Falls Church Medical Center, LLC et al v. Oliver et al

Filing 142

MEMORANDUM OPINION. Signed by District Judge Henry E. Hudson on 5/6/2019. (jsmi, )

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IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF VIRGINIA
Richmond Division

FALLS CHURCH MEDICAL CENTER,
LLC d/b/a FALLS CHURCH

HEALTHCARE CENTER,et aL,
Plaintiffs,
Civil Action No. 3:18cv428-HEH

V.

M.NORMAN OLIVER, VIRGINIA
HEALTH COMMISSIONER,et aL,
Defendants.
MEMORANDUM OPINION

(Cross-Motions for Summary Judgment)
I.

INTRODUCTION

This action challenges the constitutionality ofthe statutes and regulations
governing health care providers who offer abortion care or services in Virginia. Seeking

declaratory and injunctive relief. Plaintiffs' argue that the challenged statutes and
regulations pose a substantial obstacle to the availability of abortion services for Virginia
women,in violation ofthe Fourteenth Amendment to the United States Constitution.

This case is presently before the Court on Motions for Summary Judgment filed by both

Plaintiffs and Defendants.^ All parties have filed memoranda supporting their respective
'Plaintiffs in this case include Falls Church Medical Center, LLC; Whole Woman's Health
Alliance; Virginia League for Planned Parenthood; and Dr. Jane Doe. Dr. Jane Doe will be

referred to as Dr. Doe and the other Plaintiffs as "abortion providers." Where appropriate, the
Plaintiffs collectively will simply be referred to as "Plaintiffs."

^ The named Defendants include almost all associated regulatory agencies with jurisdiction over
abortion services, as well as commonwealth's attomeys in jurisdictions where facilities providing

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positions, accompanied by pertinent exhibits. The Court heard oral argument on April 8,
2019 and ordered supplemental briefing on several issues.

In support oftheir Motion for Partial Summary Judgment on Counts III and IV of

the Amended Complaint, Plaintiffs offer the deposition testimony of multiple physicians
and medical experts who opine that contemporary abortion procedures are extremely
safe, and, as a result, complications necessitating advanced medical care are rare, even

with respect to second trimester abortions.^ Therefore, those procedures can be
conducted by trained medical professionals other than licensed physicians. Defendants,
on the other hand, seek summary judgment on Counts I-IV and VII and VIII ofthe

Amended Complaint. Similarly, Defendants offer expert testimony to contend that while
serious complications are admittedly rare, when they do occur, particularly with respect
to second trimester procedures, they are most effectively addressed in a hospital setting
by a physician.

such services are located. Defendants are M. Norman Oliver, Virginia Health Commissioner;
Robert Payne, Acting Director of the Virginia Department of Health's Office of Licensure and
Certification; Faye O. Prichard, Chairperson ofthe Virginia Board of Health; Theophani Stamos,
Commonwealth's Attomey for Arlington County and the City of Falls Church; Robert Tracci,
Commonwealth's Attomey for Albermarle County; Anton Bell, Commonwealth's Attomey for
the City of Hampton; Michael N. Herring, Commonwealth's Attomey for the City of Richmond;
and Colin Stolle, Commonwealth's Attomey for the City of Virginia Beach. Each individual

Defendant has been sued in his or her official capacity, as well as their employees, agents, and
successors. They will be collectively referred to as "Defendants."

^ While the statutory language at issue in this case is somewhat antiquated, this Court is neither
inclined nor empowered to engraft amendatory language. Therefore, for the purpose of
constitutional review, this Court will limit the term "second trimester abortion" to pre-viability
procedures. See Virginia, v. Am. Booksellers Ass'n, Inc.^ 484 U.S. 383, 397(1988); see also
Whole Woman's Health v. Hellerstedt, 136 S. Ct. 2292, 2303(2016).

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II.

BACKGROUND

Distilled to their essence, Plaintiffs' individual counts in the Amended Complaint

are largely premised on the United States Supreme Court's analysis in Whole Woman's
Health v. Hellerstedt, 136 S. Ct. 2292(2016). In Whole Woman's Health, the Court

restated with approval the time-honored standard for judicial review of allegedly
burdensome abortion regulations that the Court originally articulated in Planned
Parenthood ofS.E. Pa. v. Casey, 505 U.S. 833 (1992). Justice Breyer, speaking for the
Court in Whole Woman's Health, described that standard as follows:

[A]plurality ofthe Court [in Casey] concluded that there "exists" an
"undue burden" on a woman's right to decide to have an abortion, and

consequently a provision oflaw is constitutionally invalid, if the ''purpose
or effecC ofthe provision "is to place a substantial obstacle in the path of a
woman seeking an abortion before the fetus attains viability."[] The
plurality [ofthe Court in Casey] added that "[ujnnecessary health
regulations that have the purpose or effect of presenting a substantial
obstacle to a woman seeking an abortion impose an undue burden on that
right."

136 S. Ct. at 2300(quoting Casey, 505 U.S. at 878)(emphasis in original).
Informed by Casey, the Court in Whole Woman's Health also cautioned that "a

statute which, while furthering [a] valid state interest, has the effect of placing a

substantial obstacle in the path of a woman's choice cannot be considered a permissible
means ofserving its legitimate ends." Whole Woman's Health, 136 S. Ct. at 2309

(quoting Casey, 505 U.S. at 877). The rule announced in Casey, however, requires that
courts "consider the burdens a law imposes on abortion access together with the benefits
those laws confer." Id. (citing Casey, 505 U.S. at 887-98).

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The claims advanced by Plaintiffs in this case are closely moored to the foregoing

analytical framework articulated in Casey and Whole Woman's Health. Plaintiffs urge
the Court to find that, in their view, the needless and antiquated administrative and
legislative burdens on abortion providers in Virginia are constitutionally offensive
obstacles to a woman's right to seek an abortion. Plaintiffs charge that
Virginia has adopted an array of unnecessary and discriminatory laws,
some over four decades old, that target the provision of abortion care
without any meaningful improvement to safety or health, or any benefits—
let alone benefits that outweigh burdens. Instead, these laws serve only to
negatively impact Virginians' access to reproductive healthcare.
(Am. Compl. H 65,ECF No.41.)

According to Plaintiffs, the resulting mandate prescribed a wide array of restrictive
regulations, which dictate strict standards for construction, staffing, equipment, enhanced
training, infection prevention, and facility security. {Id. ^ 68.) In addition, the Virginia
Board of Health promulgated a host of regulations that govern first trimester abortion

facilities, including increased record keeping, additional personnel and staffing
requirements, restrictions on employment of physicians not licensed to practice in the
Commonwealth of Virginia, periodic inspections by the Virginia Department of Health,

including allowing such inspectors to review patient records, and requiring staff to
provide certain medical information to patients prior to administering an abortion.
{Id. H 69.)

Further, according to Plaintiffs, Va. Code Ann. § 18.2-73, enacted in 1975,

working in conjunction with other regulations, requires that lawful abortions performed
during the second trimester of pregnancy must be carried out in a licensed hospital that
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qualifies and meets the regulatory requirements of an outpatient surgical hospital.
{Id. H 72.) Also adopted in 1975, Va. Code Ann. § 18.2-72, the so-called "PhysicianOnly Law," exempts licensed physicians from Virginia's general criminal ban on
abortion—^Va. Code Ann. § 18.2-71, sometimes referred to as Virginia's felony abortion

statute. Plaintiffs contend that the Physician-Only Law unjustifiably limits "the pool of
abortion providers, even while advanced practice clinicians("APCs")—including
licensed nurse practitioners, CNMs [certified nurse midwives], and physician assistants—
safely and routinely provide abortion care, including medication and aspiration abortion,
in other states throughout the country." {Id. 73.)
Plaintiffs' constitutional challenges to the regulatory and statutory provisions at
issue were originally framed in an eight-count Amended Complaint; however, only seven
counts remain, six of which are presently challenged by at least one ofthe parties under

Federal Rule of Civil Procedure 56."* The parties have challenged the following counts in
their cross-motions for summary judgment: Counts I through IV are each prefaced with
the general heading of"Substantive Due Process - Rights to Liberty and Privacy." Count
I focuses on the so-called "Licensing Statute," Va. Code Ann. § 32.1-127(B)(1)in

^ Count VI was previously dismissed by the Court for its failure to state a viable independent
claim. Count V of the Amended Complaint is still before the Court, but neither party has
challenged it in their respective summary judgment motions. Count V focuses on Va. Code Ann.
§ 18.2-76, sometimes referred to as the "Two-Trip Mandatory Delay Law." This statute requires
a woman seeking abortion care in Virginia to undergo a mandatory ultrasound and then delay the
abortion procedure for at least 24 hours, unless she resides at least 100 miles from the facility
where the abortion is to be performed, in which case the delay is reduced to two hours.

