Transcripts For CSPAN Supreme 20240703

States have always been responsie r licensing doctors and setting the scope of their profsial practice. Indeed, emtala works precisely cause states regulate the practice of medicine. And thg in emtala requires doctors to ignore the scope of their liced offer medical treatments that violate state ree statutory provisions make this clear. First, section 1395, the medicare actoping provision, forbids the federal government from controlling the practice of ne. Thats the role of state regulation. Secondivision f in emtala codifies a statutory prumion against preemption of state medical regulations d, third, emtalas stabilization provision is limited to available tnts, which depends on the scope of the hospital staffs medical license. Illegal treatments are not available treatments. Add in this courts own presumption against preemption ste regulations, combine that with the need for clearnd unambiguous spending clause nditions, and the administrations adg becomes wholly untenable. The administrations misreading also lacksnyimiting principle. If er doctors can perform whatever treatment they determine is appropriate, then doctors can ignore not only state abortion laws but state regulations on opioid use and informed consent requirements. That turns the presumption against preemption on its head and leavesmergency rooms unregulated under state law. Its unsurprising that crt has endorsed such an expansive view of emtala, and tidobbs, nor had hhs. Everyone understands that licensing laws limit medical actice. Thats why a nurse isn available to perform openheart surgery, no matter the need, no matter her knowledge. The answer doesnt change just because were talking about abortion. The court should reject the adminions unlimited reading of emtala and reverse the district cours judgment. I welcome the courts questions. Justice thomas normally, when we have a preemption case, theres some relationship between the parties. The federal government under emtala, or is the atin engaged in some sort of quasicontractual relationship . Mr. Tueryes, your honor. In this case, the state, idaho, for example, has no state hospitals that participa i with the Emergency Rooms in emtala. And so, in this caere isnt even a quasirelationship. The parties regulated by emtala here are hospitals and doctors. And i think your question is geing at the armstrong issue, and we think that is a significant question. It wasnt part of e estion presented. We think the indiana amicus brief raises significant questions and deals with that argument well. But the question presented here one of direct conflict between idahos law and emtala, and on that question, we dont its hard at all. And, your honors, going to that direct conflict, i think, if you consider the e limitation within the statute of availability justckson well, before we do that, can i just step back and get your understanding of the statute . You made some representations as to how you see it working. And so let me tell you what i think, and tu can tell me whether you agree, disagree, or otherwise. So i think that the two things that are plain, pretty plain, on the face of this statute. One is that emtala is about the prisn of stabilizing care for people who are experiencin emergency medical conditions statute is doing. I think the and i also think t is operating to displace the prerogatives of hospitals or states or whomever with respect to that fairly narrow slice of the healthcare universe. This idea of Emergency Medical Services is like one very mi part or small part of of the sort of overall healthcare provision of healt so what that means is that when a hospital wants to only provide stabilizing care in emergencies ople who can pay for it, for example, emtala says, no, anyone whos experiencing anlize emergency medical con, or when a hospital wants to provide stabilizing treatments to people who are experiencing only certain kinds of emergency cond, emtala says, no, heres the list of conditio you have to provide stabilizing care for those people. Similarly, if a state look, its our job to govern all of healthcare intate and we say that only certain kinds of healthcare can be given to people whoxperiencing emergency medical conditions, we donwant whatever treatment, we want only certain kinds of ent, emtala says, no, we are directing that as a matter presents with an emergencyne condition, they have assessed and the hospital must do whatever is in its capacity to sta them. Is that your understanding of the statute . Rner partially, your honor. Agree that emtala does impose a federal stabilization requirement, but the question here is what is the content of that stabilization reqrent, and for that, you have to reference state law. Justice jackson ok. Well Justice Kagan if i could just i mean, i think what you ju said is important because, when you concede that emtala impose a stabilization requirement, it is, this statute, the federal government interfering, if you will, in a states healthcare choices. So emtala is on its face a statute th ss its not all the states way. The e federal requirements here. There is a requirement to stabilize emergency patients. And you agree with that . Mr. Turner yeah, Justice Kagan, we agree that emtala emtalas purpose was narrow to bridge this gap that existed in some states Justice Kagan k. So, i mean mr. Turner and the failure to treat. Justice kaga we can just take off the table this idea that, you know, justecse its a state and its healthrethat the federal government has nothing to say about it. The federal government has pltyo say about it in this statute. W,oure right, now theres a question of whats the content of this stabilization requirement. And as far as i understood your opening remarks, you say, well, this is left to the states. But, ifm just looking at the statute, the statute tells you wh t content of the stabilization requirement is. Its to provide such medical treatment as may be necessary to assure within reonle probabilitth no material deterioration of the condition is likely to occur if the person were transferred or didnt ge care. Itells you very clearly its an objective standard. Its basically it you know, its a standard tt early has reference to accepted medical practice, not just whatever one doctor happens to in but its re is the content of the standard. You have to stabilize. Whatoethat mean . It means to provide the eaent necessary to assure within reasonable medical obability that no material deterioration occurs. Mr. Turner yeah, let me respond in two ways. First, tective standard that you set forth there in that understainis contrary to the administrations view. They say it is a totally subjective standard and whatever treatment a doctor determines is appropriate, thats Justice Kagan i think tha thats not true. I mean, i think you guys can argue about this yoursf. But, as i understand the solicitor generals brief and we s what the solicitor general says but the solicitor general says its not up to every individual doctor. This is a standard that is objective that incorporates accepted medical standards of care. Turner well, and the more fundamental point is the definition that you quoted of stabilizing care in the operative position provio in b 1 is also textually explicitly qualified bth which is within the staff and facilities available at a hospital. So then we come Justice Jackson yes. And thatwhat Justice Kagan thats quite right. Thats quite right. It saywiin the staff and facilities available at the hospital. And if you just look at that laua, i mean, its absolutely clear that thatno a ference to what state law involves. The staff and facilities available. If you donhave staff available to provide the medical care, then i guessouant provide the medical care. You dont have the facilities available to provide the medical rethen you cant provide the medical care. A transfer has to take place for e od of the patient. Mr. Turner this is a really important Justice Kagan but this is this the availabityere, because its the availability of staff and facilities. Its, y kw, do you have the right doctors . Do you have enghoctors . Do you have the right facilies or is it better for the patient to transfer them to the hospital a few miles away . Turner youre exactly right. Do you have the right door how do you answer that question except by reference to state licensing laws . Justice jackson butou absolutely cant do that. I mean, thats sort of the initial point that i was trying to make,hich is that the federal mandate is to provide stabilizing care for emergen conditions, regardless of any other directive that the state has or the hospitathat would prevent that care from being provided. Thats thats the work of the statute. Mr. Turner Justice Jackson, thats not even hhss conclusion. T state operations manual, which they proffered on pa 3 of their brief, it defines what makes a staff person available under the state,nd they say it has to Justice Sotomayor counsel, i i this whole issue Justice Jackson and does it say that theyre not available if state law doesnt doesnt allow this procedure . Mr. Rn it says they are available to the extent they are operating withinhecope of their medical license. And that is our argument. They want to now draw it far more narrow and look only at physical availabilit we agree thats a component, but theres also aeg availability component here too. Justice sotomayor counsel, the problem were having right now is that youre sort of putting preemption on its head. The whole purpose ofreption is to say that if the state passes a l tt violates federal law, the state law is no longer effective. So there is no state licensing law that would permit you permit the state to say dont treat diabetics wi iulin. Treat them only with pills, metformin. And a doctor looks at a juvenile diabet a says, without insulin, theyre going to get seriously ill and the likelihood nd i dont know what that means under idaho law, we get to that shortly bau, i dont know, this we believe this is a better treatment. Mr. Turner Justice Sotomayor federal law would say, you cant do that. Medically accepted objective medically accepted standards o re require the treatment of the medically accepted. Obligation of doctors when they have women with certain conditions that may not result in dut more than likely will result in very serious mecal conditions, including blindness for some, for others, the loss of organs, for some, chronic blood strokes, idaho is saying, unless the doctor can say in good faith that this persons death is likely, as opposed to serusllness, they cant perform the abortion. So i dont know your argument about atlicensing law because this is what this law do. It tells states, your licensing laws cant take out objective medical conditnshat could save a person from serious injury or death. Mr. Turner yeah, i think there are two crucial responses to your poi. Let me begin with the preempti subdivision f and section 1395 actually are telling hhs, the federal government, and courts just the opposite, that you dont justice sotomar o, its saying you cant preempt unless theres a direct conflict. If oecve medical care requires you to treat women who are who present theottial of serious medical complications and the aborti ithe only thing thatanrevent that, you have to do it. Mr. Turner no Justice Sotomayor idaho law sa t doctor has to determine not that theres merely a serious medical condition but at the person will die. Mr. Turner yeah. Justice sotomayor thats a huge difference, counsel. Mr. Turner your hwe agree that the there is daylight between how e ministration is reading emtala and what idahodefense of life act permits. We agree that theres a controversy here. Justice sotomayor no, no, no, no, no, theres rehan a controversy because what youre saying to us iemtala doesnt have preemptive force in not just idaho, it has aavg condition for abortions when it threatens a womans li. Mr. Turner well, wh t Justice Sotomayor but what youre saying is that no state in the nation and there are soht now that dont even have that as an exception to their tibortion laws. What you are saying is that there is no federal law on the book that prohibits any state from saying, even if a woman will die, you cant perform an abortion. Mr. Turner your honor, i know of no state that does not ina lifesaving exception. But, secondly, the government Justice Sotomayor some have been debating it at least, if i find one butoutheory of this case leads to that conclusion. Mr. Turner i think our point is that emtala doesnt address that very Justice Sotomayor does your th chief Justice Roberts could i could i hear your answer . Mr. Turner yeah. In the administrations reliance on a standard like best Clinical Evidence e national norm, i think thats very fraught bau what it really is saying is the text itselfoet address what stabilizing treatment is required. You go outside the text to professional standards that are oating out there that might change day to day, and that really boils down to a question between a conflict between what the acog says and what idaho law saysand thats not chief Justice Roberts thank you. Thank you, counsel. Justice jackson actually, can i just clarify . Because im not sure i understand. You know, sort of looking at this from a broader perspective, it seems to me that emtala says u must provide whatever treatment you have the capacity, meaning staff and ties, to provide to stabilize patients who are experiencing emergency medinditions. Cannot provide that treatment unless doing necessary to prevent a patients death to the extent therement involves abortion. Why is that not a direct conflict . You have you must in aerin situation, thats what the federal government is saying, and you cannot if it involves abortion says idaho. Mrturner i think the nurse example really highlights the reason why, because a nurse might be available. The nurse may be may even under the flat must provision in emtala, the administrations reing would say call her into action, put her into the operatin, and open the patient up. Justice jackso rht. And mr. Turner but that is not