Planned Parenthood of the Heartland, Inc. and Jill Meadows v. Iowa Board of Medicine , 2015 Iowa Sup. LEXIS 71 ( 2015 )

IN THE SUPREME COURT OF IOWA
No. 14–1415
Filed June 19, 2015
PLANNED PARENTHOOD OF THE HEARTLAND, INC. and
JILL MEADOWS,
Appellants,
vs.
IOWA BOARD OF MEDICINE,
Appellee.
Appeal from the Iowa District Court for Polk County, Jeffrey D.
Farrell, Judge.
Providers appeal a district court judgment upholding a rule by the
Iowa Board of Medicine establishing standards of practice for physicians
who prescribe or administer abortion-inducing drugs. AFFIRMED IN
PART AND REVERSED IN PART.
Alice Clapman of Planned Parenthood Federation of America,
Washington, D.C., Sharon K. Malheiro of Davis, Brown, Koehn, Shors &
Roberts, P.C., Des Moines, and Roger Evans of Planned Parenthood
Federation of America, New York, New York, for appellant.
Thomas J. Miller, Attorney General, Jeffrey S. Thompson, Solicitor
General, and Julie J. Bussanmas and Meghan L. Gavin, Assistant
Attorneys General, for appellee.
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Paige Fiedler of Fiedler & Timmer, P.L.L.C., Urbandale, and
Holly A. Harrison, Lynn D. Fleisher, Ph.D., Patrick E. Croke, Daniel C.
Craig, and Andrew Chinsky of Sidley Austin LLP, Chicago, Illinois, for
amicus curiae American College of Obstetricians and Gynecologists.
Roxanne Barton Conlin of Roxanne Conlin & Associates, P.C.,
Des Moines, for amici curiae Iowa Coalition Against Sexual Assault, Iowa
Coalition Against Domestic Violence, and National Women’s Law Center.
Joe Austen of Austen Law Office, PLLC, West Des Moines, and Rita
Bettis of ACLU of Iowa, Des Moines, for amicus curiae American Civil
Liberties Union of Iowa.
Mailee R. Smith of Americans United for Life, Washington, D.C.,
and Arthur F. Gilloon of Gilloon, Wright & Hamel PC, Dubuque, for amici
curiae Physicians for Life, National Association of Pro Life Nurses,
Christian Medical Association, National Association of Catholic Nurses,
and The National Catholic Bioethics Center.
Timm Reid of Galligan & Reid, P.C., Des Moines, and Michael J.
Norton and Natalie L. Decker of Alliance Defending Freedom, Greenwood
Village, Colorado, for amici curiae American Association of Pro-Life
Obstetricians & Gynecologists, Donna Harrison, M.D., Iowa Right to Life,
and Susan Thayer.
Matthew F. Heffron and Christine F. Delgado of Brown & Brown,
P.C., L.L.O., Omaha, Nebraska, Patrick D. Smith of Bradshaw, Fowler,
Proctor & Fairgrave, P.C., Des Moines, and Thomas Brejcha of Thomas
More Society, Chicago, Illinois, for amici curiae Catholic Medical
Association, Catholic Medical Association—Des Moines Guild, Catholic
Medical Association—St. Thomas Aquinas Guild of the Quad Cities,
Iowans for Life, and Women’s Choice Center of the Quad Cities.
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WIGGINS, Justice.
In 2013, the Iowa Board of Medicine passed a rule establishing
standards of practice for physicians who prescribe or administer
abortion-inducing drugs. These standards require the physician to
personally perform a physical examination and to be physically present
when the abortion-inducing drug is provided. It is not disputed the rule
would have the effect of prohibiting telemedicine abortions in Iowa.
Planned Parenthood of the Heartland, Inc. and Dr. Jill Meadows,
M.D. (collectively Planned Parenthood) challenge the rule as both
improperly enacted and violative of the Iowa Constitution. For purposes
of this appeal, we will assume the Board properly enacted the rule and
did not violate any of the procedural or rulemaking provisions of Iowa
Code chapter 17A (2013), other than Planned Parenthood’s claim the rule
violates section 17A.19(10)(a), which provides an agency’s action is
invalid when “substantial rights of the person seeking relief have been
prejudiced” and the action is “[u]nconstitutional on its face or as
applied.” Iowa Code § 17A.19(10)(a). We will therefore focus on the
constitutional question.
The Board has conceded the Iowa Constitution provides a right to
an abortion that is coextensive with the right available under the United
States Constitution. Planned Parenthood argues the Iowa Constitution
affords a broader right, and we should therefore apply a strict scrutiny
analysis under the Iowa Constitution to the rule. We need not resolve
this question because we conclude, for the reasons stated herein, that
the Board’s rule violates the controlling “undue burden” test announced
by the United States Supreme Court as the federal constitutional test.
See Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 878–79, 112
S. Ct. 2791, 2821, 120 L. Ed. 2d 674, 715–16 (1992) (plurality opinion)
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and Gonzales v. Carhart, 550 U.S. 124, 146, 158, 127 S. Ct. 1610, 1626–
27, 1633, 167 L. Ed. 2d 480, 502, 509–10 (2007). Thus, the contested
rule violates the Iowa Constitution under the less stringent Iowa
constitutional standard advanced by the Board. We therefore reverse the
decision of the district court as to the contested portions of the rule.
I. Background Facts and Proceedings.
On our de novo review, we find the following facts.
A. Medication Abortions. In 2000, the United States Food and
Drug Administration (FDA) approved the distribution and use of
mifepristone in the United States. Mifepristone, also known as RU–486,
is a prescription drug that terminates a pregnancy by detaching the
gestational sac from the uterine wall. In the clinical trials, the woman
returned two to four days later and took a second medication,
misoprostol, which induced contractions to complete the medication
abortion.
Consistent with the clinical trial documents submitted in support
of the application for approval of the drug, the FDA label indicated the
appropriate treatment regimen was to administer 600 mg of mifepristone
orally, followed two days later by 0.4 mg of misoprostol administered
orally. Additionally, the label indicated the patient should take the
mifepristone within the first seven weeks of pregnancy.
Once the FDA approves a drug, the FDA does not prohibit
physicians from using the drug in a different manner than the label
provides—otherwise known as “off-label” use. See U.S. Food & Drug
Admin., “Off-Label” and Investigational Use of Marketed Drugs, Biologics,
and Medical Devices–Information Sheet, available at
www.fda.gov/regulatoryinformation/guidances/ucm126486. Off-label
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use means the safety and effectiveness of the dosing regimen has not
been established by the FDA.