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conjunction with what Plaintiffs refer to as Virginia's "Criminalization Laws."^ Section
32.1-127(B)(1)requires that any facility "in which five or more first trimester abortions

per month are performed ... be classified as a category of'hospital,'" Va. Code Aim.
§ 32.1-127(B)(1), thereby triggering a host ofregulatory requirements. Count II targets
Virginia's Licensing Regulations for first trimester abortion facilities, 12 Va. Admin.

Code § 5-412, etseq., and the Criminalization Laws, which Plaintiffs contend impose an
undue burden on Virginia women's fundamental right to have an abortion prior to
viability. Count III focuses on Va. Code Ann. § 18.2-73, referred to as the "Hospital
Requirement," in conjunction with Virginia's Licensing Regulations for hospitals, 12 Va.

Admin. Code § 5-410, et seq.,^ as a condition oflicensure of an abortion provider, and
the Criminalization Laws. Count IV challenges Va. Code Ann. § 18.2-72 that only
permits licensed physicians to lawfully perform abortion procedures.

^ Plaintiffs collectively refer to three separate sections ofthe Virginia Code as the
"Criminalization Laws." (Am Compl.^ 4f.) These sections include Va. Code Ann. §§ 18.2-71,
§32.1-27(A), and §32.1-136. Section 18.2-71 makes it a Class 4 felony for any person to
intentionally administer an abortion or destroy an unborn child. See Va. Code Ann. § 18.2-71.
Section 27(A)provides criminal penalties for individuals who violate regulations promulgated
by the Virginia State Board of Health. See Va. Code Ann. § 32.1-27(A). Section 136 makes it a
Class 6 felony to operate an unlicensed hospital. See Va. Code Ann. § 32.1-136.

^ Defendants question Plaintiffs' standing to challenge these licensing regulations. Defendants
contend that all Plaintiffs meet these regulatory requirements and, therefore. Plaintiffs do not
potentially suffer any adverse impact from the statute's regulatory content. This is a tenable
argument with respect to the first trimester abortions, but the text of Count III appears to focus
on the inability of Plaintiffs' facilities to perform second trimester abortion procedures.
Plaintiffs' overarching argument is that the burdens imposed by the regulatory regimen at

issue adversely affects their ability to provide adequate service to their patients. At Ais stage of
the proceedings, Plaintiffs have demonstrated a sufficiently concrete and particularized injury to
advance their claims. Friends ofthe Earth, Inc. v. Laidlaw Envtl Servs., Inc., 528 U.S. 167,
180-81 (2000);
also Griffin v. Dep 7 ofLabor Fed. Credit Union,912 F.3d 649,653(4th Cir.
2019).

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In Count VII, Plaintiffs allege that the Hospital Requirement is unconstitutionally
vague and violates "due process as guaranteed by the Fourteenth Amendment to the U.S.
Constitution because it fails to define the terms 'hospital' and 'second trimester of
pregnancy.'" (Am. Comp.^ 266.) Finally, Count VIII ofthe Amended Complaint
alleges that Virginia's Licensing Regulations violate the Fourth Amendment by

subjecting Plaintiffs to "biennial unannounced, warrantless inspections ...." {Id. ^ 268.)
The regulatory provision in question in Count VIII, 12 Va. Admin. Code § 5-412-90,
authorizes agents ofthe Virginia Department of Health to enter abortion facilities for the
purpose of conducting inspections. "Such entries and inspections shall be made with the

permission of the owner or person in charge, unless an inspection warrant is obtained

after denial of entry from an appropriate circuit court." 12 Va. Admin. Code § 5-412-90.
It further provides that "[i]f the owner, or person in charge, refuses entry, this [refusal]
shall be sufficient cause for immediate revocation or suspension ofthe license." Id.
Such license suspension shall be indefinite in duration, until the commissioner

"determines that the conditions upon which suspension was based have been corrected

and the interest ofthe public will not be jeopardized by resumption of operation." 12 Va.
Admin. Code § 5-412-130(C).

In their respective motions for summary judgment. Plaintiffs seek judgment only

on Counts III and IV of their Amended Complaint. Defendants seek summary judgment
on Counts I-IV as well as Counts VII and VIII. In fashioning any remedies that are

appropriate in this case, the Court's hand will be guided by the wisdom ofthe Supreme

Court in Ayotte v. Planned Parenthood ofN. New Eng., 546 U.S. 320(2006). "Generally
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speaking, when confronting a constitutional flaw in a statute, we try to limit the solution

to the problem. We prefer ... to enjoin only the unconstitutional applications of a statute
while leaving other applications in force, or to sever its problematic portions while
leaving the remainder intact." Id. at 328-29 (internal citations omitted). This Court will

hue closely to this sage principle unless the invalidation of any single element of a statute
or regulation affects its constitutionality in its entirety.
III.

STANDARD OF REVIEW

The standard for review of cross-motions for summary judgment is well-settled in
the Fourth Circuit:

On cross-motions for summary judgment, a district court should "rule upon
each party's motion separately and determine whether summary judgment
is appropriate as to each under the [Federal Rule of Civil Procedure] 56
standard." Summary judgment is appropriate only ifthe record shows
"there is no genuine issue as to any material fact and that the movant is
entitled to judgment as a matter of law."

Norfolk S. Ry. Co. v. City ofAlexandria,608 F.3d 150, 156(4th Cir. 2010)(alteration in
original)(first quoting MonumentalPaving & Excavating, Inc. v. Pa. Mfrs. Ass'n Ins.
'
Co., 176 F.3d 794,797(4th Cir. 1999), and then quoting Fed. R. Civ. P. 56(c)).
The relevant inquiry in the summary judgment analysis is "whether the evidence

presents a sufficient disagreement to require submission to a [trier offact] or whether it is

so one-sided that one party must prevail as a matter oflaw." Anderson v. Liberty Lobby,

Inc., 477 U.S. 242, 251-52(1986). Once a motion for summary judgment is properly
made and supported, the opposing party has the burden ofshowing that a genuine factual

dispute exists. See Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574,

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585-86(1986). "[T]he mere existence ofsome alleged factual dispute between the
parties will not defeat an otherwise properly supported motion for summary judgment;
the requirement is that there be no genuine issue of material fact." Anderson, All U.S. at
247-48(emphasis in original). A material fact is one that might affect the outcome of a

party's case. Id. at 248;JKCHolding Co. LLC v. Wash. Sports Ventures, Inc., 264 F.3d
459, 465 (4th Cir. 2001). A genuine issue concerning a material fact only arises when the

evidence, viewed in the light most favorable to the non-moving party, is sufficient to
allow a reasonable trier of fact to return a verdict in the party's favor. Id.
To defeat an otherwise properly supported motion for summary judgment, the
non-moving party must rely on more than conclusory allegations,"mere speculation or
the building of one inference upon another" or "the mere existence of a scintilla of

evidence" concerning a material fact. Stone v. Liberty Mut. Ins. Co., 105 F.3d 188, 191

(4th Cir. 1997)(first quoting Beale v. Hardy,769 F.2d 213,214(4th Cir.1985), and then

quoting Anderson, All U.S. at 252). Accordingly, to deny a motion for summary
judgment,"[t]he disputed facts must be material to an issue necessary for the proper
resolution ofthe case, and the quality and quantity ofthe evidence offered to create a
question of fact must be adequate

" Thompson Everett, Inc. v. Nat'I Cable Adver.,

L.P., 57 F.3d 1317, 1323 (4th Cir. 1995){citing Anderson All U.S. at 252). "Thus, if the

evidence is 'merely colorable' or 'not sufficiently probative,' it may not be adequate to
oppose entry ofsummary judgment." Id. {ciXmg Anderson, All U.S. at 249-50). Of
course, the Court cannot weigh the evidence or make credibility determinations in its

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summary judgment analysis. See Williams v. Staples, Inc., 372 F.3d 662,667(4th Cir.
2004).
IV.

