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In the United States Court of Appeals For the Seventh Circuit ____________________ȱ No.ȱ17Ȭ1883ȱ PLANNEDȱPARENTHOODȱOFȱINDIANAȱȱ ANDȱKENTUCKY,ȱINC.,ȱ PlaintiffȬAppellee,ȱ v.ȱ COMMISSIONERȱOFȱTHEȱINDIANAȱSTATEȱȱ DEPARTMENTȱOFȱHEALTH,ȱetȱal.,ȱ DefendantsȬAppellants.ȱ ____________________ȱ AppealȱfromȱtheȱUnitedȱStatesȱDistrictȱCourtȱforȱtheȱ SouthernȱDistrictȱofȱIndiana,ȱIndianapolisȱDivision.ȱ No.ȱ1:16ȬcvȬ01807ȱ—ȱTanyaȱWaltonȱPratt,ȱJudge.ȱ ____________________ȱ ARGUEDȱNOVEMBERȱ6,ȱ2017ȱ—ȱDECIDEDȱJULYȱ25,ȱ2018ȱ ____________________ȱ BeforeȱBAUER,ȱKANNE,ȱandȱROVNER,ȱCircuitȱJudges.ȱ ROVNER,ȱCircuitȱJudge.ȱSinceȱ1995,ȱtheȱStateȱofȱIndianaȱhasȱ requiredȱthat,ȱatȱleastȱeighteenȱhoursȱbeforeȱaȱwomanȱhasȱanȱ abortion,ȱ sheȱ mustȱ beȱ givenȱ informationȱ providedȱ byȱ theȱ Stateȱ about,ȱ amongȱ otherȱ things,ȱ theȱ procedure,ȱ factsȱ aboutȱ theȱ fetusȱ andȱ itsȱ development,ȱ andȱ alternativesȱ toȱ abortion.ȱ ThatȱinformationȱisȱmeantȱtoȱadvanceȱtheȱState’sȱassertedȱinȬ 2ȱ No.ȱ17Ȭ1883ȱ terestȱinȱpromotingȱfetalȱlife.ȱInȱotherȱwords,ȱtheȱStateȱhopesȱ thatȱ womenȱ whoȱ readȱ thatȱ informationȱ andȱ considerȱ itȱ willȱ optȱnotȱtoȱhaveȱanȱabortion,ȱandȱwill,ȱinstead,ȱchooseȱtoȱcarȬ ryȱ theȱ pregnancyȱ toȱ term.ȱ Afterȱ sheȱ hasȱ receivedȱ theȱ manȬ datedȱ information,ȱ aȱ womanȱ mustȱ waitȱ atȱ leastȱ eighteenȱ hoursȱ beforeȱ havingȱ anȱ abortion,ȱ thus,ȱ theȱ Stateȱ hopes,ȱ sheȱ willȱ useȱ theȱ timeȱ toȱ reflectȱ uponȱ herȱ choiceȱ andȱ chooseȱ toȱ continueȱherȱpregnancy.ȱTheȱStateȱalsoȱrequiresȱthatȱaȱwomȬ anȱ haveȱ anȱ ultrasoundȱ andȱ hearȱ theȱ fetalȱ heartbeatȱ priorȱ toȱ anȱabortionȱalthoughȱsheȱmayȱdeclineȱtheȱopportunityȱtoȱdoȱ oneȱorȱboth,ȱasȱ75%ȱofȱwomenȱgenerallyȱdo.1ȱȱ Priorȱ toȱ Julyȱ 1,ȱ 2016,ȱ womenȱ could,ȱ andȱ generallyȱ did,ȱ haveȱtheȱultrasoundȱonȱtheȱsameȱdayȱofȱtheȱprocedure.ȱThisȱ was,ȱ inȱ largeȱ part,ȱ becauseȱ almostȱ allȱ abortionsȱ inȱ Indianaȱ occurȱ atȱ oneȱ ofȱ fourȱ Plannedȱ Parenthoodȱ ofȱ Indianaȱ andȱ Kentuckyȱ(PPINK)ȱhealthȱcenters,ȱandȱonlyȱthoseȱfewȱPPINKȱ facilitiesȱ thatȱ offerȱ abortionȱ servicesȱ (mostȱ doȱ not)ȱ hadȱ theȱ ultrasoundȱ equipmentȱ onȱ site.ȱ Theȱ Indianaȱ Houseȱ Enrolledȱ Actȱ 1337ȱ (HEAȱ 1337),ȱ however,ȱ amendedȱ Indianaȱ lawȱ andȱ nowȱrequiresȱwomenȱtoȱundergoȱanȱultrasoundȱprocedureȱatȱ leastȱ eighteenȱ hoursȱ priorȱ toȱ theȱ abortion.ȱ Becauseȱ ofȱ theȱ structureȱandȱlocationȱofȱabortionȱservicesȱinȱIndianaȱandȱtheȱ populationȱ ofȱ womenȱ seekingȱ abortions,ȱ thisȱ change— movingȱ theȱ ultrasoundȱ fromȱ theȱ dayȱ ofȱ theȱ abortionȱ proceȬ dureȱtoȱatȱleastȱeighteenȱhoursȱbefore—asȱweȱwillȱexplore,ȱisȱ significant.ȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1ȱPriorȱtoȱ2011,ȱtheȱlawȱrequiredȱthatȱpriorȱtoȱanȱabortionȱtheȱwomanȱbeȱ shownȱanȱultrasoundȱ“uponȱtheȱwoman’sȱrequest.”ȱP.L.ȱ193Ȭ2011,ȱSec.ȱ9.ȱ Inȱ2011ȱtheȱlegislatureȱamendedȱtheȱstatuteȱtoȱrequireȱthatȱtheȱwomanȱbeȱ shownȱ theȱ ultrasoundȱ unlessȱ sheȱ certifiedȱ inȱ writingȱ thatȱ sheȱ didȱ notȱ wantȱto.ȱȱ No.ȱ17Ȭ1883ȱ 3 PPINKȱfiledȱsuitȱagainstȱtheȱCommissionerȱofȱtheȱIndianaȱ Stateȱ Departmentȱ ofȱ Healthȱ andȱ theȱ prosecutorsȱ ofȱ Marionȱ County,ȱ Lakeȱ County,ȱ Monroeȱ County,ȱ andȱ Tippecanoeȱ Countyȱ (collectively,ȱ“theȱState”),ȱallȱ inȱ theirȱ officialȱ capaciȬ ties.2ȱPPINKȱclaimedȱthatȱHEAȱ1337ȱunconstitutionallyȱburȬ densȱ aȱ woman’sȱ rightȱ toȱ chooseȱ toȱ haveȱ anȱ abortion,ȱ andȱ itȱ soughtȱpreliminaryȱreliefȱenjoiningȱtheȱprovisionȱduringȱtheȱ pendencyȱofȱtheȱlitigation.ȱTheȱdistrictȱcourtȱgrantedȱtheȱpreȬ liminaryȱ injunction.ȱ Weȱ agreeȱ withȱ theȱ wellȬreasonedȱ conȬ clusionsȱofȱtheȱdistrictȱcourtȱopinion,ȱfromȱwhichȱweȱborrowȱ heavily.ȱ I.ȱ A.ȱ Backgroundȱinformationȱ 1.ȱ Theȱnewȱlawȱ Indianaȱ Codeȱ §ȱ 16Ȭ34Ȭ2Ȭ1.1ȱ mandatesȱ thatȱ atȱ leastȱ eightȬ eenȱ hoursȱpriorȱ toȱ theȱabortionȱ procedure,ȱtheȱ patientȱmustȱ beȱprovidedȱwithȱtheȱ followingȱinformationȱ(amongȱothers)ȱ bothȱorallyȱandȱinȱwriting:ȱ“thatȱhumanȱphysicalȱlifeȱbeginsȱ whenȱ aȱ humanȱ ovumȱ isȱ fertilizedȱ byȱ aȱ humanȱ sperm;”ȱ theȱ probableȱgestationalȱageȱofȱtheȱfetusȱatȱtheȱtimeȱtheȱabortionȱ isȱtoȱbeȱperformed,ȱincludingȱaȱpictureȱofȱtheȱfetusȱatȱcertainȱ gestationalȱages,ȱandȱotherȱinformationȱaboutȱtheȱfetusȱatȱitsȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2ȱCourtsȱhaveȱlongȱdeclaredȱthatȱabortionȱprovidersȱhaveȱstandingȱtoȱsueȱ toȱ enjoinȱ lawsȱ thatȱ restrictȱ abortion.ȱ Plannedȱ Parenthoodȱ ofȱ Wisc.,ȱ Inc.ȱ v.ȱ Schimel,ȱ806ȱF.3dȱ908,ȱ910ȱ(7thȱCir.ȱ2015).ȱ“Theseȱcasesȱemphasizeȱnotȱtheȱ harmȱ toȱ theȱ abortionȱ clinicȱ ofȱ makingȱ abortionsȱ veryȱ difficultȱ toȱ obtainȱ legally,ȱ thoughȱ thatȱ mightȱ beȱ anȱ alternativeȱ groundȱ forȱ recognizingȱ aȱ clinic’sȱ standing,ȱ butȱ ratherȱ theȱ confidentialȱ natureȱ ofȱ theȱ physicianȬ patientȱrelationshipȱandȱtheȱdifficultyȱforȱpatientsȱofȱdirectlyȱvindicatingȱ theirȱ rightsȱ withoutȱ compromisingȱ theirȱ privacy.”ȱ Id.ȱ (internalȱ citationsȱ omitted).ȱȱ 4ȱ No.ȱ17Ȭ1883ȱ currentȱ stageȱ ofȱ development;ȱ noticeȱ thatȱ theȱ fetusȱ canȱ feelȱ painȱatȱorȱbeforeȱtwentyȱweeks;ȱinformationȱaboutȱtheȱrisksȱ ofȱ abortionȱ andȱ ofȱ carryingȱ theȱ fetusȱ toȱ term,ȱ andȱ inforȬ mationȱregardingȱalternativesȱtoȱabortionȱandȱotherȱsupportȱ servicesȱavailable.ȱInd.ȱCodeȱ §ȱ16Ȭ34Ȭ2Ȭ1.1(a)(1)Ȭ(2).ȱAȱwomȬ anȱ seekingȱ anȱ abortionȱ mustȱ alsoȱ receiveȱ aȱ colorȱ copyȱ ofȱ aȱ brochure,ȱauthoredȱandȱdistributedȱbyȱtheȱIndianaȱStateȱDeȬ partmentȱ ofȱ Health,ȱ thatȱ containsȱ allȱ ofȱ thisȱ sameȱ inforȬ mation.ȱ Theȱ Stateȱ controlsȱ everyȱ aspectȱ ofȱ theȱ informationȱ conveyedȱtoȱpatientsȱviaȱthisȱbrochure—fromȱtheȱdrawings,ȱ toȱ theȱ color,ȱ informationȱ aboutȱ development,ȱ andȱ wordingȱ ofȱtheȱrisksȱofȱtheȱprocedures.ȱNeitherȱtheȱ brochureȱnorȱtheȱ informedȬconsentȱ informationȱ hasȱ beenȱ challengedȱ inȱ thisȱ litigation.ȱȱ Priorȱtoȱtheȱenactmentȱofȱtheȱchallengedȱlaw,ȱIndianaȱreȬ quiredȱthatȱ“[b]eforeȱanȱabortionȱisȱperformed,ȱtheȱproviderȱ shallȱperform,ȱandȱtheȱpregnantȱwomanȱshallȱview,ȱtheȱfetalȱ ultrasoundȱ imagingȱ andȱ hearȱ theȱ auscultationȱ ofȱ theȱ fetalȱ heartȱtoneȱifȱtheȱfetalȱheartȱtoneȱisȱaudible,”ȱunlessȱtheȱpregȬ nantȱ womanȱ certifiedȱ inȱ writing,ȱ onȱ aȱ formȱ draftedȱ byȱ theȱ Indianaȱ Stateȱ Departmentȱ ofȱ Health,ȱ thatȱ sheȱ declinedȱ toȱ viewȱ theȱ ultrasoundȱ orȱ hearȱ theȱ fetalȱ heartȱ tone.ȱ Ind.ȱ Codeȱ §ȱ16Ȭ34Ȭ2Ȭ1.1(b)ȱ(2011).ȱInȱotherȱwords,ȱtheȱproviderȱmustȱofȬ ferȱ theȱ ultrasound,ȱ butȱ aȱ womanȱ mayȱ affirmativelyȱ decline.ȱ Priorȱ toȱ 2011ȱ theȱ providerȱ didȱ notȱ haveȱ toȱ offerȱ theȱ ultraȬ sound,ȱbutȱonlyȱhadȱtoȱprovideȱoneȱifȱspecificallyȱrequestedȱ byȱtheȱwoman.ȱP.L.ȱ193Ȭ2011,ȱSec.ȱ9.ȱInȱfiscalȱyearȱ2016,ȱonlyȱ approximatelyȱ 25%ȱ ofȱ womenȱ seekingȱ abortionȱ servicesȱ choseȱ toȱ viewȱ theirȱ ultrasoundȱ imagesȱ andȱ onlyȱ approxiȬ matelyȱ 7%ȱ choseȱ toȱ listenȱ toȱ theȱ fetalȱ heartȱ tone.ȱ Mostȱ imȬ portantlyȱ forȱ thisȱ litigation,ȱ beforeȱ 2016,ȱ theȱ statuteȱ didȱ notȱ mandateȱ whenȱ theȱ ultrasoundȱ mustȱ occur,ȱ otherȱ thanȱ priorȱ No.ȱ17Ȭ1883ȱ 5 toȱ theȱ abortion.ȱ Asȱ aȱ practicalȱ matter,ȱ however,ȱ theȱ ultraȬ soundȱ proceduresȱ wereȱ performedȱ justȱ beforeȱ theȱ abortion.ȱ Ultrasoundȱ equipmentȱ isȱ expensiveȱ andȱ scarce.ȱ Notȱ allȱ PPINKȱ locationsȱ haveȱ it,ȱ but,ȱ atȱ theȱ timeȱ theȱ newȱ lawȱ wasȱ enacted,ȱ theȱ fourȱ locationsȱ thatȱ performȱ abortionsȱ hadȱ theȱ equipment.ȱ Althoughȱ patientsȱ canȱ receiveȱ theirȱ informedȬ consentȱ consultationsȱ atȱ anyȱ oneȱ ofȱ theȱ seventeenȱ PPINKȱ healthȱ centersȱ throughoutȱ Indiana,ȱ abortionsȱ areȱ performedȱ onlyȱatȱfourȱlocationsȱthroughoutȱIndianaȱ(surgicalȱabortionsȱ areȱ availableȱ onlyȱ atȱ threeȱ locations).ȱ Therefore,ȱ toȱ preventȱ womenȱ fromȱ havingȱ toȱ travelȱ farȱ distancesȱ eighteenȱ hoursȱ apart,ȱprovidersȱperformedȱtheȱultrasoundȱonȱtheȱdayȱofȱtheȱ abortionȱ procedureȱ atȱ oneȱ ofȱ theȱ fourȱ facilitiesȱ thatȱ hadȱ ulȬ trasoundȱandȱperformedȱabortions.ȱȱ Theȱ newȱ statute,ȱ however,ȱ preventsȱ thisȱ practice.ȱ Itȱ reȬ quiresȱtheȱfollowing:ȱ Atȱleastȱeighteenȱ(18)ȱhoursȱbeforeȱanȱabortionȱ isȱ performedȱ andȱ atȱ theȱ sameȱ timeȱ thatȱ theȱ pregnantȱ womanȱ receivesȱ theȱ informationȱ reȬ quiredȱ byȱ subdivisionȱ (1),ȱ theȱ providerȱ shallȱ perform,ȱ andȱ theȱ pregnantȱ womanȱ shallȱ view,ȱ theȱfetalȱultrasoundȱimagingȱandȱhearȱtheȱausȬ cultationȱofȱtheȱfetalȱheartȱtoneȱifȱtheȱfetalȱheartȱ toneȱisȱaudibleȱunlessȱtheȱpregnantȱwomanȱcerȬ tifiesȱ inȱ writing,ȱ onȱ aȱ formȱ developedȱ byȱ theȱ stateȱ department,ȱ beforeȱ theȱ abortionȱ isȱ perȬ formed,ȱthatȱtheȱpregnantȱwoman:ȱ (A)ȱdoesȱnotȱwantȱtoȱviewȱtheȱfetalȱultrasoundȱ imaging;ȱandȱ 6ȱ No.ȱ17Ȭ1883ȱ (B)ȱ doesȱ notȱ wantȱ toȱ listenȱ toȱ theȱ auscultationȱ ofȱ theȱ fetalȱ heartȱ toneȱ ifȱ theȱ fetalȱ heartȱ toneȱ isȱ audible.ȱ Ind.ȱ Codeȱ Ann.ȱ §ȱ 16Ȭ34Ȭ2Ȭ1.1(a)(5).ȱ PPINKȱ arguesȱ thatȱ thisȱ requirementȱ undulyȱ burdensȱ aȱ woman’sȱ rightȱ toȱ anȱ aborȬ tion.ȱBecauseȱPPINK’sȱargumentȱisȱbasedȱonȱtheȱfactualȱconȬ text,ȱitȱisȱcriticalȱfirstȱtoȱunderstandȱhowȱPPINKȱhealthȱcenȬ tersȱoperateȱandȱwhereȱtheyȱareȱlocated.ȱȱ 2.ȱ PPINKȱfacilitiesȱ Atȱtheȱtimeȱtheȱlawȱsuitȱbegan,ȱPPINKȱoperatedȱtwentyȬ threeȱhealthȱcentersȱinȱIndiana.ȱDueȱtoȱfinancialȱconstraints,ȱ thatȱ numberȱ hasȱ sinceȱ dwindledȱ toȱ seventeen.ȱ Onlyȱ fourȱ ofȱ theȱcentersȱofferȱabortionȱservices—Bloomington,ȱIndianapoȬ lis,ȱMerrillvilleȱandȱLafayette—theȱlatterȱofȱwhichȱoffersȱonlyȱ nonȬsurgicalȱabortionsȱusingȱmedication.ȱOfȱtheȱcentersȱthatȱ offerȱabortionȱservices,ȱtheȱtimesȱtheseȱservicesȱareȱavailableȱ areȱ exceptionallyȱ limited.ȱ Inȱ Indianapolis,ȱ abortionȱ servicesȱ areȱonlyȱavailableȱthreeȱdaysȱperȱweek;ȱinȱMerrillville,ȱaȱdayȱ andȱaȱhalfȱperȱweek;ȱandȱinȱBloomingtonȱandȱLafayette,ȱonlyȱ oneȱdayȱaȱweek.ȱR.ȱ24Ȭ1ȱatȱ6.ȱPPINKȱwillȱperformȱaȱsurgicalȱ abortionȱonlyȱuntilȱthirteenȱweeksȱandȱsixȱdaysȱafterȱtheȱfirstȱ dayȱofȱaȱwoman’sȱlastȱmenstrualȱperiod.ȱItȱwillȱprovideȱmedȬ icationȱ abortionsȱ onlyȱ untilȱ sixtyȬthreeȱ daysȱ afterȱ theȱ firstȱ dayȱ ofȱ aȱ woman’sȱ lastȱ menstrualȱ period.ȱ Womenȱ whoȱ areȱ pushingȱ upȱ againstȱ theȱ timeȱ deadlineȱ mayȱ notȱ beȱ ableȱ toȱ waitȱ untilȱ aȱ providerȱ isȱ availableȱ atȱ theȱ facilityȱ closestȱ toȱ them,ȱbutȱmayȱneedȱtoȱtravelȱtoȱaȱmoreȱdistantȱfacilityȱwhereȱ aȱ timelyȱ appointmentȱ canȱ beȱ made.ȱ Theȱ thirteenȱ PPINKȱ healthȱcentersȱthatȱdoȱnotȱprovideȱabortionȱservicesȱprovideȱ wellȬwomenȱexaminations,ȱscreeningȱforȱcancerȱandȱsexuallyȱ No.ȱ17Ȭ1883ȱ 7 transmittedȱdiseases,ȱtreatmentȱforȱsexuallyȱtransmittedȱdisȬ easesȱandȱotherȱpreventativeȱhealthȱcare.ȱ Thereȱ areȱ noȱ clinicsȱ inȱ Indianaȱ thatȱ performȱ abortionsȱ pastȱtheseȱdates.ȱTheȱonlyȱprovidersȱofȱabortionȱservicesȱafȬ terȱ theseȱ datesȱ areȱ hospitalsȱ andȱ surgicalȱ centersȱ (allȱ ofȱ whichȱhappenȱtoȱbeȱlocatedȱinȱIndianapolis)ȱandȱthoseȱfaciliȬ tiesȱgenerallyȱonlyȱprovideȱabortionsȱthatȱareȱmedicallyȱindiȬ catedȱ becauseȱ ofȱ aȱ fetalȱ anomalyȱ orȱ aȱ threatȱ toȱ aȱ woman’sȱ health,ȱ andȱ theseȱ areȱ quiteȱ rare.ȱ Outȱ ofȱ theȱ 7,957ȱ abortionsȱ performedȱ inȱ Indianaȱ inȱ 2015ȱ (theȱ yearȱ beforeȱ enactmentȱ ofȱ theȱnewȱlaw),ȱonlyȱ27ȱoccurredȱinȱaȱhospitalȱorȱsurgicalȱcenȬ ter.ȱ Onlyȱ eighteenȱ occurredȱ afterȱ thirteenȱ weeks.ȱ Indianaȱ Stateȱ Department,ȱ Terminatedȱ Pregnancyȱ Report—2015,ȱ atȱ pp.ȱ 7,ȱ 17,ȱ 18ȱ (releasedȱ Juneȱ 30,ȱ 2016).ȱ Availableȱ atȱ https://www.in.gov/isdh/files/2015%20TP%20Report.pdfȱ [LastȱvisitedȱJuneȱ19,ȱ2018].ȱ PPINKȱ hasȱ attemptedȱ toȱ expandȱ itsȱ healthȱ servicesȱ throughoutȱ Indiana,ȱ butȱ itȱ operatesȱ onlyȱ seventeenȱ centersȱ spreadȱacrossȱaȱlargeȱstateȱandȱonlyȱfourȱthatȱprovideȱaborȬ tions.ȱ Thisȱ meansȱ thatȱ someȱ womenȱ mustȱ travelȱ greatȱ disȬ tancesȱtoȱobtainȱanȱ abortion.