Following FDA approval, additional studies led to the development
of new protocols for administering these drugs. The new off-label method
changed the dosage amounts of the drugs, lowering the amount of
mifepristone from 600 mg to 200 mg and increasing the amount of
misoprostol from 0.4 mg to 0.8 mg. The new method also changed the
administration of misoprostol from oral ingestion to buccally—placing
the pill between the cheeks and gums. The studies also showed this
method was safe and effective for use within the first nine weeks of
pregnancy. The American College of Obstetricians and Gynecologists
(ACOG) accepts and approves of this off–label protocol as the standard of
care to administer these drugs.
Since 2008, the medication abortions performed by Planned
Parenthood in Iowa have involved 200 mg of mifepristone administered
orally, followed one to four days later by 0.8 mg of misoprostol taken
buccally. The clinic then instructs the patient to return to the clinic
within two weeks after taking the misoprostol for a follow-up
appointment. Planned Parenthood utilizes the same procedures for
medication abortions if the patient is physically present in the doctor’s
clinic or if the procedure is being performed utilizing telemedicine.
Telemedicine is a method of practicing medicine in which the
physician is at one geographical location, the patient is at a different
geographical location, and the two communicate through a secure
electrical audio-visual connection that complies with the privacy
requirements of the Health Insurance Portability and Accountability Act
(HIPAA). In Iowa, physicians and hospitals deliver a variety of health
care and education services to Iowans living in rural communities
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through telemedicine. The Board has adopted a rule effective June 3,
2015, regarding the use of telemedicine by Iowa physicians. The
regulations make the following findings:
1. The board recognizes that technological advances
have made it possible for licensees in one location to provide
medical care to patients in another location with or without
an intervening health care provider.
2. Telemedicine is a useful tool that, if applied
appropriately, can provide important benefits to patients,
including increased access to health care, expanded
utilization of specialty expertise, rapid availability of patient
records, and potential cost savings.
3. The board advises that licensees using telemedicine
will be held to the same standards of care and professional
ethics as licensees using traditional in-person medical care.
Iowa Admin. Code r. 653—13.11.
The regulations also state that “[a] licensee who uses telemedicine
shall utilize evidence-based telemedicine practice guidelines and
standards of practice, to the degree they are available, to ensure patient
safety, quality of care, and positive outcomes.” Id. r. 653—13.11(2). The
regulations further require the licensee to perform “a physical
examination, when medically necessary, sufficient for the diagnosis and
treatment of the patient.” Id. r. 653—13.11(8). They identify nine
separate situations in which the licensee need not personally interview,
examine, or diagnose the patient, including when “the patient has been
examined in person by an advanced registered nurse practitioner or
physician assistant or other licensed practitioner with whom the licensee
has a supervisory or collaborative relationship.” Id. r. 653—13.11(20)(e).
Planned Parenthood has been utilizing telemedicine to perform
medication abortions in Iowa since 2008. 1 At all Planned Parenthood
1Iowa was the first state in which telemedicine abortions were widely performed.
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locations in Iowa, a trained staff member takes a medical history from
the patient, checks the patient’s vital signs, and gathers the patient’s
blood for tests to check for any medical reasons the woman should not
undergo a medication abortion.
A trained staff member then performs an ultrasound on the
woman to check for an ectopic pregnancy and obtain the gestational age
of the pregnancy. An ectopic pregnancy occurs when the fertilized egg is
implanted somewhere other than the uterus. An ectopic pregnancy is a
contraindication for a medication abortion because the drug regimen
does not work when the fertilized egg is not located in the uterus. Thus,
the doctor uses the ultrasound images to determine if the gestational sac
containing the fertilized egg implanted somewhere other than inside the
uterus. The ultrasound machine also estimates gestational age.
Prior to administering the mifepristone, the physician reviews the
lab results, the ultrasound images, and medical history provided by the
patient. After the physician determines there is no medical reason the
woman cannot proceed with the procedure, the patient and physician
speak to each other. Whether the physician is present in person or
communicating remotely through telemedicine, the physician does not
personally perform a physical exam on the patient. The standard of care
developed by ACOG is that a physical examination by the physician
before proceeding with a medical termination of a pregnancy is medically
unnecessary.
Next, the physician informs the patient about the medication
regime, potential complications, what to expect after ingesting the
misoprostol, and answers questions the patient may have. After
receiving informed consent from the patient that she wishes to go
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forward with the termination, the doctor provides the medications to the
patient.
In telemedicine administration, the patient–physician
communication occurs over a real-time two-way HIPAA secured
teleconference audio-visual connection with a staff person in the room
with the patient and the physician at a different clinical location. After
receiving informed consent, the physician remotely releases a secure
drawer containing the medications located in the patient’s room.
Regardless of whether the physician dispenses the medications in
person or by telemedicine, both the physician and the staff member
watch the patient take the mifepristone (in the telemedicine situation,
the physician watches over the two-way video). The clinic schedules a
follow-up visit within two weeks. The woman then goes home, or to a
location of her choosing, and takes the misoprostol twenty-four to forty-
eight hours later.
The woman also receives a toll-free number that she may call to
speak with medical staff or the physician regarding any complications or
questions, as the actual uterine evacuation occurs while the woman is at
home regardless of the location of the initial appointment. In the
relatively uncommon case in which the physician feels the patient needs
emergency care, the doctor refers the woman to the nearest hospital
emergency room.
B. Administrative Proceedings. On June 25, 2013, the Board
received a petition for rulemaking regarding the standards of practice for
telemedicine medication abortions. The petition proposed the following
rule:
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653-13.10 – Standards of practice – chemical
abortion.
This rule establishes the standards of practice for a
physician or osteopathic physician who induces an abortion
by an abortion-inducing drug.
13.10(1). Definition. As used in this rule, “abortion-
inducing drug” means a drug, medicine, mixture, or
preparation, when it is prescribed or administered with the
intent to terminate the pregnancy of a woman known to be
pregnant.
13.10(2). Physical Examination Required. A physician
shall not induce an abortion by providing an abortion-
inducing drug unless the physician has first performed a
physical examination of the woman to determine, and
document in the woman’s medical record, the gestational age
and intrauterine location of the pregnancy.
13.10(3). Physical Presence Required. When inducing
an abortion by providing an abortion-inducing drug, a
physician must be physically present with the woman at the
time the abortion-inducing drug is provided.