Justice Jackson and idaho Justice Kagan well, that jujackson would say no, thats still a conflict so, fine, lets say the lets say the administrations position is that nurse can do it. Are you suggesting that federal law would not take precedence, would not preempt a state law that says no, she can mr. Turner well, whether federal law could do that is a different queshan whether emtala here does do that. And i the answer is clear that it doesnt. I mean, its like the gonzales v. Ren, case where the controlled substances act, you kn, this court noted that that was the provisions ther on and and assume a medical profession being regulated by state police powers. Thats the same with emtala. Emtala is a foe statute. Congress didnt attempt to addresthstandards of care for every conceivable medical treatment in Justice Kagan it it definitely didnt address the standards of care. It did leave that to the medical community. It said, you know, the congress was notoi to address every treatment for every condio but it said you do what is needed to assure nondeterioration. So i guess the question here is, do you concede that with respect to certain medical contis, an abortion is the standard of care . Mr. Turner nouse a standard of care under idaho well, shld say, in idaho, there is a lifesaving exception for n abortions, and that is the standard of care. And the standard of care is necessarily set and determined by state Justice Kagan well, i think you have to concede that with respect to cta medical conditions abortion is the standard of care because your own ate, as interpreted by your own courts, acknowledges that when a condition gets b enough such that the womans life is in peril, then the the the docto a supposed to give abortions. Mr. Turner and Justice Kagan and the reason athats true is that with respect to certain rare but extremely obviously important conditions and circumstances, abortion is the ceed medical standard of care. Isnt that right . Mr. Turner yes, and that that was my point, that there is a lifesaving exception under idaho law. Now the question here is Justice Kagan now now the question is, is it also the cepted standard of care when, rather than the womans life being in peril, the Womans Health is in peril . So lets ta you know, all of these cesre rare, but wiinhese rare cases, theres significant number where the woman is her life inoin peril, but shes going to lose her reproductive organs, shes going to lose the ability to have children in the future, unless an aboronakes place. Now thats the category of cases in which emtala says, my gosh, of course, the abortion is necessary to assure that no material deterioration occs. And yet idaho says, sorr n abortion here. And the relts that these patients are now helicoptered out of state. Mr. Turner yeah. Your honor, the the hypothetical you raise is a ve difficult situation, ase situations, i mean, nobody is arguing that they dont raise tough medical questis at implicate deeply theological and moral questions. And idaho, like oer states, and Even Congress in emtala recognizt there are two patients to consider in those circums. And the twopatient scenario is is tough whenou have these competing interests. Justice kagan you know,ha would be a good response if federal law d t take a position on what you characterize as a toh questionbufederal law does take a position on that question. Ss that you dont have to wait until the person is on the verge of death. If the woman is going le her reproductive organs, thats engho trigger this duty on the part of the hospital to stabilize the patient. And the way to stabilize patients in these circumstances, all doctors agree. Mr. Turner and idaho law does not require that doctors wait until a patient is on the verge of death. The no imminency requirement. There is no medical certainty requirement. Thats Justice Sotomayor im sorry, answerollowing question, and these are hypotheticals that are true. Hold on one second, d you can tell me whether idahos exception and we still go back to the point that even if idaho w lly complies with federal law you he pregnant women woman who is early into her sontrimester at 16 wes,oes to the er because she felt a gush of fluid leave her body. She was diagnosed with pprom. The doctors belie at a medical intervention to terminate her pregnancy is needed to reduce theea medical possibility of experiencing ssiand uncontrolled hemorrhage from the broken sac. This is a story of a real woman. Shwas discharged in florida because the fetus still ha fetal tones and the hospital said shes not likely to die, but there are going to be serious medical complications. The doctors errefused to treat her because they couldnt say she would e. She wahoified, went home. Thne day, she bled. She passed out. Ankfully taken to the hospital. There, she receid abortion because she was about to die. Mr. Turn ah. Justice sotomayor what you are lling us, is that a case in which idaho, the day before, would have said its ok to have an abortion . Mr. Turner deidahos lifesaving exception, a doctor could in good faith if the doctor could in goodfaith medical judgment determine Justice Sotomayor no. Im asking you. E florida doctor said, i cant say shes going to die. Mr. Turner yeah. And, your honor, my point is that justicsotomayor if your doctor says, i cant, with a medical certainty,hes going to die, but i do know ss going to bleed to death if we dont have an abortion, but es not bleeding yet, so im not sure. Mr. Turner the doctor doesnt need to have medical certainty. Justice sotomayor counsel, answer yes or no. He doesnt have he doesnt cannot say that theres likely death. He can say there is likelyo be a very serious medical condition mr. Turner yeah. Justice sotomayor ke hysterectomy. Let me go to ath one. Imagine a patient who goes to the er with pprom 14 weeks. Again, aboiois the excepted. Shes up she was in and out of tpital up to 27 weeks. This particular patient, they tried had to deliver her baby. The baby died. She had a hysterectomy, and she can noonr have children. All right . Youre telling me the doctor there couldnt have done the abortion earlier . Mr. Turner again, it goes back to whether a docr n in goodfaith medical judgment make Justice Sotomayor thats a lot for the doctor to risk when mr. Turner well, i think its protective Justice Sotomayor when idaho law changed me the issue whether shes going to die or not orheer shes going to have a serious medical con. Theres a big daylight by your standards, corre mr. Turner it is very case by case. The examples, the prong Justice Sotomayor thats the problem, isnt it . Justice barrett counsel, im kind oked tually because i thought your own expert had said belowthese kinds of cases were covered. Mr. Turner yeah. Justice barrett and youre now saying theyre not . Mr. Turner no, im not saying that. Thats just my point, your honor, is that hedging. Barrett well, youre i mean, Justice Sotomayor is asking you would thiovered or not, and it was my understanding that the legislatures witnesses said that these wou be covered. Mr. Turner yeah, and those doctors said, if they exercising their medical judgment, they could in good faith determine that lifesaving care was necessary. And thats my point. This is a subjective standard. Justice barrett but some doctors couldnt, is some doctors might reacntrary conclusion, i think is what Justice Sotomayor is asking you. Mr. Turner and and let me Justice Barrett if they reached if they reached the conclusion that the legislatures doctors did, would they be prosecuted under idaho law . Mr. Turner no. No. If they if they reached the conclusion that the dr. Reynolds, dr. White did, that ese were lifesaving Justice Barrett what if t prosecutor thought differently . What if the prosecutor thought, well, i dont think any gofaith doctor could draw that conclusion, im going to put on my expe . Mr. Turner and that, your hono ithe nature of prosecutorial discretion, and it may result in a a case that require ste barrett does idaho put out any kind of guidance . You know, hhs puts out guidance out whats covered by the law and whats not. Does idaho . Mr. Turner there are regulations. Dapa has some regulations. But i think the the guiding star herhe planned parenthood v. Wasden case, which is lgthy, detailed treatment by the Idaho Supreme Court of this law, and it made clear, the court made clear, that there is no medical certainty requiremt. You do not have to wait for the th to be facing death. Justice jackson counsel, i dont chief Justice Roberts thank you, counsel. Is there hapns if a dispute arises with respect to whether or not the doctor was within the confines of idaho law or wasnt . Is the doctor subjected to vi by a medical authority . Exactly how is that evaluate because its an obvious concern. If if if you have an individual excti for a doctor, and were having a debate about is that covered by your submission that nothing in idaho law prohibits complying with emtala, i mean, who who makes the decision whether or not somethings within or without . Mr. Turner so, i mean, i i imagine there are twwa the law can be enforced or at least two. The board of medicine has licensing oversight over a doct d the Idaho Supreme Court made clear that that doctors dical judgment is not going to be judged based on an objective standard, what a reaso doctor would do. Thats not the standard. The seco w would be if a chief Justice Roberts well, what what is the standard . Mr. Turn the doctors which is subjective. Udgment, chief Justice Roberts and its subject to review by any medical board if therea complaint against the doctor that mr. Turner yeah. Chief Justice Roberts his standards nt comply . Lets say hes the only doctor at the plar emergency room, and he has his own particular standard. Mr. Turner whatat the Idaho Supreme Court has said is that you may consider another doctors opinion only oth question of was it a pretextual medical judgment, not a goodfaith one. Chief Justice Roberts thank you. Justice thomas . Justice alito . Justice alito well, i would thinth the concept of goodfaith medical judgment must kento account some objective standards, but it would leave a certain amount of leeway for an individual doctor. That was h interpreted what the what the state supreme urt said. Now you have been presented here today with very quick summaries of cases and asked to provide a snap judgment about what would be appropriate in those particular cesand, honestly, i thinyve hardly been given an opportunity to answer some of thhytheticals. But would you agree with me that if a medical doctor, whos expert in this fieldwe asked bang, bang, bang, what would you do in these particular circumstances which i am now gointonumerate, the doctor would say wait, i dont hi is not how i practice medicine. I need to know a lot more abt the individual case. Would you agree with that . Mr. Turner absolutely. And acogasyou know, in the case of prom, for example, acog t just kneejerk stay an abortion is the standard of care. Acog itself says that expectant management is oftentimeshe appropriate standard of care. And so these are difficult question turn on the facts that are on the ground between thor as he is assessing them with his medical judgment that hes bringing to bear but is also necessarily constrained by idaho law. Just like everr area of the practice of medicine, state law confines doctoment in some ways. Justice alito thank you. Chief Justice Roberts justice toyor . Justice sotomayor there is a difference between stabiling person who presents a serious mecal condition requiring stabilization than a person o presents with a conditn, quoting idahos words, where eris a poses a great risk of death to the pregnant woman. You agree theredaylight between the two . Mr. Turner aee, and i think this is most Justice Sotomayor and so there will be some women who present serious medical condition that the federal law would requirto be treated who will not be mr. Turner no, i disagree with that. Idaho hospits e treating these women. re not treating these women with Justice Sotomayor stop. Mr. Turner abortions necessarily, your hor,nd thats an important point. Juicsotomayor and thats my point. Just answer thpot, which is they will present with a serious medical condition that doctors in good faith cant y ll present death but will present potential loss of life. Those doctors pential loss of an organ or serious medical complications for the woman. They cant perform those abortions . Mrtuer yeah. Your honor, if that hypothetic exists, and i dont know of a a condition that is so cta to result in the loss of an organ but also so certain not to transpire with death. If that coitn exists, yes, idaho law does say that abortions in that case arent allowed. I think Justice Sotomayor all right. That let me stop u ere because all of your legal theories rely on us holding that federal law doesnt require cannot preempt state law on these issues and so, when i asked you the quti if a state defines likelihood of death more stringently than ida ds, you would say theres no federal law that would prohibit them from doing that . Mr. Turner well, i would say that emtala does not contain a standard of Justice Sotomayor so there is no no standard of care. Inour briefing, you make the sgs position here, a y almost argue that now, that that their position that federal law requires stabilizing treatment and not equal eaent of patients, which was a position you took in your brief, you seem to have backed off from it here, you seemo agree that federal law requires some stabilizing conditi whether or not you provide it to other patients. But i have countless briefs that say that bh that hhs has filed that predobbs, pre2009, this is not an unprecedented position, aths in countless situations cited hospitals for discharging paents who required an abortion as a stabilizing trtmt. Congress discussed that piin the Affordable Care act and explicitly said thatng in the Affordable Care act shall be construed to rie any Healthcare Provider from providing ncy services as requedy state or federal law. Medical providers have told us that for decades the understood