Planned Parenthood Assn. of Kansas City, Mo., Inc. v. Ashcroft

462 U.S. 476, 103 S. Ct. 2517, 76 L. Ed. 2d 733, 1983 U.S. LEXIS 64, 51 U.S.L.W. 4783

• Court: Supreme Court of the United States
• Decided: June 15, 1983
• Docket: 81-1255
• Status: Published

Opinions

Justice Powell

announced the judgment of the Court in Part VI and delivered the opinion of the Court with respect to Parts I and II and an opinion with respect to Parts III, IV, and V, in which The Chief Justice joins.

These cases, like City of Akron v. Akron Center for Reproductive Health, Inc., ante, p. 416, and Simopoulos v. Virginia, post, p. 506, present questions as to the validity of state statutes or local ordinances regulating the performance of abortions.

I

Planned Parenthood Association of Kansas City, Missouri, Inc., two physicians who perform abortions, and an abortion clinic (plaintiffs) filed a complaint in the District Court for the Western District of Missouri challenging, as unconstitutional, several sections of the Missouri statutes regulating the performance of abortions. The sections relevant here include Mo. Rev. Stat. § 188.025 (Supp. 1982), requiring that abortions after 12 weeks of pregnancy be performed in a hospital;¹ §188.047, requiring a pathology report for each abortion performed;² §188.030.3, requiring the presence of a second physician during abortions performed after viability;³ and §188.028, requiring minors to secure parental or judicial consent.⁴

After hearing testimony from a number of expert witnesses, the District Court invalidated all of these sections except the pathology requirement. 483 F. Supp. 679, 699-701 (1980).⁵ The Court of Appeals for the Eighth Circuit reversed the District Court’s judgment with respect to § 188.028, thereby upholding the requirement that a minor secure parental or judicial consent to an abortion. It also held that the District Court erred in sustaining §188.047, the pathology requirement. The District Court’s judgment with respect to the second-physician requirement was affirmed, and the case was remanded for further proceedings and findings relating to the second-trimester hospitalization requirement. 655 F. 2d 848, 872-873 (1981). On remand, the District Court adhered to its holding that the second-trimester hospitalization requirement was unconstitutional. The Court of Appeals affirmed this judgment. 664 F. 2d 687, 691 (1981). We granted certiorari. 456 U. S. 988 (1982).

The Court today in City of Akron, ante, at 426-431, has stated fully the principles that govern judicial review of state statutes regulating abortions, and these need not be repeated here. With these principles in mind, we turn to the statutes at issue.

II

In City of Akron, we invalidated a city ordinance requiring physicians to perform all second-trimester abortions at general or special hospitals accredited by the Joint Commission on Accreditation of Hospitals (JCAH) or by the American Osteopathic Association. Ante, at 431-432. Missouri’s hospitalization requirements are similar to those enacted by Akron, as all second-trimester abortions must be performed in general, acute-care facilities.⁶ Forthe reasons stated in City of Akron, we held that such a requirement “unreasonably infringes upon a woman’s constitutional right to obtain an abortion.” Ante, at 439. For the same reasons, we affirm the Court of Appeals’ judgment that § 188.025 is unconstitutional.

H-H h — I

We turn now to the State’s second-physician requirement. In Roe v. Wade, 410 U. S. 113 (1973), the Court recognized that the State has a compelling interest in the life of a viable fetus: “[T]he State in promoting its interest in the potentiality of human life may, if it chooses, regulate, and even proscribe, abortion except where it is necessary, in appropriate medical judgment, for the preservation of the life or health of the mother.” Id., at 164-165. See Colautti v. Franklin, 439 U. S. 379, 386-387 (1979); Beal v. Doe, 432 U. S. 438, 445-446 (1977). Several of the Missouri statutes undertake such regulation. Postviability abortions are proscribed except when necessary to preserve the life or the health of the woman. Mo. Rev. Stat. §188.030.1 (Supp. 1982). The State also forbids the use of abortion procedures fatal to the viable fetus unless alternative procedures pose a greater risk to the health of the woman. § 188.030.2.

The statutory provision at issue in this case requires the attendance of a second physician at the abortion of a viable fetus. § 188.030.3. This section requires that the second physician “take all reasonable steps in keeping with good medical practice... to preserve the life and health of the viable unborn child; provided that it does not pose an increased risk to the life or health of the woman.” See n. 3, supra. It also provides that the second physician “shall take control of and provide immediate medical care for a child bom as a result of the abortion.”