DISCUSSION

This Court's analysis ofthe parties' cross-motions for summary judgment begins

by restating the seminal language ofRoe v. Wade describing abortion in early pregnancy
as relatively safe, but not without risk. 410 U.S. 113, 149(1973). The Court in Roe
stated:

The State has a legitimate interest in seeing to it that abortion, like any
other medical procedure, is performed under circumstances that insure
maximum safety for the patient. This interest obviously extends at least to
the performing physician and his staff, to the facilities involved, to the
availability of after-care, and to adequate provision for any complication or
emergency that might arise.... Thus, the State retains a definite interest in
protecting the woman's own health and safety when an abortion is
proposed at a late stage of pregnancy.
Id. at 150.

The State, however, may not place a substantial obstacle in the path of a woman's
choice to exercise her substantive due process right to abortion care. But as Casey
counsels, courts must assess the burdens that a law imposes against the benefits that the

law confers. 505 U.S. at 887. Moreover, while this Court must review the legislative
fact-finding ofthe Virginia General Assembly under a differential standard, it must not

"place dispositive weight on [the legislature's] findings." Gonzales v. Carhart, 550 U.S.
124, 165 (2007).

Counts I-IV ofthe Amended Complaint appear to be the epicenter ofthe
controversy in this case. However, because both Plaintiffs and Defendants have moved

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for summary judgment with respect to Counts III and IV,the Court will address those
counts first. The Court will then address Counts I and II, to then be followed by Counts
VII and VIII.

A. Counts III and IV: The Hospital Requirement and Physician-Only Law
Count III challenges the requirement that second trimester abortions be

"performed in a hospital licensed by the State Department of Health or operated by the
Department of Behavioral Health and Developmental Services." Va. Code Ann. § 18.273. In addition, the statute permits such procedures to be performed by a licensed
physician during the second trimester and prior to the third trimester. Id. Count IV is

closely allied with Count III, but focuses on Va. Code Ann. § 18.2-72, which states that
[I]t shall be lawful for any physician licensed by the Board of Medicine to
practice medicine and surgery, to terminate or attempt to terminate a human
pregnancy or aid or assist in the termination of a human pregnancy by
performing an abortion or causing a miscarriage on any woman during the
first trimester of pregnancy.

Va. Code Ann. § 18.2-72. If an abortive procedure conducted in Virginia does not
conform with either ofthe exceptions provided for in § 18.2-72 and § 18-2.73, then that
conduct is punishable as a Class 4 felony under Va. Code Ann. § 18.2-71.'' Plaintiffs
argue that these superannuated regulations are unconstitutional.

^ Defendants point out that the penalty provisions have been in place for 44 years,"yet Plaintiffs
have identified only four instances where an illegal abortion was prosecuted at all, and only one
ofthose cases related to the failure to perform an abortion in a hospital...." (Defs.' Mem.
Supp. Mot. Summ. J. 14, ECF No. 85.) Absence of active enforcement, however, does not mean
that prosecutors do not have the discretion to enforce the statute ifthey deem appropriate.
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Common to both Counts III and IV is the issue of whether the Hospital

Requirement and Physician-Only Law, both individually and collectively, place an undue
burden on regional access to second trimester abortion services and care. Plaintiffs'
argument, in significant part, focuses on the paucity of facilities providing second

trimester care in certain portions of Virginia. It appears to be undisputed that only two
facilities in the Commonwealth of Virginia meet the strict licensing requirements of an
outpatient surgical hospital authorized to perform second trimester abortions. The
Virginia Beach facility provides second trimester abortions two days per week—

Tuesdays and Fridays. The second facility is the Virginia Commonwealth University
Medical Center("VCU")in Richmond. VCU allows second trimester abortion

procedures in its operating room one day per week. (Pis.' Mem. Supp. Mot. Partial
Summ. J. lO-l 1, ECF No.95; Defs.' Mem. Supp. Mot. Summ. J. 5-6.) Plaintiffs add

that because VCU is also a trauma center, care ofsecond trimester abortion patients is
often delayed because other patients requiring emergency care take priority. Plaintiffs
add that these limitations on the VCU facility often require second trimester abortion

patients to wait for extended periods oftime, and they also put second trimester abortion
patients at risk of"being cared for by staff not specialized in abortion care." (Pis.' Mem.
Supp. Mot. Partial Summ. J. 10-11.)

In their declarations accompanying Plaintiffs' Reply Memorandum,a number of

witnesses reinforce Plaintiffs' contentions. Paulette McElwain("Ms. McElwain"),
President and CEO at Virginia League ofPlanned Parenthood("VLPP"), explained that
VLPP facilities are experiencing an increased volume of women seeking first trimester
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abortions. "Although we try to treat patients before they pass the gestational age cut-off
for medication abortion or for a first-trimester procedure, we are currently unable to do so
in every case." (Pis.' Reply Mem.,Ex. 1 at 1-2, ECF No. 110.)

With respect to the availability of second trimester (pre-viability) abortions. Dr.
Shanthi S. Ramesh ("Dr. Ramesh"), a practicing obstetric and gynecological physician,
stressed the necessity for additional facilities offering second trimester abortion services.
She also testified that if additional facilities offering second trimester services were
available,"it would mean more access to second trimester abortion earlier in the second

trimester rather than pushing women out until later in the second trimester where,
although the risks are low,they do go up every week of gestation." (Pis.' Reply Mem.,
Ex. 3 at 165.)

On the other hand. Defendants counter that Virginia women seeking pre-viability
abortions are, in their view, amply served by the licensed physicians and facilities
providing that service. Defendants point out that there are fully staffed facilities located

in Falls Church, Charlottesville, Virginia Beach, and Richmond, Virginia(Defs.' Mem.
Supp. Mot. Summ. J. 8-10); however, the majority of facilities noted by Defendants

provide only first trimester abortion care. While Plaintiffs express concern about the
availability of facilities for first trimester abortions, the primary focus of Count III is the

availability of pre-viability second trimester abortion services.^

^ Defendants also contend that "there are over 100 licensed hospitals in the Commonwealth in
which abortions can be legally performed." (Defs.' Mem. Supp. Mot. Summ. J. 4.) Absent from
the record, however,is any indication of what, if any, requirements such hospitals have for
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An additional consideration in the benefits versus burden equation is whether the
potential risk of significant complications in pre-viability second trimester abortion
procedures warrants the need for hospitals that provide second trimester abortion care to
qualify as outpatient surgical facilities. Dr. Ramesh testified that the risks of

complications are low, but they "go up every week of gestation." (Pis.' Reply Mem.,Ex.
3 at 165.) Furthermore, in her Rule 26(a)(2)(c) report. Dr. Elizabeth R. Lunsford ("Dr.

Lunsford"), a board-certified obstetrician and gynecologist with eight years of experience
providing contraceptive, labor and delivery, prenatal, postnatal, ectopic pregnancy, and

miscarriage care, offered the following evaluation of potential complications encountered
during second trimester abortion procedures.