ȱForȱexample,ȱ Indiana’sȱsecondȱ largestȱcity,ȱFortȱWayne,ȱhadȱaȱPPINKȱhealthȱcenterȱuntilȱJuȬ lyȱ 9,ȱ 2018,ȱ butȱ itȱ didȱ notȱ provideȱ abortionȱ services.ȱ Nowȱ itȱ hasȱ none.3ȱ Theȱ closestȱ centerȱ providingȱ suchȱ servicesȱ isȱ 115ȱ milesȱ awayȱ inȱ Lafayetteȱ (aȱ moreȱ thanȱ twoȱ hourȱ drive).4ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3ȱPPINKȱanticipatesȱreopeningȱanotherȱclinicȱinȱFortȱWayneȱalthoughȱitȱ doesȱ notȱ haveȱ aȱ timeframeȱ forȱ doingȱ so.ȱ Seeȱ Appellateȱ Recordȱ atȱ 51,ȱ PPINKȱCitationȱofȱAdditionalȱAuthority,ȱ7/12/18.ȱ 4ȱ Accordingȱ toȱ Googleȱ Maps,ȱ theȱ distanceȱ fromȱ Fortȱ Wayneȱ toȱ theȱ adȬ dressȱofȱtheȱPPINKȱclinicsȱisȱasȱfollows:ȱ 8ȱ No.ȱ17Ȭ1883ȱ Thereȱ areȱ alsoȱ noȱ outȬofȬstateȱ abortionȱ clinicsȱ thatȱ areȱ closeȱ toȱFortȱWayne.ȱȱ Priorȱ toȱ theȱ enactmentȱ ofȱ theȱ challengedȱ law,ȱ womenȱ seekingȱ abortionsȱ couldȱ haveȱ theirȱ stateȬmandatedȱ inȬ formedȬconsentȱ sessionȱ atȱ anyȱ oneȱ ofȱ theȱ seventeenȱ centersȱ acrossȱ theȱ state.ȱ Atȱ thisȱ appointment,ȱ whichȱ usuallyȱ onlyȱ lastedȱ aboutȱ fifteenȱ minutes,ȱ healthȱ careȱ providersȱ alsoȱ calȬ culatedȱtheȱgestationalȱageȱofȱtheȱfetusȱbasedȱonȱtheȱlengthȱofȱ timeȱfromȱtheȱfirstȱdayȱofȱtheȱlastȱmenstrualȱperiod.ȱToȱmakeȱ itȱ moreȱ convenientȱ forȱ patients,ȱ PPINKȱ allowedȱ parentsȱ toȱ bringȱ childrenȱ toȱ theseȱ appointments.ȱ Womenȱ couldȱ thenȱ haveȱ anȱ ultrasound,ȱ asȱ requiredȱ byȱ thenȬexistingȱ stateȱ law,ȱ onȱ theȱ dayȱ ofȱ theȱ procedureȱ atȱ theȱ healthȱ centerȱ providingȱ theȱabortion.ȱPPINKȱwouldȱuseȱthatȱultrasoundȱinformationȱ toȱverifyȱthatȱtheȱpregnancyȱwasȱintrauterineȱ(andȱnotȱectopȬ ic)ȱ andȱ toȱ verifyȱ theȱ gestationalȱ ageȱ toȱ insureȱ thatȱ theȱ aborȬ tionsȱareȱbeingȱperformedȱwithinȱtheȱrequiredȱlimits.ȱAnȱulȬ trasoundȱisȱnotȱmedicallyȱnecessaryȱpriorȱtoȱanȱabortion,ȱbutȱ theȱ stateȱ requirementȱ toȱ performȱ anȱ ultrasoundȱ isȱ notȱ chalȬ lengedȱ inȱ thisȱ case,ȱ justȱ theȱ timingȱ ofȱ it.ȱ Allowingȱ theȱ inȬ formedȱconsentȱtoȱbeȱperformedȱatȱanyȱofȱtheȱPPINKȱcentersȱ madeȱ itȱ practicalȱ forȱ womenȱ whoȱ liveȱ aȱ longȱ distanceȱ fromȱ theȱ fewȱ centersȱ thatȱ offerȱ abortionȱ services,ȱ byȱ eliminatingȱ theȱneedȱforȱmultipleȱvisits.ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ Merrillville:ȱȱ 124ȱmilesȱȱ Lafayette:ȱ ȱ 115ȱmilesȱ Indianapolis:ȱ 122ȱmilesȱ Bloomington:ȱ 203ȱmilesȱ R.ȱ24Ȭ1ȱatȱ3.ȱ No.ȱ17Ȭ1883ȱ 9 Onceȱtheȱnewȱlawȱwasȱenacted,ȱrequiringȱ thatȱtheȱultraȬ soundȱ takeȱ placeȱ atȱ leastȱ eighteenȱ hoursȱ priorȱ toȱ theȱ aborȬ tion,ȱ theȱ barriersȱ forȱ manyȱ womenȱ increasedȱ significantly.ȱ Becauseȱultrasoundȱmachinesȱwereȱonlyȱavailableȱatȱtheȱfourȱ PPINKȱ centersȱ thatȱ provideȱ abortionȱ services,ȱ womenȱ whoȱ livedȱ aȱ significantȱ distanceȱ fromȱ oneȱ ofȱ thoseȱ centersȱ wereȱ facedȱ withȱ twoȱ lengthyȱ tripsȱ toȱ oneȱ ofȱ thoseȱ facilitiesȱ orȱ anȱ overnightȱstayȱnearby.ȱPPINKȱattemptedȱtoȱeaseȱthatȱburdenȱ byȱ purchasingȱ oneȱ additionalȱ ultrasoundȱ machineȱ forȱ oneȱ healthȱ centerȱ thatȱ doesȱ notȱ offerȱ abortionȱ services,ȱ andȱ trainedȱ aȱ staffȱ memberȱ toȱ useȱ ultrasoundȱ equipmentȱ atȱ anȬ other.ȱThoseȱexpendituresȱexactedȱaȱheavyȱtollȱonȱtheȱfinancȬ esȱ ofȱ theȱ organization,ȱ andȱ stillȱ didȱ notȱ easeȱ muchȱ ofȱ theȱ burden.ȱ Theȱ ultrasoundȱ machinesȱ PPINKȱ usesȱ costȱ approxȬ imatelyȱ$25,000ȱandȱmustȱbeȱoperatedȱbyȱtrainedȱtechnicians.ȱ Nationalȱ Plannedȱ Parenthoodȱ policies,ȱ whichȱ areȱ designedȱ toȱ alignȱ withȱ generallyȱ acceptedȱ medicalȱ standards,ȱ requireȱ thatȱanȱultrasoundȱimageȱbeȱinterpretedȱbyȱaȱphysicianȱorȱanȱ advancedȱ practiceȱ nurse.ȱ Theȱ nurseȬpractitionersȱ atȱ PPINKȱ doȱnotȱhaveȱtheȱrequisiteȱtrainingȱandȱPPINKȱassertsȱthatȱitȱ canȱ affordȱ neitherȱ theȱ costȱ norȱ timeȱ toȱ enrollȱ nursesȱ inȱ theȱ fourȬweekȱtrainingȱprogram.ȱ 3.ȱ Populationȱservedȱ Theȱ majorityȱ ofȱ womenȱ whoȱ seekȱ abortionȱ servicesȱ atȱ PPINKȱ(andȱforȱthatȱmatter,ȱtheȱrestȱofȱtheȱnation)ȱareȱpoor.ȱ Theȱ tableȱ belowȱ demonstratesȱ theȱ incomeȱ levelȱ ofȱ patientsȱ relativeȱtoȱtheȱfederalȱpovertyȱlineȱ(FPL).ȱ5ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5ȱ Povertyȱ expertsȱ generallyȱ useȱ 200%ȱ ofȱ theȱ federalȱ povertyȱ lineȱ asȱ anȱ approximationȱofȱtheȱincomeȱnecessaryȱtoȱsurviveȱonȱone’sȱown.ȱR.ȱ24Ȭ2ȱ 10ȱ No.ȱ17Ȭ1883ȱ Incomeȱ %ȱ ofȱ paȬ Unknownȱ 22%ȱ 0Ȭ100%ȱ 37%ȱ 101Ȭ150%ȱ 11%ȱ 151Ȭ200%ȱ 8%ȱ 201Ȭ250%ȱ 5%ȱ 251+%ȱ 16%ȱ R.ȱ 24Ȭ1ȱ atȱ 14.ȱ Theseȱ womenȱ oftenȱ haveȱ precariousȱ employȬ mentȱsituationsȱandȱgenerallyȱareȱnotȱpaidȱforȱdaysȱtheyȱdoȱ notȱwork.ȱManyȱofȱthemȱalreadyȱhaveȱoneȱorȱmoreȱchildren.ȱ Inȱ 2016,ȱ 33.73ȱ percentȱ ofȱ PPINKȱ patientsȱ reportedȱ thatȱ theyȱ hadȱchildrenȱlivingȱwithȱthem.ȱR.ȱ24Ȭ1ȱatȱ4–5.ȱ 4.ȱ Theȱdistrictȱcourt’sȱdecisionȱ Theȱ districtȱ courtȱ carefullyȱ weighedȱ theȱ burdensȱ identiȬ fiedȱ byȱ PPINKȱ againstȱ theȱ benefitsȱ theȱ Stateȱ hopedȱ wouldȱ accrueȱtoȱitsȱcitizens—theȱprotectionȱofȱbothȱfetalȱlifeȱandȱtheȱ mentalȱhealthȱofȱwomen.ȱItȱconcludedȱthat:ȱ Theȱ newȱ ultrasoundȱ lawȱ createsȱ significantȱ fiȬ nancialȱ andȱ otherȱ burdensȱ onȱ PPINKȱ andȱ itsȱ patients,ȱparticularlyȱonȱlowȬincomeȱwomenȱinȱ Indianaȱ whoȱ faceȱ lengthyȱ travelȱ toȱ oneȱ ofȱ PPINK’sȱ nowȱ onlyȱ sixȱ healthȱ centersȱ thatȱ canȱ offerȱ anȱ informedȬconsentȱ appointment.ȱ Theseȱ burdensȱ areȱ clearlyȱ undueȱ whenȱ weighedȱ againstȱ theȱ almostȱ completeȱ lackȱ ofȱ evidenceȱ thatȱtheȱlawȱfurthersȱtheȱState’sȱassertedȱjustifiȬ cationsȱ ofȱ promotingȱ fetalȱ lifeȱ andȱ women’sȱ mentalȱhealthȱoutcomes.ȱTheȱevidenceȱpresentȬ edȱ byȱ theȱ Stateȱ showsȱ thatȱ viewingȱ anȱ ultraȬ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ atȱ4.ȱManyȱexpertsȱdescribeȱthoseȱatȱorȱbelowȱ100%ȱofȱtheȱfederalȱpovertyȱ lineȱasȱ“poor”ȱandȱthoseȱbetweenȱ100%ȱandȱ200%ȱasȱ“lowȱincome.”ȱId.ȱȱ No.ȱ17Ȭ1883ȱ 11 soundȱ imageȱ hasȱ onlyȱ aȱ “veryȱ small”ȱ impactȱ onȱ anȱ incrementallyȱ smallȱ numberȱ ofȱ women.ȱ Andȱ thereȱ isȱ almostȱ noȱ evidenceȱ thatȱ thisȱ imȬ pactȱ isȱ increasedȱ ifȱ theȱ ultrasoundȱ isȱ viewedȱ theȱdayȱbeforeȱtheȱabortionȱratherȱthanȱtheȱdayȱ ofȱtheȱabortion.ȱMoreover,ȱtheȱlawȱdoesȱnotȱreȬ quireȱ womenȱ toȱ viewȱ theȱ ultrasoundȱ imagineȱ [sic]ȱatȱall,ȱandȱseventyȬfiveȱpercentȱofȱPPINK’sȱ patientsȱ chooseȱ notȱ to.ȱ Forȱ theseȱ women,ȱ theȱ newȱultrasoundȱ[law]ȱhasȱnoȱimpactȱwhatsoevȬ er.ȱGivenȱtheȱlackȱofȱevidenceȱthatȱtheȱnewȱulȬ trasoundȱ lawȱ hasȱ theȱ benefitsȱ assertedȱ byȱ theȱ State,ȱ theȱ lawȱ likelyȱ createsȱ anȱ undueȱ burdenȱ onȱwomen’sȱconstitutionalȱrights.ȱ Plannedȱ Parenthoodȱ ofȱ Ind.ȱ &ȱ Ky.,ȱ Inc.ȱ v.ȱ Commȇr,ȱ Ind.ȱ Stateȱ DepȇtȱofȱHealth,ȱ273ȱF.ȱSupp.ȱ3dȱ1013,ȱ1043ȱ(S.D.ȱInd.ȱ2017).ȱȱ B.ȱ Theȱlegalȱstandardȱ Weȱ reviewȱ theȱ districtȱ court’sȱ grantȱ ofȱ aȱ preliminaryȱ inȬ junctionȱinȱthisȱcaseȱforȱanȱabuseȱofȱdiscretion,ȱreviewingȱleȬ galȱ issuesȱdeȱnovo,ȱfactualȱfindingsȱforȱclearȱ error,ȱandȱgivȬ ingȱdeferenceȱtoȱtheȱdistrictȱcourt’sȱweighingȱofȱtheȱevidenceȱ andȱbalancingȱofȱtheȱequities.ȱWhitakerȱByȱWhitakerȱv.ȱKenoshaȱ UnifiedȱSch.ȱDist.ȱNo.ȱ1ȱBd.ȱofȱEduc.,ȱ858ȱF.3dȱ1034,ȱ1044ȱ(7thȱ Cir.ȱ2017).ȱ Toȱobtainȱaȱpreliminaryȱinjunction,ȱPPINKȱmustȱestablishȱ thatȱ itȱ hasȱ someȱ likelihoodȱ ofȱ successȱ onȱ theȱ merits;ȱ thatȱ itȱ hasȱ noȱ adequateȱ remedyȱ atȱ law;ȱ thatȱ withoutȱ reliefȱ itȱ willȱ sufferȱ irreparableȱ harm.ȱ Cityȱ ofȱ Chicagoȱ v.ȱ Sessions,ȱ 888ȱ F.3dȱ 272,ȱ282ȱ(7thȱCir.ȱ2018).ȱIfȱthatȱburdenȱisȱmet,ȱtheȱcourtȱmustȱ weighȱtheȱharmȱthatȱtheȱplaintiffȱwillȱsufferȱabsentȱanȱinjuncȬ 12ȱ No.ȱ17Ȭ1883ȱ tionȱ againstȱ theȱ harmȱ toȱ theȱ defendantȱ fromȱ anȱ injunction,ȱ andȱconsiderȱwhetherȱanȱinjunctionȱisȱinȱtheȱpublicȱinterest.ȱ Id.ȱ Ourȱ courtȱ employsȱ aȱ slidingȱ scaleȱ approach,ȱ “Theȱ moreȱ likelyȱtheȱplaintiffȱisȱtoȱwin,ȱtheȱlessȱheavilyȱneedȱtheȱbalanceȱ ofȱharmsȱweighȱinȱhisȱfavor;ȱtheȱlessȱlikelyȱheȱisȱtoȱwin,ȱtheȱ moreȱ needȱ itȱ weighȱ inȱ hisȱ favor.”ȱ Valenciaȱ v.ȱ Cityȱ ofȱ SpringȬ field,ȱ883ȱF.3dȱ959,ȱ966ȱ(7thȱCir.ȱ2018)ȱ(internalȱcitationsȱomitȬ ted).ȱȱ Theȱ districtȱ courtȱ correctlyȱ notedȱ thatȱ theȱ needȱ forȱ andȱ proprietyȱ ofȱ aȱ preliminaryȱ injunctionȱ ofȱ thisȱ lawȱ wouldȱ deȬ pendȱ mostlyȱ onȱ theȱ likelihoodȱ ofȱ successȱ onȱ theȱ merits.ȱ Itȱ thereforeȱfocusedȱmostȱofȱitsȱattention,ȱasȱdoȱwe,ȱonȱthatȱfacȬ tor.ȱȱ II.ȱ A.ȱ Theȱ testȱ articulatedȱ inȱ Caseyȱ andȱ Wholeȱ Women’sȱ Healthȱ Theȱbasicȱpremiseȱfromȱwhichȱweȱmustȱbeginȱourȱreviewȱ ofȱ theȱ districtȱ courtȱ opinionȱ isȱ thatȱ theȱ Supremeȱ Courtȱ hasȱ recognizedȱandȱaffirmedȱ“theȱrightȱofȱtheȱwomanȱtoȱchooseȱ toȱhaveȱanȱabortionȱbeforeȱviabilityȱandȱtoȱobtainȱitȱwithoutȱ undueȱ interferenceȱ fromȱ theȱ Stateȱ …ȱ [without]ȱ theȱ imposiȬ tionȱ ofȱ aȱ substantialȱ obstacleȱ toȱ theȱ woman’sȱ effectiveȱ rightȱ toȱelectȱtheȱprocedure.”ȱPlannedȱParenthoodȱofȱSe.ȱPenn.ȱv.ȱCaȬ sey,ȱ 505ȱ U.S.ȱ 833,ȱ 846ȱ (1992).ȱ Butȱ yet,ȱ “[t]heȱ factȱ thatȱ aȱ lawȱ whichȱ servesȱ aȱ validȱ purpose,ȱ oneȱ notȱ designedȱ toȱ strikeȱ atȱ theȱ rightȱ itself,ȱ hasȱ theȱ incidentalȱ effectȱ ofȱ makingȱ itȱ moreȱ difficultȱorȱmoreȱexpensiveȱtoȱprocureȱanȱabortionȱcannotȱbeȱ enoughȱtoȱ invalidateȱit.”ȱId.ȱatȱ874.ȱHowȱthen,ȱdoȱweȱdeterȬ mineȱ whetherȱ aȱ law’sȱ effectsȱ areȱ incidentalȱ orȱ unconstituȬ tionallyȱlimiting?ȱTheȱCaseyȱcourtȱsetȱforthȱanȱundueȱburdenȱ No.ȱ17Ȭ1883ȱ 13 testȱ whichȱ declaredȱ thatȱ aȱ stateȱ mayȱ notȱ establishȱ aȱ regulaȬ tionȱ thatȱ “hasȱ theȱ purposeȱ orȱ effectȱ ofȱ placingȱ aȱ substantialȱ obstacleȱ inȱ theȱ pathȱ ofȱ aȱ womanȱ seekingȱ anȱ abortionȱ ofȱ aȱ nonȬviableȱfetus.”ȱId.ȱatȱ877.ȱAsȱtheȱCaseyȱcourtȱexplained,ȱ Aȱstatuteȱwithȱ[anȱimproper]ȱpurposeȱisȱinvalidȱ becauseȱ theȱ meansȱ chosenȱ byȱ theȱ Stateȱ toȱ furȬ therȱtheȱinterestȱinȱpotentialȱlifeȱmustȱbeȱcalcuȬ latedȱ toȱ informȱ theȱ woman’sȱ freeȱ choice,ȱ notȱ hinderȱ it.ȱ Andȱ aȱ statuteȱ which,ȱ whileȱ furtherȬ ingȱ theȱ interestȱ inȱ potentialȱ lifeȱ orȱ someȱ otherȱ validȱ stateȱ interest,ȱ hasȱ theȱ effectȱ ofȱ placingȱ aȱ substantialȱ obstacleȱ inȱ theȱ pathȱ ofȱ aȱ woman’sȱ choiceȱ cannotȱ beȱ consideredȱ aȱ permissibleȱ meansȱofȱservingȱitsȱlegitimateȱends.ȱ Id.ȱ Recently,ȱ theȱ Supremeȱ Courtȱ reiteratedȱ thisȱ testȱ notingȱ thatȱCaseyȱheldȱthatȱaȱlawȱisȱunconstitutionalȱifȱitȱimposesȱanȱ “undueȱburden”ȱonȱaȱwomanȇsȱ abilityȱ toȱchooseȱ toȱ haveȱ anȱ abortion,ȱmeaningȱthatȱitȱ“hasȱtheȱpurposeȱorȱeffectȱofȱplacȬ ingȱaȱsubstantialȱobstacleȱinȱtheȱpathȱofȱaȱwomanȱseekingȱanȱ abortionȱofȱaȱnonviableȱfetus.”ȱWholeȱWomanȇsȱHealthȱv.ȱHelȬ lerstedt,ȱ136ȱS.ȱCt.ȱ2292,ȱ2324ȱ(2016),ȱ(citingȱCasey,ȱ505ȱU.S.ȱatȱ 877).ȱȱ Importantly,ȱbothȱWholeȱWomen’sȱHealthȱandȱCaseyȱstressȱ thatȱtheȱundueȱburdenȱtestȱisȱcontextȱspecific.ȱId.ȱatȱ2306;ȱCaȬ sey,ȱ505ȱU.S.ȱatȱ885.ȱAnȱabortionȱstatuteȱvalidȱasȱtoȱoneȱsetȱofȱ factsȱandȱexternalȱcircumstancesȱcanȱbeȱinvalidȱasȱtoȱanother.ȱ WholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱatȱ2306.ȱȱ TheȱStateȱarguesȱthatȱtheȱtestȱforȱweighingȱabortionȱreguȬ lationsȱ differsȱ dependingȱ onȱ theȱ purposeȱ ofȱ theȱ statuteȱ andȱ thatȱCaseyȱandȱWholeȱWomen’sȱHealthȱestablishȱdifferentȱtestsȱ 14ȱ No.ȱ17Ȭ1883ȱ dependingȱonȱtheȱnatureȱofȱtheȱregulation.ȱTheȱStateȱclaimsȱ thatȱ underȱ Casey,ȱ anȱ informedȬconsentȱ andȱ waitingȱ periodȱ lawȱ willȱ onlyȱ beȱ invalidatedȱ ifȱ theȱ regulationsȱ “imposeȱ aȱ ‘substantialȱobstacleȱinȱtheȱpathȱofȱaȱwomanȱseekingȱanȱaborȬ tion.’”ȱAppellant’sȱBriefȱatȱ26ȱ(citingȱ Casey,ȱ505ȱU.S.ȱatȱ877).ȱ Thisȱ standard,ȱ itȱ argues,ȱ isȱ somehowȱ differentȱ thanȱ theȱ unȬ dueȱ burdenȱ testȱ ofȱ Wholeȱ Women’sȱ Healthȱ which,ȱ theȱ Stateȱ says,ȱisȱonlyȱappropriatelyȱappliedȱtoȱregulationsȱthatȱostenȬ siblyȱpromoteȱwomen’sȱphysicalȱhealth.ȱAppellant’sȱBriefȱatȱ 17.