The lower courts invalidated § 188.030.3.⁷ The plaintiffs, respondents here on this issue, urge affirmance on the grounds that the second-physician requirement distorts the traditional doctor-patient relationship, and is both impractical and costly. They note that Missouri does not require two physicians in attendance for any other medical or surgical procedure, including childbirth or delivery of a premature infant.

The first physician’s primary concern will be the life and health of the woman. Many third-trimester abortions in Missouri will be emergency operations,⁸ as the State permits these late abortions only when they are necessary to preserve the life or the health of the woman. It is not unreasonable for the State to assume that during the operation the first physician’s attention and skills will be directed to preserving the woman’s health, and not to protecting the actual life of those fetuses who survive the abortion procedure. Viable fetuses will be in immediate and grave danger because of their premature birth. A second physician, in situations where Missouri permits third-trimester abortions, may be of assistance to the woman’s physician in preserving the health and life of the child.

By giving immediate medical attention to a fetus that is delivered alive, the second physician will assure that the State’s interests are protected more fully than the first physician alone would be able to do. And given the compelling interest that the State has in preserving life, we cannot say that the Missouri requirement of a second physician in those unusual circumstances where Missouri permits a third-trimester abortion is unconstitutional. Preserving the life of a viable fetus that is aborted may not often be possible,⁹ but the State legitimately may choose to provide safeguards for the comparatively few instances of live birth that occur. We believe the second-physician requirement reasonably furthers the State’s compelling interest in protecting the lives of viable fetuses, and we reverse the judgment of the Court of Appeals holding that § 188.030.3 is unconstitutional.

> HH

In regulating hospital services within the State, Missouri requires that “[a]ll tissue surgically removed with the exception of such tissue as tonsils, adenoids, hernial sacs and prepuces, shall be examined by a pathologist, either on the premises or by arrangement outside of the hospital.” 13 Mo. Admin. Code § 50-20.030(3)(A)7 (1977). With respect to abortions, whether performed in hospitals or in some other facility, §188.047 requires the pathologist to “file a copy of the tissue report with the state division of health . . . .” See n. 2, swpra. The pathologist also is required to “provide a copy of the report to the abortion facility or hospital in which the abortion was performed or induced.” Thus, Missouri appears to require that tissue following abortions, as well as from almost all other surgery performed in hospitals, must be submitted to a pathologist, not merely examined by the performing doctor. The narrow question before us is whether the State lawfully also may require the tissue removed following abortions performed in clinics as well as in hospitals to be submitted to a pathologist.

On its face and in effect, § 188.047 is reasonably related to generally accepted medical standards and “further[s] important health-related state concerns.” City of Akron, ante, at 430. As the Court of Appeals recognized, pathology examinations are clearly “useful and even necessary in some cases,” because “abnormalities in the tissue may warn of serious, possibly fatal disorders.” 655 F. 2d, at 870.¹⁰ As a rule, it is accepted medical practice to submit all tissue to the examination of a pathologist.¹¹ This is particularly important following abortion, because questions remain as to the long-range complications and their effect on subsequent pregnancies. See App. 72-73 (testimony of Dr. Willard Cates, Jr.); Levin, Schoenbaum, Monson, Stubblefield, & Ryan, Association of Induced Abortion with Subsequent Pregnancy Loss, 243 J. A. M. A. 2495, 2499 (1980). Recorded pathology reports, in concert with abortion complication reports, provide a statistical basis for studying those complications. Cf. Planned Parenthood of Central Missouri v. Danforth, 428 U. S. 52, 81 (1976).

Plaintiffs argue that the physician performing the abortion is as qualified as a pathologist to make the examination. This argument disregards the fact that Missouri requires a pathologist — not the performing physician — to examine tissue after almost every type of surgery. Although this requirement is in a provision relating to surgical procedures in hospitals, many of the same procedures included within the Missouri statute customarily are performed also in outpatient clinics. No reason has been suggested why the prudence required in a hospital should not be equally appropriate in such a clinic. Indeed, there may be good reason to impose stricter standards in this respect on clinics performing abortions than on hospitals.¹² As the testimony in the District Court indicates, medical opinion differs widely on this question. See 4 Record 623; 5 Record 749-750, 798-800, 845-847; n. 11, supra. There is substantial support for Missouri’s requirement. In this case, for example, Dr. Bernard Nathan-son, a widely experienced abortion practitioner, testified that he requires a pathologist examination after each of the 60,000 abortions performed under his direction at the New York Center for Reproductive and Sexual Health. He considers it “absolutely necessary to obtain a pathologist’s report on each and every specimen of tissue removed from abortion or for that matter from any other surgical procedure which involves the removal of tissue from the human body.” App. 143-144. See also id,., at 146-147 (testimony of Dr. Keitges); 5 Record 798-799 (testimony of Dr. Schmidt).¹³