both federal law and state law to require abortions as stabilizing conditions for people presenting serious medical risk. Lower courts, theres at least cas lower courts saying you have to provide abortion. So this is not a postdobbs unprecedented position by the goveme. Mr. Turner it absolutely is. The otnote 2, the administration cites to two spreadsheets that ntn 115,000 rows of enforcement ins. The administration Justice Sotomayor counsel mr. Turner has not identified a single instance justice toyor counsel, predobbs, this wasnt much of a questi but there is hhs guidance and theres at least three cases in which it was invoked. The fact that we didnt have to that hhs didnt have to i much borpredobbs doesnt make their position mr. Turner my point is more Justice Sotomayor unpreceden mr. Turner my point is more ndamental, your honor. Its not just that there are few stces. There are no instances. And not just on the issue of abortion. On any instae ere hhs has come in and told a hospital you have to provide a treatment that is contrary to state law. And this isnt just about abortion. Consider opioids. Justice sotomayor oh, now were back to that. Ok. Thank you. Chief Justice Roberts Justice Kagan . Justice kagan mr. Turner, practicing medicine is hard, but erare standards of care, arent there . Mr. Turner ye tre are. Justice kagan and one of those standards of care with respect to abortion is that in certain tragic circumstances, as you urself, as your own states law acknowledges, where a womans life is pil and abortion is the appropriate standard of care, isnt that right . Rner thats right. Justice kagan and emtala goes further. It says athe appropriate standard of care cant only be abouprecting a womans life. Ao has to be about protecting a Womans Health. Thats what emtala says, doesnt it mr. Turner no, it doesnt. It defines emergency medical condition with a broader set of triggering conditions, but the the key question here is what is the sbization requirement, and that is qualified by the availability term. Justice kagan the the stabilization requirement is is written in terms of making sure that a transfer wldot result in a material deterioration as to the emergency condition. Nothing about has to be at deaths or, right . Mr. Turner i think thats right, yeah. Justice kagan and there is a standard of care with respect that on abortions too, right . If a woman is going to lose her reproductive oanunless she has an abortion, which happens in certain tragic circumstances, a doctor is supposed to provide an abortn,snt that right . Mr. Turner emtala doesnt contain any standard of care. I dont know where the administration is drawing Justice Kagan do you do you diute that theres a medical standard of care that when a woman is about to lose her reproductive organs unless she has an abortion, that that doctors would not sath an abortion is the appropriate standard of care in that situation . Mr. Turner your honor, what i spe is that theres a National Uniform standard of care thaires a topdown approach in all states. Idaho has set its own standard of care, and it has drawn the line on a difficult question and its inconceivable to me to think that congress attempteto answer this very fraught complicated question in a fourpage in four pages of the u. S. Code. It did not Justice Kagan Congress Said as to any conti in the world, if an emergency patient comes in, yre supposed to provide the Emergency Care that will ensure that that patient does nosee a material deterioration in their health. Mrturner and always within the stice kagan thats what Congress Said. And the abortion exceptionalism here is on the part of the state saying were going to accept that with respt every other condition but not with respect to abortion mr. Turner abortion isnt exceptional. Justice kagan where we will not colyith the standard of care that doctors have accepted. Mrer your honor, abortion isnt exceptional. Ere are numerous cases where states intervene and say the standard of care in th circumstance for this condition is x, not y. Opioids, for examp. In new jersey, a doctor cannot stabilize chronic pain with more than a fivdasupply of opioids. In pennsa, it can be seven. In other states, tres no limit. Their reading of emtala requir that those limitations get out and you impose a National Standard. There are numerous other instances wheres are coming in and saying, in our state, the practice of medicine must conform to this standar and idaho has done that with abortion. Its doneth opioids. Its done it with marijuana use. There are countless examples, your honor. Justice kagan and your thry although the Supreme Court has narrowed the reach of your statute, your theory wldpply even if it hadnt . I mean, it would app t ectopic pregnancies. It would apply even if there were not a dthxception. I mean, all of your theory would apply mter what, really, idaho did, wouldnt it . The answer is emtala doesntink speak to that, but there are other background principles and limitations ke rationale basis review, justice rehnquist, the chief justice recognized juste gan but your theory of emtala is that emtala prmp none of it . That a state tomorrow could y even if death is around the rner, a state tomorrow could say even if theres an ectopic pregnancy, that still thats a thats a a choice of the state and emtala has nothing to say about that . Mr. Rn yeah. And that understanding is a humble one with respect lism rule of states. Its the primary care providers for their citizens, not e federal government. Justice kagan imabe too humble for womens health, you know . Ok. Thank you. Chief Justice Roberts Justice Gorsuch . Justice gorsuch i just wanted tonderstand some of your responses or efforts to respond to some of the questions that weve heard tay as i read urriefs, you thought idaho thinks that in cases of molar and ectopic pregnancies, for example, that that an abortion is acptle. Mr. Turner correct, your hono Justice Gorsuch and the example of someone who isnt immediately going to die but may at some point in the future, that that would be acceptable . Mr. Turner it goes back to the goodfaith medical standard, but, yes, ifoctor should determine cannot determine in good faith that death is going to afflict that woman, then no Justice Gorsuch so it doesnt matter whether it happens tomorrow or next week or mth from now . Mr. Turner there is no immirequirement. This whole notion of delayed care is just not consistent with the Idaho Supreme Courts reading of the statute and what the statute says. Justice gorsuch and the good faith, as i read the Idaho Supreme Court opinion, that that controls . Thats the end of it . Mr. Turnerablutely, it is. Justice gorsuch all right. And then what do we do with emtalas definition of individlo include both the maand, as the statute says, the unborn child . Mr. Turner yeah. Its you knowre not prohibits abortions. That emtala so, for example, in california, stabilizeatment may involve abortions consistent with what that state law allows its cts to perform. But i think our point with unborn child amendme i1989 is that it would be a very strange thing for congress to expressly enemtala to requir for unborn en, and its not just when the child when the mothers experiencing active labor. The definition of emergency medical condition requires care when the child itself haan emergency medical condition regardless of whats going on and so it would be a strange thing for congress to have regard for the unborn child and yet also be mandating termination of unborn children. Justice gouch thank you. Chief Justice Roberts Justice Kavanaugh . Justice kavanaugh i just want to focus on the actual dispu as it exists now, toda bween the governments view of emtala and idaho law, because idaho law has changed since the time of e strict courts injunction both with the Idaho Supreme Court and with a clarifying change by the idaho legislature. You say in your reply brief, and so too the the moyle rey brief says, that for each of the condio identified by the citor general where, under their view of emtala, an abortion must be availleyou say in the replyri that idaho w,n fact, allows an abortion in each of those circumstances, and you go through them on pages 8 and 9 of the reply brief, each of the conditions. There any condition that youre aref where the solicitor general says emtala requires that an abortion be available in an emergency circumstance where idaho law, as currently stated, does not . Mrturner so, certainly, the administration maintains tt there is such conditions. The ones they identify in the affidavits Justice Kavanaugh what is your wt your view . Mr. Turner d view is that yes and im going to reference footnote 5 from the gray bef the Mental Health condition situation. Thadministration says thats not on the table. Thats not a scenar wre abortion is the only stabilizing care required. And im not sure where that construct ofnlstabilizing care comes from because, under thr view, its the doctors determination that controls, not this imposed only requirement. But be that as it may, the American Psychiatric association and sim taking general prelogar up on her oern footnote 5 that there are no professional organizations that set abortion as a anrd of care. The american psyiaic association, in a 2023 position paper, says that abortions are imperative for mental al conditions. That sounds like a necessity to me. And i dont know how, if a woman presents at seven months pregnant in an idaho emergency room and says, iexriencing severe depressio this pregnancy, im having Suicidal Ideation from carrying t pregnancy forth, that that wouldnt under the admisttions reading be the only stabilizing care. Justice kavanaugh so you think the ninth circuipal, when it said every circumstance describebyhe administrations declaratns involved lifethreatening circumstances under which idaho law would allow an abortion, is what the ninth circuit pan said . Mr. Turner we agree with that because the conditions identified in the affidavits were all conditions that would fit under the lifesaving exceptio thats telling because, you know, these doctors, when put under oath in an aff, couldnt come up with any of these harrowing circumstances. Th intified other ones. But i think what the governmen doesnt want to talk about, again, is the Mental Health exception here. That is i jt nt know how you can read their understanding of Justice Kavanaugh well, im just tryg figure out is there really a other than the ntal health, which we havent had a lot of briefing about, is there any other condition identified by the solicitor gewhere you think idaho lawould not allow a physician in his or her goodfaith judgment to perform an emergency abortion . Mr. Turnernoin their affidavits. They mntn nonetheless that when you compare the definition of what an emergency medical condition is, it is broader than the definition of the lifesaving exception in idaho law. And so they present this Justice Kavanaugh well, thats what they they say, but then, when we get down to the actual conditions that e sted, the examples and Justice Sotomayor ing through some of those you have said in your brief at least that each of the conditions identified by the government, actually, idaho law allows an emergency abortion. Mr. Turner and age, and i think the injunction here is also Justice Kavanaugh well, whats whado that mean for what were deciding here . Mr. Tuwell, what it means for idaho justice kanah if idaho if idaho law allows an abortion in each of the emergency circumstances that is identified by the government as emtala mandating that it be allowed . I mean, the real practical First Response is that idas under an injunction that includes an incredibly broadrement that preempts state law Justice Kavanaugh right. I nderstand that. And that may mean that there shouldnt be an injunction. I take your point on that. Whats your second . Mr. Turner my second point, honor, is i dont know how this court can make the determination on wheerhere are any realworld cons without first answering the statutory interpretation question of whatmtas stabilization requirement actually requires. That has to be addressed, and it has to be addressed not only because thats for the direct Justice Kavanaugh well, i was just picking up onoureply brief. Youre the one who sd in your reply brief mr. Turner yeah. Justice kavanaugh that theres actually no no real ight here in terms of the conditions. So im just picking up on what you all you all said. Mr. Turner yeah. I understand, your honor. Justice kavanaugh thank you. Chief Justice Roberts Justice Barrett . Justice barrett i guess i dont really understand why we have to adthe stabilizing condition if what you say is that nobody has been able to tify a conflict. And on the Mental Health thing, the sg says i just picked it up to chotnote 5 idaho badly errs in asserting that construing emtala accordg its terms would turn emergency s into federal abortion enclaves by allowing pre termination for Mental Health concerns. So, if thats the only space that you can idewhere idaho would preclude an abortion and emtala would require one, and the government is saying no, thats not so, whats the conflict . Mr. Rn well, your honor, i mean, of course, we think we win whether you find no factual conflict and, therefore, the injunction had to go away. Justice barrett but why . Why are you here . I mean, you know, the government says say mr. Turner well, they sued us, your honor. Justice barrett well, hold on a second. Ure here because theres an injunction precluding you from enforcing your law. Anifour law can fully operate because emtala doesn idahos authority to enforce its law, whats mr. Turner well, it cant under the injunction because injunction says that idahos law is preempted in an incredibly broad range ofmstances to avoid Justice Barrett as as it conflicts with emtala, i ought. Mr. Turner it it it is much broader than that. And this was based on the proffered injunction by the adration to avoid an emergency medical condition, not in the face of an emergency so what that means is idahos law cant even operate when a doctor determines that