ȱTheȱStateȱclaimsȱthatȱtheȱbalancingȱtestȱisȱnotȱappropriateȱ hereȱ because,ȱ unlikeȱ inȱ Wholeȱ Women’sȱ Health,ȱ theȱ parties’ȱ statedȱ interestsȱ areȱ fundamentallyȱ opposed—theȱ plaintiffs’ȱ goalȱisȱtoȱhelpȱwomenȱcarryȱoutȱtheirȱdecisionsȱtoȱterminateȱ aȱpregnancyȱandȱtheȱState’sȱgoalȱisȱtoȱpersuadeȱaȱwomanȱtoȱ reconsiderȱthatȱdecision.ȱRegulationsȱthatȱaddressȱinformedȬ consentȱandȱwaitingȱperiods,ȱtheȱStateȱargues,ȱareȱsubjectȱonȬ lyȱ toȱ “demonstrationȱ thatȱ theyȱ willȱ causeȱ aȱ significantȱ deȬ clineȱ inȱ abortionsȱ unrelatedȱ toȱ theȱ persuasiveȱ impact.”ȱ ApȬ pellant’sȱBriefȱatȱ22.ȱ Theȱ Stateȱ isȱ incorrectȱ thatȱ theȱ standardȱ forȱ evaluatingȱ abortionȱregulationsȱdiffersȱdependingȱonȱtheȱState’sȱassertȬ edȱ interestȱ orȱ thatȱ thereȱ areȱ evenȱ twoȱ differentȱ tests—theȱ undueȱ burdenȱ testȱ ofȱ Wholeȱ Women’sȱ Healthȱ andȱ aȱ lessȬ exactingȱ “substantialȱ obstacle”ȱ testȱ (asȱ theȱ Stateȱ argues)ȱ deȬ rivedȱfromȱCasey.ȱToȱtheȱcontrary,ȱCaseyȱdescribedȱtheȱundueȱ burdenȱ testȱ asȱ “aȱ standardȱoneȱ ofȱ generalȱ application,”ȱ andȱ equatedȱtheȱ“substantialȱobstacle”ȱwithȱ“undueȱburden”ȱnotȬ ingȱ thatȱ “[a]ȱ findingȱ ofȱ anȱ undueȱ burdenȱ isȱ shorthandȱ forȱ theȱ conclusionȱthatȱaȱstateȱregulationȱhasȱtheȱpurposeȱorȱeffectȱofȱ placingȱaȱsubstantialȱobstacleȱinȱtheȱpathȱofȱaȱwomanȱseekingȱ anȱabortionȱofȱaȱnonȬviableȱfetus.”ȱCasey,ȱ505ȱU.S.ȱatȱ876–77ȱ (emphasisȱ ours).ȱ Inȱ fact,ȱ inȱ Casey’sȱ seminalȱ iterationȱ ofȱ theȱ No.ȱ17Ȭ1883ȱ 15 undueȱburdenȱtest,ȱtheȱCourtȱappliedȱitȱtoȱallȱofȱtheȱregulaȬ tionsȱ atȱ issueȱ inȱ thatȱ case,ȱ includingȱ thoseȱ thatȱ theȱ stateȱ claimedȱ affectedȱ women’sȱ healthȱ (recordȱ keepingȱ andȱ reȬ porting),ȱ butȱ alsoȱ toȱ spousalȱ notificationȱ andȱ parentalȱ inȬ volvement,ȱwhichȱtheȱstateȱassertedȱwereȱrelatedȱtoȱitsȱinterȬ estȱ inȱ potentialȱ life.ȱ Id.ȱ atȱ 887–99.ȱ Inȱ otherȱ words,ȱ theȱ Caseyȱ CourtȱappliedȱtheȱsameȱundueȱburdenȱtestȱtoȱallȱofȱtheȱreguȬ lationsȱatȱissueȱinȱthatȱcaseȱwithoutȱregardȱtoȱtheȱstate’sȱasȬ sertedȱ interest.ȱ Inȱ fact,ȱ Caseyȱ madeȱ clearȱ thatȱ “aȱ statuteȱ which,ȱwhileȱfurtheringȱtheȱinterestȱinȱpotentialȱlife,ȱorȱsomeȱ otherȱvalidȱstateȱinterest,ȱhasȱtheȱeffectȱofȱplacingȱaȱsubstantialȱ obstacleȱ inȱ theȱ pathȱ ofȱ aȱ woman’sȱ choiceȱ cannotȱ beȱ considȬ eredȱaȱpermissibleȱmeansȱofȱservingȱitsȱlegitimateȱends.”ȱId.ȱ atȱ877ȱ(emphasisȱadded).ȱȱ Norȱ isȱ thereȱ anythingȱ inȱ theȱ Court’sȱ decisionȱ inȱ Wholeȱ Women’sȱHealthȱtoȱsuggestȱthatȱitȱappliedȱaȱdifferentȱstandardȱ thanȱtheȱundueȱburdenȱtestȱarticulatedȱinȱCasey.ȱRather,ȱtheȱ Wholeȱ Women’sȱ Healthȱ Courtȱ clearlyȱ statesȱ toȱ theȱ contrary.ȱ Whenȱdiscussingȱ“undueȱburden”ȱitȱstartsȱwithȱtheȱsentence,ȱ “Weȱ beginȱ withȱ theȱ standard,ȱ asȱ describedȱ inȱ Casey”ȱ andȱ thenȱ goesȱ onȱ toȱ noteȱ howȱ itȱ willȱ applyȱ thatȱ standard:ȱ “Theȱ ruleȱannouncedȱinȱCaseyȱ[]ȱrequiresȱthatȱcourtsȱconsiderȱtheȱ burdensȱaȱlawȱimposesȱonȱabortionȱaccessȱtogetherȱwithȱtheȱ benefitsȱthoseȱlawsȱconfer.”ȱWholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱ atȱ2309.ȱAndȱinȱfact,ȱinȱannouncingȱthisȱrule,ȱtheȱCourtȱcitedȱ specificallyȱ toȱ theȱ balancingȱ theȱ Caseyȱ courtȱ didȱ forȱ proviȬ sionsȱ notȱ justifiedȱ byȱ aȱ concernȱ forȱ women’sȱ health—thoseȱ relatedȱ toȱspousalȱnotificationȱ andȱparentalȱconsent.ȱId.ȱ (citȬ ingȱCasey,ȱ505ȱU.S.ȱatȱ887–98,ȱ899–901).ȱȱ NotȱonlyȱdoesȱWholeȱWomen’sȱHealthȱconfirmȱthatȱcourtsȱ mustȱ applyȱ theȱ undueȱ burdenȱ balancingȱ testȱ ofȱ Caseyȱ toȱ allȱ 16ȱ No.ȱ17Ȭ1883ȱ abortionȱ regulations,ȱ itȱ alsoȱ dictatesȱ howȱ thatȱ testȱ oughtȱ toȱ beȱ applied.ȱ Citingȱ Casey,ȱ theȱ Wholeȱ Women’sȱ Healthȱ Courtȱ emphasizedȱ thatȱ theȱ undueȱ burdenȱ testȱ requiresȱ courtsȱ toȱ “retain[]ȱanȱindependentȱconstitutionalȱdutyȱtoȱreviewȱfactuȬ alȱ findingsȱ whereȱ constitutionalȱ rightsȱ areȱ atȱ stake.”ȱ Wholeȱ Women’sȱ Health,ȱ 136ȱ S.ȱ Ct.ȱ atȱ 2310.ȱ Inȱ otherȱ words,ȱ aȱ courtȱ cannotȱmerelyȱdependȱonȱlegislativeȱstatementsȱandȱfindingsȱ inȱ evaluatingȱ theȱ constitutionalityȱ ofȱ lawsȱ regulatingȱ aborȬ tion.ȱId.ȱTheȱproperȱstandardȱisȱforȱcourtsȱtoȱconsiderȱtheȱevȬ idenceȱinȱtheȱrecord—including,ȱexpertȱevidence.ȱId.ȱAnd,ȱasȱ weȱdiscussȱnext,ȱthisȱisȱpreciselyȱwhatȱtheȱdistrictȱcourtȱdidȱ below.ȱȱ B.ȱ Theȱevidenceȱofȱburdensȱandȱbenefitsȱ 1.ȱ Burdensȱ NotingȱtheȱSupremeȱCourt’sȱmandateȱtoȱconsiderȱtheȱevȬ idenceȱ inȱ theȱ recordȱ andȱ thenȱ weighȱ theȱ assertedȱ benefitsȱ againstȱ theȱ burdens,ȱ theȱ districtȱ courtȱ didȱ justȱ that;ȱ itȱ madeȱ findingsȱ andȱ evaluatedȱ theȱ persuasivenessȱ ofȱ theȱ evidenceȱ regardingȱtheȱburdensȱandȱbenefitsȱcreatedȱbyȱtheȱnewȱultraȬ soundȱ law.ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ 1021ȱ (citingȱ Wholeȱ Women’sȱ Health,ȱ 136ȱ S.ȱ Ct.ȱ atȱ 2310).ȱ Beginningȱ withȱ theȱ burdens,ȱ theȱ districtȱ courtȱ consideredȱ theȱ burdensȱ asȱ presentedȱ byȱ PPINK,ȱfocusingȱfirstȱonȱtheȱproperȱpopulationȱtoȱconsider,ȱ andȱ thenȱ consideringȱ howȱ theȱ newȱ regulationsȱ impactȱ fiȬ nances,ȱemployment,ȱchildȱcare,ȱandȱtheȱsafetyȱofȱwomenȱinȱ abusiveȱrelationships.ȱȱ Asȱtheȱdistrictȱcourtȱnoted,ȱ“[t]heȱproperȱfocusȱofȱconstiȬ tutionalȱ inquiryȱ isȱ theȱ groupȱ forȱ whomȱ theȱ lawȱ isȱ aȱ reȬ striction,ȱnotȱtheȱgroupȱforȱwhomȱtheȱlawȱisȱirrelevant.”ȱId.ȱatȱ 1021ȱ(citingȱCasey,ȱ505ȱU.S.ȱatȱ894).ȱInȱthisȱcase,ȱasȱtheȱdistrictȱ No.ȱ17Ȭ1883ȱ 17 courtȱ correctlyȱ determined,ȱ theȱ newȱ ultrasoundȱ lawȱ isȱ aȱ reȬ strictionȱ primarilyȱ forȱ womenȱ forȱ whomȱ anȱ additionalȱ lengthyȱ tripȱ toȱ aȱ PPINKȱ healthȱ centerȱ forȱ theirȱ informedȬ consentȱ appointmentȱ actsȱ asȱ anȱ impedimentȱ toȱ theirȱ accessȱ toȱabortionȱservices.ȱTheȱdistrictȱcourtȱfoundȱspecificallyȱthatȱ thisȱgroupȱconsistedȱofȱlowȱincomeȱwomenȱwhoȱdoȱnotȱliveȱ nearȱ oneȱ ofȱ PPINK’sȱ sixȱ healthȱ centersȱ whereȱ ultrasoundsȱ areȱavailable.ȱWeȱagreeȱwithȱtheȱdistrictȱcourtȱonȱthisȱpoint,ȱ butȱ alsoȱ noteȱ thatȱ theȱ concernsȱ aboutȱ confidentialityȱ inȱ emȬ ploymentȱ situationsȱ andȱ abusiveȱ spousesȱ thatȱ weȱ addressȱ furtherȱbelow,ȱcanȱcreateȱimpedimentsȱthatȱspanȱincomeȱlevȬ els.ȱNevertheless,ȱourȱanalysis,ȱlikeȱtheȱdistrictȱcourt’s,ȱdoesȱ notȱrelyȱuponȱthisȱlargerȱgroup.ȱȱ Allȱofȱtheȱburdenȱinȱthisȱcaseȱoriginatesȱfromȱtheȱlengthyȱ travelȱthatȱisȱrequiredȱofȱsomeȱwomenȱwhoȱhaveȱtoȱtravelȱfarȱ distancesȱ forȱ anȱ ultrasoundȱ appointmentȱ atȱ leastȱ eighteenȱ hoursȱpriorȱtoȱanȱabortion.ȱRecallȱthatȱbeforeȱtheȱenactmentȱ ofȱ theȱ newȱ ultrasoundȱ regulation,ȱ allȱ womenȱ seekingȱ anȱ abortionȱ hadȱ toȱ travelȱ someȱ distanceȱ toȱ theȱ nearestȱ PPINKȱ facilityȱ atȱ leastȱ eighteenȱ hoursȱ priorȱ toȱ anȱ abortionȱ inȱ orderȱ toȱ participateȱ inȱ anȱ informedȬconsentȱ informationȱ session.ȱ Becauseȱ theȱ lawȱ didȱ notȱ requireȱ thatȱ womenȱ haveȱ anȱ ultraȬ soundȱ untilȱ justȱ beforeȱ theȱ abortionȱ procedure,ȱ however,ȱ theyȱ couldȱ participateȱ inȱ thatȱ informedȬconsentȱ meetingȱ atȱ anyȱ ofȱ theȱ twentyȬthreeȱ PPINKȱ facilitiesȱ spreadȱ throughoutȱ Indiana.6ȱ Now,ȱ however,ȱ theyȱ mustȱ travelȱ onȱ theȱ dayȱ priorȱ toȱtheȱabortion,ȱtoȱoneȱofȱsixȱPPINKȱfacilitiesȱthatȱhasȱultraȬ soundȱequipment.ȱAsȱweȱnotedȱabove,ȱthisȱmeansȱthatȱsomeȱ womenȱmustȱtravelȱgreatȱdistancesȱtwiceȱinȱorderȱtoȱreceiveȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6ȱDueȱtoȱbudgetȱproblemsȱthereȱareȱnowȱonlyȱseventeenȱPPINKȱfacilitiesȱ inȱIndiana.ȱȱ 18ȱ No.ȱ17Ȭ1883ȱ anȱ abortion.ȱ Forȱ example,ȱ womenȱ inȱ theȱ secondȱ largestȱ cityȱ inȱIndiana,ȱFortȱWayne,ȱmustȱnowȱtravelȱapproximatelyȱ400ȱ milesȱoverȱtwoȱdaysȱtoȱobtainȱanȱabortion,ȱasȱtheȱclosestȱulȬ trasoundȱmachineȱisȱ87ȱmilesȱawayȱinȱMishawakaȱ(174ȱmilesȱ roundȱtrip)ȱandȱtheȱnearestȱabortionȬprovidingȱhealthȱcenterȱ isȱ115ȱmilesȱawayȱinȱLafayetteȱ(230ȱmilesȱroundȱtrip).ȱR.ȱ24Ȭ1ȱ atȱ 3,ȱ 13–14.ȱ Previously,ȱ whenȱ Fortȱ Wayneȱ stillȱ hadȱ itsȱ nonȬ abortionȬprovidingȱ healthȱ clinic,ȱ womenȱ inȱ Fortȱ Wayneȱ couldȱ haveȱ theirȱ fifteenȬminuteȬlongȱ informedȬconsentȱ apȬ pointmentȱrightȱatȱtheȱPPINKȱhealthȱcenterȱinȱFortȱWayne.ȱ Althoughȱ theȱtravelȱ distanceȱisȱtheȱoriginȱofȱtheȱburden,ȱ theȱdistrictȱcourtȱfoundȱthatȱtheȱstrainȱofȱtheȱlawȱextendsȱintoȱ theȱrealmȱofȱfinances,ȱemployment,ȱchildȱcare,ȱandȱdomesticȱ safety.ȱ Theȱ districtȱ courtȱ consideredȱ theȱ testimonyȱ ofȱ PPINK’sȱ expertȱ inȱ genderȱ studies,ȱ poverty,ȱ andȱ lowȬwageȱ laborȱmarkets,ȱDr.ȱJaneȱCollins,ȱwhoȱexplainedȱtheȱimpactȱofȱ theȱnewȱlawȱonȱtheseȱinterconnectedȱstressorsȱandȱonȱtheȱalȬ readyȱ precariousȱ financialȱ livesȱ ofȱ poorȱ womenȱ seekingȱ anȱ abortion.ȱ R.ȱ 24Ȭ2.ȱ Sheȱ analyzedȱ theȱ familyȱ budgetsȱ ofȱ lowȬ incomeȱwomenȱandȱassessedȱhowȱtheȱadditionalȱcostsȱassoȬ ciatedȱ withȱ theȱ newȱ ultrasoundȱ lawȱ wouldȱ impactȱ theseȱ womenȱ andȱ theirȱ families.ȱ Herȱ testimonyȱ confirmedȱ whatȱ commonȱ senseȱ suggests.ȱ Manyȱ lowȬincomeȱ womenȱ doȱ notȱ haveȱ employmentȱ thatȱ paysȱ themȱ whenȱ theyȱ missȱ aȱ dayȱ ofȱ workȱ orȱ theyȱ mayȱ haveȱ precariousȱ jobȱ situationsȱ inȱ whichȱ theyȱcouldȱbeȱfiredȱforȱexcessiveȱabsences.ȱAȱsecondȱlengthyȱ tripȱforȱanȱ ultrasoundȱappointmentȱlikelyȱrequiresȱaȱsecondȱ missedȱdayȱofȱwork.ȱAndȱwomenȱwithȱyoungȱchildrenȱwhoȱ couldȱ previouslyȱ bringȱ themȱ alongȱ toȱ anȱ informedȬconsentȱ sessionȱ mustȱ leaveȱ themȱ behindȱ forȱ theȱ ultrasound,ȱ asȱ PPINK’sȱ policiesȱ prohibitȱ childrenȱ fromȱ beingȱ presentȱ durȬ ingȱ anȱ ultrasound.ȱ (Andȱ asȱ weȱ discussȱ below,ȱ bothȱ safetyȱ No.ȱ17Ȭ1883ȱ 19 andȱ commonȱ senseȱ supportȱ suchȱ aȱ policy).ȱ Theȱ newȱ ultraȬ soundȱ lawȱ thereforeȱ requiresȱ womenȱ toȱ arrangeȱ childȱ careȱ forȱanȱadditionalȱday.ȱ Dr.ȱ Collinsȱ calculatedȱ thatȱ theȱ additionalȱ costȱ posedȱ byȱ theȱnewȱultrasoundȱlawȱforȱaȱwomanȱlivingȱinȱFortȱ Wayne,ȱ Indianaȱ whoȱ hasȱ children,ȱ noȱ car,ȱ andȱ wouldȱ loseȱ aȱ day’sȱ wagesȱ wouldȱ beȱ betweenȱ $219ȱ toȱ $247.ȱ R.ȱ 24Ȭ2ȱ atȱ 18.ȱ Manyȱ lowȬincomeȱfamiliesȱhaveȱaȱdiscretionaryȱmonthlyȱbudgetȱofȱ approximatelyȱ$40.ȱId.ȱTheȱadditionalȱexpensesȱofȱoverȱ$200ȱ constituteȱ roughlyȱ 25%ȱ ofȱ theirȱ entireȱ monthlyȱ budget.ȱ Id.ȱ Theseȱ expensesȱ areȱ aboveȱ andȱ beyondȱ theȱ costȱ ofȱ theȱ aborȬ tionȱitselfȱwhichȱwas,ȱatȱtheȱtimeȱofȱtheȱhearing,ȱ$410ȱforȱtheȱ abortionȱandȱ$100ȱforȱtheȱultrasound.ȱR.ȱ24Ȭ1ȱatȱ8;ȱR.ȱ35Ȭ5ȱatȱ 35.ȱ Dr.ȱ Collinsȱ explainedȱ thatȱ toȱ coverȱ theȱ costsȱ associatedȱ withȱabortions,ȱmanyȱwomenȱ(aboutȱoneȱthird)ȱwillȱdelayȱorȱ stopȱpayingȱbasicȱbillsȱinȱorderȱtoȱaffordȱanȱabortion.ȱR.ȱ24Ȭ2ȱ atȱ21.ȱUpȱtoȱ50%ȱofȱwomenȱborrowȱmoneyȱfromȱfamilyȱandȱ friends.ȱ R.24Ȭ1ȱ atȱ 20.ȱ Theȱ districtȱ courtȱ concludedȱ that,ȱ “forȱ manyȱ womenȱ facedȱ withȱ theȱ alreadyȱ highȱ costsȱ ofȱ anȱ aborȬ tionȱ andȱ aȱ lackȱ ofȱ meansȱ toȱ affordȱ them,ȱ theȱ additionalȱ exȬ pensesȱ ofȱ lengthyȱ travel,ȱ lostȱ wages,ȱ andȱ childȱ careȱ createdȱ byȱtheȱnewȱultrasoundȱlawȱcreateȱaȱsignificantȱburden.”ȱ273ȱ F.ȱSupp.ȱ3dȱatȱ1028.ȱȱ Theȱ costȱ ofȱ theȱ ultrasoundȱ ruleȱ isȱ measuredȱ notȱ onlyȱ inȱ dollarsȱbutȱinȱtimeȱandȱaccessȱasȱwell.ȱSurgicalȱabortionsȱareȱ availableȱ atȱ PPINKȱ healthȱ centersȱ untilȱ thirteenȱ weeksȱ andȱ sixȱ daysȱ afterȱ theȱ lastȱ menstrualȱ period.ȱ Inȱ fiscalȱ yearȱ 2016,ȱ approximatelyȱ 22%ȱ ofȱ allȱ abortionsȱ andȱ moreȱ thanȱ 34%ȱ ofȱ surgicalȱ abortionsȱ performedȱ atȱ PPINKȱ tookȱ placeȱ inȱ theȱ threeȱweeksȱbeforeȱtheȱdeadline.ȱR.ȱ24Ȭ1ȱatȱ7–8.ȱWomenȱoftenȱ pushȱupȱagainstȱtheȱdeadlineȱbecauseȱtheyȱareȱgatheringȱtheȱ 20ȱ No.ȱ17Ȭ1883ȱ necessaryȱfunds,ȱmakingȱlogisticalȱarrangementsȱorȱbecauseȱ theyȱ failedȱ toȱ promptlyȱ recognizeȱ theȱ signsȱ ofȱ pregnancy.ȱ R.ȱ24Ȭ1ȱatȱ7–8.