As for the requirement that second trimester abortions be performed in a
hospital, this is prudent as complications rise progressively with gestational
age
Second trimester abortions carry potential for hemorrhage,
cervical lacerations, uterine perforation with subsequent injury to bowel,
blood vessels and the renal tract, retained products of conception, and
infection.... At this rate, it is possible for a woman to become
exsanguinated (lose all of her blood) within 10 minutes, which would not

allow time for transfer to a hospital facility if the procedure was being
performed in a clinic setting. This highlights the necessity ofthe hospital
requirement, ensuring physician access to additional resources and staffing
at a hospital in case any unexpected complications rapidly develop.
(Defs.' Reply, Ex. 1 at 17, ECF No. 109.) This appears to be a material issue in dispute
with respect to second trimester procedures.

Plaintiffs contend that the burden imposed by the Hospital Requirement is

significantly compounded by the Physician-Only Law. According to the deposition

elective abortion procedures, or whether Virginia women are even able to have an elective
abortion procedure in those hospitals.
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testimony of Dr. Ramesh and Ms. McElwain, these provisions, in tandem, significantly
limit the availability of abortion care in underserved areas of Virginia, citing the City of
Hampton as an example. (Pis.' Mem. Opp'n Defs.' Mot. Summ. J., Ex. G at 183, ECF
No. 106; Pis.' Mem. Opp'n Defs.' Mot. Summ. J., Ex. B at 24-25.) As mentioned above,

only two facilities in Virginia offer second trimester abortions, and they do so on a

limited basis. (Pis.' Mem. Opp'n Defs.' Mot. Summ. J., Ex. B at 24,28.)
Relying on the testimony of their medical experts. Plaintiffs also point out that
"[i]n Virginia, procedures with risks comparable to or higher than the risks from

abortion—including endometrial biopsy, colposcopy, hysteroscopy (scoping ofthe cervix

and uterus). Loop Electrosurgical Excision Procedure("LEEP")(removing pre-cancerous
cells from the cervix), and dilation and curettage from miscarriage management—are
routinely performed in outpatient clinics and physicians' offices." (Pis.' Mem. Supp.
Mot. Partial Summ.J. 8.)

Plaintiffs' medical experts are also ofthe opinion that APCs "are fully capable of
performing the two most common forms of abortion—medication and aspiration
abortion—in Virginia as they do elsewhere." {Id. at 5.) Dr. Lunsford testified in her

deposition that APCs provide medical care with complication rates as low as physicians.
(Defs.' Mem. Supp. Mot. Summ. J., Ex. 13 at 310:2-6.) She further testified that APCs

can prescribe almost every medication that a licensed physician could prescribe. {Id. at
310:11-20.) Dr.Lunsford also opined that there is no medical reason why an APC could

not be trained to provide first trimester abortions. {Id.) The capability of APCs to
perform first trimester abortions does not appear to be in serious dispute, but that does not
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necessarily mean that restrictions on APCs performing such procedures is an
unconstitutional burden. See June Med. Sers., LLC. v. Gee,905 F.3d 787, 803(5th Cir.
2018).

As this Court noted in its Memorandum Opinion addressing Defendants' Motion

to Dismiss under Fed. R. Civ. P. 12(b)(6), if waged by Plaintiffs as a facial challenge,
their argument with respect to APCs could face a formidable arsenal of countervailing
authority. As the Court in Casey reiterated, "[o]ur cases reflect the fact that the

Constitution gives the States broad latitude to decide that particular functions may be

performed only by licensed professionals

" 505 U.S. at 885. This position was

restated by the Supreme Court in Mazurek v. Armstrong,520 U.S. 968,974(1997).

Plaintiffs' challenge, however, is more narrowly focused to the specific application ofthe
Physician-Only Law to access abortion care in the Commonwealth of Virginia.
Both parties agree that the constitutionality ofthe abortion restrictions at issue in

this case must be reviewed by applying the undue burden test articulated by the Supreme

Court in Casey. The Court in Casey reaffirmed a woman's right to terminate a pregnancy
prior to viability. It also recognized a state's legitimate interest in ensuring that abortion
is performed under circumstances that ensure the maximum safety for the patient. Roe v.
Wade,410 U.S. 113, 150. The Court in Casey, however, emphasized that "a statute

which, while furthering ...[a] valid state interest, has the effect of placing a substantial
obstacle in the path to a woman's choice cannot be considered a permissible means of
serving its legitimate ends." Casey, 505 U.S. at 877. The Court defined an undue burden

as "shorthand for the conclusion that a state regulation has the purpose or effect of
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placing a substantial obstacle in the path of a woman seeking an abortion of a non-viable
fetus." Id. The Casey Court also observed that "the incidental effect of making it more
difficult or more expensive to procure an abortion", standing alone, is generally
insufficient to invalid an abortion regulation. Id. at 874. As with any medical procedure,

the State may enact regulations to further the health or safety of a woman seeking an
abortion. Id. at 878.

As Plaintiffs point out, reviewing courts have an "independent, constitutional
duty" to closely review a state's assertions concerning the benefits of abortion

restrictions. Whole Woman's Health, 136 S. Ct. at 2310(quoting Gonzales, 550 U.S. at
165). Applying the teachings of Casey, the Court in Whole Woman's Health restated that
"[u]nnecessary health regulations that have the purpose or effect of presenting a
substantial obstacle to a woman seeking an abortion impose an undue burden on the
right." Id. (quoting Casey, 505 U.S. at 878).

Focusing more closely on the issue of availability oflicensed physicians to serve
Virginia women seeking pre-viability abortions, Defendants take issue with Plaintiffs'

assessment. In her deposition testimony, Rosemary Codding("Ms. Codding"), Director

ofthe Falls Church Health Care Center("Falls Church facility"), indicated that her staff

included four physicians who perform medication and aspiration procedures. Ms.
Codding further testified that the Falls Church facility had no waiting list and that most

women seeking an abortion are seen within 24 hours. (Pis.' Mem. Opp'n Defs.' Mot.
Summ. J., Ex. E at 41:15-42:1; 95:16-22.)

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Amy H. Miller("Ms. Miller"), representing Whole Woman's Health Alliance,

testified in her deposition that their Charlottesville facility has physicians available to
provide abortion services. Plaintiff Dr. Doe is among them. Like the Falls Church

facility, the Charlottesville facility has no waiting list. (Pis.' Notice Submission of Exs.,
Ex. I at 15:7-9, 50:9-11, ECF No. 107.)

Ms. McElwain,President of VLPP, described her organization as providing health
care to approximately 3,000 patients in the Richmond area. (Pis.' Mem. Opp'n Defs.'
Mot. Summ. J., Ex. B at 99:19-100:22.) According to Ms. McElwin, VLPP has four
staff physicians to perform first and second trimester abortions—^two in Richmond and

two in Virginia Beach. First trimester medication abortions are offered Monday through
Friday at each VLPP facility. (Pis.' Mem. Opp'n Defs.' Mot. Summ. J. 2.) The
Richmond VLPP facility provides first trimester surgical abortions up to two and a half
days a week. {Id.) Second trimester surgical abortions are available on Fridays at VCU
in Richmond. {Id.) In Virginia Beach, VLPP physicians perform first and second
trimester surgical abortions on Tuesdays and Fridays. {Id.)
Assuming, without deciding, that the number and geographic distribution of
facilities providing abortion care are sufficient without posing a significant undue burden,

the record evidence fails to demonstrate a scarcity of physicians available to perform first
or second trimester abortion procedures at any ofPlaintiffs' clinical facilities. Each

appears to be amply staffed. Plaintiffs argue, however, perhaps persuasively, that such
procedures could be capably performed by APCs or other nurse practitioners. Plaintiffs
contend that "[a]bortion is one ofthe safest medical procedures available today." (Pis.'
18

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Mem. Supp. Mot. Partial Summ. J. 3.) They further explained that there are two basic
abortion methods—oral medication and surgical abortion procedure. {Id.) Abortion by

medication is typically available in the first trimester of pregnancy. It culminates in an
experience similar to a miscarriage, which typically occurs after the patient leaves the
clinic. It can be performed up to ten weeks after the first day ofthe patient's last

menstrual period and usually entails taking two medications. {Id.) There appears to be
no controversy between the parties that APCs are competent and capable of performing

first trimester abortions less expensively in a non-hospital setting.
Turning to surgical abortion, there are two forms—aspiration, and dilation and

evacuation. {Id. at 4.) These two procedures can be utilized in the first and early second

trimester of pregnancy. Surgical abortions need not be performed in a sterile operating
room. {Id.) It is reasonable to assume that providing abortion services offered by APCs

would be less expensive, but the present record evidence fails to support the argument
that there are insufficient physicians available to perform pre-viability second trimester
procedures in existing abortion clinics.