13.10(4). Follow-Up Appointment Required. If an
abortion is induced by an abortion-inducing drug, the
physician inducing the abortion must schedule a follow-up
visit with the woman at the same facility where the abortion-
inducing drug was provided, 12 to 18 days after the use of
an abortion-inducing drug to confirm the termination of the
pregnancy and evaluate the woman’s medical condition. The
physician shall use all reasonable efforts to ensure that the
woman is aware of the follow-up appointment and that she
returns for the appointment.
13.10(5). Parental Notification regarding Pregnant
Minors. A physician shall not induce an abortion by
providing an abortion-inducing drug to a pregnant minor
prior to compliance with the requirements of chapter 135L of
the Iowa Code and Rules 641-89.12 and 641-89.21 adopted
by the Public Health Department.
On June 28, the Board held a public meeting and discussed the
proposed rule. Three members of the public spoke at the meeting, Daniel
McConchie, Vice President of Government Affairs for Americans United
for Life, spoke in favor of the rule; Tom Ross, M.D., a doctor at Planned
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Parenthood, spoke against the rule; and Kelly Larson, a registered nurse
at InnerVisions HealthCare, spoke in favor of the rule. After hearing the
public comments, board member Allison Schoenfelder, M.D., moved to
accept the petition and begin the rulemaking process. The Board voted
eight to two to accept the petition.
The Board held a public hearing on the proposed rule on
August 28, and the public had thirty-five days to submit written
comments on the proposed rule. The Board heard testimony from
twenty-eight individuals at the public hearing and received 244 written
comments from both individuals and organizations. The Board heard
from many doctors both for and against the rule.
Dr. Sean Kenney, a practicing obstetrician and gynecologist from
Lincoln, Nebraska, spoke in favor of the rule. Dr. Daniel Grossman, an
obstetrician and gynecologist from Oakland, California, spoke against the
rule. The Board also received public comment from the Iowa Medical
Society and the Iowa Osteopathic Medical Association, both of which
expressed concern regarding the procedures used to implement the rule
and opposed the rule itself. Other physicians also testified the Planned
Parenthood clinics follow the standard of care used for medication
abortions, whether the physician performs the procedure at an in-clinic
visit or by telemedicine.
On August 30, the Board held a meeting to determine whether it
should adopt the rule. The Board passed the rule, again with an eight to
two vote. The Board announced it would publish the adopted rule on
October 2, and it would become effective November 6.
On September 27, the Board issued a statement regarding the
adoption and filing of the rule. The Board listed its principal reasons in
support of the rule as follows:
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1. To protect the health and safety of patients,
standards of practice are needed for physicians who
prescribe and administer abortion-inducing drugs to
terminate a pregnancy.
2. The practices used by physicians who prescribe and
administer abortion-inducing drugs using telemedicine
are inconsistent with the protocols approved by the U.S.
Food and Drug Administration (FDA) and the
manufacturer of the drugs.
3. Iowa Code Section 707.7(3) only allows physicians to
perform abortions in Iowa.
4. A physical examination of the patient in telemedicine
settings is not being performed by the physician who
prescribes and administers the abortion-inducing drugs,
but is delegated to non-physician persons who do not
have appropriate training to confirm or discover
contraindications or to perform an ultrasound to
determine the age and location of the embryo.
5. Physicians who prescribe and administer abortion-
inducing drugs using telemedicine may never meet with
the patient in person and may never see the patient
again for a follow-up appointment.
The Board also provided its reasons for overruling the objections to
the rule.
1. The rule would limit rural Iowa women’s access to
medical abortions. The new rule does not restrict where
medical abortion services may be provided. The emphasis of
the rule is on the patient’s health and safety and the
responsibility of physicians who perform medical abortions.
The Board believes that all Iowans are entitled to the same
high level of health care, regardless of whether they live in
rural or urban areas. The Board believes that the physician’s
decision that the patient should have a medical or surgical
abortion should depend on multiple factors including patient
preference, medical and psychological status of the patient,
and the patient’s access to emergency medical services.
2. The rule is politically motivated and is not sound
public policy. While issues such as abortion have been
politicized, the Board does not have authority to react
politically to any issue. The Board is only authorized to adopt
all necessary and proper rules for the licensure and
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standards of practice for health care providers licensed
pursuant to Iowa Code Chapters 148 (physicians) and 148E
(acupuncturists). The Board is motivated to adopt this
administrative rule by its mandate to protect the health and
safety of Iowans.
3. The rule is an attempt to ban access to a procedure
that is legal. It deprives Iowa women of their
constitutionally protected right to obtain a pre-viability
abortion. Abortion is legal in Iowa and the goal of the new
rule is to protect the health and safety of patients who seek
medical abortions. Federal court decisions have set the
guidelines for the availability of abortion. Nothing in the rule
bans medical abortion. Rather, the rule sets forth the
standards of practice that must be followed by physicians
who perform medical abortions.
4. The Board previously addressed this matter in 2010
when it reviewed Planned Parenthood of the Heartland’s
medical abortion services using telemedicine and
concluded they were safe. The membership of the Board
has changed completely over the past three years. The Board
has not previously promulgated any rules addressing medical
abortion services using telemedicine. This is the first
rulemaking proceeding which has given licensed physicians
and the public an opportunity to comment on the use of
telemedicine in this context. Because there was no rule in
place addressing this particular procedure, the Board
determined a rule was necessary to protect the health and
safety of Iowans.
5. The Board promulgated rulemaking without a
thorough study or analysis of the matter under
regulatory consideration and the Board did not take into
consideration the impact the rule may potentially have
on expectations and requirements for telemedicine
delivery of other medical services. After accepting a
petition on June 28, 2013, to promulgate rulemaking on the
standards of practice for physicians who perform medical
abortions, Board members studied the matter and reviewed
medical research papers and a significant amount of public
comments received on a broad spectrum of issues regarding
medical abortions. The Board determined that the new rule is
narrowly focused on the standards of practice for physicians
who perform medical abortions. The Board may determine in
the future to more broadly address the standards of practice
for other medical services using telemedicine.
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6. An appropriate physical examination, including an
ultrasound to determine age and location of the embryo,
is performed by appropriately trained staff in the
telemedicine setting and this information is provided to
an off-site physician who remotely prescribes and
administers the abortion-inducing drugs. The Board
considers a thorough medical history and physical
examination to be the cornerstone of good medical care. On
this foundation an accurate diagnosis can be made and the
most appropriate treatment plan offered to the patient. The
Board is concerned about the quality and sufficiency of the
physical examination being performed prior to a medical
abortion. The first area of concern is the lack of opportunity
for a physician to perform a basic physical examination of the
patient to screen for conditions that would be
contraindications to medical abortion. The drugs used in a
medical abortion are mifepristone and misoprostol. As listed
in the FDA literature the contraindications to these
medications include “confirmed or suspected ectopic
pregnancy or undiagnosed adnexal mass; an intrauterine
device (IUD) in place; chronic adrenal failure; concurrent long-
term corticosteroid therapy; history of allergy to mifepristone,
misoprostol, or other prostaglandins; hemorrhagic disorders or
concurrent anticoagulant therapy; and inherited porphyrias.”