ȱ(Mostȱwomenȱcannotȱknowȱtheyȱareȱpregnantȱ untilȱ atȱ leastȱ 4ȱ weeksȱ followingȱ theirȱ lastȱ menstrualȱ period,ȱ thusȱreducingȱtheȱtimeȱtheyȱhaveȱtoȱdiscoverȱtheȱpregnancy,ȱ exploreȱtheirȱoptionsȱandȱdiscussȱthemȱwithȱaȱpartner,ȱfamiȬ lyȱorȱdoctor,ȱarrangeȱforȱmissedȱworkȱandȱchildȱcare,ȱandȱseȬ cureȱ twoȱ appointments—toȱ onlyȱ nineȱ weeks,ȱ 6ȱ daysȱ forȱ aȱ surgicalȱ abortionȱ andȱ thirtyȬfiveȱ days,ȱ forȱ aȱ medicalȱ aborȬ tion).ȱ Beforeȱtheȱnewȱultrasoundȱlaw,ȱPPINKȱcouldȱusuallyȱacȬ commodateȱ womenȱ imminentlyȱ facingȱ theȱ deadlineȱ byȱ schedulingȱanȱ informedȬconsentȱ appointmentȱatȱ theȱ nearestȱ PPINKȱhealthȱcenterȱandȱthen,ȱtheȱnextȱday,ȱsheȱcouldȱtravelȱ theȱfurtherȱdistance,ȱifȱnecessary,ȱtoȱaȱPPINKȱfacilityȱthatȱofȬ feredȱ abortionȱ services.ȱ Afterȱtheȱenactmentȱ ofȱtheȱnewȱlawȱ (andȱ beforeȱ theȱ districtȱ courtȱ issuedȱ aȱ preliminaryȱ injuncȬ tion),ȱ theȱ PPINKȱ healthȱ centersȱ withȱ ultrasoundȱ machinesȱ becameȱ soȱ overwhelmedȱ withȱ appointmentsȱ thatȱ PPINKȱ couldȱ notȱ adequatelyȱ respondȱ toȱ womenȱ whoȱ contactedȱ PPINKȱ nearȱ theȱ endȱ ofȱ theȱ allowableȱ timeȱ period.ȱ Asȱ aȱ reȬ sult,ȱ PPINKȱ hadȱ toȱ doubleȱ bookȱ appointmentsȱ causingȱ furȬ therȱ delaysȱ forȱ womenȱ andȱ longerȱ waitȱ timesȱ forȱ womenȱ whoȱ wereȱ alreadyȱ missingȱ workȱ timeȱ andȱ needingȱ toȱ arȬ rangeȱ childȱ care.ȱ Evenȱ withȱ overscheduling,ȱ appointmentȱ availabilityȱ grewȱ scarceȱ andȱ womenȱ hadȱ toȱ waitȱ longerȱ toȱ haveȱ anȱ abortion.ȱ Thisȱ precludedȱ theȱ optionȱ ofȱ medicationȱ abortionsȱforȱsomeȱwomenȱandȱanyȱabortionȱchoicesȱforȱothȬ ers.ȱ Abortionȱ appointmentsȱ wereȱ alreadyȱ scarceȱ inȱ Indianaȱ givenȱ thatȱ physiciansȱ areȱ onlyȱ availableȱ atȱ theȱ fourȱ healthȱ centersȱ offeringȱ abortionsȱ atȱ limitedȱ times:ȱ Indianapolisȱ (3ȱ days/week);ȱ Bloomingtonȱ (1ȱ day/week);ȱ Merrillvilleȱ (1.5ȱ No.ȱ17Ȭ1883ȱ 21 days/week);ȱ andȱ Lafayetteȱ (1ȱ dayȱ perȱ week).ȱ R.ȱ 24Ȭ1ȱ atȱ 6.ȱ Withȱ suchȱ limitedȱ availability,ȱ delaysȱ inȱ gettingȱ anȱ ultraȬ soundȱ appointmentȱ mightȱ meanȱ havingȱ toȱ waitȱ anȱ entireȱ weekȱ longerȱ beforeȱ aȱ physicianȱ isȱ availableȱ atȱ theȱ closestȱ PPINKȱcenter,ȱorȱtravellingȱtoȱtheȱhealthȱcenterȱwhereȱaȱphyȬ sicianȱisȱonȱduty.ȱMoreover,ȱtheȱnewȱlawȱcausesȱotherȱprobȬ lemsȱ relatedȱ toȱ delay.ȱ Althoughȱ theȱ informedȬconsentȱ proȬ cessȱ onlyȱ tookȱ approximatelyȱ fifteenȱ minutesȱ before,ȱ afterȱ theȱ enactmentȱ ofȱ theȱ newȱ law,ȱ theȱ processȱ tookȱ asȱ longȱ asȱ seventyȬfiveȱ minutes.ȱ Thisȱ addedȱ toȱ theȱ costȱ ofȱ childȱ care,ȱ missedȱ workȱ time,ȱ andȱ madeȱ itȱ harderȱ toȱ hideȱ visitsȱ fromȱ abusiveȱpartners.ȱ Theȱdistrictȱcourtȱcreditedȱtheȱevidenceȱthatȱtheȱdemandsȱ onȱ theȱ PPINKȱ staffȱ tryingȱ toȱ accommodateȱ soȱ manyȱ addiȬ tionalȱ ultrasoundȱ appointmentsȱ duringȱ theȱ periodȱ ofȱ timeȱ theȱ lawȱ wasȱ enforcedȱ wereȱ unsustainable.ȱ Theȱ additionalȱ quantityȱofȱappointmentsȱrequiredȱstaffȱtoȱstayȱlateȱandȱtookȱ awayȱ resourcesȱ fromȱ theȱ manyȱ nonȬabortionȱ servicesȱ thatȱ PPINKȱ providesȱ suchȱ asȱ cancerȱ screening,ȱ wellȬwomenȱ healthȱscreening,ȱfamilyȱplanning,ȱandȱpreventativeȱservices.ȱ Accordingȱ toȱ PPINK’sȱ CEO,ȱ requiringȱ staffȱ toȱ workȱ atȱ thisȱ paceȱ andȱ levelȱ ofȱ intensityȱ isȱ notȱ workableȱ overȱ theȱ longȱ term,ȱandȱultimatelyȱleadsȱtoȱhighȱstaffȱturnover,ȱexacerbatȬ ingȱtheȱproblemȱfurther.ȱR.ȱ24Ȭ1ȱatȱ11.ȱ Finally,ȱ theȱ districtȱ courtȱ foundȱ thatȱ theȱ newȱ regulationȱ hasȱ anȱ impactȱ onȱ victimsȱ ofȱ domesticȱ violence.ȱ Theȱ districtȱ courtȱ notedȱ thatȱ oneȱ nationalȱ studyȱ showedȱ thatȱ 13.8%ȱ ofȱ womenȱ whoȱ hadȱ anȱ abortionȱ hadȱ beenȱ inȱ anȱ abusiveȱ relaȬ tionshipȱwithinȱaȱyearȱbeforeȱtheȱabortion.ȱ273ȱF.ȱSupp.ȱ3dȱatȱ 1026.ȱInsteadȱofȱstealingȱawayȱforȱaȱfifteenȬminuteȱinformedȬ consentȱ sessionȱ atȱ aȱ nearbyȱ PPINKȱ healthȱ center,ȱ abusedȱ 22ȱ No.ȱ17Ȭ1883ȱ womenȱ tryingȱ toȱ keepȱ theirȱ choiceȱ confidentialȱ haveȱ toȱ arȬ rangeȱtoȱbeȱawayȱforȱallȱorȱmostȱofȱtwoȱdays.ȱȱ Theȱdistrictȱcourtȱalsoȱconsideredȱtheȱanecdotalȱevidenceȱ submittedȱbyȱPPINKȱ aboutȱ nineȱwomenȱ whoȱ couldȱ notȱ obȬ tainȱanȱabortionȱdueȱtoȱtheȱburdensȱimposedȱbyȱtheȱnewȱulȬ trasoundȱlaw.ȱTheȱcourtȱconsideredȱtheȱfollowingȱnarrativesȱ collectedȱbyȱPPINKȱfromȱwomenȱwhoȱdescribedȱtheirȱexpeȬ riencesȱasȱfollows:ȱ •ȱTheȱnearestȱPPINKȱhealthȱcenterȱtoȱaȱwomanȱ seekingȱ anȱ abortionȱ wasȱ overȱ anȱ hourȱ away,ȱ andȱ dueȱ toȱ theȱ factȱ thatȱ sheȱ hasȱ twoȱ youngȱ childrenȱandȱdifficultyȱwithȱtransportation,ȱsheȱ wasȱ unableȱ toȱ scheduleȱ theȱ twoȱ lengthyȱ tripsȱ duringȱtheȱthirteenȱweek,ȱsixȱdayȱtimeframeȱinȱ whichȱanȱabortionȱisȱavailable.ȱ •ȱAȱwomanȱfromȱtheȱFortȱWayneȱareaȱdidȱnotȱ scheduleȱ anȱ abortionȱ becauseȱ ofȱ theȱ twoȱ lengthyȱtripsȱnecessary.ȱSheȱwasȱelevenȱweeks,ȱ fourȱ daysȱ pregnantȱ whenȱ sheȱ contactedȱ PPINK,ȱ butȱ couldȱ notȱ missȱ workȱ twiceȱ withinȱ theȱshortȱtimeframeȱremaining.ȱ •ȱAȱwomanȱwhoȱpreviouslyȱhadȱanȱabortionȱatȱ PPINKȱ calledȱ toȱ scheduleȱ another,ȱ butȱ ultiȬ matelyȱ saidȱ sheȱ couldȱ notȱ scheduleȱ oneȱ afterȱ sheȱwasȱinformedȱsheȱwouldȱhaveȱtoȱmakeȱtwoȱ tripsȱ toȱ theȱ PPINKȱ healthȱ centerȱ inȱ BloomingȬ ton,ȱIndiana.ȱ •ȱAȱwomanȱlivingȱinȱaȱshelterȱwithȱtwoȱyoungȱ childrenȱ decidedȱ notȱ toȱ scheduleȱ anȱ abortionȱ appointmentȱbecauseȱofȱtheȱtransportationȱandȱ No.ȱ17Ȭ1883ȱ 23 childcareȱ difficultiesȱ twoȱ appointmentsȱ wouldȱ cause.ȱ •ȱAȱwomanȱwhoȱrecentlyȱstartedȱaȱnewȱjobȱafȬ terȱ aȱ yearȱ ofȱ unemploymentȱ statedȱ thatȱ sheȱ couldȱ notȱ driveȱ theȱ threeȬhourȱ roundtripȱ toȱ aȱ PPINKȱhealthȱcenterȱonȱtwoȱseparateȱoccasionsȱ dueȱtoȱtheȱcombinationȱofȱwork,ȱchildcare,ȱandȱ transportationȱ expenses,ȱ inȱ additionȱ toȱ herȱ concernsȱ regardingȱ theȱ confidentialityȱ ofȱ theȱ abortion.ȱ •ȱ Aȱ womanȱ whoȱ didȱ notȱ learnȱ sheȱ wasȱ pregȬ nantȱ forȱ tenȱ weeksȱ facedȱ aȱ longȱ delayȱ beforeȱ sheȱ couldȱ haveȱ herȱ informedȬconsentȱ appointȬ mentȱ thatȱ requiredȱ travelȱ toȱ aȱ PPINKȱ healthȱ center,ȱandȱbyȱtheȱtimeȱofȱherȱappointmentȱsheȱ wasȱoneȱdayȱbeyondȱtheȱdeadlineȱforȱanȱaborȬ tion.ȱ •ȱ Aȱ womanȱ fromȱ Fortȱ Wayneȱ whoȱ hadȱ aȱ preȬ viousȱabortionȱatȱPPINKȱcalledȱtoȱscheduleȱanȬ other,ȱ butȱ onceȱ sheȱ wasȱ informedȱ thatȱ sheȱ wouldȱ haveȱ toȱ makeȱ twoȱ lengthyȱ tripsȱ toȱ aȱ PPINKȱhealthȱcenter,ȱsheȱsaidȱsheȱcouldȱnotȱafȬ fordȱtoȱdoȱsoȱandȱdidȱnotȱscheduleȱanȱabortion.ȱ •ȱ Aȱ womanȱ livingȱ anȱ hourȱ northȱ ofȱ Fortȱ Wayneȱ whoȱ hasȱ specialȱ needsȱ childrenȱ deȬ clinedȱ toȱ scheduleȱ anȱ abortionȱ afterȱ learningȱ thatȱsheȱwouldȱhaveȱtoȱmakeȱtwoȱlengthyȱtripsȱ forȱ eachȱ appointment,ȱ asȱ sheȱ couldȱ notȱ affordȱ toȱ beȱ awayȱ fromȱ herȱ childrenȱ forȱ thatȱ longȱ onȱ twoȱoccasions.ȱ 24ȱ No.ȱ17Ȭ1883ȱ •ȱ Aȱ womanȱ fromȱ Fortȱ Wayneȱ whoȱ wasȱ apȬ proachingȱtheȱdeadlineȱtoȱhaveȱanȱabortionȱdeȬ clinedȱ toȱ scheduleȱ anȱ appointmentȱ dueȱ toȱ theȱ requiredȱ travelȱ andȱ riskȱ ofȱ missingȱ theȱ deadȬ lineȱ byȱ theȱ timeȱ sheȱ couldȱ scheduleȱ bothȱ apȬ pointments.ȱ 273ȱF.ȱSupp.ȱ3dȱatȱ1029–30ȱ(citingȱR.ȱ24–1ȱatȱ16–17;ȱR.ȱ38–1ȱatȱ 1–2).ȱȱ Beforeȱ theȱ districtȱ court,ȱ andȱ againȱ onȱ appeal,ȱ theȱ Stateȱ arguedȱthatȱPPINK’sȱexamplesȱwereȱunreliableȱasȱtheyȱwereȱ passedȱonȱtoȱaȱPPINKȱstaffȱmemberȱandȱthenȱtoȱtheȱ declarȬ antȱ withoutȱ PPINKȱ takingȱ anyȱ actionȱ toȱ verifyȱ theȱ inforȬ mation.ȱTheȱdistrictȱcourtȱconsideredȱtheȱreliabilityȱissueȱbut,ȱ notingȱ thatȱ aȱ courtȱ couldȱ baseȱ aȱ preliminaryȱ injunctionȱ onȱ lessȱ formalȱ proceduresȱ andȱ lessȱ extensiveȱ evidenceȱ thanȱ aȱ trialȱonȱtheȱmeritsȱ(citingȱDexiaȱCreditȱLocalȱv.ȱRogan,ȱ602ȱF.3dȱ 879,ȱ885ȱ(7thȱCir.ȱ2010)),ȱtheȱdistrictȱcourtȱfoundȱtheȱevidenceȱ toȱbeȱsufficientlyȱreliableȱforȱtheȱpurposeȱatȱhand.ȱTheȱcourtȱ reasonedȱ thatȱ theȱ reportsȱ reflectedȱ aȱ plausible,ȱ ifȱ notȱ likely,ȱ consequenceȱofȱtheȱnewȱultrasoundȱlaw.ȱMoreover,ȱtheȱcourtȱ recognizedȱthat,ȱasȱweȱexploreȱmoreȱfullyȱbelow,ȱtheȱState’sȱ “onlyȱevidenceȱthatȱtheȱlawȱfurthersȱitsȱinterestȱinȱpromotingȱ fetalȱ lifeȱ isȱ fromȱ aȱ womanȱ whoseȱ testimonyȱ wasȱ admittedȱ intoȱevidenceȱthroughȱtheȱdeclarationȱofȱherȱphysician.”ȱ273ȱ F.ȱSupp.ȱ3dȱatȱ1030ȱ(emphasisȱinȱoriginal).ȱInȱaȱgoodȬforȬtheȬ gooseȬandȬganderȱway,ȱtheȱdistrictȱcourtȱpointedȱoutȱthatȱif,ȱ forȱpurposesȱofȱtheȱpreliminaryȱinjunction,ȱtheȱcourtȱignoredȱ allȱevidenceȱnotȱdirectlyȱfromȱitsȱsource,ȱ“theȱStateȱwouldȱbeȱ leftȱ withoutȱ anyȱ evidenceȱ directlyȱ supportingȱ itsȱ position.”ȱ Id.ȱ Theȱ districtȱ court’sȱ comparisonȱ wasȱ aptȱ andȱ itsȱ concluȬ No.ȱ17Ȭ1883ȱ 25 sionsȱ reasonable.ȱ Weȱ cannotȱ sayȱ thatȱ thisȱ wasȱ anȱ abuseȱ ofȱ discretionȱtoȱconsiderȱtheȱanecdotalȱevidenceȱonȱbothȱsides.ȱ Theȱ Stateȱ arguedȱ thatȱ PPINKȱ couldȱ mitigateȱ theseȱ burȬ densȱ byȱ makingȱ differentȱ medicalȱ andȱ businessȱ decisions,ȱ primarilyȱ byȱ outfittingȱ allȱ ofȱ itsȱ healthȱ centersȱ withȱ lessȱ exȬ pensiveȱ ultrasoundȱ equipmentȱ andȱ byȱ puttingȱ moreȱ reȬ sourcesȱtowardȱabortionȱservices.7ȱPPINK’sȱdirectorȱofȱaborȬ tionȱservicesȱexplainedȱthatȱtheȱ$25,000ȱmachineȱthatȱPPINKȱ ordinarilyȱ purchasesȱ comesȱ withȱ anȱ extendedȱ warranty,ȱ inȬ cludesȱ plannedȱ maintenance,ȱ replacementȱ parts,ȱ softwareȱ updates,ȱsupport,ȱandȱaȱguaranteedȱ24Ȭhourȱresponseȱtimeȱifȱ thereȱ areȱ anyȱ problemsȱ withȱ theȱ machine.ȱ R.ȱ 38Ȭ1ȱ atȱ 3–4.ȱ Itȱ alsoȱintegratesȱwithȱPPINK’sȱelectronicȱrecordȱsystemȱwhichȱ isȱ criticalȱ whenȱ theȱ ultrasoundȱ andȱ abortionȱ appointmentȱ occurȱ atȱ differentȱ healthȱ centers.ȱ Id.ȱ atȱ 4.ȱ And,ȱ asȱ PPINKȱ pointsȱ out,ȱ evenȱ ifȱ itȱ couldȱ affordȱ toȱ buyȱ theȱ machines,ȱ itȱ wouldȱ stillȱ beȱ limitedȱ byȱ spaceȱ andȱ personnel.ȱ Theȱ districtȱ courtȱ rejectedȱ theȱ State’sȱ mitigationȱ argument,ȱ notingȱ thatȱ theȱ “undueȱ burdenȱ inquiryȱ doesȱ notȱ contemplateȱ reȬ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7ȱ Beforeȱ theȱ districtȱ court,ȱ theȱ Stateȱ alsoȱ arguedȱ thatȱ PPINKȱ shouldȱ acȬ ceptȱultrasoundsȱresultsȱfromȱotherȱproviders,ȱbutȱhasȱdroppedȱthatȱarȬ gumentȱ onȱ appeal.ȱ Theȱ Stateȱ lawȱ requiresȱ thatȱ theȱ sameȱ providerȱ whoȱ performsȱtheȱultrasoundȱalsoȱengageȱtheȱpatientȱinȱtheȱinformedȬconsentȱ process.ȱTheȱrequiredȱinformedȬconsentȱprocessȱisȱveryȱspecificȱandȱdeȬ tailedȱ andȱ requiresȱ thatȱ theȱ personȱ providingȱ theȱ informationȱ provideȱ someȱ informationȱ thatȱ onlyȱ theȱ abortionȱ providerȱ mightȱ have,ȱ suchȱ asȱ theȱnameȱofȱtheȱphysicianȱperformingȱtheȱabortion,ȱtheȱphysician’sȱmediȬ calȱlicenseȱnumber,ȱandȱtheȱemergencyȱphoneȱnumberȱwhereȱtheȱphysiȬ cianȱcanȱbeȱreachedȱtwentyȬfourȱhoursȱaȱday,ȱsevenȱdaysȱaȱweek.ȱInd.ȱSt.ȱ 16Ȭ34Ȭ2.1.1(a)(4).ȱTheȱdistrictȱcourtȱfoundȱthat,ȱgivenȱtheseȱrequirements,ȱ itȱ seemsȱ unlikelyȱ thatȱ anȱ outsideȱ providerȱ couldȱ complyȱ withȱ theȱ inȬ formedȬconsentȱprocedureȱasȱdictatedȱbyȱtheȱstatute.ȱWeȱagree.ȱȱ 26ȱ No.ȱ17Ȭ1883ȱ examiningȱ everyȱ preȬexistingȱ policyȱ orȱ practiceȱ ofȱ abortionȱ providersȱ toȱ seeȱ ifȱ theyȱ couldȱ furtherȱ mitigateȱ burdensȱ imȬ posedȱ byȱ aȱ newȱ abortionȱ regulation.”ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ 1023.ȱ Inȱ general,ȱ courtsȱ doȱ notȱ micromanageȱ anȱ entity’sȱ businessȱ decisions.ȱ Seeȱ Rileyȱ v.ȱ Elkhartȱ Cmty.ȱ Sch.,ȱ 829ȱ F.3dȱ 886,ȱ895ȱ(7thȱCir.ȱ2016)ȱ(notingȱthat,ȱinȱtheȱTitleȱVIIȱcontext,ȱ courtsȱ doȱ notȱ “secondȬguess[]ȱ employers’ȱ businessȱ judgȬ ments”).ȱProvidedȱPPINKȱsetȱforthȱaȱreasonableȱexplanationȱ forȱpurchasingȱtheseȱparticularȱultrasoundȱmachines—andȱitȱ has,ȱindeed,ȱdoneȱso—theȱdistrictȱcourtȱwasȱentitledȱtoȱdeferȱ toȱ PPINK’sȱ justifiableȱ businessȱ decisionsȱ andȱ considerȱ theȱ burdensȱofȱtheȱnewȱultrasoundȱlawȱwithinȱtheȱcontextȱofȱtheȱ realityȱ thatȱ existsȱ forȱ bothȱ PPINKȱ inȱ operatingȱ itsȱ businessȱ andȱ forȱ theȱ patientsȱ itȱ serves.ȱ Weȱ agreeȱ withȱ theȱ districtȱ court’sȱ assessmentȱ andȱ itsȱ deferenceȱ toȱ PPINK’sȱ reasonableȱ businessȱdecisions.