On the other hand, the burden imposed by the Physician-Only Law must be

weighed against the potential benefit to the abortion patient who experiences
complications. As Dr. Lunsford explained during her deposition, some APCs with
adequate training could capably perform first trimester abortions, but "I don't believe

their training would support them managing complications." (Defs.' Mem. Supp. Mot.
Summ. J., Ex. 13.) See W. Ala. Women's Ctr. v. DonaldE. Williamson, 900 F.3d 1310

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(11th Cir. 2018)(describing the great technical skills required in performing dilation and
evacuation abortions and the possible complications that can arise).
Applying the burden versus benefits analysis to the record at hand, this Court finds

that there is no genuine issue of material fact as to whether the Physician-Only Law poses
a substantial burden on a woman's access to first trimester abortion care. Conversely, the

present record is sufficient for this Court to conclude, beyond peradventure, that there is

no genuine issue that potential complications in performing second trimester abortions
may arise that may warrant the judgment and skills that a physician can best provide. As
the Supreme Court recognized in Roe v. Wade, states have "a legitimate interest in seeing

to it that abortion, like any other medical procedure, is performed under circumstances
that insure maximum safety for the patient." 410 U.S. at 150. As the Court further

explained in Roe,"the State retains a definite interest in protecting the woman's own
health and safety when an abortion is proposed at a later stage of pregnancy." Id. This
appears to be particularly true with respect to pre-viability second trimester abortions.

Plaintiffs have failed to produce or plausibly forecast evidence indicating that the
Physician-Only Law places a substantial obstacle in the path of a woman's access to safe
pre-viability second trimester abortion care.

Therefore, based on the foregoing analysis, the Court will deny Plaintiffs' and

Defendants' Motions for Summary Judgment as to Count 111. Regarding Count IV,the
Court will grant Plaintiffs' Motion for Partial Summary Judgment in part—^that is, as it
pertains to first trimester abortions—and deny it regarding second trimester abortions.

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Accordingly, Defendants' Motion for Summary Judgment on Count IV will be denied as
to first trimester abortions and granted as to second trimester abortions.
B. Counts I and II: The Licensing Statute and Licensing Regulations

Next, the Court turns to the questions raised in Counts I and II, which focus on the
Licensing Statute, Va. Code Ann. § 32.1-127(B)(1), and the Licensing Regulations set
forth in 12 Va. Admin. Code § 5-412, et seq. The statute at issue in Count I prescribes
the minimum standards for medical facilities, including hospitals. In pertinent part, it
defines "facilities in which five or more first trimester abortions per month are performed
... as a category of'hospital.'" Va. Code Ann. § 32.1-127(B)(l)(v). The Licensing
Regulations, the focus of Count II, prescribe the minimum standards that first trimester
abortion facilities must meet in order to receive licensure. Because many of the issues

and evidence pertinent to Counts III and IV are likewise relevant to Counts I and II, the
Court draws on the analysis already discussed above.

Particularly enlightening to Counts I and II is the deposition ofDr. M.Norman
Oliver("Dr. Oliver"), who serves as the Commissioner ofthe Virginia Department of
Health("VDH"). Dr. Oliver testified that neither medication nor aspiration abortions

involve surgery. (Notice, Ex. Q at 143.) When asked whether it is necessary to create

regulations and minimum standards for medical facilities or physicians' offices that
provide five or more first trimester abortions per month in order to protect the health of
the woman and insure high quality care, the Commissioner gave the following answer:
"[I]n my own personal opinion, abortion services are outpatient services that do not need
to be regulated in the same way as, say, surgical procedures." (Id. at 175-76.)
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Dr. Oliver was next asked whether these minimum standards for medical facilities,

which form the basis of Counts I and II of the Amended Complaint, further the health and
safety of women in Virginia. Dr. Oliver again expressed his personal view:"I think it
restricts access to abortion care ...I can't tell you how detrimental it is, but I don't feel
that it's in the interest of women." {Id. at 200.)

Another integral component ofthe burden analysis is the Licensing Statute, Va.
Code Ann. § 32.1-127(B)(1), mentioned by Dr. Oliver above and its relation to the

Licensing Regulations. Plaintiffs argue that as a result of being classified as a hospital
pursuant to § 32.1-127(B)(1), first trimester abortion facilities are needlessly subjected to

oppressive regulatory requirements, such as record keeping, equipment, personnel, and

compliance requirements. Plaintiffs add that a number of the Defendants' own expert
witnesses conceded that facility licensure has not made first trimester abortion safer in
Virginia. (Pis.' Mem. Opp'n Defs.' Mot. Summ. J. 21-22.) Furthermore, a number of

Plaintiffs' witnesses are ofthe opinion that the Licensing Statute and Regulations were
adopted to curtail access to legal abortion care. {Id.) Conspicuously apparent is the fact
that, since the statute was adopted by the Virginia General Assembly, there has been a
significant reduction in the number of abortion care facilities in Virginia. {Id. at 22.)

Whether there is a direct causal effect between the Licensing Statute and Regulations and
the closure ofthese abortion care facilities is a genuine dispute offact.
Defendants offer minimal evidentiary opposition to Plaintiffs' contention that the

regulatory scheme at issue fails to enhance the safety of first trimester abortions.

Defendants focus their opposition on the lack of any cogent evidence that the Licensing
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Statute and Regulations, while clearly inconvenient to abortion providers, has actually
"impose[d] any burden on the right of women to choose a pre-viability abortion." (Defs.'
Mem. Supp. Mot. Summ. J. 23.) Defendants also point out that irrespective ofthe
Licensing Statute, the Virginia Board of Health is empowered to adopt similar
regulations. {Id.)

Plaintiffs have clearly demonstrated that the regulatory requirements mandated
pursuant to Va. Code Ann. § 32.1-127(B)(1) and 12 Va. Admin. Code 5-412 etseq. are

not medically necessary to ensure safe first trimester abortion care. However,the opinion
evidence of abortion providers that the regulations significantly burden women seeking
first trimester abortion care is thin, particularly when squared with other evidence that

most facilities offering such services have a minimal waiting period. {Id. at 4-5.) The
actual burden imposed by § 32.1-127(B)(1) and 12 Va. Admin. Code 5-412 etseq. is a
material fact in dispute.