As stated in the FDA literature on abortion-inducing drugs,
“There are no data on the safety and efficacy of mifepristone
in women with chronic medical conditions such as
cardiovascular, hypertensive, hepatic, respiratory, or renal
disease; insulin-dependent diabetes mellitus; severe anemia
or heavy smoking. Women who are more than 35 years of
age and who also smoke 10 or more cigarettes per day should
be treated with caution because such patients were generally
excluded from clinical trials of mifepristone.” The Board
believes that a basic physical examination of a patient is
necessary to exclude this narrower list of contraindications
and essential to exclude the list of exclusionary conditions
that were not part of the clinical studies. The second area of
concern is the quality of the ultrasound that is being
performed prior to a medical abortion. Without the option of a
clinical pelvic examination of the patient to confirm dating of
the embryo, these remote clinics are relying primarily on
ultrasound to date the embryo and rule out ectopic pregnancy,
which occurs when an embryo implants somewhere other
than the uterus. The Board is concerned about the
uncertainty of whether clinic staff members providing the
ultrasounds are actually qualified to produce useful images to
sufficiently rely upon for diagnostic purposes. If an ectopic
pregnancy was missed the medications may not expel the
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embryo and may lead to delayed diagnosis and treatment of
this dangerous condition. In the FDA reports of deaths from
mifepristone and misoprostol two of the 14 deaths were
related to ruptured ectopic pregnancies, and 58 other women
suffered morbidity from failed diagnosis of ectopic pregnancy.
The Board believes that a basic physical examination for
every patient will help to exclude the conditions that are
contraindications to the medications. The Board believes that
a pelvic examination may be necessary in some cases to
correlate with ultrasound findings and should be available to
all women presenting for a medical abortion. The Board
believes that adequate ultrasound services and interpretation
are necessary if a clinical pelvic examination is not being used
to date the embryo. For all these reasons the Board believes
that a physician should be present to conduct this physical
examination before proceeding with a medical abortion.
7. The treatment and consultation recommendations
made by the physician in the telemedicine setting are
the same standards of appropriate practice as those in
face-to-face settings. The physician does not have to be
present to perform a medical abortion. Iowa Code section
707.7(3) requires that abortions in Iowa be performed by
physicians. The Board believes that the prescribing physician
must be physically present with the patient to administer the
abortion-inducing drug. This physician-patient relationship is
fundamental to the provision of a safe medical abortion. It is
the expectation of the Board that physicians recognize the
obligations, responsibilities and patient rights associated with
establishing and maintaining an appropriate physician-patient
relationship in the specific context of prescribing and
administering abortion-inducing drugs.
8. Patients are already receiving appropriate follow-up
care to their medical abortions in remote clinics where a
physician is not physically present. The Board believes
that follow-up care of the patient is critical after providing a
medical abortion. The new rule requires the physician who
prescribes and performs a medical abortion to make all
reasonable efforts to ensure that the patient is aware of the
importance of follow-up care and that she returns for an
appointment with the prescribing physician. The Board
believes that the physician’s in-person interview to collect the
patient’s medical history and an in-person physical
examination will strengthen the physician-patient relationship
and result in improved and increased follow-up care of the
patient.
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The final rule adopted by the Board reads:
653—13.10 Standards of practice–physicians who
prescribe or administer abortion-inducing drugs.
13.10(1) Definition. As used in this rule:
“Abortion-inducing drug” means a drug, medicine,
mixture, or preparation, when it is prescribed or
administered with the intent to terminate the pregnancy of a
woman known to be pregnant.
13.10(2) Physical examination required. A physician
shall not induce an abortion by providing an abortion-
inducing drug unless the physician has first performed a
physical examination of the woman to determine, and
document in the woman’s medical record, the gestational age
and intrauterine location of the pregnancy.
13.10(3) Physician’s physical presence required. When
inducing an abortion by providing an abortion-inducing
drug, a physician must be physically present with the
woman at the time the abortion-inducing drug is provided.
13.10(4) Follow-up appointment required. If an
abortion is induced by an abortion-inducing drug, the
physician inducing the abortion must schedule a follow-up
appointment with the woman at the same facility where the
abortion-inducing drug was provided, 12 to 18 days after the
woman’s use of an abortion-inducing drug to confirm the
termination of the pregnancy and evaluate the woman’s
medical condition. The physician shall use all reasonable
efforts to ensure that the woman is aware of the follow-up
appointment and that she returns for the appointment.
13.10(5) Parental notification regarding pregnant
minors. A physician shall not induce an abortion by
providing an abortion-inducing drug to a pregnant minor
prior to compliance with the requirements of Iowa Code
chapter 135L and rules 641—89.12(135L) and 641—
89.21(135L) adopted by the public health department.
Iowa Admin. Code r. 653—13.10.
C. District Court Proceedings. On September 30, Planned
Parenthood filed a petition for judicial review and a motion to stay the
enforcement of the rule. The district court granted Planned Parenthood’s
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motion to stay the enforcement of the rule pending its ruling. On
August 18, 2014, the district court denied Planned Parenthood’s claims
and upheld the rule addressing each of Planned Parenthood’s challenges.
Planned Parenthood appealed and asked us to stay the
enforcement of the rule pending the resolution of its appeal. We entered
a stay and retained the appeal.
II. Issues.
Planned Parenthood raised a number of issues before the district
court challenging both the rulemaking process and the constitutionality
of the rule. For purposes of this appeal, we will assume the Board
properly enacted the rule and did not violate any of the procedural or
rulemaking provisions of Iowa Code chapter 17A other than Planned
Parenthood’s claim the rule is unconstitutional and violates Iowa Code
section 17A.19(10)(a). Under the Code, we can provide appropriate relief
when the agency action is “[u]nconstitutional on its face or as applied or
is based upon a provision of law that is unconstitutional on its face or as
applied.” Iowa Code § 17A.19(10)(a).
Planned Parenthood did not challenge the ruling regarding
provisions (1) and (5) of rule 653—13.10. Therefore, we will affirm the
district court judgment regarding rule 653—13.10(1) and 13.10(5).