ȱInȱaddition,ȱweȱnoteȱthatȱitȱalsoȱwouldȱbeȱ reasonableȱ forȱ PPINKȱ toȱ makeȱ decisionsȱ aboutȱ itsȱ medicalȱ equipmentȱneedsȱbasedȱnotȱonlyȱonȱeconomicȱconcerns,ȱbutȱ alsoȱonȱitsȱabilityȱtoȱprovideȱtheȱbestȱmedicalȱcareȱforȱitsȱpaȬ tients,ȱtoȱattractȱcertainȱmedicalȱprofessionals,ȱforȱtheȱsafetyȱ ofȱ itsȱ technicians,ȱ toȱ preventȱ malpracticeȱ claims,ȱ orȱ forȱ anyȱ numberȱofȱotherȱlegitimateȱreasons.ȱȱ TheȱsameȱcanȱbeȱsaidȱofȱPPINK’sȱstaffingȱdecisions.ȱTheȱ Stateȱ thoughtȱ thatȱ PPINKȱ alsoȱ couldȱ mitigateȱ burdensȱ byȱ trainingȱ nurseȱ practitionersȱ toȱ interpretȱ ultrasounds.ȱ Thisȱ training,ȱhoweverȱisȱbothȱexpensiveȱandȱrequiresȱfourȱweeksȱ awayȱfromȱclinicalȱwork.ȱPPINKȱrationallyȱcouldȱdetermineȱ thatȱitȱwasȱnotȱtheȱbestȱallocationȱofȱitsȱresources.ȱTheȱStateȱ arguesȱthatȱtheȱrightȱtoȱanȱabortionȱdoesȱnotȱinsulateȱPPINKȱ fromȱ makingȱ difficultȱ decisionsȱ aboutȱ theȱ allocationȱ ofȱ reȬ sources.ȱThatȱmayȱbeȱtrue,ȱbutȱneitherȱisȱitȱappropriateȱforȱanȱ opposingȱpartyȱorȱaȱcourtȱtoȱdictateȱtheȱbestȱuseȱofȱresourcesȱ No.ȱ17Ȭ1883ȱ 27 forȱ aȱ business,ȱ providedȱ itsȱ choicesȱ areȱ withinȱ theȱ rangeȱ ofȱ reasonableness—butȱ particularlyȱ inȱ theȱ caseȱ ofȱ aȱ nonȬprofitȱ agencyȱwithȱlimitedȱfundingȱseekingȱtoȱprovideȱtheȱmostȱefȬ ficientȱhealthȱcareȱservicesȱtoȱaȱmostlyȱpoorȱpopulation.ȱȱ Theȱ districtȱ courtȱ creditedȱ theȱ attestationȱ byȱ PPINK’sȱ presidentȱ andȱ CEOȱ thatȱ PPINKȱ wasȱ unableȱ toȱ supplyȱ eachȱ centerȱwithȱtheȱequipmentȱandȱstaffȱitȱneededȱtoȱprovideȱulȬ trasounds.ȱ Inȱ responseȱ toȱ theȱ newȱ law,ȱ PPINKȱ didȱ buyȱ oneȱ newȱ ultrasoundȱ machineȱ forȱ oneȱ ofȱ itsȱ nonȬabortionȬ providingȱ healthȱ centersȱ andȱ trainedȱ aȱ staffȱ memberȱ toȱ useȱ ultrasoundȱequipmentȱatȱanother,ȱindicatingȱitsȱcommitmentȱ toȱprovidingȱasȱmuchȱserviceȱasȱitȱcouldȱdespiteȱtheȱburdensȱ ofȱ theȱ newȱ law.ȱ Theȱ State’sȱ argumentȱ aboutȱ PPINKȱ merelyȱ needingȱtoȱshiftȱresourcesȱtoȱaffordȱtheȱultrasoundȱmachinesȱ isȱ bothȱ oddȱ andȱ unworkable.ȱ Onlyȱ 7%ȱ ofȱ PPINK’sȱ patientsȱ receiveȱabortionȱservices,ȱsoȱinȱtheoryȱPPINKȱcouldȱshiftȱreȬ sourcesȱforȱtheȱ93%ȱofȱitsȱotherȱservicesȱtoȱabortionȱservices.ȱ Itȱ seemsȱ illogicalȱ forȱ aȱ stateȱ withȱ anȱ assertedȱ interestedȱ inȱ protectingȱfetalȱlifeȱtoȱbeȱencouragingȱPPINKȱtoȱshiftȱallȱofȱitsȱ resourcesȱfromȱotherȱhealthcare,ȱsuchȱasȱpregnancyȱprevenȬ tionȱandȱcancerȱscreening,ȱtoȱabortionȱservices.ȱItȱisȱunworkȬ ableȱ because,ȱ asȱ weȱ noted,ȱ neitherȱ theȱ Stateȱ norȱ theȱ courtsȱ hasȱ theȱ authorityȱ toȱ rewriteȱ PPINK’sȱ missionȱ andȱ dictateȱ howȱitȱmustȱallocateȱitsȱlimitedȱresources.ȱPPINKȱoperatesȱinȱ aȱ worldȱ whereȱ limitedȱ healthȱ careȱ dollarsȱ forȱ mostlyȱ poorȱ womenȱmustȱbeȱallocatedȱinȱanȱefficientȱway,ȱandȱ inȱ aȱwayȱ thatȱprovidesȱtheȱgreatestȱcareȱforȱtheȱgreatestȱneeds.ȱȱ Theȱfactȱthatȱcourtsȱareȱboundȱbyȱtheȱrealityȱinȱwhichȱtheȱ lawsȱ operateȱ isȱ reflectedȱ inȱ otherȱ abortionȱ cases.ȱ Inȱ Wholeȱ Women’sȱ Health,ȱ theȱ Courtȱ foundȱ thatȱ theȱ requirementȱ thatȱ allȱabortionȱfacilitiesȱmeetȱtheȱstandardsȱforȱambulatoryȱsurȬ 28ȱ No.ȱ17Ȭ1883ȱ gicalȱcentersȱwouldȱreduceȱtheȱnumberȱofȱabortionȱfacilitiesȱ inȱ Texasȱ fromȱ fortyȱ toȱ sevenȱ andȱ thusȱ unconstitutionallyȱ burdenȱ theȱ rightȱ toȱ anȱ abortion.ȱ Wholeȱ Women’sȱ Health,ȱ 136ȱ S.ȱCt.ȱ atȱ 2301,ȱ 2318.ȱ Theȱ Courtȱ lookedȱ atȱ theȱ costȱ aȱ facilityȱ wouldȱ haveȱ toȱ incurȱ toȱ meetȱ theȱ requirements—$1–$3ȱ milȬ lion—andȱassumedȱthatȱtheȱfacilitiesȱwouldȱcloseȱratherȱthanȱ beȱ ableȱ toȱ meetȱ theȱ requirements,ȱ despiteȱ theȱ factȱ thatȱ eachȱ facilityȱcould,ȱinȱanȱalternateȱuniverseȱwhereȱresourcesȱwereȱ unlimited,ȱsimplyȱmakeȱtheȱchanges.ȱId.ȱatȱ2318.ȱȱ Similarly,ȱinȱSchimel,ȱthisȱcourtȱlookedȱatȱtheȱburdenȱimȬ posedȱ byȱ theȱ proposedȱ abortionȱ lawȱ requiringȱ physiciansȱ whoȱ provideȱ abortionȱ servicesȱ toȱ haveȱ admittingȱ privilegesȱ atȱ aȱ hospitalȱ withinȱ thirtyȱ milesȱ ofȱ theȱ abortionȱ clinic.ȱ PlannedȱParenthoodȱofȱWisc.,ȱInc.ȱv.ȱSchimel,ȱ806ȱF.3dȱ908,ȱ918ȱ (7thȱCir.ȱ2015).ȱInȱgrantingȱanȱinjunction,ȱweȱrecognizedȱthatȱ theȱdelaysȱcausedȱbyȱtheȱnewȱlawȱmightȱcauseȱsomeȱwomenȱ toȱloseȱtheȱchanceȱtoȱhaveȱanȱabortionȱwithinȱtheȱtimeȱperiodȱ thatȱ Plannedȱ Parenthoodȱ allowed.ȱ Noȱ oneȱ inȱ thatȱ caseȱ sugȬ gestedȱ thatȱ Plannedȱ Parenthoodȱ provideȱ laterȱ termȱ aborȬ tions.ȱId.ȱInsteadȱthisȱcourtȱspentȱmostȱofȱtheȱopinionȱexamȬ iningȱ theȱ realityȱ ofȱ whatȱ anȱ emergentȱ situationȱ mightȱ lookȱ likeȱinȱtheȱabortionȱcontextȱandȱhowȱaȱpatientȱinȱsuchȱaȱsituaȬ tionȱ mightȱ receiveȱ care.ȱ Id.ȱ atȱ 912–16.ȱ Courtsȱ mustȱ considerȱ theȱimpactȱofȱtheȱnewȱultrasoundȱlawȱbasedȱonȱtheȱrealityȱofȱ theȱabortionȱproviderȱandȱitsȱpatients,ȱnotȱasȱitȱcouldȱifȱproȬ vidersȱandȱpatientsȱhadȱunlimitedȱresources.ȱȱ Theȱ State’sȱ argumentsȱ aboutȱ mitigatingȱ childȱ careȱ burȬ densȱsimilarlyȱmissȱtheȱmark.ȱTheȱStateȱsuggestsȱthatȱwomenȱ simplyȱcouldȱbringȱalongȱtheirȱchildrenȱtoȱtheȱultrasound— mostȱ ofȱ whichȱ areȱ performedȱ transvaginallyȱ atȱ theseȱ earlyȱ stages.ȱ Seeȱ R.ȱ 35Ȭ5ȱ atȱ 27.ȱ Butȱ Plannedȱ Parenthood’sȱ policyȱ No.ȱ17Ȭ1883ȱ 29 prohibitsȱ childrenȱ atȱ ultrasoundȱ appointments,ȱ andȱ withȱ goodȱreason.ȱOneȱwondersȱatȱwhatȱageȱaȱchildȱcouldȱapproȬ priatelyȱsitȱthroughȱsuchȱaȱprocedure?ȱAȱwomanȱundergoingȱ aȱtransvaginalȱultrasoundȱmustȱlieȱstillȱwhileȱtheȱtransducerȱ isȱ insertedȱ intoȱ herȱ vaginaȱ andȱ usedȱ toȱ viewȱ theȱ fetusȱ andȱ herȱ organs.ȱ Seeȱ https://www.healthline.com/health/transvagȱ inalȬultrasound.ȱSheȱ wouldȱhaveȱnoȱwayȱ toȱsootheȱ aȱ cryingȱ babyȱorȱmonitorȱaȱtoddlerȱrunningȱthroughȱtheȱexamȱroom.ȱ Neitherȱ theȱ personȱ performingȱ theȱ ultrasoundȱ norȱ theȱ paȬ tientȱ isȱ inȱ aȱ positionȱ toȱ monitorȱ theȱ safetyȱ ofȱ theȱ childȱ inȱ aȱ medicalȱ examinationȱ room,ȱ andȱ PPINKȱ submittedȱ evidenceȱ ofȱitsȱconcernsȱaboutȱtheȱ“seriousȱriskȱofȱdistraction”ȱforȱtheȱ doctorȱ performingȱ theȱ procedure.ȱ R.ȱ 35Ȭ5ȱ atȱ 26.ȱ Norȱ wouldȱ mostȱwomenȱwishȱtoȱundergoȱsuchȱaȱprocedureȱwithȱaȱpreȬ teenȱ sonȱ orȱ daughterȱ inȱ theȱ room,ȱ evenȱ with,ȱ asȱ theȱ Stateȱ suggests,ȱaȱsheetȱdrapedȱoverȱherȱlegs.ȱLikeȱallȱwomen,ȱpoorȱ womenȱdeserveȱaȱlevelȱofȱdignityȱandȱchoiceȱaboutȱtheȱconȬ fidentialityȱofȱtheirȱhealthcare.ȱMoreover,ȱthisȱisȱaȱperplexingȱ argumentȱ fromȱ aȱ Stateȱ thatȱ wantsȱ womenȱ toȱ seriouslyȱ “reȬ flectȱuponȱcompellingȱevidenceȱofȱfetalȱhumanity,”ȱandȱformȱ aȱ bondȱ withȱ theȱ fetusȱ “whileȱ viewingȱ thisȱ live,ȱ movingȱ imȬ ageȱofȱtheirȱbaby,ȱwithȱarmsȱandȱlegs.”ȱAppellant’sȱBriefȱatȱ2,ȱ 4.ȱ Itȱ seemsȱ likelyȱ thatȱ havingȱ childrenȱ inȱ theȱ roomȱ wouldȱ significantlyȱdecreaseȱtheȱabilityȱforȱseriousȱreflectionȱinȱtheȱ bulkȱofȱsituations.ȱȱ 2.ȱ Benefitsȱ Balancedȱ againstȱ theseȱ substantialȱ burdens,ȱ theȱ districtȱ courtȱ consideredȱ theȱ intendedȱ benefitsȱ ofȱ theȱ newȱ law.ȱ Asȱ weȱjustȱnoted,ȱtheȱStateȱwishesȱtoȱ“encourageȱwomenȱtoȱreȬ flectȱ uponȱ compellingȱ evidenceȱ ofȱ fetalȱ humanity,”ȱ andȱ toȱ persuadeȱ aȱ womanȱ toȱ reconsiderȱ herȱ decisionȱ toȱ haveȱ anȱ 30ȱ No.ȱ17Ȭ1883ȱ abortion.ȱ Appellant’sȱ Briefȱ atȱ 2,ȱ 18,ȱ 20,ȱ 23.ȱ Theȱ Stateȱ arguesȱ thatȱultrasoundsȱhaveȱaȱuniqueȱimpactȱonȱaȱpregnantȱwomȬ anȱbecauseȱtheyȱallowȱherȱtoȱseeȱherȱownȱfetusȱratherȱthanȱaȱ photographȱ orȱ illustrationȱ ofȱ aȱ genericȱ fetus,ȱ andȱ this,ȱ theȱ Stateȱhopes,ȱhelpsȱ“createȱaȱbondȱthatȱleadsȱthemȱtoȱcontinueȱ theirȱpregnancy.”ȱAppellant’sȱBriefȱatȱ4.ȱȱ Theȱ newȱ ultrasoundȱ lawȱ encouragesȱ womenȱ toȱ carryȱ pregnanciesȱ toȱ termȱ inȱ twoȱ ways,ȱ theȱ Stateȱ argues.ȱ First,ȱ itȱ givesȱthemȱinformationȱaboutȱtheirȱparticularȱfetusȱand,ȱsecȬ ond,ȱ itȱ givesȱ themȱ timeȱtoȱreflectȱuponȱ thatȱinformationȱ beȬ foreȱ theyȱ makeȱ theirȱ finalȱ decision.ȱ Accordingȱ toȱ theȱ State,ȱ “Aȱ womanȱ offeredȱ theȱ chanceȱ toȱ viewȱ anȱ ultrasoundȱ 18ȱ hoursȱbeforeȱanȱabortionȱmayȱwellȱhaveȱaȱdifferentȱmindsetȱ thanȱ aȱ womanȱ whoȱ hasȱ alreadyȱ madeȱ aȱ finalȱ decisionȱ andȱ presentsȱ herselfȱ atȱ theȱ clinicȱ toȱ carryȱ itȱ out.”ȱ Appellant’sȱ Briefȱatȱ25.ȱToȱsupportȱitsȱclaimȱthatȱultrasoundsȱmatter,ȱtheȱ Stateȱ introducedȱ aȱ studyȱ demonstratingȱ thatȱ forȱ theȱ 7%ȱ ofȱ womenȱwhoȱseekȱabortionsȱandȱhaveȱmediumȱtoȱlowȱ“deciȬ sionȱcertainty,”ȱ(presumablyȱmeaningȱthatȱtheyȱareȱnotȱveryȱ certainȱaboutȱtheirȱchoice),ȱthoseȱwhoȱviewedȱanȱultrasoundȱ imageȱhadȱaȱ95.2%ȱrateȱofȱproceedingȱwithȱanȱabortionȱcomȬ paredȱtoȱ97.5%ȱrateȱforȱwomenȱwithȱhighȱdecisionȱcertaintyȱ whoȱ viewedȱ anȱ ultrasound.ȱ Maryȱ Gatterȱ et.ȱ al.ȱ Relationshipȱ Betweenȱ Ultrasoundȱ Viewingȱ andȱ Proceedingȱ toȱ Abortion,ȱ 123ȱ Obstetricsȱ &ȱ Gynecologyȱ 81,ȱ 83ȱ (2014).ȱ Thisȱ evidence,ȱ howȬ ever,ȱisȱfocusedȱonȱtheȱbenefitsȱofȱanȱultrasoundȱandȱnotȱtheȱ benefitsȱofȱanȱultrasoundȱeighteenȱhoursȱbeforeȱanȱabortion.ȱ TheȱState’sȱstrongestȱevidenceȱthatȱtheȱeighteenȬhourȱreȬ quirementȱ providesȱ someȱ benefit,ȱ however,ȱ cameȱ fromȱ theȱ testimonyȱofȱDr.ȱChristinaȱFrancis,ȱaȱboardȬcertifiedȱobstetriȬ cianȬgynecologistȱ whoȱ testifiedȱ thatȱ sheȱ hadȱ aȱ patientȱ whoȱ No.ȱ17Ȭ1883ȱ 31 wouldȱhaveȱbenefittedȱfromȱtheȱnewȱlaw.ȱTheȱpatientȱhadȱaȱ medicationȱ abortionȱ atȱ PPINKȱ inȱ Indianapolisȱ andȱ underȬ wentȱ theȱ requiredȱ ultrasoundȱ thatȱ day,ȱ asȱ requiredȱ byȱ theȱ lawȱatȱtheȱtime.ȱSheȱtoldȱDr.ȱFrancis,ȱthatȱsheȱregrettedȱhavȬ ingȱtheȱabortionȱȱ andȱ feelsȱ thatȱ anȱ ultrasoundȱ waitingȱ periodȱ wouldȱ haveȱ givenȱ herȱ moreȱ timeȱ toȱ considerȱ herȱ decisionȱ andȱ changeȱ herȱ mind.ȱ …ȱ Sheȱ unȬ derwentȱtheȱultrasoundȱonȱtheȱdayȱofȱherȱaborȬ tion,ȱ immediatelyȱ priorȱ toȱ receivingȱ theȱ mediȬ cation.ȱ Sheȱ choseȱ notȱ toȱ viewȱ theȱ ultrasoundȱ imageȱbecauseȱsheȱfeltȱthatȱifȱsheȱsawȱanȱimageȱ ofȱ herȱ babyȱ itȱ wouldȱ causeȱ herȱ toȱ changeȱ herȱ mind.ȱ Sheȱ toldȱ [Dr.ȱ Francis]ȱ thatȱ sheȱ didȱ notȱ wantȱtoȱbeȱpersuadedȱnotȱtoȱabortȱbecauseȱsheȱ wasȱalreadyȱatȱtheȱclinic,ȱhadȱpaidȱforȱtheȱaborȬ tion,ȱandȱfeltȱpressuredȱbyȱthoseȱcircumstancesȱ toȱ goȱ throughȱ withȱ it.ȱ [She]ȱ toldȱ [Dr.ȱ Francis]ȱ thatȱhadȱsheȱundergoneȱtheȱultrasoundȱtheȱdayȱ beforeȱ theȱ abortion,ȱ sheȱ likelyȱ wouldȱ haveȱ viewedȱ theȱ imageȱ andȱ sheȱ doesȱ notȱ thinkȱ sheȱ wouldȱhaveȱcomeȱbackȱtheȱnextȱdayȱtoȱproceedȱ withȱtheȱmedicationȱabortion.ȱ R.ȱ35Ȭ1ȱatȱ5.ȱThisȱisȱtheȱState’sȱstrongestȱevidenceȱbecauseȱitȱisȱ theȱonlyȱevidenceȱthatȱtheȱeighteenȬhourȱwaitingȱperiodȱmatȬ tersȱ forȱ womenȱ seekingȱ abortions,ȱ asȱ opposedȱ toȱ theȱ ultraȬ soundȱitself.ȱȱ TheȱStateȱalsoȱarguedȱthatȱvoluntaryȱwaitingȱperiodsȱareȱ commonȱ forȱ otherȱ proceduresȱ whereȱ physiciansȱ giveȱ paȬ tientsȱtheȱopportunityȱtoȱweighȱtheȱcostsȱandȱbenefitsȱofȱvarȬ iousȱ optionsȱ andȱ thinkȱ ofȱ additionalȱ questionsȱ orȱ concerns.ȱ 32ȱ No.ȱ17Ȭ1883ȱ Asȱevidence,ȱtheȱstateȱpresentedȱtheȱdeclarationȱtestimonyȱofȱ Dr.ȱ Francis,ȱ whoȱ explainedȱ herȱ preferenceȱ toȱ “giveȱ patientsȱ timeȱtoȱreflectȱonȱtheȱinformationȱtheyȱhaveȱreceived,ȱweighȱ theȱpossibleȱrisksȱandȱbenefitsȱofȱtheȱprocedure,ȱdiscussȱtheȱ procedureȱwithȱlovedȱones,ȱandȱaskȱquestionsȱofȱtheȱdoctor.”ȱ R.ȱ35Ȭ1ȱatȱ2–3.ȱSheȱstatedȱthatȱforȱ“lifeȱaltering”ȱprocedures,ȱ sheȱ providesȱ informedȬconsentȱ informationȱ oneȱ toȱ fourȱ weeksȱpriorȱtoȱtheȱprocedure.ȱR.ȱ35Ȭ1ȱatȱ3.ȱTheȱStateȱdidȱnotȱ argueȱ thatȱ aȱ waitingȱ periodȱ isȱ mandatoryȱ forȱ anyȱ ofȱ theseȱ procedures.ȱȱ Finally,ȱtheȱStateȱarguesȱthatȱtheȱultrasoundȱlawȱadvancȬ esȱ importantȱ stateȱ interestsȱ inȱ theȱ psychologicalȱ healthȱ ofȱ womenȱ consideringȱ abortion.ȱ Forȱ thisȱ propositionȱ itȱ reliedȱ onȱaȱcontroversialȱandȱmuchȱmalignedȱ(seeȱbelow)ȱstudyȱbyȱ PriscillaȱK.ȱColemanȱwhichȱconcludedȱthatȱ“quiteȱconsistentȬ lyȱ …ȱ abortionȱ isȱ associatedȱ withȱ moderateȱ toȱ highlyȱ inȬ creasedȱ risksȱ ofȱ psychologicalȱ problemsȱ subsequentȱ toȱ theȱ procedure.”ȱ Priscillaȱ K.ȱ Coleman,ȱ Abortionȱ andȱ Mentalȱ Health:ȱ Quantitativeȱ Synthesisȱ andȱ Analysisȱ ofȱ Researchȱ Published,ȱ1995Ȭ2009,ȱ199ȱBritishȱJournalȱofȱPsychiatry,ȱ180– 86ȱ(2011).