Plaintiffs also advance a plausible argument that regulatory burdens may limit the

availability of pre-viability second trimester abortions in portions of Virginia. Unlike

first trimester abortions, pre-viability second trimester abortions must be performed in an
outpatient surgical center. Still, the record at hand is inadequate for the Court to
determine the number of women who have been significantly burdened by limited
availability of such services. Several of Plaintiffs' witnesses described clinics as full to

capacity at times, but not all women were seeking abortion care. (Defs.' Mem. Opp'n
Pis.' Mot. Partial Summ. J., Ex. 7 at 62-63, BCF No. 105.) However,some ofPlaintiffs'

deponents also conceded on cross-examination that they had not consulted with any
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Virginia-based women before forming their opinion on the burden resulting from the
alleged limited availability. (Defs.' Mem. Opp'n Pis.' Mot. Partial Summ. J., Ex. 11 at

96-97.) Furthermore, this Court cannot assess the number of women residing in the
Commonwealth who choose to seek such abortion care or services in nearby adjoining
states or the District of Columbia. Accordingly, the absence of a more complete

evidentiary record at this point in the litigation, coupled with the multiple disputes
enumerated above, counsels this Court against granting Defendants' Motion for

Summary Judgment on Counts I and 11.^
C. Count VII: Plaintiffs' Challenge the Hospital Requirement as being
Unconstitutionally Vague

In Count VII ofthe Amended Complaint, Plaintiffs state that the "Hospital
Requirement, in conjunction with the Criminalization Laws, is unconstitutionally vague
and violates Plaintiffs' rights to due process as guaranteed by the Fourteenth Amendment
to the U.S. Constitution ...." (Am. Compl. H 266.) Plaintiffs contend that Count VII

should proceed to trial because disputed facts exist regarding the Hospital Requirement's
vagueness (Pis.' Mem. Opp'n Defs.' Mot. Summ. J. 16), while Defendants argue that
Count VII is without merit(Defs.' Mem. Supp. Mot. Summ. J. 13.) Noting that Count
VII raises a legal question, the mere fact that the parties dispute whether the statute is

vague does not prevent the Court from resolving the question at this stage. See United

^ In the event that this Court were to find that certain regulations do impose an undue burden on
the access to abortive procedures. Defendants contend that various statutes and regulations
require the severance ofindividual, offending regulations, rather than striking the entire
regulatory scheme. Addressing this question is premature and the Court will await a more

complete record to determine ifthe regulatory scheme is in fact unduly burdensome.
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States V. Bronstein, 849 F.3d 1101, 1106(D.C. Cir. 2017)(explaining that a question of
statutory vagueness is a "pure question oflaw"(citing Hodge v. Talkin, 799 F.3d 1145,
1171 (D.C. Cir. 2015))).

"Our first step in interpreting a statute is to determine whether the language at

issue has a plain and unambiguous meaning with regard to the particular dispute in the
case. Our inquiry must cease ifthe statutory language is unambiguous and 'the statutory
scheme is coherent and consistent.'" Robinson v. Shell Oil Co., 519 U.S. 337, 340(1997)
(quoting United States v. Ron Pair Enter., Inc., 489 U.S. 235,240(1989)). As a matter

of law,"[a] statute is impermissibly vague if it either(1)'fails to provide people of
ordinary intelligence a reasonable opportunity to understand what conduct it prohibits' or
(2)'authorizes or even encourages arbitrary and discriminatory enforcement.'" United
States V. Shrader, 675 F.3d 300, 310(4th Cir. 2012)(quoting Hill v. Colorado,530 U.S.
703, 732(2000)). Evaluating a statute against these standards does not require,"perfect
clarity and precise guidance," Ward v. Rock Against Racism, 491 U.S. 781, 794(1989);
rather, a court considers whether the statute's prohibitions "are set out in terms that the

ordinary person exercising ordinary common sense can sufficiently understand" and
abide by them. Shrader,675 F.3d at 310(quoting U.S. Civil Serv. Comm 'n v. Nat'I Ass'n
ofLetter Carriers, 413 U.S. 548, 579(1973)).

As stated above, Virginia law criminalizes the provision of an abortion as a Class

4 felony. See Va. Code Ann. 18.2-71. The law, however, provides multiple exceptions,
such as an exception for licensed physicians who administer first trimester abortions, see
Va. Code Ann. § 18.2-72, as well as an exception for abortions after the second trimester
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where the mother's life is at risk, see Va. Code § 18.2-74. The Hospital Requirement,

§ 18.2-73, which Plaintiffs challenge as being vague, provides an exception to § 18.2-71

for licensed physicians who conduct second trimester abortions in a licensed hospital. It
states:

Notwithstanding any ofthe provisions of§ 18.2-71 and in addition to the
provisions of§ 18.2-72, it shall be lawful for any physician licensed by the
Board of Medicine to practice medicine and surgery, to terminate or
attempt to terminate a human pregnancy or aid or assist in the termination
of a human pregnancy by performing an abortion or causing a miscarriage
on any woman during the second trimester of pregnancy and prior to the
third trimester of pregnancy provided such procedure is performed in a
hospital licensed by the State Department of Health or operated by the
Department of Behavioral Health and Developmental Services.
Va. Code Ann. § 18.2-73 (emphasis added). Plaintiffs contend this statute is vague
because it fails to define two terms: "hospital" and "second trimester." "In most
instances,'[s]tatutory definitions control the meaning of statutory words.'" United States
V. Goforth, 546 F.3d 712, 714(4th Cir. 2008)(quoting Lawson v. Suwannee Fruit <St S.S.
Co., 336 U.S. 198, 201 (1949)). In the event that a statutory term is not defined by

statute, then a reviewing court looks to other sources for clarity. See id. Consequently,
because these terms are not defined by § 18.2-73, the Court must look to other areas of
Virginia law.

The Code of Virginia defines "hospital" as follows:
"Hospital" means any facility licensed pursuant to this article in which the
primary function is the provision of diagnosis, oftreatment, and of medical
and nursing services, surgical or nonsurgical, for two or more nonrelated
individuals, including hospitals known by varying nomenclature or
designation such as children's hospitals, sanatoriums, sanitariums and
general, acute, rehabilitation, chronic disease, short-term, long-term,
outpatient surgical, and inpatient or outpatient maternity hospitals.
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Va. Code Ann. § 32.1-123. In Simopoulos v. Virginia, the U.S. Supreme Court applied
this statutory definition of hospital to Va. Code Ann. § 18.2-73. See 462 U.S. 506, 512
n.4(1983)("There is no basis for assuming that the [Supreme Court of Virginia]

interpreted 'hospital' in § 18.2-73 any differently from its interpretation in title 32.1 and

specifically in § 32.1-123.1").^® Accordingly, and consistent with the U.S. Supreme
Court, this Court will apply the definition of"hospital" in § 32.1-123 to determine if
§ 18.2-73 is vague.

Regarding "second trimester," the term is not explicitly defined by a Virginia
statute. However, the term's meaning can be ascertained by looking to Virginia's

Administrative Code, which states that "[ajbortions performed in abortion facilities shall

be performed only on patients who are within the first trimester of pregnancy meaning 13
weeks and 6 days after last menstrualperiod or based on an appropriate clinical estimate
by a licensed health care provider." 12 Va. Admin. Code § 5-412-230(A).^^
Accordingly, it logically follows that the second trimester of pregnancy, as defined under

Virginia law, begins at 14 weeks after last menstrual period.

In Simopoulos,the U.S. Supreme Court referred to the statute as "32.1-123.1," merely to
indicate that "hospital" was defined in the first subparagraph of § 32.-1-123 (1979).

The Amended Complaint applies this same language, stating that "only two facilities regularly
provide abortion care in the second trimester, which Virginia defines as more than 13 weeks,6

days after a patient's last menstrual period

"(Am. Compl. ^11.) Thus, it appears that

Plaintiffs' pleading contradicts itself by referencing a Virginia definition for "second trimester"

in paragraph 11, while subsequently claiming that the term is not defined in paragraph 266. The
Court need not resolve this contradiction to resolve the matter at hand.
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Applying Virginia's definitions of"hospital" and "second trimester," Plaintiffs'

facilities are properly classified as hospitals because they provide medical services to two

or more non-related individuals.^^ See Va. Code Ann. § 32.1-123. Therefore, because
their facilities are classified as hospitals. Plaintiffs' facilities can provide second trimester
abortions—^that is, an abortion 14 weeks after a woman's last menstrual period and before

the third trimester—^without triggering Virginia's felony abortion statute. See Va. Code

Ann. §§ 18.2-71, 18.2-73. However, whether applicable state regulations permit
Plaintiffs to provide second trimester abortions is an entirely different question.
Compare Va. Code Ann. §§ 18.2-71, 18.2-73 with 12 Va. Admin. Code § 5-412-230(A).
While it is not a felony for Plaintiffs to provide second trimester abortions in their

abortion facilities, the State Board ofHealth, by regulation, does not permit second
trimester abortions to be performed in those facilities. See 12 Va. Admin. Code § 5-412230(A)("Abortions performed in abortion facilities shall be performed only on patients
who are within the first trimester of pregnancy meaning 13 weeks and 6 days after last
menstrual period or based on an appropriate clinical estimate by a licensed health care
provider."(emphasis added)). As previously stated, second trimester abortions must be

administered in an outpatient surgical hospital. See 12 Va. Admin. Code § 5-412-40
("Facilities licensed as either a general hospital or an outpatient surgical hospital by the
department are not subject to the provisions of this chapter.").