a conditiot need to be avoided that hasnt yet presented itself. Thats far broader than the emergency medical condition an stabilization requirement under emtala because the stabilizaon requirement under emtala is only triggered when there has b determination that Justice Barrett ok. Well, i i would like to hear the solicitor generals respon to that. But let me just ask you one oting about the Mental Health consideration because i can i cerstand idahos point that a Mental Health exception would be far broader daho law and had the potential to expand the beyond what idaho law permits. But the stabiln requirement only exists up until transfer, right, until transfer is possible . Ss hard for me to see how, with a Mental Health condition, that couldnt be stabilized before needing to transfer, ght . At that point, the idaho youre stable, youre noture immediately going to be suicidal, well leave you in the care of, you know, a parent or a partner who will then seek appropriate ent. Mr. Turner well, that flexible view of stabilization iser different than the governments very rigid view of stabilization, which is, if an emergency medical condition lls for an abortion, its got to be provided right therend then if its available in this very limited sense. And so the stabilization continuum that youre talking about, i agree, thats built into emtala because Justice Barrett the statute says until transfer is possible. Mr. Turner well, the the trsfer provision kicks in if a hospital is unable to stabile a condition. And so, if a patient pses at a hospital and that hospital has the capability, the availability to stabilize the condition, in the case of health, i invite general prelogar to come up here and tell you that ive got it all wrong and that, you know, the mother that i ded would not need to receive stabilization in that circumstance and instead would be transferred to a pshiric hospital or something and that wouldnt nstitute dumping under their reading. I just dot see how that comports with everything theyve said about the rigid view of stabilization that if a condition calls and a hospital can do it, its got to be done there and then. Justice barrett does idaho have for doctors under state law . Tion mr. Turner it does. And there are federal conscience protections as well. And i think thats key point here, your honor. The administration told this court in the fda case that individual doctors are never required to perform an abortion from what i could tell, but that dont extend to hospitals. And so, in the case of catho hospitals, and there are hundreds of them treating millions of patients every year, under the administrations reading, catholic hospitals who faithfully adhere to the ethical and religious directives are now required to perform abortions. Justice barrett is that because no federal conscience exemption applies . Mr. Turner i dont know why they say thats the line that they draw between indidu doctors and religious institutions because coatssnowe on its face seems to cover both. Justice barret ok. Thank you. Chief Justice Roberts Justice Jackson . Ice jackson im really surprised to hear you say that idaho law permits everything that the federal law requires. Understand that because it seems to me that if thats the case, then why coult Emergency Room Physicians iido just ignore idaho law and follow the federal standard . I me if if the state is doing exactly what the what the federal law says is quired, if its ok by idaho, then, fine, we set idaho ade we do what the federal law says and we all go home. Mr. Turner well, i mean, our reading, of course, is that there is no conflict. And so as doctors arent having to make this choice of do i follow emtala or do i follow Justice Jackson so your reprention on the on behalf of idaho is that if a an emergency room physicia idaho follows emta iterms of when an abortion is required to stabilize a patient, they will be complying with idaho law such that theres going to be no prosecution and no problem . Mr. Turner yes, because they have to complyidaho law to comp wh emtala. Justice jackson no, no. Im asking you, if they if they comply with emtala, will they necessarily htisfied the requirements of idaho law . Because thats what you seemed to say ionse to Justice Kavanaugh and in response to Justice Barrett. So i just want to make clear if thats the position o state. Mr. Turner emtala the scope of emtalas stabilization requirement is necessari determined by idaho law in this case. So Justice Jackson no. Youre sin if they follow idaho law, then they will be following emtala law. Mr. Turn ll, i Justice Jackson id like for you to id like for you to mr. Turner ihi its both, your honor. Justice jackson no, its id like for you to entertain other possibility. You seem to be sayinevy situation inhi the united stats heres a stabilization situation that the United States would say the person has to have an abortion, thphysicians would say were following emtala and abortion is required, i thought you said in response to Justice Kavanaugh, yes, idaho law would also say thats a situation in which an abortion is allowed. If thats the case, then it seems to mthe is no daylight, theres no conflict, as yve said, but its because idaho law is in full complnc saying. At the federal law is were gettingt ong, youre saying. Like this death thing, thats not what we mean. What we mean is whenever its necessary bilize a patient who is experiencing deterioration, as federal law requires. Mr. Turner no. I i i think i understand the point that youre making. And the best wt i can think of it, your honor, is that emtalas stabilization judgment to determine what is the appropriate stabilizing treatment, right . And how does a doctor exercise medical judgment . Well, his training, his ence, perhaps reference to professional standards of care that are national, but Justice Jackson how about how about mr. Turner necessarily state law standas well. Justice jackson how about thats not justhing youre sort of coming up with. I mean, as jusagan said at the beginning, emtala tells the doctor hos supposed to decide it in this particular circumstance with reference to e dical standards of care deteriorating in an emergency condition situatio mr. Turner yeah, emtala justice jacko, if thats the standard in emtala, are you representing that that is exacat idaho is saying so that all the doctors need to do is follow emtala and theyll be fine under idaho law . Mr. Turner well, of c were saying that idaho doctors need to comply with emtala. The question is how do doctors comply with emtala, and emtala Justice Jackson let me ask you let me i i think i understand your point. re saying idaho is actually could actually be requiring more and the federal law has to make them do what idaho says. Mr. Turner well, and its impothat Justice Jackson yeah. Mr. Turner ala itself, it codifies this presumption of a backdrop of state law. There are background principles here, and thats wh Justice Jackson all right. Let me explore that with you for just a second. I i had thought that this case was about preemption and that the entirety of preemption jurisprudence is the notion that the federal government in certain circumstcan make policy pronents that differ from what the state may want or what ody else may want, and the supremacy clause says that the federal government says takes precedent. So youve been saying over and over again ida i you know, a state and we have healthcare policy choices and wve made weve set a standard of care in this situaon all thats true. But the question is to what exnt can the federal government say no, in this situation, ourard is going to apply . Mr. Turner and Justice Jackson thas what the government is saying, and i dont undersow, consistent with our preemption jurisprudence,ouan be saying otherwise. Mr. Turner yeah, if i can put a finer point on it. I dont think its the qu is necessarily what can congress do but what did congress do ith emtala, and Justice Jackson all right. What did it do here . Mr. Turner yeah. It started, it opened the medicare act by saying the federal government not control the practice of medicine. And then, in emtala itself, it says laws are not preempted. And then, when it and then, when you get to Justice Jackson state laws ar not preempted to the extent mr. Turner of a direct Justice Jackson or are only preempted to the extent of a direct conflict. And so now we are we are identifying a direct conflict. So why is preemption not working there . Mr. Turner and and whether theres a direct conflicd on this courts longstanding precedent includes clear statement canons that we think wen the text. Let me be very clear. The text to us is very clear, itan easy question. But the governments got to come oe a lot of other hurdles, one being justicson i hear you saying two things, that were thes not a direct conflict because everything we the federal government requires, we allow, which the amici, ians for human rights, who have looked at idahos laan says it prevents a lot of things in circumstances in which th federal government would require them, they disagree with y o the facts, but, anyway, you say no conflt cause we actually are doing exactly whor allowing exactly wt e federal government allows. And you say no conflict because the federal government in this situation wanted the states to be able to set the standards. And i i dont understand how thats even conceivable, given this standard, given this statute mr. Turner yeah. Justice jackson that is coming in to displace state prerogatives. Mr. Turner and if i cant convince you on the second, let me add a third. Justice jackson yes, please. Mr. Turner and there the clear statement canon. Sohepending clause condition nature of this requires congress to speak clearly and unequivocally that it is imposing a abortion mandate. It thats not here in e statute. And, secondly, this courts presumption Justice Jackson but doesn that make abortion different . I mean, what do you mean . They say provide whatever is necessary to stabilize. So youre saying theyd have to say provatever is necessary, including abortion . Thats the only way that is taken account of here . Mr. Turner no, what im saying is, when we when we go d look at the phrase available and what it means, the government the adniration is saying, well, theyre adding this tag that saysstent with state law. And were saying no, under the clear statement no its a presumption against preemption. And what ternment actually what congress would need to do if it wanted to preempt this very traal area of state law is to put a tag regardless of sta, and that is missing. Justice jackson thank you chief Justice Roberts thank you, counsel. General prelogar. General prelogar mr. Chief justice, and may it please the court emtalas promise is simp b profound. O who comes to an emergency room in need of urgent treatnt shld be denied necessary stabilizing care. This case is about how that guarantee applies to pregnant women in medical crisis. In some tragic cases, women suffer emergcyomplications that make continuing their pregnanca ave threat to their lives or their health. A womawhe amniotic sac has ruptured prematurely, for expl needs immediate treatment to avoid a serious risk of infection that could cascade into sepsis and e sk of hysterectomy. A woman with severe preeclampsia can face a high risk of kidney failure thatou require lifelong dialysis. In cases like these, where there is no other way to stabilize the womans medical condition d prevent her from deteriorating, emtalas plain text reqre that she be offered pregnancy termination as the necessary treatment. And thats how this law has been understood andpped for decades. That usually poses no conflict with state law. Even states that have sharply restricted access to abortion after bbgenerally allow exceptions to safeguard the but idaho makes ternaon a felony punishable by years of imprisonme uess its necessary to prevent the womans death. I think i understood my friend today to acknowledge several times that there is daylight between thattaard and the necessary stabilizing treatment at emtala would require. And the Idaho Supreme Court recognized the same thing when itpecifically contrasted the necessary to prevent deat exception and said it was materially narrower than a prior idaho law th h a health exception that tracked emtala. The situation on the ground in idahishowing the devastating consequences of that gap. Today, doctors in idaho and e men in idaho are in an impossible position. If a woman comes to an emergency room facing a grave threat to her health, but shit yet facing death, doctors either have to latreatment and allow her condition to material tmaterially deteriorate, or theyre airlifting her out of the statsohe can get the Emergency Care that she needs. One Hospital System in idaho says that right nois having to transfer pregnant women in medical crisis out of the state about once every other week. Thas untenable, and emtala does not countenance it. None of petions interpretations fit with the te, and so they have tried to make this case be abouth broader debate for access to abortion in cases of unwanted pregnc t thats not what this case is about at all. Idahos ban on abortion is enforceable in virtually all of its applications, but in the narrow circumstances involving grave medical emergencies, idaho cannot criminalize t eential care that emtala requires. I welcome the courts questions. Justice thomas general, are you aware of any other spending clause legislation that preempts criminal law . General prelogar with respect to criminal law in particular, justice thomas, im not immediately thinking of relevant cases. We have a whole string cite of cases in our brief at page 46 at reflect times where the court has recognized the preemptive force of spending clause legislation, including in situations whe t funding restrictions apply to private parties, so that could include the Coventry Health case, for example. Leaddeadwood is another example ts. But im not immediately recalling how that would app in criminal law. Of course, this court hast drawn those kinds of distinctions