III. Standard of Review.
We review Planned Parenthood’s constitutional claims de novo.
Gartner v. Iowa Dep’t of Pub. Health, 830 N.W.2d 335, 344 (Iowa 2013).
IV. Analysis.
A. The Right of a Woman to an Abortion Under the Iowa
Constitution. On appeal, Planned Parenthood asks us to declare the
rule unconstitutional under the Iowa Constitution. We have yet to
determine if the Iowa Constitution protects a woman’s right to terminate
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her pregnancy. Over forty years ago, the United States Supreme Court
recognized a woman has a constitutionally protected liberty interest in
the decision to terminate a pregnancy. Roe v. Wade, 410 U.S. 113, 153–
54, 93 S. Ct. 705, 727, 35 L. Ed. 2d 147, 177–78 (1973). The Supreme
Court reaffirmed the “constitutional liberty of the woman to have some
freedom to terminate her pregnancy” in 1992. Casey, 505 U.S. at 869,
112 S. Ct. at 2816, 120 L. Ed. 2d at 709.
Many states considering this issue under their state constitutions
have found their state constitutions provide such a right. See, e.g.,
Valley Hosp. Ass’n, Inc. v. Mat-Su Coal. for Choice, 948 P.2d 963, 967–69
(Alaska 1997); Comm. to Defend Reprod. Rights v. Myers, 625 P.2d 779,
784 (Cal. 1981); In re T.W., 551 So. 2d 1186, 1192–93 (Fla. 1989); Hope
Clinic for Women, Ltd. v. Flores, 991 N.E.2d 745, 760 (Ill. 2013); Moe v.
Sec’y of Admin. & Fin., 417 N.E.2d 387, 398–99 (Mass. 1981); Women of
the State of Minn. by Doe v. Gomez, 542 N.W.2d 17, 27 (Minn. 1995); Pro-
Choice Miss. v. Fordice, 716 So. 2d 645, 653 (Miss. 1998); Reprod. Health
Servs. of Planned Parenthood of St. Louis Region, Inc. v. Nixon, 185
S.W.3d 685, 692 (Mo. 2006) (en banc) (per curiam); Armstrong v. State,
989 P.2d 364, 374–75 (Mont. 1999); Hope v. Perales, 634 N.E.2d 183,
186 (N.Y. 1994); Planned Parenthood of Middle Tenn. v. Sundquist, 38
S.W.3d 1, 15 (Tenn. 2000). But cf. Taylor v. Kurapati, 600 N.W.2d 670,
687 (Mich. Ct. App. 1999) (“This Court has held that the Michigan
Constitution does not provide a right to end a pregnancy.”); Mahaffey v.
Att’y Gen., 564 N.W.2d 104, 111 (Mich. Ct. App. 1997) (“We merely hold
that the Michigan Constitution does not guarantee a right to abortion
that is separate and distinct from the federal right.”); MKB Mgmt. Corp. v.
Burdick, 855 N.W.2d 31, 31–32, 52, 64, 89, 91, 98 (N.D. 2014) (per
curiam) (upholding the constitutionality of amendments to the state
18
abortion control act that limited medication abortions where two justices
determined the law violated the North Dakota Constitution, two justices
concluded the law did not violate the state constitution, three justices
determined the statute violated the Federal Constitution, one justice
concluded the law did not violate the Federal Constitution, and one
justice concluded the federal constitutional issue was not properly before
the court because there was not a sufficient majority of the court that
agreed the law was unconstitutional). However, in this case, we need not
decide whether the Iowa Constitution provides such a right, and if so,
whether regulations affecting that right must pass strict scrutiny. 2 The
Board in its brief and in its oral argument conceded a woman has a right
to terminate her pregnancy protected by the Iowa Constitution that is
coextensive with the federal right.3 For the reasons discussed herein, we
2As previously noted, Planned Parenthood urges that the Iowa Constitution
provides greater protection than the Federal Constitution for a woman’s right to
terminate her pregnancy. It urges us to adopt a strict scrutiny standard under the Iowa
Constitution. Several state courts have previously reached this conclusion. See Valley
Hosp. Ass’n, 948 P.2d at 968–69 (applying a strict scrutiny analysis to abortion
regulations under its state constitution while noting that Alaska’s constitution has a
privacy provision and “provides more protection of individual privacy rights than the
United States Constitution”); In re T.W., 551 So. 2d at 1191, 1195–96 (applying a strict
scrutiny analysis under the Florida Constitution, which provides that “[e]very natural
person has the right to be let alone and free from governmental intrusion into his
private life except as otherwise provided herein”); Women of the State of Minn., 542
N.W.2d at 31 (applying strict scrutiny under the Minnesota Constitution which has no
separate privacy provision); Armstrong, 989 P.2d at 372, 373–74 (applying strict
scrutiny under the Montana Constitution which provides that “[t]he right of individual
privacy is essential to the well-being of a free society and shall not be infringed without
the showing of a compelling state interest”); Planned Parenthood of Middle Tenn., 38
S.W.3d at 14–15 (applying strict scrutiny under the Tennessee Constitution which has
no separate privacy provision). Other courts have found a state constitutional right
that is coextensive with the federal right. See, e.g., Hope Clinic, 991 N.E.2d at 760;
Reprod. Health Servs., 185 S.W.3d at 692 (“There is no reason, within the context of this
case, to construe this language from the Missouri constitution more broadly than the
language used in the United States constitution.”); Pro-Choice Miss., 716 So. 2d at 655.
3In its brief, the Board asserts, “[T]his Court should adopt [under the Iowa
Constitution] the undue burden standard set forth in Casey.”
19
find the challenged rule fails to meet the federal undue burden test for
constitutionality.
B. The Federal Undue Burden Test. In a plurality decision, the
Supreme Court developed the undue burden test to reconcile the state’s
interest with the constitutionally protected interest of the woman.
Casey, 505 U.S. at 876–80, 112 S. Ct. at 2820–22, 120 L. Ed. 2d at 714–
17. Generally, under the undue burden test for a state regulation to
place an undue burden on a woman’s right to terminate a pregnancy, the
state regulation must have “the purpose or effect of placing a substantial
obstacle in the path of a woman seeking an abortion of a nonviable
fetus.” Id. at 877, 112 S. Ct. at 2820, 120 L. Ed. 2d at 714.
