The fair argument in case 23726 borilla versus the state in the consolidating case. Mr. Turner. Thankr. Chief justice and may it pleas court but when congress amended the medicare 1986 to put them pull on the centurys own speak up if it had bee responsible for licensing doctors and setting practice indeed paula works precisely because states regulate theice of medicine and nothing nothing in an paula requires doctors to ignore the scope of their license and offecal treatments that viola state law. Three statutory provisions make this clear. First sec390 by the medicare act opening provision prevents the federal gover from controlling the practice of medicine. Thats a state regulation per second subdivision f i and presumption against they preemption of state medical replacement in the stabilization is limited to be able to do ich depends on the scope o the Hospital Steps medical license for illegal treatments are not ava treatments. Add in the courts on presumption against preemption of state regulations and combine that with the need for clear and unambiguous spending clause conditions and administrations reading becomes wholly untenable nable. Administrations misre also any limiting principle. If er doctors can perform whatever treatment they determine is appropriate doctors n ignore not only abortion laws that state regulationzero. He is an informed conse presumption against preemption on head diverts it es leaves Emergency Rooms underlay am surprising that no cos endorsed such an expansive view of and paula and everyone understand licensing laws limit medical practice. Thats why and nurse and available to perform openheart surgery no matter thed, no matter her knowledge the answer doesnt change just because we areking about abortion. The should reject the administrations unlimited reading of shifty shellshock. Normally when we have a preemption case theres some relationship between the parties. If the state being regulat the federal government under emtais the state engaged in some sort of qualified contractual relationship . Yes your honor this case the staten idaho for example has no state hospitals that participate Emergency Rooms and emtala so in this case the emtala or hospitals and doctors. They thinkre questions g at the armstrong issue and we think that is a significant quesut it wasnt part of theion presented and we think the indiana amicus brief raises significant questions and deal that argumentell is one of directict andted here emtala and we dont think its hard at all. Your honor going to that direct conflict i think you considered press limitation within the statute of availability. And before we do that just step back and get your understanding of the statute . You made some representation to how you see it working so let me tell you what i think and then you tell me whether you agree disagree or otherwise. I there to things that are plain, plain on the face of the statute. One is that emtala is about the provision of stabilizing care people who are experiencing emergency medical conditions. Thats one thing i think the statute i doing and i also think that its operating to lace the prerogatives of hospitals were states or omever with respect to that fairly narrow slice of the health care universe. This idea rgency med services is like one very minor or small part of the Overall HealthCare Provision of health care. What that means is he stabilizing care in emergvide for people who cant pay for it for example, emtala says no im sorry anyone whos experie in eme condition or a stabilizing treatment to people experiencing only certain ki of emergency conditionala says heres a list oftions you haveo provide an ilizing care for those people. Similar if the says its our job t govern all of health care in our state and we say ertain kinds of health care can be given to people who are experiencinency medical conditions we dont want emtala says no we are directing is a matter of federal law when condition we have to do whatever and its capacity tolize up is that your understanding of the statute . We believe that emtala doesnt post the federal stabilization requirement that the question here is what is the content of that stabilization requirement and for that you have to okay w state law. I think we just said is important because many can see emtala imposes a stabilization requiremen it is the statute, the f government interfering if you will in the States Health care choices. Emtala is on its face the statute says its not all the states way. Federal work where messier and requirementso stabilize emergency patients and you agree with that . Just as kagan the purpose was narrowed to bridge this gap that d. Santa lets tf the table the state and its health cares the federal government has the federal government has plenty to say about it in the statute. Youre right now theres a the stabilization requirement of and as fi understood in ur opening remarks you say well if this is left to the states if im just looking at the statute, the statute tells you what the content of the stabilizationrement is. Its to provide such medical treatment as may be necessary to ensure within reason probability that material deterioration of the condition is likely to occur. Its the person who didet care. So it tells you very clearly its an objective standard and s basically a standardhat clearly has reference to accepted medical practice not to think heres the c of happens the standardou have to stabilize and what does that mean . Means to provide t treatment necessary to assure within reasonable medical probability that no material deterioration occurs. Would respond in two ways the first the ive standard they set forth in that understanding is contrary to that view. They say its a subjective standard and whatever treatment of doctor determines since thats not true. I think you can argue about this yourself but as i under the solicitor generals brief and we will see what the solicitor general says that the solicitor general says its not up to every individual. This is a standard thats accepted medical standards of care. The more fundamental point is the definition of stabilizing ca operati position prohibition iscitly qualified by that which is within the staff and facilities available. Thats quite right. S within the staff and facilities available at the hospital and if you just look at clear that thats