in recog the force of the supremacy clause. Justice thomas now the normwhen we have a a preemption case, its a guted party who is involved in the suit, and they use it as an affirmative defense example, in wyeth or something. On the in this case, you are bringing an acongainst the state, and the states not regulated. Are there otheexples of these types of suits . Geraprelogar sure. I mean, there are numero examples where the United States has sought to protect its sovereign tests in situations where a state has done what idaho has done here and interposed a law that colicts. So id point to arizona versus United States as an example of that. United states vers whington. There are a number of cases where this crtas recognized that the federal government can protect its terests in this kindf eemption action. And, as i mentioned before, th court has a long line of cases recognizing that that prmpon principle applies in the context of federal funding restrictions that apply to private parties too. Justice thomas but even when the rtthat youre bringing the action against is not a guted party . General prelogar that correct, because what idaho has done here is directly interfered with the ability of the regulated parties who have taken these funds, federal funds with conditionstthed, from being able to comply with the federal law that governs their behavior. And this was an essential part of the bargain that the federal government struck with hosta in substantially investing in their Hospital Systems. And what the state has done is said you, through our operation ofta law, are no longer permitted to comply with this fundamental stabilization requirenin emtala in this narrow category of cases. Justice thomas well, normally, wouldnt it be the regulated party that would actually be asserting the preemption that youre talking about . General prelogar certainly, i can imagine situations, for ample, where a regulated party woulasrt a preemption defense and to say the state law itself is preempted to the tent that it prevents that party from being able toomy with federal law. But im not aware a principle or precedent in this courts case lawggest that thats the only way for the government to protect its sovereign interests. Justicthas that is the normal way, though . General prelari think that thats often the fact pattern of particul ces. Justice alito i dont derstand how your argument about preemption here squares wi t theory of spending clause of congresss spdi clause power. The theory is congress c tl a state or any other entity or person, look, hers some money or other thing of value, and if you want to acptt, fine, then you have to accept certain conditions. But how does the congresss ability to do that authorize it to impose duties on another pay at has not agreed to accept this money . General prelogar there areo duties being imposed on idaho re its not required to provide emergency stabilizing treaen itself. The duties are are Justice Alito well, all right. General prelogar applied to thhoital. Justice alito not not duties. How can you impose restrictions on what idaho can criminalize simply because hospitals in idaho have chosen to participate in medicare . I dont understand how this sqrewith the whole theory of the spending clause. Genel elogar well, i think that it squares with this cots long line of precedents cited at Justice Alito wel general prelogar page 46 of our brief Justice Alito well, i ive ive looked at them. Geraprelogar that the court has recognized that Justice Alito ive looked at those cases. I havent found any square discussion of this particular issue. But i im interested in the theory. Can you just explain how it works in theory . Generalregar sure. So spending clause legislation is fedalaw. Its passed by both houses of congress. Its signed by the president. It qualifies as law within the meaning of the supremacy clae, and Justice Alito absolutely. Solutely. General prelogar and and so i think the supremy ause dictates the relevant principle here ste alito no, but what the law general prelogar that in a suaon where Justice Alito ill let you finish. Yes, go ahead. General prelarin a situation where congress has enacted law, it has full force and effect under the supremacy clause, an what a state cant do is interpose its own law as a rect obstacle to being able to fulfill the federal funding coitns. And this theory, Justice Alito Justice Alito no, its is a general prelogar would mean no conditions Justice Alito its a question general prelogar under medicare are enforceable. Justice alito s no. Theyre absolutely enforceable against the hospital that chooses ticipate. General prelogar well, i guess the the argument then would be that if a hospital is instead und by the state law and the state law gets to control, it would mean that hospitals couldnt participate in medice at all. And thats not the argument that e ates making here. What it wants is for its hospitals to bab to accept medicare funding but not have to face the resicons that are attached to those funds as an essential part of e rgain. And there is no precento support that outcome. Justice alit wl, i i i just dont think i dont understa h how the theory works. But let me move on to something else. Let im going to try to restate ureneral theory, and i want you to tell me if this is right. I think your argument is, if a woman go tan emergency room and she has a condition that requires an abortion in order to eliminate serious jeopardy to her health, the hospital must perform the abortion or transf the woman to another hospital where that can be ne is that a fair statement of your argument . Genel elogar so it includes not just serious jeopardy to her health but, obviously, also serious dysfunction h bodily Justice Alito right. Righ general prelogar organs or a serious impairme oa bodily function. Justice alito right. General prelogar and the other caveat would make is that it would it would require pregnancy termination only in a circumstance where thats the only possible way to stabilize her and prevent atascade of health conseens. Justice alito does this apply at any point in pregnancy . General prelogar so the pregnancy complications that we have focused on genelloccur in early pregnancy, often before the point of viability there can be complications that happen after viabili, t there, the standard of care is to deliver the baby if you need the pregnancy toecause its causing these Severe Health consequences for the mom. Justice alit well, what if it what if it occurs at a point where delivering the baby is not an optn . Youre out of the third trimester, but its really not anption to deliver the baby. General prelogar you said that youre in the Justice Alito out of the first trimester. General prelogar third trimester . Justice alito no. Im sorry. Out of the first tmeer. General prelogar so, if youre contemplating a situation where delivery is not an option, then i think, in that circumstance, if the only way to prevent grave ri to the Womans Health or life is for the pregnancy to end antermination is the only option, then, yes, thats the required care that emtala has through its stabilization mandate. But, critically, in in many of these cases Justice Alito ok. Th that general prelogar the very same pregnancy compcaon means the fetus cant survive regardless. Justice alito i i understand that. General prelogar thes not going to be any way to sustain that prean. Justice alito let me ask you squarely the queiothat was discussed during mr. Turners arment. Does the term health in emtala mean just physalealth, or does it also include Mental Health . General prelogar there can be grave Mental Health emergencs, but emtala could never require pregnancy termination as the stabilizing care. Ste alito why . General prelogar and heres why. s because that wouldnt do anything to address the deying brain chemistry issue thats causing the t mtal Health Emergency in the first place. This is not about Mental Health generally. Iss about treatment by er doctors in an emergency room. And wh aoman comes in with some grave Mental Health emergency, if she has happens to be pregnant, it would be incredibly unethical to terminate her pregnancy. She might not be isition to give any informed consent. Instead, the way you tre Mental Health emergency is to address whats ppening in the brain. If youre having a yctic episode, you administer antipsycti. Justice alito well, i i really want a simple, clearcu aner to this question so that Going Forward everybody wi know what the federal governments position is. Does health mean only physical heth, or does it also include Mental Health . General prelog th respect to what qualifies as an emergencmecal condition, it can include grave Mental Health emergencies, but let me be very clear about our position. That could never lead to pregnancy termination because that is not the accepted standard of practice to treat any nt Health Emergency. Justice alito does the term rious jeopardy in in e 11 i mean an immediate serious risk or may a risk of serious consequenc asome future point suffice . General prelogarthe standard is defined in terms of whether you need immediate medical treatment. And so the relevant questions, the absence of immediate medical treatment, are y gng to have this serious jeopardy to your health, dysfunction of your organswi your bodily systems start shutting down, so it is pegged to the urgency of acute ca in an emergency room. Justice alito so it has to be immediate . General prelogar the the relevant staarunder the statute is phrased in terms of whether the nsequences will occur without immediate trtmt, yes. Sots focused on the tection between having some kind of Urgent Health crisis that takes you to an emergency room in the first place and then how proximate these tse consequences are likely to be. Justice alito well, there are two Different Things there, whether the persons whether the woman is in immediate jeopardyr ether the person the womanee Immediate Care in order to eliminate jear at a later point. So i understand your ansr be that the woman need not be in immediate jeopardy, but if she doesnt get care right away, jeopardy at some future point may suffice . General prelogar so the statutorstdard itself is focused on Immediate Health risks. Is looking at the possibility that if the woman doesnt get trtment then and there, what wi happen, what will reasonably be expected to occur is that heorns could start shutting down or she might lose r fertility or have other serious Health Consequences. It is focused on this temporal link between the immediate need for treatment, whi ii think reflective of the fact that congress was narrowly focused on this emergcycute medical situation. Justice alito do the terms impaiento bodily functions or serious dysfunction of a bodily organ or part refer only pmanent impairment or dysfunction . General prelogar i think Justice Alito or do does it also refer to temporary impairment or dysfunction . General prelogar i think it can also refer to temporary impairment, butm not sure that its syo parse the two. For example, a lot of times a pregnant woman in distress, she might start suffering liver damage or kidney malfunconnd you dont know ex ante whether thats going to be permanent or not. The stction that Congress Gave in emtala is you need to stabilize to guard against those very serious heah sks. Justice gorsuch general, id id like to if you yeah, just understand kind of the e ofour argument here on the suprclause and how it operates in your mind, putting aside the this case. Could the federal goveme condition the receipt of funds on hospitals that they comply with medical ethics rules ovided for by the federal government, a medical malpractice regime, and a medical licensing regime such that effectively all state medical malpractice laws, all state medical licensing laws would be preempted . General prelogar and youre imagining that this is regulatory action or that congress hasasd a statute creating kind of a federal malpcte regime . Justice gorsuch you call it. General prelogar i mean, i think i have a broad view of coresss authority to enact statutes, and so what id want to assess in that situation is, you know, whether congress is acting pursuant to one of its enumerated powers. Justice gorsuch spending ause. This is all spending clause. General prelogar yeah. So so i think that very likely congress could make those kinds of judgments and attach conditions to the receipt of federal funds. And, you know, in medicare, e are substantial conditions. Justice gorsuch even if it covers all hospitals in the state and effectively transforms the regulation of medici io a federal function general prelogar you know, there mit be a. Justice gorsuch storically . General prelogar at which this court thinks that its really encroaching on the states prerogatives in ways that are inconsistent with o constitutional structure, but i dont think Justice Gorsuch you dt general prelogar were anywhere close to that Justice Gorsuch you dont see general prelogar in this case. Justice gorsuch but do yose any bounds just in principle . General prelogar i think the bounds, you know, would have to come from isourts case law concerning federalism prciples. The court has said in cases like gonzales versus oreg tt, of course, the federal government has authority to comprehensively regulate on health and set including with respect to medical care. And so i dont think that theres any principle of exclusive governcef this area by the state. But, obviously,m sure you could construct hypotheticals that really ce gorsuch all right. Ok. Genel elogar seem to be the federal government entirely takingvea state function and maybe that would be subject to a different principle. Justice gorsuch yeah. And ta and and medicare allow the federal government to enforce the emtala dictate through civil monetary penalties . Nel prelogar thats correct, yes. Ste gorsuch and also, you can terminate the medicare agreements if a hospital violates emtala in your view . General prelogar yes. Generally, the hospital is given the opportunity to come into compliance and to develop a