In adopting the test, the Supreme Court recognized that even
though a woman has a liberty interest in deciding whether to terminate a
pregnancy, the right to do so is limited. Id. at 869, 112 S. Ct. at 2816,
120 L. Ed. 2d at 709–10. The limitation imposed by the Supreme Court
is the state’s “important and legitimate interests in preserving and in
protecting the health of the pregnant woman” and “in protecting the
potentiality of human life.” Roe, 410 U.S. at 162, 93 S. Ct. at 731, 35 L.
Ed. 2d at 182. The Court balanced a woman’s right to terminate her
pregnancy against the legitimate interests of the state by developing the
undue burden test. Casey, 505 U.S. at 876, 112 S. Ct. at 2820, 120
L. Ed. 2d at 714.
In the most recent case, Gonzales v. Carhart, the Court—
considering a ban on late term abortions—stated the undue burden test
as
[w]here it has a rational basis to act, and it does not impose
an undue burden, the State may use its regulatory power to
bar certain procedures and substitute others, all in the
furtherance of its legitimate interests in regulating the
20
medical profession in order to promote respect for life,
including life of the unborn.
Carhart, 550 U.S. at 158, 127 S. Ct. at 1633, 167 L. Ed. 2d at 509–10.
The Court applies the undue burden test differently depending on
the state’s interest advanced by a statute or regulation. If the state’s
interest is to advance fetal life, “[a]n undue burden exists, and therefore
a provision of law is invalid, if its purpose or effect is to place a
substantial obstacle in the path of a woman seeking an abortion before
the fetus attains viability.” Casey, 505 U.S. at 878, 112 S. Ct. at 2821,
120 L. Ed. 2d at 715.
On the other hand, if the state’s interest is to further the health or
interest of a woman seeking to terminate her pregnancy, “[u]nnecessary
health regulations that have the purpose or effect of presenting a
substantial obstacle to a woman seeking an abortion impose an undue
burden on the right.” Id. at 878, 112 S. Ct. at 2821, 120 L. Ed. 2d at
716. Some federal courts applying this test have interpreted it to mean
“[t]he feebler the medical grounds, the likelier the burden, even if slight,
to be ‘undue’ in the sense of disproportionate or gratuitous.” Planned
Parenthood of Wis., Inc. v. Van Hollen, 738 F.3d 786, 798 (7th Cir. 2013);
see also Planned Parenthood Ariz., Inc. v. Humble, 753 F.3d 905, 912–14
(9th Cir. 2014). Under this approach, we are required “to weigh the
extent of the burden against the strength of the state’s justification in the
context of each individual statute or regulation.” Planned Parenthood
Ariz., 753 F.3d at 914.
In contrast to the Seventh and Ninth Circuits, the Fifth and Sixth
Circuit Courts of Appeals have applied Casey differently to measures
passed by their state to promote the health or interest of a woman
seeking to terminate her pregnancy. The Fifth and Sixth Circuits do not
21
weigh the strength of the state’s justifications against the burden placed
on women. Under the Fifth Circuit’s approach, once the state sets forth
a justification for an abortion regulation sufficient to pass rational basis
review, it is not necessary to consider the strength of the state’s
justification in its analysis. Planned Parenthood of Greater Tex. Surgical
Health Servs. v. Abbott, 748 F.3d 583, 593–99 (5th Cir. 2014). The Sixth
Circuit took the same approach as the Fifth Circuit when it decided its
case without considering the strength of the state’s justification in its
analysis. See Planned Parenthood Sw. Ohio Region v. DeWine, 696 F.3d
490, 513–18 (6th Cir. 2012).
Like the Seventh and Ninth Circuits, we believe the “unnecessary
health regulations” language used in Casey requires us to weigh the
strength of the state’s justification for a statute against the burden
placed on a woman seeking to terminate her pregnancy when the stated
purpose of a statute limiting a woman’s right to terminate a pregnancy is
to promote the health of the woman.
C. Applying the Federal Undue Burden Test to this Case. We
will assume for purposes of this appeal that the Board has a rational
basis to act under the federal constitutional test. Therefore, we will
analyze the rule under the undue burden prong of the test.
1. Substance of Iowa Administrative Code rule 653—13.10. The
rule creates a standard of practice for physicians who perform
medication abortions. Planned Parenthood is challenging rule 653—
13.10(2) through 13.10(4). The crux of this rule is to require greater
physician involvement in the termination of a pregnancy than is now
provided by Planned Parenthood for medical terminations of pregnancies.
Rule 653—13.10(2) requires a physician to perform a physical
examination of the woman for the purposes of determining the
22
gestational age and intrauterine location of the pregnancy. Iowa Admin.
Code r. 653—13.10(2). Rule 653—13.10(3) requires the physician to be
physically present in the room and give the medications to the woman.
Id. r. 653—13.10(3). Finally, rule 653—13.10(4) requires the physician
to schedule a follow-up visit with the woman at the same facility where
the physician dispensed the medication to confirm the termination of the
pregnancy and to evaluate the woman’s medical condition. Id. r. 653—
13.10(4). Planned Parenthood challenges the rule as applied to
medication abortions done with the physician present or by telemedicine.
2. Purpose of Iowa Administrative Code rule 653—13.10. The
Board did not pass this rule to advance the state’s interest in advancing
fetal life. Rather, the Board passed this rule to promote the health or
interest of a woman seeking to terminate her pregnancy. The first reason
given by the Board for the enactment of the rule is “[t]o protect the health
and safety of patients.” The reasons given by the Board also state the
rule is necessary because “physicians who prescribe and administer
abortion-inducing drugs using telemedicine are inconsistent with the
protocols approved by the U.S. Food and Drug Administration (FDA) and
the manufacturer of the drugs.” Additionally, in its explanations for
overruling the reasons presented in opposition to the rule, the Board
stated, “[t]he Board is motivated to adopt this administrative rule by its
mandate to protect the health and safety of Iowans.” Finally,
“[p]hysicians who prescribe and administer abortion-inducing drugs
using telemedicine may never meet with the patient in person and may
never see the patient again for a follow-up appointment.” Under the
undue burden test, we “weigh the extent of the burden against the
strength of the state’s justification in the context of each individual
statute or regulation.” Planned Parenthood Ariz., 753 F.3d at 914.
23
3. The strength of the Board’s justification of the rule. The
underpinning of the Board’s rule is that competent medical care to
promote the health of a woman seeking to terminate her pregnancy
requires a physician to do a physical examination. In its explanations for
overruling the reasons presented in opposition to the rule, the Board
said:
The Board considers a thorough medical history and
physical examination to be the cornerstone of good medical
care. On this foundation an accurate diagnosis can be made
and the most appropriate treatment plan offered to the
patient. The Board is concerned about the quality and
sufficiency of the physical examination being performed prior
to a medical abortion.