ȱMoreover,ȱtheȱStateȱargued,ȱtheȱearlierȱultrasoundȱ ensuresȱ thatȱ aȱ womanȱ doesȱ notȱ becomeȱ psychologicallyȱ committedȱtoȱhavingȱanȱabortionȱonlyȱtoȱarriveȱforȱtheȱproȬ cedureȱandȱlearnȱthatȱsheȱhasȱwaitedȱtooȱlong.ȱ Theȱ districtȱ courtȱ unequivocallyȱ acceptedȱ theȱ State’sȱ asȬ sertedȱ interestsȱ asȱ legitimate.ȱ Indeed,ȱ Caseyȱ instructsȱ thatȱ “theȱ Stateȱ hasȱ aȱ legitimateȱ interestȱ inȱ promotingȱ theȱ lifeȱ orȱ potentialȱlifeȱofȱtheȱunborn.”ȱCasey,ȱ505ȱU.S.ȱatȱ870.ȱAnd,ȱofȱ course,ȱ noȱ oneȱ wouldȱ argueȱ thatȱ protectingȱ maternalȱ psyȬ chologicalȱhealthȱisȱnotȱaȱlegitimateȱstateȱinterest.ȱȱ No.ȱ17Ȭ1883ȱ 33 3.ȱ Weighingȱȱ AfterȱthisȱthoroughȱcompilationȱofȱtheȱburdensȱandȱbeneȬ fits,ȱtheȱdistrictȱcourtȱturnedȱitsȱattentionȱtoȱresolvingȱtheȱulȬ timateȱ question—whether,ȱ afterȱ consideringȱ theȱ burdenȱ theȱ lawȱ imposesȱ onȱ abortionȱ access,ȱ togetherȱ withȱ theȱ benefitsȱ thoseȱlawsȱconfer,ȱtheȱnewȱultrasoundȱlawȱhasȱ“theȱeffectȱofȱ placingȱ aȱ substantialȱ obstacleȱ inȱ theȱ pathȱ ofȱ aȱ woman’sȱ choice”ȱtoȱhaveȱanȱabortion.ȱWholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱ atȱ 2309ȱ (citingȱ Casey,ȱ 505ȱ U.S.ȱ atȱ 877).ȱ Butȱ beforeȱ theȱ courtȱ couldȱweighȱtheȱbenefitsȱandȱburdens,ȱitȱhadȱtoȱanswerȱtwoȱ baselineȱ questions:ȱ first,ȱ whatȱ groupȱ ofȱ womenȱ shouldȱ theȱ courtȱ considerȱ whenȱ weighingȱ theȱ burdensȱ imposed,ȱ andȱ second,ȱonȱwhatȱaspectȱofȱtheȱlawȱshouldȱtheȱcourtȱfocusȱitsȱ benefitȱandȱburdenȱweighingȱanalysis—inȱotherȱwords,ȱwhatȱ isȱtheȱrelevantȱquestionȱpresentedȱbyȱthisȱcase.ȱTheȱCourtȱinȱ WholeȱWomen’sȱHealthȱmadeȱtheȱanswerȱtoȱtheȱfirstȱquestionȱ clearȱ byȱ explainingȱ thatȱ aȱ courtȱ mustȱ lookȱ specificallyȱ atȱ “thoseȱ womenȱ forȱ whomȱ theȱ provisionȱ isȱ anȱ actualȱ ratherȱ thanȱ anȱ irrelevantȱ restriction.”ȱ Id.ȱ (citingȱ Casey,ȱ 505ȱ U.S.ȱ atȱ 895).ȱInȱthisȱcase,ȱtheȱdistrictȱcourtȱdeterminedȱthatȱtheȱreleȬ vantȱgroupȱconsistedȱofȱlowȬincomeȱwomenȱwhoȱliveȱaȱsigȬ nificantȱ distanceȱ fromȱ oneȱ ofȱ theȱ sixȱ PPINKȱ healthȱ centersȱ offeringȱinformedȬconsentȱappointments.ȱȱ Asȱ forȱ theȱ questionȱ ofȱ whichȱ benefitsȱ andȱ burdensȱ theȱ courtȱ mustȱ weigh,ȱ theȱ districtȱ courtȱ emphasizedȱ thatȱ theȱ questionȱitȱwasȱrequiredȱtoȱconsiderȱwasȱ“whetherȱtheȱultraȬ soundȱ lawȱ providesȱ theȱ assertedȱ benefitsȱ asȱ comparedȱ toȱ theȱ priorȱlaw.”ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1031ȱ(emphasisȱinȱoriginal)ȱ(citȬ ingȱWholeȱWomen’sȱHealth,ȱ136ȱS.ȱCt.ȱatȱ2311).ȱInȱotherȱwords,ȱ theȱonlyȱrelevantȱburdensȱandȱbenefitsȱtoȱconsiderȱasȱaȱcourtȱ weighsȱoneȱagainstȱtheȱotherȱareȱtheȱburdensȱimposedȱbyȱtheȱ 34ȱ No.ȱ17Ȭ1883ȱ requirementȱtoȱ haveȱ anȱ ultrasoundȱatȱ leastȱ eighteenȱhoursȱbeȬ foreȱanȱabortion,ȱandȱtheȱbenefitsȱofȱhavingȱtheȱultrasoundȱatȱ leastȱ eighteenȱ hoursȱ beforeȱ theȱ procedureȱ (notȱ theȱ burdensȱ orȱ benefitsȱ ofȱ theȱ ultrasoundȱ itself).ȱ PPINKȱ didȱ notȱ challengeȱ theȱ requirementȱ thatȱ aȱ patientȱ undergoȱ anȱ ultrasoundȱ atȱ someȱ pointȱ priorȱ toȱ theȱ abortion.ȱ Norȱ wasȱ itȱ challengedȱ whenȱ itȱ wasȱ enacted.ȱ Seeȱ Appellant’sȱ Briefȱ atȱ 4.ȱ Thereforeȱ theȱbenefitsȱofȱhavingȱanȱultrasoundȱatȱsomeȱtimeȱpriorȱtoȱanȱ abortionȱ (withoutȱ regardȱ toȱ theȱ “eighteenȱ hourȱ prior”ȱ reȬ quirement)ȱareȱirrelevant.ȱItȱisȱtheȱburdenȱofȱtravellingȱtwiceȱ whichȱbecomesȱtheȱobstacleȱtoȱaccess.ȱ Havingȱ determinedȱ theȱ properȱ focusȱ ofȱ theȱ inquiry,ȱ theȱ districtȱ courtȱ couldȱ turnȱ toȱ itsȱ ultimateȱ taskȱ ofȱ determiningȱ whetherȱ theȱ burdensȱ ofȱ theȱ law’sȱ requirementsȱ wereȱ “disȬ proportionate,ȱ inȱ theirȱ effectȱ onȱ theȱ rightȱ toȱ anȱ abortion”ȱ comparedȱtoȱtheȱbenefitsȱthatȱtheȱrestrictionsȱareȱbelievedȱtoȱ confer.”ȱ Schimel,ȱ 806ȱ F.3dȱ atȱ 919.ȱ Toȱ determineȱ whetherȱ aȱ burdenȱisȱundue,ȱtheȱcourtȱmustȱ“weighȱtheȱburdensȱagainstȱ theȱ state’sȱ justification,ȱ askingȱ whetherȱ andȱ toȱ whatȱ extentȱ theȱchallengedȱregulationȱactuallyȱadvancesȱtheȱstate’sȱinterȬ ests.ȱ Ifȱ aȱ burdenȱ significantlyȱ exceedsȱ whatȱ isȱ necessaryȱ toȱ advanceȱtheȱstate’sȱinterests,ȱitȱisȱ‘undue,’”ȱandȱthusȱunconȬ stitutional.ȱSchimel,ȱ806ȱF.3dȱatȱ919.ȱȱ Theȱ districtȱ courtȱ foundȱ thatȱ theȱ burdensȱ wereȱ signifiȬ cant:ȱ additionalȱ travelȱ expenses,ȱ childcareȱ costs,ȱ lossȱ ofȱ enȬ tireȱ days’ȱ wages,ȱ riskȱ ofȱ losingȱ jobs,ȱ andȱ potentialȱ dangerȱ fromȱanȱabusiveȱpartner.ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1037.ȱIncreasedȱ travelȱ distance,ȱ theȱ Wholeȱ Women’sȱ Healthȱ Courtȱ instructed,ȱ constitutesȱ aȱ concreteȱ hardshipȱ thatȱ canȱ ultimatelyȱ contribȬ uteȱ toȱ theȱ burdenȱ beingȱ undue.ȱ Wholeȱ Womanȇsȱ Health,ȱ 136ȱ S.ȱCt.ȱ atȱ 2313.ȱ Seeȱ alsoȱ Schimel,ȱ 806ȱ F.3dȱ atȱ 919ȱ (notingȱ thatȱ No.ȱ17Ȭ1883ȱ 35 theȱ90Ȭmile,ȱoneȬwayȱtripȱfromȱMilwaukeeȱtoȱChicagoȱmightȱ notȱcauseȱaȱsignificantȱburdenȱtoȱaȱpersonȱwhoȱcanȱaffordȱaȱ carȱorȱtrainȱticket,ȱbutȱwasȱindeedȱanȱundueȱburdenȱforȱtheȱ largeȱ percentȱ ofȱ womenȱ seekingȱ abortionsȱ whoȱ liveȱ belowȱ andȱ farȱ belowȱ theȱ povertyȱ line).ȱ Theseȱ areȱ justȱ theȱ typesȱ ofȱ burdens,ȱ theȱ districtȱ courtȱ concluded,ȱ thatȱ preventȱ womenȱ fromȱexercisingȱtheirȱrightȱtoȱhaveȱanȱabortion.ȱ Theȱ funnelingȱ ofȱ allȱ informedȬconsentȱ appointmentsȱ toȱ theȱ sixȱ PPINKȱ healthȱ centersȱ withȱ ultrasoundȱ equipmentȱ imposedȱ otherȱ burdens.ȱ Itȱ requiredȱ PPINKȱ toȱ doubleȬbookȱ appointmentsȱ whichȱ increasedȱ waitȱ timesȱ forȱ appointmentsȱ andȱ elongatedȱ theȱ durationȱ ofȱ thoseȱ appointments.ȱ Theseȱ wereȱ theȱ kindsȱ ofȱ incrementalȱ burdensȱ thatȱ theȱ Supremeȱ Courtȱ consideredȱ inȱ Wholeȱ Women’sȱ Healthȱ asȱ well,ȱ whenȱ itȱ notedȱ thatȱ “[t]hoseȱ closuresȱ meantȱ fewerȱ doctors,ȱ longerȱ waitingȱtimes,ȱandȱincreasedȱcrowding,”ȱandȱthatȱthoseȱburȬ dens,ȱ alongȱ withȱ increasedȱ drivingȱ distancesȱ wereȱ theȱ typeȱ ofȱ incrementalȱ burdens,ȱ which,ȱ whenȱ takenȱ togetherȱ adeȬ quatelyȱsupportȱanȱ“undueȱburden”ȱconclusion.ȱWholeȱWomȬ anȇsȱHealth,ȱ136ȱS.ȱCt.ȱatȱ2313.ȱȱ Onȱ theȱ otherȱ sideȱ ofȱ theȱ scale,ȱ theȱ districtȱ courtȱ foundȱ thatȱtheȱState’sȱmanyȱargumentsȱregardingȱtheȱbenefitsȱofȱtheȱ ultrasoundȱmissedȱtheȱmarkȱbyȱaddressingȱtheȱutilityȱofȱtheȱ ultrasoundȱ itselfȱ asȱ opposedȱ toȱ theȱ periodȱ ofȱ reflection.ȱ Butȱ evenȱ consideringȱ theȱ meritsȱ ofȱ thatȱ dataȱ submittedȱ byȱ theȱ State,ȱtheȱdistrictȱcourtȱnotedȱthatȱtheȱultrasoundȱeffectȱstudyȱ reliedȱ uponȱ byȱ theȱ Stateȱ describedȱ theȱ potentialȱ impactȱ ofȱ viewingȱanȱultrasoundȱtoȱhaveȱaȱ“veryȱsmall”ȱeffectȱonȱaȱpoȬ tentialȱpoolȱofȱonlyȱaboutȱ7%ȱofȱwomenȱseekingȱabortions— thoseȱ whoȱ hadȱ lowȱ orȱ mediumȱ decisionȱ certainty,ȱ andȱ noȱ impactȱ onȱ womenȱ withȱ highȱ decisionȱ certainty—thoseȱ whoȱ 36ȱ No.ȱ17Ȭ1883ȱ makeȱ upȱ 93%ȱ ofȱ womenȱ seekingȱ abortions.ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ1032–33ȱ(citingȱGatter,ȱObstetricsȱ&ȱGynecology,ȱVol.ȱ123ȱ atȱ83).ȱAndȱ althoughȱtheȱstudyȱ statesȱ thatȱ womenȱ withȱlowȱ decisionȱ certaintyȱ whoȱ viewedȱ anȱ ultrasoundȱ imageȱ hadȱ aȱ 95.2%ȱ rateȱ ofȱ proceedingȱ withȱ anȱ abortionȱ comparedȱ toȱ 97.5%ȱ rateȱ forȱ womenȱ withȱ highȱ decisionȱ certaintyȱ whoȱ viewedȱ anȱ ultrasound,ȱ (Gatter,ȱ Obstetricsȱ &ȱ Gynecology,ȱ Vol.ȱ 123ȱ atȱ 83)ȱ theȱ Stateȱ doesȱ notȱ tellȱ usȱ howȱ manyȱ womenȱ withȱ lowȱ decisionȱ certaintyȱ changedȱ theirȱ mindsȱ evenȱ withȬ outȱ seeingȱ anȱ ultrasoundȱ image.ȱForȱ theȱ ultrasoundȱtoȱhaveȱ anyȱ impact,ȱ theȱ womenȱ mustȱ actuallyȱ viewȱ theȱ ultrasound,ȱ andȱonlyȱapproximatelyȱ25%ȱofȱPPINKȱpatientsȱchoseȱtoȱdoȱ soȱ (Weȱ doȱ notȱ knowȱ whetherȱ thatȱ numberȱ differsȱ betweenȱ lowȱ andȱ highȱ decisionȬcertaintyȱ patientsȱ becauseȱ theȱ Stateȱ presentedȱ noȱ evidenceȱ onȱ thatȱ point.).ȱ Thisȱ meansȱ thatȱ ifȱ thereȱ isȱ anyȱ chanceȱ thatȱ thisȱ “veryȱ small”ȱ impactȱ willȱ sucȬ ceedȱ itȱ willȱ doȱ soȱ onlyȱ forȱ theȱ poolȱ ofȱ womenȱ consistingȱ ofȱ theȱ7%ȱofȱabortionȱseekersȱwithȱlowȱorȱmediumȱdecisionȱcerȬ taintyȱandȱ onlyȱonȱwhateverȱpercentageȱofȱthatȱ7%ȱwhoȱacȬ tuallyȱ chooseȱ toȱ alsoȱ viewȱ theȱ ultrasound,ȱ butȱ likelyȱ onlyȱ 25%ȱ ofȱ thatȱ 7%ȱ orȱ 1.75%.ȱ Norȱ canȱ weȱ tellȱ ifȱ theseȱ lowȱ deciȬ sionȬcertaintyȱpatientsȱmightȱhaveȱchangedȱtheirȱmindsȱevenȱ withoutȱtheȱultrasound.ȱInȱgeneral,ȱtheȱstudyȱthatȱbothȱparȬ tiesȱ citeȱ ofȱ overȱ 15,000ȱ womenȱ seekingȱ abortionsȱ atȱ aȱ PlannedȱParenthoodȱinȱLosȱAngelesȱdemonstratedȱthatȱmostȱ visitsȱendȱinȱabortion—98.8%.ȱGatter,ȱObstetricsȱ&ȱGynecolȬ ogy,ȱ Vol.ȱ 123ȱ atȱ 82.ȱ Forȱ theȱ wholeȱ populationȱ ofȱ womenȱ inȱ thatȱ studyȱ whoȱ viewedȱ anȱ ultrasound,ȱ 98.4%ȱ hadȱ anȱ aborȬ tion.ȱ Id.ȱ Itȱ seemsȱ fromȱ theȱ studyȱ thatȱ increasingȱ gestationalȱ ageȱofȱtheȱfetusȱ(somethingȱthatȱcanȱbeȱdeterminedȱwithoutȱ ultrasound),ȱhadȱmoreȱtoȱdoȱwithȱtheȱdecisionȱnotȱtoȱproceedȱ toȱ abortionȱ thanȱ viewingȱ ofȱ anȱ ultrasound.ȱ Id.ȱ Theȱ districtȱ No.ȱ17Ȭ1883ȱ 37 courtȱ concludedȱ thatȱ ifȱ viewingȱ theȱ ultrasoundȱ hasȱ littleȱ toȱ noȱ impact,ȱ thenȱ “[i]tȱ isȱ simplyȱ notȱ aȱ reasonableȱ assumpȬ tionȱ…ȱ thatȱ furtherȱ timeȱ toȱ deliberateȱ onȱ anȱ imageȱ thatȱ hasȱ nearlyȱ noȱ impactȱ atȱ theȱ time,ȱ wouldȱ createȱ aȱ meaningfullyȱ strongerȱ impactȱ afterȱ eighteenȱ hours.”ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ 1034.ȱȱ Weȱ agreeȱ withȱ theȱ Stateȱ thatȱ itȱ isȱ entitledȱ toȱ tryȱ toȱ perȬ suadeȱ womenȱ notȱ toȱ haveȱ anȱ abortionȱ evenȱ ifȱ theȱ impactȱ isȱ minimal.ȱNevertheless,ȱinȱweighingȱtheȱbenefitȱofȱtheȱparticȬ ularȱmeasureȱatȱissue,ȱaȱcourtȱmayȱconsiderȱtheȱminimalȱpuȬ tativeȱeffectsȱofȱtheȱState’sȱaction.ȱTheȱmoreȱfeebleȱtheȱstate’sȱ assertedȱinterest,ȱ“theȱlikelierȱtheȱburden,ȱevenȱifȱslight,ȱtoȱbeȱ ‘undue’ȱ inȱ theȱ senseȱ ofȱ disproportionateȱ orȱ gratuitous.”ȱ Plannedȱ Parenthoodȱ ofȱ Wisconsin,ȱ Inc.ȱ v.ȱ Vanȱ Hollen,ȱ 738ȱ F.3dȱ 786,ȱ798ȱ(7thȱCir.ȱ2013).ȱȱ Moreȱ importantly,ȱevenȱifȱtheȱultrasoundȱdoesȱinfluenceȱ aȱveryȱsmallȱpercentageȱofȱwomenȱtoȱalterȱtheirȱdecision,ȱallȱ ofȱthatȱisȱirrelevant,ȱbecause,ȱasȱtheȱdistrictȱcourtȱexplained,ȱ “[e]videnceȱ thatȱ someȱ women’sȱ decisionsȱ asȱ toȱ whetherȱ toȱ haveȱanȱabortionȱareȱimpactedȱbyȱviewingȱtheȱultrasoundȱisȱ notȱevidenceȱthatȱdoingȱsoȱatȱleastȱeighteenȱhoursȱbeforeȱtheȱ abortion,ȱratherȱthanȱonȱtheȱdayȱofȱtheȱabortion,ȱhasȱanyȱadȬ ditionalȱpersuasiveȱimpact.”ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1032.ȱ Theȱ State’sȱ argumentȱ thatȱ theȱ additionalȱ eighteenȱ hoursȱ givesȱwomenȱtimeȱforȱdeeperȱreflectionȱandȱtoȱabsorbȱinforȬ mation,ȱ actuallyȱ doesȱ addressȱ theȱ questionȱ atȱ issueȱ inȱ theȱ case,ȱ butȱ itsȱ argumentȱ isȱ unsupportedȱ byȱ anythingȱ otherȱ thanȱDr.ȱFrancis’ȱoneȱanecdote.ȱMoreover,ȱoneȱcouldȱjustȱasȱ easilyȱinferȱthatȱtheȱimpactȱofȱviewingȱtheȱultrasoundȱimage,ȱ forȱ someȱ women,ȱ dissipatesȱ overȱ theȱ eighteenȱ hoursȱ beforeȱ theȱ abortion.ȱ Theȱ Stateȱ asksȱ usȱ toȱ inferȱ thatȱ someȱ womenȱ 38ȱ No.ȱ17Ȭ1883ȱ whoȱ chooseȱ notȱ toȱ viewȱ theȱ ultrasoundȱ doȱ soȱ becauseȱ theyȱ areȱunderȱaȱtimeȱpressureȱandȱbecauseȱtheyȱhaveȱarrivedȱatȱ theȱ healthȱ centerȱ havingȱ alreadyȱ madeȱ upȱ theirȱ minds,ȱ butȱ theȱ Stateȱ offersȱ noȱ evidenceȱ forȱ this.ȱ Recallȱ thatȱ evenȱ underȱ theȱoldȱlaw,ȱwomenȱwhoȱarrivedȱatȱtheȱhealthȱcenterȱonȱtheȱ dayȱ ofȱ theirȱ abortionȱ hadȱ alreadyȱ receivedȱ copiousȱ inforȬ mationȱ fromȱ theȱ Stateȱ designedȱ toȱ alterȱ theirȱ decisionȱ toȱ abort,ȱ andȱ hadȱ plentyȱ ofȱ time—atȱ leastȱ eighteenȱ hours—toȱ digestȱ andȱ considerȱ theirȱ optionsȱ whileȱ notȱ underȱ anȱ acuteȱ timeȱpressure.ȱȱ Theȱ onlyȱ relevantȱ evidenceȱ theȱ Stateȱ submittedȱ toȱ supȬ portȱ theȱ propositionȱ thatȱ theȱ eighteenȬhourȱ requirementȱ inȬ creasesȱ aȱ woman’sȱ abilityȱ toȱ reflectȱ moreȱ seriouslyȱ onȱ herȱ decisionȱcameȱfromȱtheȱtestimonyȱofȱDr.