theencely to what the state law involved. The staff and facilities available if you dont hav medical care then i guess youe cant provide the medical care. If you dont have facilities available to provide the medical care tu cant provide the dical care care in the tranad to take place for the good of the patient. The availability here, its the of availability of staff and facilities. Do you have the right doctors and you have enough doctors and the right facilities or is it better for the patient to transfer them to the hospital of you are exactly right do you have the right doctors and how do you have that answer except. Thats the initial point that i was trying to make which is at the federal mandate is to e stabilizing care for emergency conditions regardless of any other directive that the has that would prevent that care from being provided. Thats the work of the statute. Justice thats not the conclusion in the state operationsl which they are from page 36 of the brief it defines what makes a staff person availaber the atute. Does it say they arent available in the state law doesnt allow this pro . That they are available to the extent they are operating with that in tpe of their medical license and thats our argument they want to now draw far m normal. We agree thats the component andhes illegal avaabity component here. The problem we are having right now is that yo putting preemption on its head. The whole purpose of preemption is to say that if the state passes a lt violates federal law the stateno longer effective. So there is no sta licensing law ould permit you and permit the state to say dont treat diabetics with insulin. Treat them only with pills and a doctor looks at the juve ic and says without insulin they are goingt seriously ill. The likelihood and i dontnow what that means under idaho law and well get to that shortly, because i dont know we believe this is a better treatment. Federal law would ou cant do that. Medically it have to be accepted in shakir to require the treatm diabetics with insulin for the medically accepted obligation of doctors and women with certain conditions that may not r in death but more than likely will result in very serious medical cons including blindness for sd for others the loss of organs. For some to blood strokes. Idaho is sayings the doctor and say in good faith thats persons death as likely as opposedo s illness they cant perform the aborti so i dont know your argument about state licensing law because this is what this law does. Tells states you are licensing laws cant take out objective medical conditions that could save a person fm serious injury or dea i i think they are two crucial responses to your point. Let me begin preemption point. 1595 are telling hhs the federal government and court sug you cant unless theres a direct conflict if objective medical care requires you to potential serious medicalith the compons and abortion is the only thing that says you have to do it. E doctor has determined not that theres aerious med condition but that the person will die. Thats a huge difference council. Weee there is daylight between how the administration is reading emtala with idahos act permits. We agree theres a controversy here but what im saying. No, n theres more than than a controversy because what you emtala is not preemptive force is not just idaho, at half the saving condition forrtions when it threatens a womans life for what you were saying is that no state in the nation and theres some right now that dont even have that as an exception to their antion laws. What you areaying is there is no federal law on the that prohibits state from saying even if the women will die you cant perform an abortion. I know of no shat does not include a lifesaving exceptio since save debating it and if i find one your theory of this case leads to that conclusion. Her point is emtala doesnt address could i hear your answer . The administratioliance on a standard like is Clinical Evidence for some National Norm i think thats very fraught because it really is saying it nt address what the stabilizing treatment required if you go outside the that are floating out there that might change daytoday and that boils down to a question between conflict between what a cog says and what idaho law says. Actually can i just clarify because im not sure he understands flex lookingt is from a broader perspective it seems to me that emt says you must provide whatever treatment you have the capacity tong staff and to provide to stabilize patients who are experiencing emergen medical cons. Idaho law says you cannot provide that treatment unless doing so necessaprevent a patients death if the treatment involves an but why is not not at conflict . In a certain situation thats what the federal government saying and you you cannot if it involves abortion says idaho. I think the example highlights the reason why. Aurse might be available. The nurse may think she knows how to enter the fla must provision in emtala the frustrations reading would call her into action putter in the operating room and open the patient up. In idaho would say no still a complex opined that say t administrations provision is thatse can do it very suggesting federal law would not take precedence and would not she cant . Ate law that says no that is a different question and let whether the emtala law clear that it doesnt. Er is in the casre the controlled substanc, this court noted that was the provisions there rely upon and assume a medical profession being regulated by police powers. Thats the same as emtala. Emtala safor page statute to address the standards of care for every conceivable medical treatment. It definitely didnt address the care but it left it to the what congress was not going tod adevery treatment for the condition. It says you do what is needed to assure nondeterioration i guess the question is do you conceive tth respect to certain medical conditions and abortion is the standard of care . No because the staof theres a lifesaving exceptionho for certain abortions. That is the standard of care in the standard of care is necessarily set and determined by the state. Your own statute has interpreted by yourourts acknowledges that whendition gets bad enough shat the womans life is imperil that doctors are supposed to give abortions. With respect to certain raret extremely obviously