However, the weight of the record evidence indicates that a pelvic
examination prior to administering the mifepristone does not provide any
measurable gain in patient safety.
Dr. Kenney was the only actively practicing doctor who opined that
a doctor should give a patient seeking a medical termination of a
pregnancy a physical exam that includes a pelvic exam before proceeding
with the termination. 4 This opinion was contrary to the opinions of the
other board certified obstetricians and gynecologists. This opinion was
also contrary to the standards of practice developed by ACOG. In their
view, the medically necessary information a physician needs to determine
whether to proceed with a medication abortion is contained in the
patient’s history, blood work, vital signs, and ultrasound images—which
can be accessed by reviewing the patient’s records remotely or in person.
4He testified the ultrasound would not be sufficient to diagnose an ectopic
pregnancy and that a pelvic exam is also needed. All other actively practicing
physicians who testified on that issue disagreed.
24
The physician reads the ultrasound images before giving the
patient the medication. The physician uses the ultrasound images to
determine the location of the gestational sac. If the ultrasound images
are of poor quality or do not clearly show the gestational sac, the
physician does not dispense the medication to the woman. If the
gestational sac is located outside the uterus, the woman may have an
ectopic pregnancy. The physician will not dispense the medication if the
patient is experiencing an ectopic pregnancy. The physician only
dispenses the medication if the gestational sac is in the uterus.
The physician also reviews the patient’s medical history, blood
work, and vital signs. The physician reviews the history taken by the
medical provider who takes the history in-person and asks further
questions of the patient as needed. A person other than a physician
draws the patient’s blood and a lab processes it. These results are
reviewed by the physician, who can order further blood work if
necessary. Finally, the physician reviews the vital signs, which a person
other than the physician normally takes. If the doctor has any questions
regarding a patient’s vital signs, the physician can have a vital sign
retaken.
The next justification for the presence of a physician was the off-
label use of the medications by Planned Parenthood. However, studies
have shown that the off-label protocol is safer and more effective than the
FDA approved protocol for administering the drugs. The method
presently used by Planned Parenthood conforms to the present medical
standard of care for administering the drug.
An additional reason for the rule prohibiting telemedicine abortions
is that a patient may never meet face-to-face with the physician
prescribing the medication. The Board determined a face-to-face meeting
25
was important in promoting the health or interest of a woman seeking to
terminate her pregnancy. However, an increasing number of medical
procedures are being performed today by telemedicine. Studies have
shown medical termination of pregnancies can be “provided safely and
effectively by nonphysician clinicians.” Medical Management of First-
Trimester Abortion, Practice Bulletin No. 143 (Am. Coll. of Obstetricians &
Gynecologists, Wash., D.C.) Mar. 2014, at 11 (hereinafter ACOG
Bulletin). Second, studies have shown that telemedicine abortions pose
no further risk of complications to the woman than medication abortions
done with the physician present. Daniel Grossman, et al., Effectiveness
and Acceptability of Medical Abortion Provided Through Telemedicine, 118
Obstetrics & Gynecology 296, 302 (2011). 5
Based on these studies, ACOG issued a practice bulletin. A
practice bulletin is
designed to aid practitioners in making decisions about
appropriate obstetric and gynecologic care. These guidelines
should not be construed as dictating an exclusive course of
treatment or procedure. Variations in practice may be
warranted based on the needs of the individual patient,
resources, and limitations unique to the institution or type of
practice.
ACOG Bulletin at 1. The ACOG Bulletin recommends that the off-label
use of mifepristone and misoprostol are superior to the FDA protocol. Id.
at 11. In addition, the bulletin recommends that “[m]edical abortion can
be provided safely and effectively via telemedicine with a high level of
patient satisfaction; moreover, the model appears to improve access to
early abortion in areas that lack a physician health care provider.” Id. at
12.
5The record indicates there has been no increase in complications reported since
telemedicine abortions began being performed in Iowa in 2008.
26
The rule also requires the physician’s physical presence with the
woman at the time the physician provides the drug to terminate the
pregnancy. The record does not show the necessity of this part of the
rule to promote the woman’s health. In fact, when a speaker asked a
physician board member whether it was her practice to be present when
she dispensed drugs, the board member did not answer. Planned
Parenthood has a health care professional in the room when the patient
ingests the drug to make sure the patient swallows the pill.
The final part of the Board’s rule requires the physician to
schedule a follow-up visit with the woman at the same facility where the
physician dispensed the medication to confirm the termination of the
pregnancy and to evaluate the woman’s medical condition. The purpose
of the follow-up visit is to make sure the termination of the pregnancy
was complete. The record, however, established that a clinic equipped to
detect and examine women for signs of pregnancy could make this
determination.
4. The burden on a woman seeking to terminate her pregnancy.
Planned Parenthood urges that the telemedicine rule imposes a
substantial burden on a woman seeking to terminate her pregnancy
because it only has physicians at its clinics in Des Moines, Iowa City,
and Ames. This means that a woman seeking a medication abortion in
Iowa potentially would have to drive hundreds of miles. Additionally,
requiring two visits to the same clinic would cause a working mother to
potentially miss two to four days of work and incur additional childcare
expense. Planned Parenthood claims these additional costs are a
significant financial strain on low-income women and their families, and
for some individuals these costs are prohibitive. Finally, it asserts that
increased travel means a greater possibility that an abusive spouse,
27
partner, or relative could find out the woman is terminating her
pregnancy. This may cause the woman to lose the ability to make the
abortion decision privately and discretely. See Casey, 505 U.S. at 887–
98, 112 S. Ct. at 2826–31, 120 L. Ed. 2d at 721–28 (striking down a
spousal notification requirement as an undue burden because it was
“likely to prevent a significant number of women from obtaining an
abortion”).
There is no question the rule imposes some burdens that would
not otherwise exist and did not exist before the rule was adopted.
Planned Parenthood provides telemedicine abortions at clinics in
Burlington, Cedar Falls, Council Bluffs, Dubuque, the Quad Cities, and
Sioux City. Clearly, those services would end and women in those
communities would have to travel—in many cases hundreds of miles—to
obtain abortions from Planned Parenthood if the rule took final effect. 6
Even opponents did not dispute the rule would impose some
burdens on women seeking abortion services. Their contention was that
a woman who wants an abortion, even if she was indigent, would
overcome these burdens. 7
The Board has several responses to Planned Parenthood’s position
regarding burden. First, it points out that the twenty-four-hour waiting
period in Casey resulted in additional trips and therefore additional
driving, but was upheld. See id. at 885–87, 112 S. Ct. at 2825–26, 120
6After the adoption of the rule, Planned Parenthood for a period of time provided
in-person physician services in the Quad Cities and Sioux City but claims it did so at a
financial loss and ceased providing that service at those locations when it could no
longer sustain the loss.