Classifying Plaintiffs' facilities as hospitals is also consistent with the Licensing Statute,
§ 32.1-127(B)(1), which states that "facilities in which five or more first trimester abortions per
month are performed shall be classified as a category of"hospital."' Va. Code Ann § 32.1127(B)(1).
28

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Therefore, reading the Hospital Requirement and the Licensing Regulations
together, it is not a felony for Plaintiffs to provide second trimester abortions in their

facilities, but they risk a loss of licensure if they do so. In addition, failure to abide by the

Licensing Regulations may result in criminal misdemeanor charges. See Va. Code Ann.
§ 32.1-27(A). As a matter of law, the Court finds that § 18.2-73's language is not vague,
and that persons of ordinary intelligence can understand its distinction and thereby avoid
potential civil and criminal penalties.

Plaintiffs' arguments to the contrary are unavailing. First, Plaintiffs suggest that
these "contradictory statutory definitions and regulations" indicate that Plaintiffs' first

trimester abortion facilities do not qualify as hospitals. (Pis.' Suppl. Mem.2, ECF No.
121.) To the extent that this argument even addresses whether § 18.2-73 is

unconstitutionally vague. Plaintiffs offer no binding authority which definitively supports
their position.

Second, Plaintiffs argue that § 32.1-124 exempts their facilities from being

classified as a "hospital" because modem abortive procedures are generally not

considered to be surgical procedures.'^ Again,to the extent this argument addresses the
vagueness of § 18.2-73, the argument fails because the statutory definition of"surgery"
cited by Plaintiffs does not apply to Title 32.1 as it is explicitly restricted in that

Section 32.1-124 states in relevant part that "[t]he provisions of §§ 32.1-123 through 32.1-136
shall not be applicable to ... an office of one or more physicians or surgeons unless such office
is used principally for performing surgery " Va. Code Ann. § 32.1-124(v)(emphasis
added).

29

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subsection.''^ See Dolan v. U.S. Postal Serv., 546 U.S. 481,486(2006)("The definition
of words in isolation, however, is not necessarily controlling in statutory construction

Interpretation of a word or phrase depends upon reading the whole statutory text,
considering the purpose and context ofthe statute, and consulting,any precedents or
authorities that inform the analysis."); see also Lawson, 336 U.S. at 201 (stating that a
statutory definition is not controlling if it would create "obvious incongruities in the
[statutory] language," that would disrupt the legislature's purpose).

Here, if the Court were to apply Plaintiffs' definition of surgery, an incongruity
would exist between § 32.1-124(v) and § 18.2-73 and § 32.1-127(B)(1). That is, ifthe

Court were to adopt Plaintiffs' view, then the Code of Virginia would explicitly classify
Plaintiffs' facilities as "hospitals"(§ 32.1-127(B)(1)) while simultaneously codifying an
exception that exempts them from this classification(§ 32.1-124(v)). The Court does not
adopt this view. Therefore, the Court finds that § 32.1-124 and § 54.1-2400.01:1 are

Section 54.1-2400.01:1 states in relevant part:

For the purposes ofthis subtitle, except as used in Chapter 38(§ 54.1-3800 et
seq.) related to veterinary medicine,"surgery" means the structural alteration of
the human body by the incision or cutting into oftissue for the purpose of
diagnostic or therapeutic treatment of conditions or disease processes by any
instrument causing localized alteration or transposition of live human tissue, but
does not include the following: procedures for the removal of superficial foreign
bodies from the human body, punctures, injections, dry needling, acupuncture, or
removal of dead tissue. For the purposes ofthis section, incision shall not mean
the scraping or brushing of live tissue.
Va. Code Ann. § 54.1-2400.01:1 (emphasis added).

Plaintiffs argue that the Court should interpret the term "surgery," as expressed in § 32.1124(v)'s exemption, consistent with the above definition, which, as the dominoes fall, would
make § 32.1-123's definition of"hospital" inapplicable to Plaintiffs' facilities. However,this

definition's explicit language, which is emphasized above, prevents the Court from extending its
definition of"surgery" to Title 32.1 ofthe Virginia Code.
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inapplicable in the immediate application. In addition, the Court finds that the general
exemption contained in § 32.1-124(v) is not sufficient to overcome the specific language
contained in § 32.1-127(B)(1). See D.B. v. Cardall, 826 F.3d 721, 736(4th Cir. 2016)

("To overcome the presumption that a specific statutory provision controls a general one,
[the legislature's] contrary intent must be "clear."(citing Crawford Fitting Co. v. J.T.
Gibbons, Inc., 482 U.S. 437, 445 (1987)).

Consequently, the Court finds that the plain language of § 18.2-73 is clear and
does not violate the Due Process Clause ofthe Fourteenth Amendment. Furthermore, the

Court finds that persons of ordinary intelligence are capable of understanding the
exception that § 18.2-73 provides and distinguishing between the potential criminal and

civil penalties that may be incurred if Plaintiffs, or other individuals, provide second
trimester abortions in a way that is inconsistent with § 18.2-73 and applicable state
regulations. Therefore, Defendants' Motion for Summary Judgment on Count Vll ofthe
Amended Complaint will be granted.

D. Count Vlll: Plaintiffs' Fourth Amendment Challenge
Count Vlll alleges that Virginia's Licensing Regulations run afoul ofthe Fourth

Amendment by requiring "biennial unannounced, warrantless inspections ofPlaintiffs'

facilities under threat of license suspension or revocation, in the absence of probable
cause to believe that any violation has occurred." (Am. Compl.^ 268.) Defendants
counter that there is no Fourth Amendment violation because Plaintiffs must "consent to

the entry of[Virginia Department of Health] inspectors prior to entry ...." (Defs.'
Mem. Supp. Mot. Summ. J. 15.) The General Assembly has codified the terms under
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which the Virginia Department of Health may enter property to perform health
inspections to ensure compliance with Virginia law under Va. Code. Ann. § 32.1-25.

According to that section, the State Health Commissioner, or his designee, enjoy a right
of entry to perform an inspection "[ujpon presentation of appropriate credentials and
upon consent ofthe owner or custodian." Va. Code Ann. § 32.1-25. If entry is denied,
the statute provides that the inspector "may apply to an appropriate circuit court for an
inspection warrant" to authorize the search. (Id.)
Pursuant to § 32.1-25, related regulations under 12 Va. Admin. Code § 5-412-90

grant the Virginia Department of Health's "duly designated employee[s]" a right of entry
to abortion facilities for the purpose of conducting inspections. 12 Va. Admin. Code § 5412-90. "Such entries and inspections shall be made with the permission ofthe owner or
person in charge, unless an inspection warrant is obtained after denial of entry from an

appropriate circuit court." Id.(emphasis added). Central to Plaintiffs' Fourth
Amendment challenge, the regulation further states,"Ifthe owner, or person in charge,
refuses entry, this [refusal] shall be sufficient causefor immediate revocation or

suspension ofthe license.'" Id.(emphasis added). Importantly, VDH performs biennial,
unannounced inspections ofPlaintiffs' facilities. (See Am.Compl.^ 268.)
"The Fourth Amendment prohibits unreasonable searches, and searches conducted

without a warrant are per se unreasonable unless a valid exception to the warrant

requirement is applicable. Voluntary consent to a search is such an exception." United
States V. Lattimore, 87 F.3d 647,650(4th Cir. 1996)(citing Schneckloth v. Bustamonte,
412 U.S. 218,219(1973)). "This rule 'applies to commercial premises as well as to
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homes.'" City ofLos Angeles v. Patel,

U.S.