plan eure that there wont be future emtala violations. It would obviously be an extreme sanction to to terminate medicare funding, but that is a possibility. Justice gorsuch and theres also a private right of action for emtala violations that it have the posbity of Equitable Relief as well . Genel elogar yes. Certainly, monetary relief and and possibly Equitable Relief as well. Justice gorsuch in in this case, you you you brought an eitle cause of action. You didnt cite any statuteo enforce emtala. And one of the rules in equity traditionally at least is that you dont get an equab relief if theres an adequate remedy at law. And as we just discussed, theres a prtyeticulated statute here. Seminole tribe says, when you have a reticulated statute and lots of remedialptions, you dont get Equitable Relief. Thoughts . General prelogar so let me say at the outt at the United States has long been recognized to have an actn equity, an inherent action in equity to appeal to the courts of this of this nation to protect its sovereign interests. And thats been reflected in thgs like Justice Gorsuch its sovereign its proprietary tests . You mentioned washington and you mentioned geral prelogar arizona versus Justice Gorsuch arizona. General prelogar United States ste gorsuch arizona was an general prelogar is another ame of that. Justice gorsuch Arizona Arizona was just sorry to interrupt, but arizona was an immigration case and general prelogar right. Justice gouc the border, and washington was an attempt by a state to impose its Worker Compensation laws on the federal government in a way different from others. I i take those points. And equity is all about proprietary interests and things like that. We have that here . General prelogar the el i think that the court its not i want to make sure to make clear that there are a long line of cases that stand for this principle, including cases that have addressed it directly like in re debs Justice Gorsuch oh, debs. General prelogar wyandot, so Justice Gorsuch do you really want to rely on debs, general . I mean, that wasnt exactly our brightest moment. General prelogar i do think, though, that it reflects the history and tradition of this nation in recognizing that its entirely appropriate for the United States to seek ptect its interests in this manner. And let me say, Justice Gorsuch Justice Gorsuch what do you general prelogar this is a really important issue to the United States. It wasnprsed below. It wasnt passed upon. Justice gorsuch im just tin general prelogar we havent briefed it at all. Justice gorsuch im trying to general prelogar its not jurisdictional. Justice gorsuch im just trying to understand where it comes from. What is thprrietary interest here . General prelogar it comes from Justice Gorsuch it seems to me is ts your money and how its being spent, and ress has given you lots of tools. General prelogar i think it also comes from the recognition under obstacle preemption principl tt there are important functions to be served by having the Medicare Program inla. And idaho has directly interfered with the abilitof hospitals to accept these federal funds when they stand willing and able to comply with emtalas maat and fulfill congresss sire here to make sure thanoatter where you are in this country, if you have an Urgent Medical need and you go to an er, you can be stabilized. Justice gorsuch thank you. Justice jackson general, is there chief Justice Roberts counsel, your friend on the other side saith your position would require religiously affiliated hospitals with emergcyooms to perform abortions. Was heig . General prelogar no. My friend was wrong. The e federal conscience protections that apply at the enty level to hospitals as well. The key provisions are in the weldon amendment and also coatssnowe, although at depends on the Residency Program of a particular spal. Now hhs said in a 2008 rulemaking on conscience protections that it had never come across a hospital that had a blanket objection to providing lipserving and healthpreserving pregnancy termination care, buif spital had that kind of objection and hhs recently informed me they still have not come across that hospital, that would be honored visaishss enforcement ability. Chief Justice Roberts you said that applies at e tity level. Can individual doctors in the emergency room do they have a conscience exemption . Neral prelogar oh, yes. Yes. Theyre protected uerhe Church Amendments principally. And our position is that emtala does not override either set of coce protections. So, if an individual doctor ha a conscience objection to providing pregnancy termination, emtala itself impose obligations at the entity level, and the hospalhould have plans in place to honor the indivialoctors conscience objection while ensuring prriate staffing for Emergency Care. Chf stice roberts well, does that does that mean that there must be somebody in e emergency room that can provide an abortion . What if what if trere two doctors, three doctors, and they all have a coniee exemption . General prelogar no. In that circumstance, emtala could t erride those individual doctors conscienc protections, but my understanding is that as a matter of best practice, because hospitals wabe able to provide Emergency Care, they do things like ask doctors to articulate their objections in advance so that that can be takein account in making staffing decio and whos on call. Hospits ve a lot of plans in place chief Justice Roberts are are you saying general prelogar for these kinds of contingencies. Chief Justice Roberts yeah. Are are you saying that there must be somebody available and on call in in a hospital of that sort . General prelogar e nditions of participation for medicare require hospits be appropriately staffed to provide emgency treatment. Now, in a situation where a hospital doet hasnt done that and it doesnt have anyone on hand who can provide care, you know, maybe all of the doorcalled in sick that day and theres just literally no one in the emergency room, or in this case, if everyone conscience objection, then the hospital would not be able to provide the care. But there are conditions of participation that are meant to ensure that there isoo governance of hospitals and organizaono account chief Justice Roberts heyou say general prelogar for these situations. Chief Justice Roberts and the consequence of them not being able to provide the care would be what . General prelogar in that ciance, i think they would likely be out of compliance with the conditions of participation that require them to appropriately staffed. But, if the question is could you force an individual doctor to step in then over conscience objection, the answer is no. And i want to be really clear chief Justice Roberts i know, but the question genel prelogar we dont understand emtala to displace it. Chief justice ro excuse me. The question is whether or not they must have available someone who can comply the procedures required by emtala. And what would be the conseque they didnt . Would it be eventual termination of theircipation in medicare . General prelogats right. So, if a hospital was conty disobeying the requirement to have in place sufficient persoo run their emergency room, then i imagine that hhs would, through enforcement action, work with that hospital to try tbrg it into compliance. And if the hospital ultimately is just leaving itself in a position where it n ver provide care, then it would terminate the medicare fundi agreement. Justice gorsuch i thought justice barrt eneral Justice Gorsuch you just said a minute ago im sorry. Justice barrett oh, n g ahead. Justice gorsuch i thought you i just wa tclarify this colloquy. I thghyou said a minute ago, though, if the hospital had a conscien oection and therefore didnt provide certain re, that that wouldnt render it out of compliance. Which is it . General prelogar thats correct. Justice gorsuch ok. All right. General prelogarsohe hospital could assert a consciencebjtion Justice Gorsuch thatall. General prelogar and emtala would not override that. Justice barrett my question i have a questn out the Hyde Amendment. So i gather from theriing that there might be some situationsn ich emtala would require an abortion, but the Hyde Amendment wouldnt permit federal ndto be used to pay for it. And you said in yo bef that emtala requires in other circumstances as well stabilizing treatment to be given that federal funds don cover. N u give an example of that . And am i right about the hyd amendment . And then can you give an example of that . General prelogar yes. So you are right about both things. It is common undermta that hospitals are going to have to provide care where trs not federal funding available. And ill give you an example of a medicare patient who goes in and his emergency medical coitn means he needs a particular drug thats not covered by medicare benefits. Still, the hospital has to pride him with stabilizing treatment and give him tha medication, even though the deral funding isnt going to pay for it. D at also applies to people who are uninsured, who arent ved by medicare in the first instance. The the whole pntf emtala was it doesnt matter your ciumances, it doesnt matter whether you can pay or not, it dont matter the particulars of your situation, this is a guarantee. U n get stabilizing treatment. I want to say, though, that dont think theres any consistency between the lines Congress Drew in emtala and hyde. And congress itselha recognized that these statutes address discrete issues. Im thinking here of the provision in the Affordable Care act that was exclusively about abortion, and there, Congress Said nothing in the aca displaces hyde and the other federal funding restrictions on on, but also, nothing in requirement to stabilize. S and that shows twos. It shows first that congress recognized that stabilizing care can sotis be pregnancy termination. And i think it also showed cos recognition that these statutes addressed their own distinct spheres. And one final point on hyde, my friend isnt drawing a line based on hyde eitherse his point is, even if a woman is on the brink of death and she goes to an emergenc and there are federal Funds Available under hyde to treat her, still, hospitals have no obligation under emtala tprovide that care. Justice barrett so what about the colloquy i was having with your friend about what stabilizing treatment entails lets imagine a situation in which a woman is, i dont know, 10 weeks, anisold that if you carry this pregnancy to term, it could have,ounow, consequences for your health, but you just would nd abort before, like, say, 15 weeks, something kehat. So theres not an immediacy, like so shestable when she leaves the hospital, but in idaho, theres no place else that she cano least until shes 15 weeks. What is e deral governments position then . General prelogar i thk,f im understanding the hypothetical correctly, that she ke wouldnt have an emergency medical condition in the first place because the definition of having an emergency medical condition is that, without immediate trt, you are reasonably you will reasonably be expecte to have serious dysfunction of your organs or serious pairment of your bodily functions. And so, in that situation a woman is somewhat high risk, you know, maybe she she has certain complications where docan say theres some danger with continuing this pregnancy, i dont think that that creates t kd of emergency medical condition that emtala is meat. Justice barrett ok. Last question, and this is about the sp clause issue. So it does seem odd and i think kind of what some of the questions are getting at it does seem odd that through a de agreement between a private entity and the federal governmee private entity can get out of state law, right . So, in another administration, would it be possible the reliance on the spending power for congresay, you know, any hospital that takes these funds cannot perbortions or any hospital despite state law requiring a ste constitutional amendment requinabortion to be available, is that possible or, u ow, with gender reassignment surgery . I mean, you can imagine it kind going back and forth through spending clause litigati i ways that would be unusual. General prelogar yes, i think congress has broad power under the spending clause to attach conditions. Now it doesnt mean tt s wholly unlimited. Obviously, congress ulbe having to act pursuant to an enumerated power, it would have to comply with other constitutional limits, and so the law would habe valid. The spending clause itself has builtin limits, things like relatedness and pure notice. Justice barrett so it would have to be acting pursuant to an enumerated power in forbidding geereassignment surgery or abortion or those sorts of things . General prelogar oh, no. I just meant that it would have to be valid spending. Justice barrett the spending clause . General prelogar the spending clause. Juice barrett the spending clause. General prelogar itsel would be enough. Justice barrett ok. Ok. General prelogar yes. So we think Justice Gorsuch yeah. So general prelogar the spending clause itself would be enough. Justice gorsuch so just to follow up on that and going back to where i started with could could the federal government seially regulate the practice of medicine of the states through the spending clause, the answer, i think, is yes, congress could prohibit gender reassignment surgeries across theatn, it could ban abortion across the nation, through the use i spending clause authority, right . Generaprogar congress does have Broad Authority under the spending clause. And, yes, if it satisfies the cons that the spending clause themself itself requires, then i think that that uld be valid legislation. Justice gorsuch how general prelogar and the court has in many contexts recognized Justice Gorsuch how do we genel elogar the spending clause legislation preempts. Soo stice Justice Gorsuch so the the answeis yes . Ok. So how do we recci that with the statement in 1395 that nothing in this subchapter allows a federal officer to erse any control over the practice of medicine . General prelogar so, at the outset, i think, if congress itself is doing itth that provision is inapplicable by its own terms. Thats looking at the Justice Gorsuch you don think it informs our view and unrstanding of the statute in any way . General prelogar well, thk, in the event of some kind of direct conflict, you know, looking at emtala in particular, its the later in time enacted statute, and its clearly more specific, so it would control. But this court itself has rejected the idea that there would behat kind of conflict. And im thinking of the cms vaccine case where the litigants lied on this exact same section 1395, and this courtt, said no, that canbear the weight that those litigants could place on it or it call into question all of the conditions of participation medicare. Justice gorsuch do you agree that our cle stement rule with respect to spending clause legislation, our statement rule with respect to federalism are in play general prelogar i think that here, congress has spoke clearly with respect to what oh, i i general prelogar are supposed to d Justice Gorsuch thats not the question. Do you those presumptions apply . Forget about w you can satisfy them. General prelogar the requt of clear notice under spending clause legislates, i think that that does apply, and providers have always unod their obligations under emtala. Justice gorsuch ok. Justice jackson general, let me ask you to respond to a couple of things petitioners counsel said and just give you the opportunity to respond. He suggested or said that you havent identified a circumstance in which something that emtala requires idaho wouldnt allow. And i i didnt get a chance tosk him, but i took i took him to sort of mean that the way that idahos statute operates, it basically allowfoa doctor to say, well, in my view, you know, th hlththreatening circumstance could eventually lead to death, and so igog to do it. , to the extent that doctors are still able to do that, guess, hes saying theres no preemption. But is it true that there really isnt in operation a difference between the twhe emtala and what ihoas required here . General prelogar no. That is gravely mistaken on threlels. Its inconsistent with the actual text of the idaho law. Its inconsistent with medical reality. And its inconsistent with whats happinon the ground. And this is a really important point, so let me try to unpack this. On theexitself, idahos law only allows termination if its necessary to prevent death. And that is textually very narr cpared to what emtala requires with the category of harm to begin with. In idaho, doctors have to shut theiey to everything except death, whereas, under emtala, you sposed to be thinking about things like, is she about to lose her fertility . Is h urus going to become incredibly scarred because of the bleedi . Is she about to undergo the possibility of kidney failure . So i think tt at is one critical distinction. The other critical textu distinction is the idea of necessity. Under idaho law,ouave to conclude that deatwi necessarily result, which is also materially different, and the Idaho Supreme Court specifically recognized it. Cond, with respect to the actual medical reality here, there are numerous conditions that we are worried about er a doctors immediate concern is not death. Thats a far more remote possibility. Eyre thinking about the Health Circumstances that ta guards against. And let me give you two expl. The first is pprom, premature rupture of the membres we have declarations at 594 that explain this in detail and ao at ja 615 to 617. What the docrsxplained there this is dr. Fleischer and dr. Oper is a woman comes in with pprom, her sac is ruptured. Es no chance the fetus is going to be able to survive, but at that point, she doesnt have active signs of feion, and so, until she deteriorates, you cant think sheclose to death. What youre worried about is she will become infected. She might develop sepsis. She might have tseramatic consequences for her future, but its not about at so i think that is one example where you ct do it. And then, finally, just the actual practice on the gun women in idaho today are not getting treatment. They are getting airlifted out of the state to Salt Lake City and to neighboring states whe there are health exceptis d there are laws because the doctors are facing mandatory minimum two years inrin, loss of their license, criminal prosecution. The doctors cant provide the care because until they can conclude thaa prosecutor looking over their shoulder wot sendguess that maybe it wasnt really necessary t prevent death. F Justice Roberts thank you, counsel. Justice thomas . Justice alito . Justice alito weve now heard lets see an hour and a half of argument on isase, and one potentially very important phrase in emtala has hardly been mentioned. Maybe it hasnt even been meioned at all. And that is emtalas reference to the womans unborn child. Isnt that an odd phrase to put in a statute that imposes a maatto perform abortions . Have you ever seen an abortion statute that uses the phrase unborn child . General prelogar its not an odd phrase when you look at what congre doing in 1989. There were wellpublicized cases where wore experiencing conditions, their own health and life were not in danger, but the fetus was in grave distress and hospitals werent treating them. So what congress did Justice Alito wele you seen general prelogar is that it Justice Alito you seen abortion statutes that use the phrase unborn child doesnt that tell us something . General prelogar it tells us that congress wanted to expand the protection for pregnant women so that they could get the same duties to sand stabilize when they have a conditn ats threatening the health and wellbeing of the unborn child. But what it doesnt suggest is that congress simultaneously displaced the independent preexisting obligation to treat a woman who herself is facing gre life and Health Consequences. Justice alito well, lets walk roh the provisions of the statute that are relevant to this issue regarding the status and the potential interests of an unborn child. Under b 1 , if a woman goes to ital with an emergency medical condition thatthe phrase the hospital mt either stabilize the condition or, under some cirmsnces, transfer the the woman to anothefality. So we have this phrase, emeen medical condition, in that provision. And enunder e 1 , the term emergency medical condition is defined to include a condition that plas e health of the womans unborn child in serious jeopardy. So, in that situation, the hospital must stabilize the threat to the unborn child. And it seems that the plain meinis that the hospital must try to eliminate any immediate threat to the child, but performing an abortion is antithetical to that duty. General prelogar but, in a circumstance Justice Alito now and you you go yo go so far as to say that the statute is clear in your favor. I i dont know how you can say that in lighofhe of those provisions that i just read to you. General prelogar the statute did nothg displace the maherself as an individual th an emergency medical condition when her lifisn danger, when her health is in danger. That stabilization obligation equally ru ther and makes clear that the hospital has to give h nessary stabilizing treatment. And in many of the cases youre thinking about, there is no possible way to to stabilize the unborn child because fetus is sufficiently before viability that its inevitable that the pregnancy is going to be lost, but idaho would deny women treatment in that circumstance Justice Alito doesnt general prelogar even though its senseless. Justice alito doesnt what ive read to you show that the statute imposes on the hospital a duty to the woman certainly and also a duty to the child . And dsnt tell the hospital how it is to adjudicate colis between those interests and it leaves that to state law. Now maybe a lot most of your argument today has dedicated to the proposition that the idaho law is a bad law, and that may well be the cas but what youre asking us to do is to construe this statute that was enacted back during the Reagan Administration and signed president reagan to mean that theres an obligation under ceain circumstances to perform an abortion even if doing that is a violation of state law. General prelogar if cgrs had wanted to displace protections foprnant women who are in danger of losing their own lives tir health, then it could have redefined the statute so that the fetus itself is an individual wh emergency medical condition. But thats not how congss structured this. Instead, it put the protection in to expand protectiofothe pregnant woman. The duties still run to r. And in a situation where her own life and health is gravely endangeredth, in that situation, emtala is clear. Ss the hospital has to offer her stabilizing treatment. Justice alito the the only general prelogar and she doesnt have to acce i these are tragic circumstances. And many women want to do whatever they can to save that pregnancy. Buthe statute protects her and gives her that choice. Justice alito the only way you try to get out othstatutory interpretation that i just positeisy focusing on the term individual. And you say, aha, in the dictionary act, iividual is defined to excludannborn child or a fetus. Thats the only way you can try g out of what ive just outlined. And it it true that under the dictionary that dictionary t definitions apply only if they are not inconsistent with the statutory text . And when you have a text that, certainly, y wldnt dispute the fact that the hospital has a duty to the unborn child where the woman wants to wants to ha t pregnancy go to term, it indisputably protects the interests of the unborn il so its inconsistent with the definition in the in the dictionary act. General prelogar no, not at all. The duty runs to the individual with the emergcyedical condition. The statutmas clear thats the pregnant woman. And,f urse, congress wanted to be able to protect her in situio where shes suffering some kind of emergency and her own health isnt at risk, but the fetus might die. Atncludes common things like a prolapse of the umbilical rd into the cervix where the fetus is in grave distress, t e woman is not at all affected. Hospitals otherwise ult have an obligation to treat her, and congress wanted to fix that. But to suggest that in doing so congress suggested that the woman herself nt an individual, that she doesnt deserve stabilization, i think that that is an erroneous reading of this statute. Justice alito nobodys suggesting that the woman is not an individual and she doesnt e doesnt deserve stabilization. General prelogar well, e Justice Alito nobodys suggesting that. General prelogar i think the premise of the question would be that the state of idaho Justice Alito it wasnth predicate. It wasnt general prelogar can declare that she nn get the stabilizing treatment even if shes about to die. That is their theory of this case and this stut and its wrong. Chief Justice Roberts Justice Sotomayor . Ste sotomayor general, this this lack of conflict whi your opposing counsel colleague says doesnt exist, you mentioned a situation where it does. Why dont you succinctly state what you they admit theres daylight. Tell uextly how you define where the daylight exists. Generaprogar the daylight, as i see it, exists on two dimensions. They think that doctors can only provide stabilizing care when the woman is facing death. And we think, no, you can take into accounthis like kidney failure, the risk of a seizure, and lifelong neurological impacts seon that. Justice sotomayor well, they th sd the recent decision of the oregon court says you dont need death to be imminent or immediate, i think, is the wor they used if im not wrong. General prelogar so what the Idaho Supreme Court said in that decision is that theres no particular level of imminency and no certain chce requirement. But what the court couldnt do is turaw from the language requiring the type of harm to exclusively be death. And alsothinherent concept of necessity requiring some gree of imminence, its true that its a subjective standard under idaho law, and the court made that clear, but what the Idaho Supreme Court also said is osutors are free to come in and have other medical expts secondguess doctors decisions by saying maybe you didnt subjectively think s rlly needed it as necessary to prevent death because, look, h her sac had ruptured, but she wasnyet infected. And thats exactly the kind of situation that leads to women beg driven out of state, dumped on neighboring states by idaho,ndriminalizing the re, the essential care that they need. Justice sotomayor thank you. Chief Justice Roberts Justice Kagan . Justice kagan yeah, if you could just talk a little bit about that becseas i understood it, for example, i read recently that the hospil that has the greatest Emergency Room Services in idaho has just in the few months that ts s been in place had to airlift six pregnant women to neighboring stateswheas, in the prior year, they did one the entire year. So, if mr. Turner is right about what the state is trying to convey to hospitals about when theyll be prosecuted, like, why is this happenin general prelogar i think that the reason this is happening is because those doctors can look at the text of the statute itself, they can look at the ido Supreme Courts decision, which made clear, very cle, that this was a departure from prior idaho laws that tracked emtala. And they can recognize that their livelihood is on the line, their medical license, their abilittoractice medicine, thr eedom if they have to go to jail and serve one of these minimum twoyear sentences of imprisonment, and they simply cannot provide the car en consistent with their subjective medical judgment, because as a matter matter of medical reality, for many of these coitns, its not yet putting a woman at the brink of death or necessary to prevent her death, yet they know thathetandard of care is to provide her with termination because she is just going to getor and worse and worse if they wait it out. And e her important point about