7Planned Parenthood witnesses testified that the introduction of telemedicine
abortions has not increased the number of abortions in Iowa, but has resulted in their
occurring, on average, earlier in the pregnancy.
28
L. Ed. 2d at 720–21.8 Second, the Board relies on the following language
from Casey:
The fact that a law which serves a valid purpose, one not
designed to strike at the right itself, has the incidental effect
of making it more difficult or more expensive to procure an
abortion cannot be enough to invalidate it.
Id. at 874, 112 S. Ct. at 2819, 120 L. Ed. 2d at 712. Third, the Board
notes that in Casey, the Supreme Court upheld a requirement that a
physician provide the informed consent form to the patient. It argues
that if a physician can be required to obtain informed consent, a
physician also can be required to perform a physical exam. The Board
directs us to this passage from Casey:
The Pennsylvania statute also requires us to
reconsider the holding in [City of Akron v. Akron Center for
Reproductive Health, Inc., 462 U.S. 416, 103 S. Ct. 2481, 76
L. Ed. 2d 687 (1983)] that the State may not require that a
physician, as opposed to a qualified assistant, provide
information relevant to a woman’s informed consent. Since
there is no evidence on this record that requiring a doctor to
give the information as provided by the statute would
amount in practical terms to a substantial obstacle to a
woman seeking an abortion, we conclude that it is not an
undue burden. Our cases reflect the fact that the
Constitution gives the States broad latitude to decide that
particular functions may be performed only by licensed
professionals, even if an objective assessment might suggest
that those same tasks could be performed by others.
Id. at 884–85, 112 S. Ct. at 2824, 120 L. Ed. 2d at 719–20 (citation
omitted).
Lastly, the Board argues that undue burden should not be
determined by the decisions and circumstances of a single provider. The
rule does not mandate that Planned Parenthood close clinics. If Planned
Parenthood could deploy physicians in more communities, its clients
8The Board also notes that Iowa, unlike a majority of states, does not have a
mandatory waiting period and thus does not automatically require two visits.
29
would not have to travel as far. An additional noteworthy point is that
telemedicine abortions have existed in Iowa only since 2008 and do not
exist in the vast majority of states. Thus, as compared to the situation
before 2008 or in many other states, the Board’s rule does not have a
significant adverse effect.
5. Weighing the strength of the Board’s justification for its rule
against the burden placed on a woman seeking to terminate a pregnancy.
Consistent with United States Supreme Court precedent, we must now
weigh the health benefits of rule 653—13.10(2) through 13.10(4) against
the burdens they impose on a woman who wishes to terminate a
pregnancy. As the foregoing indicates, the record evidence showed very
limited health benefits. While undoubtedly at an abstract level everyone
would prefer to see a doctor in person every time they have a medical
issue, the reality of modern medicine is otherwise. In this case, the
record indicates the physician plays an important role in reviewing the
ultrasound images and dispensing the prescribed medications, but those
roles can be performed without the physician being personally present.
The record also provides almost no medical support for the necessity of a
pelvic exam prior to dispensing the medication. At the same time, the
record indicates that the telemedicine rule would make it more
challenging for many women who wish to exercise their constitutional
right to terminate a pregnancy in Iowa to do so.
A general concern we have with the Board’s appellate arguments is
that they are not “context-specific.” See Planned Parenthood Ariz., 753
F.3d at 914 (indicating “the undue burden test is context-specific, and . .
. both the severity of a burden and the strength of the state’s justification
can vary depending on the circumstances”). Rather, the Board argues
broadly that because travel burdens and physician presence
30
requirements were acceptable in Casey, they must be acceptable here.
But as we read Casey, it turned on the evidence and record in that case,
including a recognition that the informed consent requirement served a
“substantial government interest,” including the “psychological well-
being” of the woman. Casey, 505 U.S. at 882, 112 S. Ct. at 2823, 120 L.
Ed. 2d at 718. As we have discussed already, this record, which is based
on 2013 medical standards and practices in Iowa, reveals only minimal
medical justification for the challenged aspects of the rule.
Given the strongly held beliefs on both sides of the issue, it is not
surprising that the Board received many thoughtful comments
expressing a variety of viewpoints. While the commenters vigorously
disagree as to the extent of the burden imposed by the rule, there was
little discussion in medical terms as to how the rule was medically
necessary to protect a woman’s health. Whenever telemedicine occurs,
the physician at the remote location does not perform a physical
examination of the patient. It is difficult to avoid the conclusion that the
Board’s medical concerns about telemedicine are selectively limited to
abortion.
Most significantly, as noted above, the Board has adopted a rule
that generally approves of the use of telemedicine, recognizing the
existence of “technological advances [that] have made it possible for
licensees in one location to provide medical care to patients in another
location with or without an intervening health care provider.” Iowa
Admin. Code r. 653—13.11. The rule authorizes the use of telemedicine
in accordance with “evidence-based” guidelines and standards. Id.r. 653—11(2). As the Seventh Circuit observed in the somewhat different
circumstances presented in Van Hollen, “An issue of equal protection of
31
the laws is lurking in this case.” 738 F.3d at 790. The Board appears to
hold abortion to a different medical standard than other procedures. 9
After careful consideration, we hold that rule 653—13.10(2)
through 13.10(4) place an undue burden on a woman’s right to terminate
her pregnancy as defined by the United States Supreme Court in its
federal constitutional precedents. Because the Board agrees the Iowa
Constitution protects a woman’s right to terminate her pregnancy to the
same extent as the United States Constitution, we find the rule violates
the Iowa Constitution.
V. Disposition.
For the foregoing reasons, we find Iowa Administrative Code rule
653—13.10(2) through 13.10(4) is unconstitutional. Therefore, we
reverse that part of the district court’s judgment finding rule 653—
13.10(2) through 13.10(4) constitutional. We affirm the district court’s
judgment as to rule 653—13.10(1) and 13.10(5). We also lift our stay as
to the Board’s enforcement of rule 653—13.10(1) and 13.10(5).
AFFIRMED IN PART AND REVERSED IN PART.
Zager, J., takes no part.
9The Board’s recent rule endorsing evidence-based telemedicine in other
contexts exempt abortion. See Iowa Admin. Code r. 653—13.11(22).