corrected them—in one
case twice. See In re Rutledge, No. 20-1791, 2020 WL 1933122 (8th Cir. Apr. 22, 2020); In re
Abbott, No. 20-50296, 2020 WL 1911216 (5th Cir. Apr. 20, 2020); In re Abbott, 954 F.3d 772 (5th
Cir. 2020). But cf. Robinson v. Att’y Gen., No. 20-11401-B, 2020 WL 1952370, at *4 (11th Cir.
Apr. 23, 2020) (denying a stay pending appeal in “an atypical case” because, among other things,
the state “concede[d] that the substance of the district court’s preliminary injunction is consistent
with its own . . . interpretation of [its executive order]”). We should have done the same.

***

To sum up: the district court granted an injunction without much effort to apply the
relevant law, without specific factual findings, and without any attempt to tailor the remedy to the
purported constitutional violation. If that doesn’t count as an abuse of discretion, I don’t know
what would. I respectfully dissent.