important conditions a circumstances abortion is the accepted mical standard of care. Isnt that right . Yes and that was my point that there is a lifesaving exception undeidaho law. Also the accepted standard of care when r than a womans life being imperiled, the Womans Health is imperiled so s take you now all of care rare within these rare cases there a significant number ere the woman, her life is not imperiled that sheng to leads her reproductive organ and youd you lose the ability to have children in the future unless anion takes place. Thats the category of cases in which emtala says my gosh a course t abortion is necessary to ensure that no material deterioration occurs and yet idaho says sno abortions here and the result is these patients are now helicoptered ouof the state. Sinecure under the hypothetical raise is a very diffic situation in these situations and nobodys arguing that the dont raise tough medical questions that implicate deeply theol and mor questions ho like 22 other states and congress and emtala recognizes there are two patients to consider in thos circumstances. In t patients scenario its tough when you havese competing interests. That wou be a good responsive federal law did not take a position on what you characterize as a t question federal law does take aion on that question. It say you dont have to wait until the person is on tge death. If the woman is going to her reproductive organs that enough to trigger this duty on the part o the hospital to stabilize patient in the way to stabilize patients in these circumstances all doctors agree. Law does not require that doctors wait until the patient is on rge of death. Theres no mnc requirement in no medical certainty requirement. And answer the following questions and these are hypothetically if youell me whether idahos exception going back to the point that even if idaho law fully complies with federal law you pregnant woman whose early into her second trimester at 16 weeks. She felt ah of fluid leave her body. She was diagnosed. The doctors believe a medical intervention to terminate her pregnanc is needed toeduce the real medical possibility of experiencing sepsis and uncontrolled hemorrhage from t broken its a story of a row on it. She was discharged in florida because the fetus sad fetal tones in the hospital said shes not likely to die they are going to be serious med the doctors they refuse the treatment. Because they couldnt say she woe. She was and went home and the next day she b she passed out and thankfully ken to hospital. There she received an abortion before she was about to die. What you are telling is that a case in which idaho would have said is okay to have an abortion clinics com i dont lifesaving exception the document could if the good if the doctor in good faith they know im asking you ithe document says i cant say shes going to die if youre doctor says with medical certainty say shing to die but i do shes going to to death if we dont have an abortion but shes not bleeding yet so im note. The doctor doesnt need to have medical certainty. Council answer yes or no. He cany that theres likely destiny can say theres likely to be a serious medical condition. Let me go toer wet pavement and patient who goes to the er at 14 weeks and again a portion using an out of the hospital up to 27 weeks. This particularnt had to deliver her baby. The baby dies and she had a hysterectomy. He can no longer have children. You are telling me the doctor could have done the abortion r . Again it goes back to whether it. Iraq can in good faith clinical judgment thats a lot for the doctor to risk. Whendaho law changed to make the issue whether shes going to die or not or r shell have a serious medical condition theres a lot of daylight by your standards. It varies casebycase. Thats the problem. I shocked actually because i thought your own experts said these cases were covered and now youre saying they are not . Im not saying that and thats Justice Sotomayor is asking i they were covered it or not and understanding of that would be covered. Those doctors said that th were eing tical judgment they could in good faith determine lifesaving care was necessary and thats my point. Is the subject of . But some doctors might reach a contrary conclusion. If theyea the conclusion that the legislatures doctors didnt would they be prosecuted under idaho . No, no. Ifreach the conclusio that dr. Run with dr. What if th prosecutor thought differently what the prosecutor thought dont any dont think any goodfaith doctor about that inclusion . That your honors the nature of prosecutorial discretion and mayesult in a case. Is idaho put out any kind of guidance hhs guidance about was covered by the law a what is not in idaho . T regulatio. The g star here is the case which the lengthy detailed treatment under the supreme cour of this law may clear come to court made clear theres no medical certainty will cram a have to wait for the mothertobe facing death. Thank you couns what hapf a dispute arises with respect to whether or not ctor was within the confines of i law as the doctor subjeo if you buy a medical authority to . Exactly how a s elevated because its an obvious concern if individual eon for doctor and we are having a debate is that covered by your subn that nothing in idaho law prohibits complying with emtala. It begs the decision whether or not something is within or out. Same i imagine there two ways the law can be enforced. The board of me has licensing oversight over doctor in Idaho Supreme Court may clear that doctors fisma will be judge an objective standard for w reasonable doctorld do. The second way would be. What is the standard . The the doctors could medical statement which is subjective. If its a complaint again doctor that his standards dont con a particular emergencyroom and he has a particular standard . Than with Idaho Supreme Court says you may consider another dr. s question of the pretextual medical judgmt. Justice thomas. Justice alito . Well i would think that the concept of good medical judgment must take into acc some objective standards but it would leave certain amount of leeway for an individual doctor and thats how i interpreted what the state Supreme Court sa you have been present here today witery quick summaries of cases and asked to pra snap judgment about what would b appropriate in those partic