In weighing the balance between protection of a woman’s health and the comparatively small additional cost of a pathologist’s examination, we cannot say that the Constitution requires that a State subordinate its interest in health to minimize to this extent the cost of abortions. Even in the early weeks of pregnancy, “[c]ertain regulations that have no significant impact on the woman’s exercise of her right [to decide to have an abortion] may be permissible where justified by important state health objectives.” City of Akron, ante, at 430. See Danforth, supra, at 80-81. We think the cost of a tissue examination does not significantly burden a pregnant woman’s abortion decision. The estimated cost of compliance for plaintiff Reproductive Health Services was $19.40 per abortion performed, 483 F. Supp., at 700, n. 48, and in light of the substantial benefits that a pathologist’s examination can have, this small cost clearly is justified. In Danforth, this Court unanimously upheld Missouri’s record-keeping requirement as “useful to the State’s interest in protecting the health of its female citizens, and [as] a resource that is relevant to decisions involving medical experience and judgment,” 428 U. S., at 81.¹⁴ We view the requirement for a pathology report as comparable and as a relatively insignificant burden. Accordingly, we reverse the judgment of the Court of Appeals on this issue.

Y

As we noted in City of Akron, the relevant legal standards with respect to parental-consent requirements are not in dispute. See ante, at 439; Bellotti v. Baird, 443 U. S. 622, 640-642, 643-644 (1979) (Bellotti II) (plurality opinion); id., at 656-657 (White, J., dissenting).¹⁵ A State’s interest in protecting immature minors will sustain a requirement of a consent substitute, either parental or judicial. It is clear, however, that “the State must provide an alternative procedure whereby a pregnant minor may demonstrate that she is sufficiently mature to make the abortion decision herself or that, despite her immaturity, an abortion would be in her best interests.”¹⁶ City of Akron, ante, at 439-440.¹⁷ The issue here is one purely of statutory construction: whether Missouri provides a judicial alternative that is consistent with these established legal standards.¹⁸

The Missouri statute, § 188.028.2,¹⁹ in relevant part, provides:

“(4) In the decree, the court shall for good cause:

“(a) Grant the petition for majority rights for the purpose of consenting to the abortion; or

“(b) Find the abortion to be in the best interests of the minor and give judicial consent to the abortion, setting forth the grounds for so finding; or

“(c) Deny the petition, setting forth the grounds on which the petition is denied.”

On its face, §188.028.2(4) authorizes Juvenile Courts²⁰ to choose among any of the alternatives outlined in the section. The Court of Appeals concluded that a denial of the petition permitted in subsection (c) “would initially require the court to find that the minor was not emancipated and was not mature enough to make her own decision and that an abortion was not in her best interests.” 655 F. 2d, at 858. Plaintiffs contend that this interpretation is unreasonable. We do not agree.

Where fairly possible, courts should construe a statute to avoid a danger of unconstitutionality. The Court of Appeals was aware, if the statute provides discretion to deny permission to a minor for any “good cause,” that arguably it would violate the principles that this Court has set forth. Ibid. It recognized, however, that before exercising any option, the Juvenile Court must receive evidence on “the emotional development, maturity, intellect and understanding of the minor.” Mo. Rev. Stat. §188.028.2(8) (Supp. 1982). The court then reached the logical conclusion that “findings and the ultimate denial of the petition must be supported by a showing of ‘good cause.’” 655 F. 2d, at 858. The Court of Appeals reasonably found that a court could not deny a petition “for good cause” unless it first found — after having received the required evidence — that the minor was not mature enough to make her own decision. See Bellotti II, 443 U. S., at 643-644, 647-648 (plurality opinion). We conclude that the Court of Appeals correctly interpreted the statute and that §188.028, as interpreted, avoids any constitutional infirmities.²¹

<1 l-H

The judgment of the Court of Appeals, insofar as it invalidated Missouri’s second-trimester hospitalization requirement and upheld the State’s parental- and judicial-consent provision, is affirmed. The judgment invalidating the requirement of a pathology report for all abortions and the requirement that a second physician attend the abortion of any viable fetus is reversed. We vacate the judgment upholding an award of attorney’s fees for all hours expended by plaintiffs’ attorneys and remand for proceedings consistent with Hensley v. Eckerhart, 461 U. S. 424 (1983).