this, and i think it goes back to isual stabilization idea, is that, tragically, in many of these cases, the pregnancy is lost. Theres t going to be any way to save that fetus because a woman who has pprom at 17 weeks, there is no mecaway to sustain the pregnancy to give the fetus a chance. So in that situation, what iho is doing is waiting for women to wait and deteriotend suffer the lifelong Health Consequences wi no possible upside for the fetus. It just stksragedy upon tragedy. Juste gan and it it it cant be the appropriate you know, its like its become transfer is the appropriatstandard of care in idaho. But it ct be the right standard of care to force somebody onto a helicopter. General prelogar and its enrely inconsistent with what congress was trying to do in the statut yoknow, one of the primary motivators here was to prevent patient dumpg. The idea was we dont want people to have to go sewre else to get their care. You go to the fit ergency room in your state, and they have to treat you and stabilize you. But this effectively allows states to takenyarticular treatment they dont want their hospitals to provide and dump those patitsut of state. And you can imagine what would ppen if every state started to take this approach. Justice kagan a question on the spending clause questions that yve been asked. I mean, what would if you accepted some of these theories, what what would the consequenc osomething like that be that we would have to worry about . General prelogar i think that it would call intoueion any number of federal spending statutes thapride funds to private paie and there are a bunch of them. You know, theres the medicare system itself, which is of course a major federal spending program. There are funds provided under title vi, under title ix, a t of federal statutes out there that give funds to priva parties and insist on conditions of compliance with the federal funding restctns. And if the court were to suddenly say that cant preempt contrary state law, then i thi that it would seriously interfere with the ability of the federal government to t its benefit of the bargain in those spending programs. Justice kagan and you menon before that this question has never been aarof this case . General prelogar thats right. They did n me these arguments in the lower court. They briefly referred t spending clause, but i dont undersndhem to have pressed this argument specifically. And so i thi tt the lower courts did not address it. I ink the District Court said in a footnote, they briefl refer to it in a footnote of their brief, and its essentially waived. Justice kagan tha. Chief Justice Roberts justice Justice Kavanaugh . Justice kavanaugve touched on whats happening on the ground, and thats an important consideration in answer to the question of whats happ but idaho is representing and i just want to get your sw on this that, as i count it, nine conditions that have been identifiede government where emtala would require that an abortion be available, an aborti iavailable under idaho law. D ats in the reply brief. Now, are there other conditions . Youve ruled outl health. Are there other conditions you would identify, or are you just sayi tt thats not really happening on the ground . I think thats part of your answer, but i just want to get a fuller answeonhat. Nel prelogar it certainly isnt happening on t gund. These are the conditions that were worried about. And i think the problem with my frns theory that idaho law would permit it is that you just nt square it with the text of the statute. You know, the the Justice Kavanaugh what ifhe were general prelogar the state of idaho ste kavanaugh im sorry keep going. General prelogar well, i just wanted to say theyre nothe ultimate authority on what the idaho law means. Thats the idaho supre urt, of course. And it has addressed this issue in the plaedarenthood case. Ani ink its really significant that, in planned parenthood, the Idaho Supreme Court expressly contrasted this statute with other statutes that contain healthrerving measures and recognized this was a a total departure from that. The legislurwanted to focus exclusively and more narrowly on a necessary to prevent death exception. So i think that that that esntlly means that the Supreme Court of idaho has already touched on this issue, d its no wonder, then, that doctors who are facing these kinds of pregnancy complications, where in their medical judgment its not necessarily to prevent death yet, but the woman is going to suffer Serious Health equences, their hands are tied and they cant provide that care under the idaho law. Justice kavanaugh if the whats on page 8 and 9 of the reply brief were idaho law, would there be a problem still . General prelogar so if we had uthoritative Idaho Supreme Court decision that said iho law allows for termination in the circumstances where emtala wod require it, yes, of course. Then the conflict goes away. Justice kavanaugh well general prelogar t cant imagine the court would say that because, of coursehe Justice Kavanaugh thats not quite what 8 say, but i i take your point on that. Separate question, dfent category. I think one of the themes on the otr de is that this law passed in 1986 was a very important law addressing a very important problem; namely, the m where hospitals were turning away poor and uninsured patien came in for Emergency Care. D the idea was that cant happen. We cant allow hos in this country to turn away poor and uninsured people i emergencies. But their theme is that the law was not designed contextually to deal with specific with ab or other specific kinds of care. And so they make a textual argument, but i think they also make a broader contextual argument about the whole idea of what was going on in 1986. And i want to make sure i dot think thats really come up too much. I want t sure you respond to that. General prelogar i appreciate having the chance to address so at the outset, i dont think they can square that theory with the text of the statute, which says, in no unceterms, here is the fundamental guarantee. If you havmergency medical condition and you go to an er in this country, they have to stabilize you. Theyto give you such treatment as may be necessary within reasonable medical ability to ensure that you dont deteriorate. And, yes, congress did not provide a reticulated list of l possible emergency medical conditions and all possie treatments, but it was very clear that congress set a baseline National Standard of careo sure that, no matter where you live in this country, you cant be declid rvice and the the urgent urgent needs of your medical condition addressed. An you know, it would be no different if the state had come out and decided to ban epinephrine. Thats the siul way to treat anaphylaxis, a severe allergic reaction. That would viotehe statute, and we would be up here making the exactly same arguments, becauscoress didnt want that. If you have anaphylaxis and you go tanr anywhere around this cotry, theyre going to give you epinephrine. And Congress Mandated that. And i donsee any way to try to draw lines around to exclude pregnancy complications in the very narrow but tragic circumstances where the only way to address the womans cond and prevent material deterioration is for the pregnancy to end. Justice kavanaugh thank you. Chief Justice Roberts Justice Barrett . Justice baet so, general, i i understand the primary dierence between emtala and the idaho statute to be this heal, at that idaho focuses on the risk of life, b the federal government says that tala well, emtala says that the health is am i right, its health and life . General prelogar thats thats the principal difference, but i think its also the difference between necessary to prevent death versus the Health Concerns would be reasonably expected to cu so i think that that is a stda that builds in a little more space for doctors to take action Justice Barrett got it. Is the federal goverenaware of any state, other than idaho, that has a law that do n take health into account . General prelogar there are six other states that have severe abortion restrictions without a health exception. So i think that those are the primary catego ostates were concerned about here. Justice barrett thank you. General prelogar i should i should make clear that the some pending judicial challenges in those states, and so thei laws are not always enforceable or in fe right now. Justice barrett besides texas, has the federal government has the federal government brought suits silato the one brought in idaho and texas in anofhese other states . General prelogar to be clear, texas wanoour Justice Barrett right. Ok. General prelogar affirmative litigation. Th sd us. But we have not brought affirmative litigation in othe states. D i think its this case has been on a course and idahos law was particularly severe because at the point at which we sued it seemed to cover ectopic pregnancy, and the state conceded that. Now, they have modified the law to exclude that, but it was one of the most pressing concerns because of that. Justice barrett thank you. Chief justicrts Justice Jackson . Justice jackson gen petitionies pretty heavily principles. Atement rule and i wonder wheou might comment on my thought that those principles actually cut against them in ase. As you said, congress set a ne National Standard of care. It has said, in no uncertain terms, that the al must provide stabilizing care to people experiencing emy medical conditions. There was no, as yve said, you know, particular conditions or particular tnts talked about, carved out, et cetera. So if a clear statement is requwouldnt it be the requiremenxemption of exempting abortion . Justice alito has talked about of the exemptions for unborn child. None of them we like an exemption. Nothing that is this clear National Standard of care. Think congress was clearly requiring stabilization. It wasnt exempting particular conditions or particular types of treatment. This court has said there is no canon of duluth donaos when you have a provision like that, the fact that you dont have a specific enumeration of one of its applications does not mean you should read in some side of some kind of impli exception. What i think we would ne see is a clear statement that congress meant for you to not provide abortions. Think it is important to recognize that every relevant actor has understood it this way fr the beginning. Then the Agency Position all along we not aptg a new position. Oviders have understood it. They have always provided lifesustaining anhethy stating pregnancy termination consistent wh d tyler. Congress rogzed it in the Affordable Care act. And i inthere is any argument to be made thapele understood what congress is doing the statute. Tnk you, counsel. Quick than your honor. Practice standards as they find them. As Justice Gorsuch noted, that is what section 1395 said. In the Vaccine Mandate case that was referenced, that is what the Generals Office told th crt when is at 1395 does not rui does not allow federal officials totate particular trea for particular cases. That is what they are to do here with it is it is confirmed by subdivision anything that could cody this, to jusceacksons colloquy at the end, that is the point. You do presume that steaw continue to operate alongside impala. You donpresume the opposite. It is supported the operatanual. That is the Rosetta Stone of intel enforc it tells doctors, it tells cms enforcement en on the ground that you consir at is in the scope of that doctors is cee. That is exactly what we are saying. It is also specifically directed it requires hospitals comply with state law. That directs hospitals to acquire their hospitals staff. They totly lack any cas history that would support the administrationting. This always was understood to be the case will you think we wo find those 115,000 instaes a single instance where state law was overridden. And finally, the text. The text qua and tell us steve dw stabilization requirement. We know they can perform open heart surgery and we know debtors can draw blood. It is not just a plain mandate devoid of refencto state law. We know the word available en in common usage incorporates state law. You are just the other day that when considering whether this is availablfohomeless people, it is in a physical and legal sense. There is a physicalion and a legal question. Opioidar available in the hospital. Eyre on the shelf, physically there. There is a legal question that comes into play there. The same with abortions. In response to the chief justice question, the general said both hospitals and doctors are exempt from andus suppose it weelieved to hear that. Inconsistency of thes the utter administrations meeting. If the establishing requirement is done onhenot to oveid conscious protections, and it cae so specific and include requirement that is in direct conflict with state law. Those two do not drive. This court does not lately find a direct conflict. Congress must speak clearly. It has not done so here. The ainistrations position ultimately is untethered from any limiting principle. But i think we heard that. There is no way to limit this to abortion. There is no to limit it to idaho. They are 2stes with an abortion law on the books. This isnt going to end with or the six states because l the states that have abortion regulations define the health and the emergcy exception narrower than m tele does. This question will come up in state after state after state. Itt limited to physical health. I know they say there is n circumstance in which a medical ion can require abilization within abortion. Now he is just fighting with the American Psychiatric association. That is not consistent. It isnt limited to an tele. You will point out the major ng because implications that are at play here. Recognize this is usually concerning if the federal government can p private actors to buy the state law. In by enumerated powers. I think they aitted that. The court does not have to answer that question by our reading. Thank you, counsel. Thursday, the u. S. 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