ȱFrancisȱwhoȱstatedȱ thatȱoneȱpatientȱreportedȱtoȱherȱthatȱsheȱmightȱhaveȱoptedȱtoȱ viewȱ theȱ ultrasoundȱ andȱ thenȱ mightȱ haveȱ continuedȱ herȱ pregnancyȱhadȱsheȱbeenȱgivenȱtheȱoptionȱtoȱviewȱtheȱultraȬ soundȱeighteenȱhoursȱbeforeȱherȱprocedure,ȱasȱopposedȱtoȱatȱ theȱ timeȱ ofȱ theȱ procedure.ȱ Theȱ districtȱ courtȱ notedȱ thatȱ thisȱ wasȱ indeedȱ someȱ evidenceȱ thatȱ womenȱ mayȱ changeȱ theirȱ mindsȱifȱtheyȱhaveȱmoreȱtimeȱtoȱreflectȱonȱtheȱdecision,ȱbutȱitȱ alsoȱfoundȱthisȱsingularȱexampleȱtoȱbeȱexceedinglyȱspeculaȬ tive.ȱ “Sheȱ canȱ onlyȱsayȱ thatȱsheȱ‘likely’ȱwouldȱhaveȱviewedȱ theȱ ultrasound,ȱ ifȱ itȱ wasȱ offeredȱ aȱ dayȱ earlier”ȱ (whichȱ curȬ rentlyȱonlyȱaboutȱ25%ȱofȱwomenȱdo),ȱandȱ“sheȱ‘likely’ȱwouldȱ notȱhaveȱreturnedȱforȱanȱabortionȱtheȱnextȱday.”ȱ273ȱF.ȱSupp.ȱ 3dȱ atȱ 1035.ȱ Theȱ districtȱ court,ȱ whenȱ weighingȱ howȱ muchȱ weightȱ toȱ giveȱ thisȱ evidence,ȱ concludedȱ thatȱ thisȱ wasȱ “farȱ fromȱ compellingȱ evidenceȱ thatȱ theȱ newȱ ultrasoundȱ lawȱ wouldȱ haveȱ theȱ impactȱdesiredȱbyȱtheȱ State,ȱandȱasȱsuch,ȱ itȱ mustȱbeȱgivenȱdiminishedȱweightȱinȱtheȱbalancingȱprocess.”ȱ No.ȱ17Ȭ1883ȱ 39 Id.ȱ Weȱ seeȱ noȱ reasonȱ toȱ disruptȱ theȱ districtȱ court’sȱ vastȱ disȬ cretionȱinȱweighingȱthisȱevidence.ȱ Dr.ȱFrancis’ȱotherȱ testimony—thatȱsomeȱofȱherȱ pregnantȱ patientsȱhaveȱtoldȱherȱthatȱ“viewingȱanȱultrasoundȱimageȱofȱ theirȱ babyȱ causedȱ themȱ toȱ decideȱ notȱ toȱ haveȱ anȱ abortion”ȱ (R.ȱ35Ȭ1ȱatȱ4)—doesȱnotȱaddȱanythingȱtoȱtheȱconsiderationȱofȱ whetherȱ viewingȱ theȱ ultrasoundȱ eighteenȱ hoursȱ priorȱ toȱ theȱ abortionȱaltersȱtheȱcalculusȱinȱanyȱway.ȱ Theȱ State’sȱ argumentȱ thatȱ doctorsȱ commonlyȱ useȱ inȬ formedȬconsentȱwaitingȱperiodsȱtoȱgiveȱpatientsȱtimeȱtoȱconȬ siderȱ importantȱ medicalȱ decisionsȱ doesȱ comeȱ closerȱ toȱ theȱ relevantȱquestionȱinȱtheȱcase—theȱbenefitȱofȱaȱwaitingȱperiodȱ betweenȱacquisitionȱofȱknowledgeȱandȱaȱmedicalȱprocedureȱ itself.ȱDr.ȱFrancisȱtestifiedȱaboutȱtheȱimportanceȱofȱgivingȱpaȬ tientsȱ timeȱ toȱ reflect,ȱ weighȱ risksȱ andȱ benefits,ȱ andȱ thinkȱ ofȱ questions.ȱSeeȱR.ȱ35Ȭ1ȱatȱ3.ȱTheȱdistrictȱcourtȱnoted,ȱhowever,ȱ thatȱ Dr.ȱ Francisȱ doesȱ notȱ provideȱ abortionȱ servicesȱ andȱ thereforeȱ couldȱ notȱ attestȱ toȱ theȱ utilityȱ ofȱ aȱ waitingȱ periodȱ afterȱ anȱ informedȬconsentȱ processȱ precedingȱ anȱ abortion.ȱ Theȱ districtȱ courtȱ insteadȱ gaveȱ moreȱ weightȱ toȱ PPINK’sȱ arȬ gumentȱ thatȱ abortionȱ proceduresȱ areȱ differentȱ thanȱ otherȱ proceduresȱ whereȱ doctorsȱ giveȱ informationȱ longȱ beforeȱ aȱ procedure,ȱ becauseȱ unlikeȱ inȱ theȱ contextȱ whereȱ aȱ doctorȱ isȱ providingȱaȱpreviouslyȱunknownȱdiagnosisȱtoȱaȱpatientȱandȱ thenȱ detailingȱ variousȱ options,ȱ aȱ womanȱ visitingȱ PPINKȱ toȱ haveȱ anȱ abortionȱ knowsȱ herȱ diagnosisȱ (sheȱ isȱ pregnant),ȱ asȱ wellȱ asȱ herȱ options—sheȱ mayȱ continueȱ theȱ pregnancyȱ orȱ haveȱ anȱ abortion.ȱ Moreover,ȱ theȱ lawȱ alreadyȱ requiresȱ thatȱ sheȱbeȱinformedȱofȱherȱoptionsȱandȱwaitȱeighteenȱhoursȱuntilȱ theȱ procedure.ȱ Theȱ onlyȱ issueȱ isȱ whetherȱ havingȱ theȱ ultraȬ soundȱ eighteenȱ hoursȱ beforeȱ altersȱ theȱ calculus.ȱ Finally,ȱ 40ȱ No.ȱ17Ȭ1883ȱ thereȱ isȱ aȱ qualitativeȱ differenceȱ betweenȱ aȱ stateȬmandatedȱ waitingȱ period,ȱ whichȱ theȱ Stateȱ requiresȱ onlyȱ forȱ abortions,ȱ andȱotherȱoptionalȱwaitingȱperiods,ȱforȱallȱotherȱprocedures,ȱ whereȱaȱdoctorȱandȱherȱpatientȱmayȱdecideȱtogetherȱwhetherȱ timeȱ forȱ reflectionȱ wouldȱ beȱ optimalȱ orȱ whether,ȱ forȱ examȬ ple,ȱwaitingȱwouldȱcauseȱtheȱpatientȱanxiety,ȱinconvenience,ȱ orȱdeterȱherȱfromȱhavingȱtheȱdesiredȱprocedureȱatȱall.ȱ Moreover,ȱasȱtheȱdistrictȱcourtȱdiscussed,ȱthereȱareȱmanyȱ officeȱproceduresȱthatȱgynecologistsȱmightȱperformȱimmediȬ atelyȱafterȱdiscussingȱtheȱprocedureȱandȱaskingȱforȱconsent,ȱ suchȱasȱcolposcopiesȱandȱLEEPȱprocedures.ȱ273ȱF.ȱSupp.ȱ3dȱ atȱ 1034.ȱ Andȱ thereȱ areȱ manyȱ timesȱ thatȱ doctorsȱ mightȱ needȱ toȱ performȱ anȱ emergentȱ procedureȱ immediatelyȱ afterȱ providingȱ informedȱ consent,ȱ orȱ timesȱ inȱ whichȱ patientsȱ mightȱ optȱ forȱ immediacyȱ evenȱ inȱ aȱ nonȬemergentȱ situationȱ forȱ theȱ sakeȱ ofȱ convenienceȱ orȱ becauseȱ theyȱ areȱ certainȱ ofȱ theirȱ decision.ȱ Unlikeȱ forȱ aȱ hysterectomyȱ orȱ tubalȱ ligation,ȱ waitingȱaȱfewȱweeksȱforȱanȱabortionȱisȱnotȱanȱoptionȱbecauseȱ abortionsȱareȱnotȱavailableȱatȱPPINKȱafterȱ13ȱweeksȱandȱsixȱ daysȱpostȱlastȱmenstrualȱperiod,ȱandȱtheȱmostȱvigilantȱwomȬ anȱwillȱnotȱknowȱsheȱisȱpregnantȱuntilȱaboutȱfourȱweeksȱafȬ terȱherȱlastȱmenstrualȱperiod.ȱInȱshort,ȱabortionsȱareȱfarȱmoreȱ timeȱsensitiveȱthanȱmostȱotherȱelectiveȱprocedures.ȱ Ultimately,ȱtheȱdistrictȱcourt’sȱconclusionȱthatȱtheȱnewȱulȬ trasoundȱlawȱposedȱ anȱundueȱburdenȱwasȱsolidifiedȱbyȱtheȱ factȱthatȱtheȱStateȱhadȱalmostȱnoȱevidenceȱthatȱtheȱadditionalȱ timeȱtoȱreflectȱadvancedȱitsȱinterests.ȱAlmostȱallȱofȱtheȱState’sȱ evidenceȱ onȱ theȱ benefitsȱ ofȱ theȱ newȱ eighteenȬhourȱ ultraȬ soundȱ lawȱ focusedȱ onȱ theȱ benefitsȱ womenȱ mightȱ receiveȱ fromȱhavingȱanȱultrasound,ȱandȱnotȱtheȱbenefitsȱfromȱhavingȱ toȱwaitȱeighteenȱhoursȱafterȱhavingȱanȱultrasoundȱtoȱobtainȱ No.ȱ17Ȭ1883ȱ 41 theȱ procedure.ȱ Theȱ districtȱ courtȱ notedȱ thisȱ andȱ thereforeȱ dismissedȱmuchȱofȱthisȱevidenceȱasȱirrelevantȱtoȱtheȱdiscusȬ sionȱ atȱ hand.ȱ Butȱ beforeȱ theȱ districtȱ courtȱ didȱ so,ȱ itȱ wentȱ aboveȱ andȱ beyondȱ itsȱ dutyȱ andȱ thoroughlyȱ evaluatedȱ theȱ meritsȱofȱtheȱevidenceȱnevertheless.ȱForȱexample,ȱtheȱdistrictȱ courtȱrejectedȱtheȱState’sȱevidenceȱregardingȱwomen’sȱmenȬ talȱhealthȱnotingȱthatȱtheȱscienceȱbehindȱDr.ȱColeman’sȱstudȬ ies,ȱdescribedȱabove,ȱhadȱbeenȱnearlyȱuniformlyȱrejectedȱbyȱ otherȱexpertsȱinȱtheȱfield.ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1036.ȱTheȱdistrictȱ courtȱchoseȱtoȱcreditȱinsteadȱtwoȱmentalȱhealthȱorganizationsȱ thatȱconductedȱaȱcomprehensiveȱreviewȱofȱstudiesȱonȱmentalȱ healthȱ andȱ abortionȱ andȱ concludedȱ thatȱ “onȱ theȱ bestȱ eviȬ denceȱavailableȱ…ȱ[t]heȱratesȱofȱmentalȱhealthȱproblemsȱforȱ womenȱ withȱ unwantedȱ pregnancyȱ wereȱ theȱ sameȱ whetherȱ theyȱhadȱanȱabortionȱorȱgaveȱbirth.”ȱR.ȱ38Ȭ3ȱatȱ3.ȱAȱtaskȱforceȱ ofȱ theȱ Americanȱ Psychologicalȱ Associationȱ similarlyȱ reȬ viewedȱstudiesȱandȱconcludedȱthat,ȱ“theȱmostȱmethodologiȬ callyȱsoundȱresearchȱindicatesȱthatȱamongȱwomenȱwhoȱhaveȱ aȱsingle,ȱlegal,ȱfirstȱtrimesterȱabortionȱofȱanȱunplannedȱpregȬ nancyȱforȱnonȬtherapeuticȱreasons,ȱtheȱrelativeȱrisksȱofȱmenȬ talȱ healthȱ problemsȱ areȱ notȱ greaterȱ thanȱ theȱ risksȱ amongȱ womenȱ whoȱ deliverȱ anȱ unplannedȱ pregnancy.”ȱ Id.ȱ atȱ 2–3.ȱ Thatȱ reportȱ specificallyȱ criticizesȱ Dr.ȱ Coleman’sȱ 2002ȱ reportȱ asȱbeingȱ“characterizedȱbyȱaȱnumberȱofȱmethodologicalȱlimiȬ tationsȱthatȱmakeȱitȱdifficultȱtoȱinterpretȱtheȱresults.”ȱId.ȱatȱ4.ȱ Theȱ districtȱ court,ȱ usingȱ itsȱ substantialȱ discretionȱ weighedȱ theȱ competingȱ evidenceȱ andȱ determinedȱ thatȱ PPINK’sȱ eviȬ denceȱ wasȱ “significantlyȱ moreȱ persuasiveȱ onȱ thisȱ issue,ȱ esȬ peciallyȱ givenȱ thatȱ Dr.ȱ Coleman’sȱ studiesȱ areȱ theȱ subjectȱ ofȱ significantȱ criticism.”ȱ 273ȱ F.ȱ Supp.ȱ 3dȱ atȱ 1036.ȱ Thisȱ typeȱ ofȱ evidenceȱ weighingȱ isȱ wellȱ withinȱ theȱ districtȱ court’sȱ provȬ 42ȱ No.ȱ17Ȭ1883ȱ ince,ȱ andȱ weȱ seeȱ noȱ reasonȱ toȱ disturbȱ itsȱ thoroughlyȱ reaȬ sonedȱfindings.ȱ Moreȱimportantly,ȱtheȱcourtȱbelowȱnoted,ȱDr.ȱColeman’sȱ studyȱ failedȱ toȱ addressȱ theȱ relevantȱ question:ȱ whetherȱ havȬ ingȱanȱultrasoundȱeighteenȱhoursȱbeforeȱanȱabortionȱleadsȱtoȱ moreȱfavorableȱpsychologicalȱoutcomes.ȱId.ȱAnd,ȱasȱweȱhaveȱ discussedȱextensively,ȱthisȱwasȱtheȱultimateȱquestionȱthatȱtheȱ districtȱcourtȱhadȱtoȱaddress.ȱ Theȱdistrictȱcourtȱconsideredȱallȱ ofȱtheȱfollowingȱtogethȬ er:ȱtheȱfactȱthatȱoverȱaȱthirdȱofȱsurgicalȱabortionsȱoccurȱwithȬ inȱ threeȱ weeksȱ ofȱ PPINK’sȱ deadlineȱ forȱ performingȱ aborȬ tions;ȱtheȱdifficultyȱofȱmakingȱtwoȱlengthyȱtripsȱinȱquickȱsucȬ cession;ȱ theȱ overȬbookingȱ ofȱ informedȬconsentȱ appointȬ ments;ȱandȱtheȱfactȱthatȱphysiciansȱonlyȱprovidedȱabortionsȱ onȱlimitedȱdaysȱinȱeachȱhealthȱcenter.ȱAddingȱtheseȱburdensȱ together,ȱ theȱ districtȱ courtȱ concluded,ȱ “itȱ wouldȱ beȱ surprisȬ ingȱ ifȱ theȱ newȱ ultrasoundȱ lawȱ didȱ notȱ preventȱ aȱ significantȱ numberȱofȱlowȱincomeȱwomenȱfromȱobtainingȱanȱabortion.”ȱ 273ȱF.ȱSupp.ȱ 3dȱatȱ1038.ȱ Andȱindeedȱ theȱevidenceȱprovidedȱ byȱ PPINKȱ fromȱ nineȱ womenȱ whoȱ were,ȱ inȱ fact,ȱ severelyȱ burdenedȱ andȱ impededȱ inȱ theirȱ attemptsȱ atȱ obtainingȱ anȱ abortionȱinȱtheȱshortȱtimeȱthatȱtheȱlawȱwasȱinȱeffect,ȱconfirmsȱ thisȱprediction.ȱ Theȱ districtȱ courtȱ didȱ notȱ errȱ byȱ concludingȱ thatȱ theȱ ulȬ trasoundȱ lawȱ “imposesȱ significantȱ burdensȱ againstȱ aȱ nearȱ absenceȱofȱevidenceȱthatȱtheȱlawȱpromotesȱeitherȱofȱtheȱbeneȬ fitsȱ assertedȱ byȱ theȱ State.”ȱ Id.ȱ atȱ 1039.ȱ Seeȱ Wholeȱ Women’sȱ Health,ȱ136ȱS.ȱCt.ȱatȱ2318ȱ(strikingȱdownȱtheȱchallengedȱaborȬ tionȱrestrictionsȱbecauseȱtheȱlawȱ“providesȱfew,ȱifȱany,ȱhealthȱ benefitsȱ forȱ women”ȱ andȱ “posesȱ aȱ substantialȱ obstacleȱ toȱ womenȱseekingȱabortions.”).ȱ“AȱstatuteȱthatȱcurtailsȱtheȱconȬ No.ȱ17Ȭ1883ȱ 43 stitutionalȱ rightȱ toȱ anȱ abortionȱ …ȱ cannotȱ surviveȱ challengeȱ withoutȱevidenceȱthatȱtheȱcurtailmentȱisȱjustifiableȱbyȱreferȬ enceȱ toȱ theȱ benefitsȱ conferredȱ byȱ theȱ statute.”ȱ Schimel,ȱ 806ȱ F.3dȱatȱ921.ȱȱ TheȱStateȱwouldȱlikeȱtoȱsimplifyȱtheȱcourt’sȱcomplexȱburȬ denȱ andȱbenefitȱ weighingȱtoȱ aȱmoreȱcookieȱcutterȱ approachȱ andȱ haveȱ usȱ concludeȱ thatȱ Caseyȱ pavedȱ theȱ wayȱ forȱ anȱ alȬ mostȱperȱseȱapprovalȱofȱallȱreasonableȱwaitingȱperiods.ȱApȬ pellant’sȱBriefȱatȱ20–22,ȱ38.ȱTheȱSupremeȱCourtȱinȱCaseyȱupȬ heldȱ aȱ twentyȬfourȱ hour,ȱ informedȬconsentȱ waitingȱ periodȱ despiteȱtheȱfactȱpatientsȱwouldȱneedȱtoȱmakeȱtwoȱsometimesȱ lengthyȱtripsȱinȱorderȱtoȱobtainȱanȱabortion.ȱCasey,ȱ505ȱU.S.ȱatȱ 885–87.ȱ Andȱ weȱ followedȱ suitȱ inȱ Aȱ Womanȇsȱ ChoiceȬE.ȱ Sideȱ WomenȇsȱClinicȱv.ȱNewman,ȱ305ȱF.3dȱ684,ȱ691ȱ(7thȱCir.ȱ2002),ȱ upholdingȱ Indiana’sȱ eighteenȬhourȱ waitingȱ periodȱ afterȱ anȱ inȬpersonȱinformedȬconsentȱmeeting.ȱButȱoneȱofȱtheȱprimaryȱ lessonsȱofȱWholeȱWomen’sȱHealthȱisȱthatȱtheȱburdenȱandȱbeneȬ fitȱweighingȱisȱcontextȬspecific.ȱInȱWholeȱWomen’sȱHealth,ȱtheȱ courtȱ basedȱ itsȱ conclusionsȱ aboutȱ undueȱ burdenȱ onȱ theȱ 280,000ȱsquareȱmilesȱofȱTexasȱterritory,ȱtheȱnumberȱofȱaborȬ tionȬofferingȱfacilitiesȱthatȱcouldȱoperateȱafterȱtheȱenactmentȱ ofȱtheȱcontestedȱlaw,ȱtheȱnumberȱofȱpatientsȱeachȱremainingȱ facilityȱ wouldȱ haveȱ toȱ accommodateȱ (1,200ȱ perȱ month),ȱ theȱ distanceȱ womenȱ wouldȱ haveȱ toȱ travelȱ toȱ getȱ toȱ aȱ clinicȱ andȱ theȱ populationȱ numbersȱ forȱ womenȱ whoȱ wouldȱ haveȱ toȱ travelȱ thisȱ far,ȱ theȱ rateȱ ofȱ deathsȱ andȱ complicationsȱ fromȱ abortionsȱ inȱ Texas,ȱ andȱ theȱ costȱ toȱ clinicsȱ ofȱ comingȱ intoȱ complianceȱ withȱ theȱ newȱ regulation.ȱ Wholeȱ Women’sȱ Health,ȱ 136ȱS.ȱCt.ȱatȱ2301–03.ȱTheȱCourtȱspentȱmuchȱtimeȱdiscussingȱ theȱimportanceȱofȱtheseȱfactsȱinȱassessingȱtheȱconstitutionaliȬ tyȱofȱtheȱcontestedȱlaw,ȱnotingȱthatȱaȱstatuteȱvalidȱasȱtoȱoneȱ 44ȱ No.ȱ17Ȭ1883ȱ setȱ ofȱ factsȱ mayȱ beȱ invalidȱ asȱ toȱ another.ȱ Id.ȱ atȱ 2306ȱ (citingȱ Nashville,ȱC.ȱ&ȱSt.ȱL.R.ȱCo.ȱv.ȱWalters,ȱ294ȱU.S.ȱ405,ȱ415ȱ(1935)).ȱȱ Theȱ Courtȱ inȱ Caseyȱ notedȱ thatȱ “inȱ theoryȱ atȱ least,ȱ theȱ waitingȱ periodȱ isȱ aȱ reasonableȱ measureȱ toȱ implementȱ theȱ State’sȱ interestȱ inȱ protectingȱ theȱ lifeȱ ofȱ theȱ unborn,”ȱ andȱ wentȱonȱtoȱanalyzeȱwhethersuchȱaȱ“waitingȱperiodȱisȱnoneȬ thelessȱ invalidȱ becauseȱ inȱ practiceȱ itȱ isȱ aȱ substantialȱ obstacleȱ toȱaȱwoman’sȱchoiceȱtoȱterminateȱherȱpregnancy.”ȱCasey,ȱ505ȱ U.S.ȱatȱ885ȱ(emphasisȱours).