It is so ordered.

1 Missouri Rev. Stat. § 188.025 (Supp. 1982) provides: “Every abortion performed subsequent to the first twelve weeks of pregnancy shall be performed in a hospital.”

2 Missouri Rev. Stat. §188.047 (Supp. 1982) provides:

“A representative sample of tissue removed at the time of abortion shall be submitted to a board eligible or certified pathologist, who shall file a copy of the tissue report with the state division of health, and who shall provide a copy of the report to the abortion facility or hospital in which the abortion was performed or induced and the pathologist's report shall be made a part of the patient’s permanent record.”

3 Missouri Rev. Stat. § 188.030.3 (Supp. 1982) provides:

“An abortion of a viable unborn child shall be performed or induced only when there is in attendance a physician other than the physician performing or inducing the abortion who shall take control of and provide immediate medical care for a child bom as a result of the abortion. During the performance of the abortion, the physician performing it, and subsequent to the abortion, the physician required by this section to be in attendance, shall take all reasonable steps in keeping with good medical practice, consistent with the procedure used, to preserve the life and health of the viable unborn child; provided that it does not pose an increased risk to the life or health of the woman.”

4 Missouri Rev. Stat. § 188.028 (Supp. 1982) provides:

“1. No person shall knowingly perform an abortion upon a pregnant woman under the age of eighteen years unless:

“(1) The attending physician has secured the informed written consent of the minor and one parent or guardian; or

“(2) The minor is emancipated and the attending physician has received the informed written consent of the minor; or

“(3) The minor has been granted the right to self-consent to the abortion by court order pursuant to subsection 2 of this section, and the attending physician has received the informed written consent of the minor; or

“(4) The minor has been granted consent to the abortion by court order, and the court has given its informed written consent in accordance with subsection 2 of this section, and the minor is having the abortion willingly, in compliance with subsection 3 of this section.

“2. The right of a minor to self-consent to an abortion under subdivision (3) of subsection 1 of this section or court consent under subdivision (4) of subsection 1 of this section may be granted by a court pursuant to the following procedures:

“(1) The minor or next friend shall make an application to the juvenile court which shall assist the minor or next friend in preparing the petition and notices required pursuant to this section. The minor or the next friend of the minor shall thereafter file a petition setting forth the initials of the minor; the age of the minor; the names and addresses of each parent, guardian, or, if the minor’s parents are deceased and no guardian has been appointed, any other person standing in loco parentis of the minor; that the minor has been fully informed of the risks and consequences of the abortion; that the minor is of sound mind and has sufficient intellectual capacity to consent to the abortion; that, if the court does not grant the minor majority rights for the purpose of consent to the abortion, the court should find that the abortion is in the best interest of the minor and give judicial consent to the abortion; that the court should appoint a guardian ad litem of the child; and if the minor does not have private counsel, that the court should appoint counsel. The petition shall be signed by the minor or the next friend;

“(8) A hearing on the merits of the petition, to be held on the record, shall be held as soon as possible within five days of the filing of the petition. ... At the hearing, the court shall hear evidence relating to the emotional development, maturity, intellect and understanding of the minor; the nature, possible consequences, and alternatives to the abortion; and any other evidence that the court may find useful in determining whether the minor should be granted majority rights for the purpose of consenting to the abortion or whether the abortion is in the best interests of the minor;

“(4) In the decree, the court shall for good cause:

“(a) Grant the petition for majority rights for the purpose of consenting to the abortion; or

“(b) Find the abortion to be in the best interests of the minor and give judicial consent to the abortion, setting forth the grounds for so finding; or

“(c) Deny the petition, setting forth the grounds on which the petition is denied;

“3. If a minor desires an abortion, then she shall be orally informed of and, if possible, sign the written consent required by section 188.039 in the same manner as an adult person. No abortion shall be performed on any minor against her will, except that an abortion may be performed against the will of a minor pursuant to a court order described in subdivision (4) of subsection 1 of this section that the abortion is necessary to preserve the life of the minor.”