, 135 S. Ct. 2443,2452(2015)

(citing Marshall v. Barlow's, Inc., 436 U.S. 307, 312(1978)). Due to the risk of

revocation or suspension of licensure as a result ofrefusing entry to inspectors under 12
Va. Admin. Code § 5-412-90, Plaintiffs contend that they are effectively coerced to
consent to warrantless VDH inspections.
Defendants argue that the Court should award summary judgment on Count VIII

because Plaintiffs consent to VDH inspections. According to Defendants, the undisputed
facts show that under the relevant Virginia statute and regulation. Plaintiffs must consent
in order for VDH inspectors to gain entry to their facilities absent a warrant. (Defs.'

Mem. Supp. Mot. Summ. J. 16-17.) Further, they cite testimony from corporate

representatives of select Plaintiffs describing the extent to which clinic representatives
understand the regulations and facilitate VDH inspections. {Id. at 17-18.)
With respect to the risk of revocation or suspension of licensure under § 5-412-90,

Defendants contend that "there is no record evidence suggesting that any ofthe Plaintiff
facilities only consented to the Department's inspection due to fear of license
revocation." {Id. at 18.) Moreover, they indicate that Plaintiffs have not identified a

single situation in which a facility's license has been impacted due to refusal of entry.
{Id. at 18-19.)

To the contrary. Plaintiffs argue that a genuine issue of material fact exists with

respect to whether Plaintiffs voluntarily consent to regulatory inspections, given the

statutory risk to licensure if they refuse access to inspectors. (Pis.' Mem. Opp'n Defs.'
Mot. Summ. J. 27-29.) According to Plaintiffs, although the regulation does not provide
33

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for the immediate revocation or suspension of a license, the potential remains under the
statute as written. (Id. at 28.) They cite several instances in which corporate

representatives for select Plaintiffs maintain that they consent to inspections in order to
avoid the risk of license revocation. (Id.) Further, they argue that Defendants have
ignored testimony by VDH and OLC officials, which Plaintiffs construe as evidence that

officials do not believe they need consent in order to enter Plaintiffs' facilities. (Id. at
28-29.)

As the Supreme Court highlighted in Casey and Whole Woman's Health, states
have a legitimate interest in ensuring that abortion care, like other medical services, are

performed "under circumstances that insure maximum safety for the patient." Whole
Woman's Health, 136 S. Ct. at 2309; Casey, 505 U.S. at 877. In order to maintain this
standard, some level ofregulatory oversight is necessary. The State Board of Medicine

has a statutory obligation to ensure that medical procedures are administered competently

and under sanitary conditions. See Va. Code Ann. § 32.1-25. Compliance with such
regulatory oversight is a common condition of licensure to perform medical related
services. See Va. Code Ann. § 32.1-25.

While Plaintiffs broadly question the constitutionality ofthe entire regulatory

compliance regime, their sight is focused primarily on the required consent to inspection

provision, which they allege is coercive and unduly burdensome. Obviously to prevail on
Count VIII, Plaintiffs must demonstrate more than mere inconvenience and discontent.

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Although the Commonwealth has a compelling interest in regulating abortion care,
that function must be carried out in a constitutionally permissible manner. Whether it has
done so in practice must await the development of a more complete factual record at trial.
Defendants also raise an issue as to Plaintiffs' standing to assert the Fourth
Amendment rights oftheir patients, to which Plaintiffs lodge their objection. (Defs.'

Mem. Supp. Mot. Summ. J. 19; Pis.' Mem. Opp'n Defs.' Mot. Summ. J. 29.) While
Plaintiffs' right to assert their patients' Fourth Amendment rights may raise an arguable
question. Plaintiffs clearly have a protectable expectation of privacy as to their premises
and required patient records. Accordingly, the Court will deny Defendants' Motion for
Summary Judgment as to Count VIII.
V.

SUMMARY

In reviewing the parties' well-crafted Motions for Summary Judgment, this Court

is mindful ofthe significance of the controversy before it. It also acknowledges that the
constitutionality of a woman's right to seek a pre-viability abortion is a settled

constitutional issue. In this case. Plaintiffs seek abrogation of legislation adopted by the
Virginia General Assembly. While it is this Court's constitutional duty to review the
statutes at issue, it must do so cautiously, according respect but not deference to the
legislative branch. Therefore, in its analysis ofthe parties' Motions, any doubt as to the

adequacy ofthe evidence will be resolved in favor of deferring final judgment until trial.
There are, however, a number ofindividual issues on which there is no genuine issue of
material fact.

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After reviewing both Motions individually, along with supporting exhibits, the
Court draws the following conclusions: With respect to Count I, the Licensing Statute,

the overwhelming weight of the evidence supports the contention that the regulatory
regime necessitated under the Licensing Statute, Va. Code Ann. § 32.1-127, is
unnecessary and provides minimal medical benefits with respect to first trimester

abortions. In fact, it may limit access to second trimester care as well. The present

record, however, is less clear as to the extent ofthe burden to women seeking abortions in
Virginia as a result ofthe Licensing Statute. This appears to be a material fact genuinely
in dispute. Furthermore, for these same reasons, the Court will await a more complete
evidentiary record as to whether the Licensing Regulations, as challenged under Count II,
present an undue burden for Virginia women who seek an abortion in the first and second

trimesters. Consequently, Defendants' Motion for Summary Judgment on Counts I and II
will be denied.

The requirement that second trimester abortions be performed in licensed hospitals
is challenged in Count III. Given the potential complications that can be encountered in

second trimester procedures, unlike first trimester abortions, this appears to be a factual
issue clearly in dispute.'^ Similarly, the burden on reasonable access to second trimester
abortion services and care, with only two facilities available, is sufficiently debatable to

be a fact genuinely at issue. Both Plaintiffs' and Defendants' Motions for Summary
Judgment with respect to Count III will be denied.

Although not clearly at issue,the record would not support a hospital requirement for first
trimester procedures.
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After a careful review ofthe experts' opinions fi^om both sides, a consensus

appears to have evolved that first trimester abortions, which typically require only

medication, do not require the onsite presence of a licensed physician and is consequently
unduly burdensome. As the Supreme Court has often restated, "[ujnnecessary health

regulations that have the purpose or effect of presenting a substantial obstacle to a woman
seeking an abortion impose an undue burden on the right." Casey, 505 U.S. at 878. The
undisputed evidence appears to support this finding.
Conversely, several ofthe physician witnesses described serious complications

that can arise in the later stages of second trimester abortions, amply justifying the
requirement of Va. Code Ann. § 18.2-72 that only physicians perform second trimester
abortions.

Accordingly, Plaintiffs' Motion for Summary Judgment on Count IV will be
granted with respect to first trimester abortions and denied as to second trimester

abortions. The Defendants' Motion for Summary Judgment on Count IV will be denied
as to first trimester abortions and granted as to second trimester abortions.

Regarding Plaintiffs' contention under Count VII that Va. Code Ann. § 18.2-73 is
vague to the point of being unconstitutional, the Court finds this is not supported, and
therefore. Defendants' Motion for Summary as to Count VII will be granted. And

finally, for the reasons already discussed. Defendants' Motion for Summary Judgment on
Count VIII will be denied.

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An appropriate Order will accompany this Memorandum Opinion.

Henry E. Hudson
Senior United States District Judge
Vii
Richmond, Virginia

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