ȱThisȱwasȱtheȱexactȱreasoningȱweȱ adoptedȱlater,ȱinȱlightȱofȱCasey,ȱwhereȱweȱnotedȱthatȱ“[w]hileȱ aȱtwentyȬfourȱhourȱwaitingȱperiodȱthatȱrequiresȱtwoȱtripsȱtoȱ anȱabortionȱproviderȱhasȱbeenȱfoundȱnotȱtoȱimposeȱanȱundueȱ burdenȱonȱPennsylvaniaȱwomenȱbasedȱonȱtheȱcircumstancesȱ ofȱ thatȱ stateȱ atȱ theȱ timeȱ theȱ Courtȱ decidedȱ Casey,ȱ aȱ similarȱ provisionȱ inȱ anotherȱ state’sȱ abortionȱ statuteȱ couldȱ wellȱ beȱ foundȱ toȱ imposeȱ anȱ undueȱ burdenȱ onȱ womenȱ inȱ thatȱ stateȱ dependingȱonȱtheȱinterplayȱofȱfactors”—factorsȱsuchȱasȱ“theȱ numberȱofȱphysiciansȱwhoȱperformȱabortions,ȱtheȱnumberȱofȱ abortionȱfacilities,ȱtheȱdistancesȱwomenȱmustȱtravelȱinȱorderȱ toȱ reachȱ anȱ abortionȱ facility,ȱ andȱ theȱ averageȱ incomeȱ ofȱ womenȱseekingȱabortions.”ȱKarlinȱv.ȱFoust,ȱ188ȱF.3dȱ446,ȱ485ȱ (7thȱ Cir.ȱ 1999).ȱ Theȱ languageȱ inȱ theseȱ casesȱ reflectsȱ thatȱ theȱ factsȱandȱcontextȱruleȱtheȱdayȱwhenȱevaluatingȱwaitingȱperiȬ ods.ȱ Thisȱ isȱ farȱ fromȱ beingȱ aȱ blanketȱ stampȱ ofȱ approvalȱ onȱ them.ȱȱ Analyzingȱtheȱregulationȱinȱlightȱofȱtheȱrealityȱofȱtheȱfactsȱ inȱIndianaȱisȱpreciselyȱwhatȱtheȱdistrictȱcourtȱdidȱinȱthisȱcase.ȱ AȱcourtȱcannotȱassessȱtheȱlawȱinȱaȱworldȱwhereȱPPINKȱhasȱ unlimitedȱresourcesȱtoȱopenȱdozensȱofȱclinics,ȱeachȱwithȱtheȱ abilityȱ toȱ provideȱ ultrasoundȱ andȱ abortionsȱ alongȱ withȱ unȬ limitedȱaccessȱtoȱotherȱhealthȱcareȱneeds,ȱorȱinȱaȱworldȱwhereȱ No.ȱ17Ȭ1883ȱ 45 allȱ womenȱ haveȱ paidȱ sickȱ days,ȱ andȱ reliableȱ childȱ careȱ andȱ transportation.ȱTheȱcourtȱmustȱtakeȱtheȱfactsȱasȱtheyȱareȱpreȬ sentedȱbeforeȱitȱandȱcompareȱtheȱburdensȱagainstȱtheȱweightȱ ofȱtheȱevidenceȱofȱtheȱbenefitsȱspecificȱtoȱtheȱproposedȱlaw.ȱ Wholeȱ Women’sȱ Health,ȱ 136ȱ S.ȱ Ct.ȱ atȱ 2310.ȱ Theȱ districtȱ courtȱ didȱjustȱthatȱandȱconcludedȱthatȱtheȱevidenceȱofȱbenefitsȱwasȱ exceptionallyȱ slightȱ ifȱ any,ȱ andȱ theȱ burdenȱ imposedȱ byȱ theȱ doubleȱ travelȱ requirementȱ great.ȱ Asȱ theȱ districtȱ courtȱ conȬ cluded,ȱ“theȱnewȱultrasoundȱlawȱcreatesȱsignificantȱfinancialȱ andȱotherȱburdensȱonȱPPINKȱandȱitsȱpatients,ȱparticularlyȱonȱ lowȬincomeȱ womenȱ inȱ Indianaȱ whoȱ faceȱ lengthyȱ travelȱ toȱ oneȱofȱPPINK’sȱnowȱonlyȱsixȱhealthȱcentersȱthatȱcanȱofferȱanȱ informedȬconsentȱ appointment.ȱ Theseȱ burdensȱ areȱ clearlyȱ undueȱ whenȱ weighedȱ againstȱ theȱ almostȱ completeȱ lackȱ ofȱ evidenceȱ thatȱ theȱ lawȱ furthersȱ theȱ State’sȱ assertedȱ justificaȬ tionsȱofȱpromotingȱfetalȱlifeȱandȱwomen’sȱmentalȱhealthȱoutȬ comes.”ȱ273ȱF.ȱSupp.ȱ3dȱatȱ1043.ȱ TheȱStateȱarguesȱtoȱthisȱcourtȱthatȱtheȱdistrictȱcourt’sȱfindȬ ingsȱareȱclearlyȱerroneous.ȱWeȱcannotȱagree.ȱUnderȱtheȱclearȱ errorȱstandardȱweȱcanȱreverseȱaȱdistrictȱcourt’sȱfactualȱfindȬ ingsȱonlyȱifȱ“basedȱonȱtheȱentireȱrecord,ȱweȱareȱleftȱwithȱtheȱ definiteȱandȱfirmȱconvictionȱthatȱaȱmistakeȱhasȱbeenȱcommitȬ ted.”ȱUnitedȱStatesȱv.ȱOrillo,ȱ733ȱF.3dȱ241,ȱ244ȱ(7thȱCir.ȱ2013).ȱ Theȱ districtȱ thoroughlyȱ addressedȱ eachȱ ofȱ theȱ burdensȱ andȱ benefitsȱ assertedȱ byȱ theȱ partiesȱ andȱ engagedȱ inȱ aȱ painstakȬ inglyȱthoroughȱweighing.ȱItsȱfactualȱfindingsȱwereȱnotȱclearȬ lyȱerroneousȱandȱareȱentitledȱtoȱourȱdeference.ȱȱ C.ȱ Theȱremainingȱpreliminaryȱinjunctionȱconsiderationsȱ Thatȱ conclusionȱ aboutȱ theȱ likelihoodȱ ofȱ successȱ onȱ theȱ meritsȱ doesȱ notȱ endȱ theȱ inquiry,ȱ althoughȱ itȱ certainlyȱ putsȱ theȱheaviestȱweightȱonȱtheȱscale.ȱPPINKȱmustȱalsoȱshowȱthatȱ 46ȱ No.ȱ17Ȭ1883ȱ itȱ isȱ likelyȱ toȱ sufferȱ irreparableȱ harmȱ inȱ theȱ absenceȱ ofȱ preȬ liminaryȱ reliefȱ andȱ thatȱ itȱ hasȱ noȱ adequateȱ remedyȱ atȱ law.ȱ CityȱofȱChicagoȱv.ȱSessions,ȱ888ȱF.3dȱ272,ȱ282ȱ(7thȱCir.ȱ2018).ȱ“Ifȱ thoseȱ burdensȱ areȱ met,ȱ theȱ courtȱ mustȱ weighȱ theȱharmȱ thatȱ theȱplaintiffȱwillȱsufferȱabsentȱanȱinjunctionȱagainstȱtheȱharmȱ toȱ theȱ defendantȱ fromȱ anȱ injunction,ȱ andȱ considerȱ whetherȱ anȱinjunctionȱisȱinȱtheȱpublicȱinterest.”ȱId.ȱȱ Forȱ PPINKȱ andȱ itsȱ patientsȱ whoȱ loseȱ theȱ opportunityȱ toȱ exerciseȱ theirȱ constitutionalȱ rightȱ toȱ anȱ abortion,ȱ theȱ irrepaȬ rabilityȱ ofȱ theȱ harmȱ isȱ clear.ȱ Evenȱ anȱ extendedȱ delayȱ inȱ obȬ tainingȱ anȱ abortionȱ canȱ causeȱ irreparableȱ harmȱ byȱ “reȬ sult[ing]ȱ inȱ theȱ progressionȱ ofȱ aȱ pregnancyȱ toȱ aȱ stageȱ atȱ whichȱ anȱ abortionȱ wouldȱ beȱ lessȱ safe,ȱ andȱ eventuallyȱ illeȬ gal.”ȱPlannedȱParenthoodȱofȱWis.,ȱ738ȱF.3dȱatȱ796.ȱTheȱevidenceȱ suggestsȱthatȱtheȱnewȱultrasoundȱlawȱhasȱalreadyȱpreventedȱ someȱ womenȱ fromȱ exercisingȱ theirȱ constitutionalȱ rights.ȱ Itȱ hasȱ causedȱ delayȱ toȱ others.ȱ Becauseȱ we,ȱ likeȱ theȱ districtȱ court,ȱ haveȱ concludedȱ thatȱ thereȱ isȱ noȱ substantialȱ evidenceȱ thatȱtheȱlawȱfurthersȱitsȱstatedȱinterest,ȱanyȱharmȱtoȱtheȱStateȱ isȱminimal,ȱatȱworst.ȱAndȱtheȱStateȱcertainlyȱhasȱmyriadȱreȬ mainingȱ methodsȱtoȱ persuadeȱwomenȱtoȱ carryȱaȱpregnancyȱ toȱtermȱinȱorderȱtoȱpromoteȱtheȱState’sȱinterestȱinȱpromotingȱ fetalȱlife.ȱȱ TheȱStateȱarguesȱthatȱPPINKȱcanȱavoidȱsomeȱofȱtheȱharmȱ byȱ expendingȱ moreȱ resourcesȱ onȱ abortionȱ services,ȱ buyingȱ moreȱ ultrasoundȱ machines,ȱ butȱ again,ȱ theȱ courtȱ mustȱ takeȱ theȱrecordȱasȱitȱfindsȱitȱandȱnotȱbaseȱitsȱfindingȱonȱwhatȱtheȱ factsȱ mightȱ lookȱ likeȱ ifȱ theȱ courtȱ couldȱ deviseȱ aȱ differentȱ businessȱ orȱ careȱ modelȱ forȱ PPINK.ȱ See,ȱ e.g.,ȱ Wholeȱ Women’sȱ Health,ȱ136ȱS.ȱCt.ȱatȱ2318.ȱInȱanyȱcase,ȱPPINKȱpresentedȱeviȬ denceȱthatȱitȱhasȱalreadyȱshiftedȱresourcesȱandȱtriedȱtoȱmitiȬ No.ȱ17Ȭ1883ȱ 47 gateȱharmȱtoȱtheȱbestȱofȱitsȱability.ȱSomeȱofȱtheseȱchangesȱareȱ unsustainableȱlongȱterm.ȱOthersȱcannotȱbeȱmadeȱatȱall.ȱȱ Balancedȱ againstȱ theȱ harmȱ toȱ PPINKȱ patientsȱ isȱ theȱ State’sȱ claimȱ ofȱ irreparableȱ harm.ȱ Theȱ Stateȱ facesȱ theȱ sameȱ harmȱ anyȱ Stateȱ facesȱ whenȱ aȱ democraticallyȱ enactedȱ lawȱ isȱ enjoined.ȱItȱalsoȱclaimsȱthatȱitȱwouldȱpreventȱitȱfromȱfurtherȬ ingȱitsȱgoalȱofȱpromotingȱfetalȱlife.ȱThisȱweȱthink,ȱisȱaȱminiȬ mal,ȱpotentiallyȱtemporaryȱharmȱinȱthisȱcase,ȱcomparedȱwithȱ theȱburdensȱonȱtheȱwomenȱthatȱtheȱdistrictȱcourtȱidentified.ȱ Thisȱisȱparticularlyȱtrueȱwhenȱweȱconsiderȱthat—evenȱcreditȬ ingȱtheȱState’sȱassertedȱbenefitȱofȱtheȱlaw—theȱpotentialȱabilȬ ityȱ toȱ alterȱ anyȱ woman’sȱ decisionȱ inȱ aȱ mannerȱ thatȱ protectsȱ fetalȱlifeȱwouldȱbeȱminimal,ȱatȱbest.ȱȱ Asȱ forȱ theȱ publicȱ interest,ȱ theȱ districtȱ courtȱ foundȱ thatȱ upholdingȱ constitutionalȱ rightsȱ servesȱ anȱ importantȱ publicȱ interestȱandȱweȱseeȱnoȱreasonȱtoȱaddȱtoȱorȱupsetȱthisȱfinding.ȱ AndȱbecauseȱtheȱStateȱhadȱnotȱdemonstratedȱthatȱitsȱinterestȱ wouldȱbeȱservedȱbyȱtheȱlaw,ȱneitherȱcouldȱtheȱpublic’sȱinterȬ est.ȱ III.ȱ Theȱ Stateȱ assertsȱ thatȱ itsȱ reasonȱ forȱ thisȱ newȱ eighteenȬ hourȱ ultrasoundȱ requirementȱ isȱ toȱ persuadeȱ womenȱ notȱ toȱ haveȱanȱabortion.ȱThereȱisȱnoȱdoubtȱthatȱthisȱisȱaȱlegitimateȱ positionȱ forȱ aȱ stateȱ toȱ take.ȱ Butȱ itȱ isȱ alsoȱ trueȱ thatȱ womenȱ haveȱ theȱ rightȱ toȱ chooseȱ toȱ haveȱ anȱ abortion,ȱ albeitȱ withȱ someȱlimitations.ȱCasey,ȱ505ȱU.S.ȱatȱ846.ȱWomen,ȱlikeȱallȱhuȬ mans,ȱ areȱ intellectualȱ creaturesȱ withȱ theȱ abilityȱ toȱ reason,ȱ consider,ȱponder,ȱandȱchallengeȱtheirȱownȱideasȱandȱthoseȱofȱ others.ȱTheȱusualȱmannerȱinȱwhichȱweȱseekȱtoȱpersuadeȱisȱbyȱ rhetoricȱ notȱ barriers.ȱ Theȱ Stateȱ certainlyȱ isȱ entitledȱ toȱ useȱ 48ȱ No.ȱ17Ȭ1883ȱ theseȱ rhetoricalȱ toolsȱ toȱ persuadeȱ womenȱ notȱ toȱ haveȱ anȱ abortion.ȱ Itȱ hasȱ chosenȱ toȱ doȱ soȱ byȱ requiringȱ anȱ informedȬ consentȱ process—theȱ requiredȱ contentsȱ ofȱ whichȱ itȱ hasȱ deȬ signedȱ andȱ mandated—andȱ anȱ ultrasoundȱ andȱ fetalȱ heartȱ beatȱrequirement.ȱItȱalsoȱrequiresȱeveryȱwomanȱtoȱreceiveȱaȱ brochureȱaboutȱabortion,ȱtheȱcontentsȱofȱwhichȱtheȱStateȱconȬ trolsȱinȱtoto—fromȱhowȱitȱwillȱpresentȱtheȱimagesȱofȱfetusesȱ toȱ theȱ decisionsȱ aboutȱ whichȱ medicalȱ risksȱ itȱ includesȱ andȱ whichȱ itȱ omitsȱ (forȱ example,ȱ theȱ brochureȱ whichȱ aȱ womanȱ takesȱ homeȱ andȱ isȱ supposedȱ toȱ ponderȱ forȱ eighteenȱ hours,ȱ doesȱnotȱspeakȱofȱtheȱriskȱtoȱtheȱfetusȱfromȱdrugsȱandȱalcoȬ holȱ thatȱ aȱ womanȱ mayȱ haveȱ consumedȱ priorȱ toȱ knowingȱ aboutȱ anȱ unplannedȱ pregnancy).ȱ Moreover,ȱ itȱ statesȱ asȱ factȱ thatȱ“humanȱphysicalȱlifeȱbeginsȱwhenȱaȱhumanȱovumȱisȱferȬ tilizedȱ byȱ aȱ humanȱ sperm”—aȱ propositionȱ debatedȱ amongȱ scientists,ȱ religiousȱ leaders,ȱ andȱ medicalȱ ethicists.ȱ Theȱ Stateȱ hasȱvastȱpowerȱtoȱuseȱtheȱinformationȱthatȱitȱprovidesȱtoȱperȬ suadeȱwomenȱnotȱ toȱhaveȱanȱabortion.ȱButȱtheȱrequirementȱ thatȱwomenȱhaveȱtheȱultrasoundȱeighteenȱhoursȱpriorȱtoȱtheȱ abortionȱ placesȱ aȱ largeȱ barrierȱ toȱ accessȱ withoutȱ anyȱ eviȬ denceȱthatȱitȱservesȱtheȱintendedȱgoalȱofȱpersuadingȱwomenȱ toȱcarryȱaȱpregnancyȱtoȱterm.ȱInstead,ȱitȱappearsȱthatȱitsȱonlyȱ effectȱ isȱ toȱ placeȱ barriersȱ betweenȱ aȱ womanȱ whoȱ wishesȱ toȱ exerciseȱ herȱ rightȱ toȱ anȱ abortionȱ andȱ herȱ abilityȱ toȱ doȱ so.ȱ Rhetoricȱandȱpersuasionȱareȱcertainlyȱlegitimateȱmethodsȱforȱ aȱstateȱtoȱassertȱitsȱpreference,ȱbutȱitȱcannotȱforceȱcomplianceȱ withȱ itsȱ otherwiseȱ legitimateȱ viewsȱ byȱ erectingȱ barriersȱ toȱ abortionȱwithoutȱevidenceȱthatȱthoseȱbarriersȱserveȱtheȱbeneȬ fitȱtheȱstateȱintended.ȱ“UntilȱandȱunlessȱRoeȱv.ȱWadeȱisȱoverȬ ruledȱbyȱtheȱSupremeȱCourt,ȱaȱstatuteȱlikelyȱtoȱrestrictȱaccessȱ toȱabortionȱwithȱnoȱoffsettingȱmedicalȱbenefitȱcannotȱbeȱheldȱ toȱ beȱ withinȱ theȱ enactingȱ state’sȱ constitutionalȱ authority.”ȱ No.ȱ17Ȭ1883ȱ 49 Schimel,ȱ806ȱF.3dȱatȱ916.ȱInȱlightȱofȱtheȱevidenceȱofȱsubstantialȱ burdensȱ imposedȱbyȱ theȱlawȱ andȱwithoutȱ evidenceȱ thatȱ theȱ additionalȱ eighteenȱ hoursȱ followingȱ anȱ ultrasoundȱ hasȱ anyȱ legitimateȱ persuasiveȱ effectȱ onȱ decisionȬmaking,ȱ theȱ lawȱ constitutesȱ anȱ undueȱ burdenȱ onȱ thoseȱ seekingȱ anȱ abortionȱ withoutȱanyȱknownȱbenefitsȱtoȱbalanceȱit.ȱTheȱopinionȱofȱtheȱ districtȱcourtȱisȱAFFIRMEDȱinȱallȱrespects.ȱ 50ȱ ȱ No.ȱ17Ȭ1883ȱ ȱ KANNE,ȱ Circuitȱ Judge,ȱ concurringȱ inȱ theȱ judgment.ȱ Ourȱ decisionȱ todayȱ isȱ compelledȱ byȱ longȬstandingȱ Supremeȱ Courtȱprecedent.ȱSeeȱRoeȱv.ȱWade,ȱ410ȱU.S.ȱ113ȱ(1973);ȱPlannedȱ ParenthoodȱofȱSe.ȱPa.ȱv.ȱCasey,ȱ505ȱU.S.ȱ833ȱ(1992).ȱ Theȱ State’sȱ reasonȱ forȱ theȱ newȱ 18Ȭhourȱ ultrasoundȱ reȬ quirementȱisȱtoȱpersuadeȱwomenȱnotȱtoȱhaveȱanȱabortion.ȱAsȱ theȱ opinionȱ notes,ȱ “[t]hereȱ isȱ noȱ doubtȱ thatȱ thisȱ isȱ aȱ legitiȬ mateȱpositionȱforȱaȱstateȱtoȱtake.”ȱMajorityȱOp.ȱatȱ47.ȱThis,ȱofȱ course,ȱ isȱ weighedȱ againstȱ theȱ factȱ thatȱ “womenȱ haveȱ theȱ rightȱtoȱchooseȱtoȱhaveȱanȱabortion,ȱalbeitȱwithȱsomeȱlimitaȬ tions.”ȱId.ȱ Inȱ thisȱ caseȱ twoȱ evidentiaryȱ factorsȱ leadȱ meȱ toȱ concludeȱ thatȱtheȱ18Ȭhourȱrequirementȱimposesȱanȱundueȱburdenȱonȱaȱ woman’sȱrightȱtoȱchoose,ȱwhichȱrequiresȱaffirmingȱtheȱdeciȬ sionȱ ofȱ theȱ districtȱ court.ȱ Theȱ firstȱ factorȱ isȱ theȱ additionalȱ travelȱnecessitatedȱbyȱtheȱavailabilityȱofȱonlyȱsixȱultrasoundȱ imagingȱ sitesȱ locatedȱ inȱ Indianaȱ atȱ PPINKȱ healthȱ centers. ȱ Theȱ secondȱ factorȱ isȱ thatȱ theȱ Stateȱ offeredȱ littleȱ evidenceȱ toȱ showȱ thatȱ anȱ 18Ȭhourȱ waitȱ followingȱ anȱ ultrasoundȱ wouldȱ persuadeȱthoseȱseekingȱanȱabortionȱtoȱpreserveȱfetalȱlife.ȱȱ Basedȱonȱtheȱforegoingȱfactors,ȱIȱagreeȱthat,ȱinȱtheȱcontextȱ presentedȱ byȱ thisȱ appeal,ȱ Ind.ȱ Codeȱ §ȱ 16Ȭ34Ȭ2Ȭ1.1(a)(5)—asȱ written—constitutesȱanȱundueȱburdenȱonȱwomenȱseekingȱanȱ abortion.ȱ Thisȱ concurrenceȱ extendsȱ toȱ theȱ finalȱ judgmentȱ setȱ forthȱ byȱ myȱ esteemedȱ colleague,ȱ Judgeȱ Rovner,ȱ butȱ doesȱ notȱ enȬ Onȱappeal,ȱtheȱStateȱdidȱnotȱpursueȱtheȱargumentȱthatȱPPINKȱshouldȱ acceptȱultrasoundȱresultsȱfromȱtheȱmanyȱotherȱIndianaȱprovidersȱofȱulȬ trasoundȱimagingȱthroughoutȱtheȱState.ȱSeeȱMajorityȱOp.ȱatȱ24,ȱn.6.ȱ No.ȱ17Ȭ1883ȱ 51ȱ dorseȱ theȱ proprietyȱ ofȱ theȱ ancillaryȱ findingsȱ ofȱ theȱ districtȱ court.ȱ
Document Info
Docket Number： 17-1883
Judges： Rovner
Filed Date： 7/25/2018
Precedential Status： Precedential
Modified Date： 7/26/2018