5 The District Court also awarded attorney’s fees for all hours claimed by the plaintiffs’ attorneys. The Court of Appeals affirmed this allocation of fees. See 655 F. 2d 848, 872 (CA8 1981). The petition for certiorari raises the issue whether an award of attorney’s fees, made pursuant to 42 U. S. C. § 1988 (1976 ed., Supp. V), should be proportioned to reflect the extent to which plaintiffs prevailed.

6 Missouri does not define the term “hospital” in its statutory provisions regulating abortions. We therefore must assume, as did the courts below, see 483 F. Supp. 679, 686, n. 10 (1980); 664 F. 2d 687, 689-690, and nn. 3,5, and 6 (1981), that the term has its common meaning of a general, acute-care facility. Cf. Mo. Rev. Stat. § 188.015(2) (Supp. 1982) (defining “abortion facility” as “a clinic, physician’s office, or any other place or facility in which abortions are performed other than a hospital”). Section 197.020.2 (1978), part of Missouri’s hospital licensing laws, reads:

“ ‘Hospital’ means a place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment or care for not less than twenty-four hours in any week of three or more nonrelated individuals suffering from illness, disease, injury, deformity or other abnormal physical conditions; or a place devoted primarily to provide for not less than twenty-four hours in any week medical . . . care for three or more nonrelated individuals. . . .”

Cf. Mo. Rev. Stat. § 197.200(1) (1978) (defining “ambulatory surgical center” to include facilities “with an organized medical staff of physicians” and “with continuous physician services and registered professional nursing services whenever a patient is in the facility”); 13 Mo. Admin. Code § 50-30.010(1)(A) (1977) (same). The regulations for the Department of Social Services establish standards for the construction, physical facilities, and administration of hospitals. §§50-20.010 to 50-20.030. These are not unlike those set by JCAH. See City of Akron, ante, at 432, and n. 16.

7 The courts below found, and Justice Blackmun’s partial dissenting opinion agrees, post, at 499-500, that there is no possible justification for a second-physician requirement whenever D&E is used because no viable fetus can survive a D&E procedure. 483 F. Supp., at 694; 655 F. 2d, at 865. Accordingly, for them, § 188.030.3 is overbroad. This reasoning rests on two assumptions. First, a fetus cannot survive a D&E abortion, and second, D&E is the method of choice in the third trimester. There is general agreement as to the first proposition, but not as to the second. Indeed, almost all of the authorities disagree with Justice Blackmun’s critical assumption, and as the Court of Appeals noted, the choice of this procedure after viability is subject to the requirements of § 188.030.2. See id., at 865, and n. 28. Nevertheless, the courts below, in conclusory language, found that D&E is the “method of choice even after viability is possible.” Id., at 865. No scholarly writing supporting this view is cited by those courts or by the partial dissent. Reliance apparently is placed solely on the testimony of Dr. Robert Crist, a physician from Kansas, to whom the District Court referred in a footnote. 483 F. Supp., at 694, n. 25. This testimony provides slim support for this holding. Dr. Crist’s testimony, if nothing else, is remarkable in its candor. He is a member of the National Abortion Federation, “an organization of abortion providers and people interested in the pro-choice movement.” 3 Record 415-416. He supported the use of D&E on 28-week pregnancies, well into the third trimester. In some circumstances, he considered it a better procedure than other methods. See id., at 427-428. His disinterest in protecting fetal life is evidenced by his agreement “that the abortion patient has a right not only to be rid of the growth, called a fetus in her body, but also has a right to a dead fetus.” Id., at 481. He also agreed that he “[njever ha[s] any intention of trying to protect the fetus, if it can be saved,” ibid., and finally that “as a general principle” “[t]here should not be a live fetus,” id., at 435. Moreover, contrary to every other view, he thought a fetus could survive a D&E abortion. Id., at 433-434. None of the other physicians who testified at the trial, those called both by the plaintiffs and defendants, considered that any use of D&E after viability was indicated. See 2 Record 21 (limiting use of D&E to under 18 weeks); 3 Record 381, 410-413 (Dr. Robert Kretzschmar) (D&E up to 17 weeks; would never perform D&E after 26 weeks); 5 Record 787 (almost “inconceivable” to use D&E after viability); 7 Record 52 (D&E safest up to 18 weeks); id., at 110 (doctor not performing D&E past 20 weeks); id., at 111 (risks of doing outpatient D&E equivalent to childbirth at 24 weeks). See also 8 Record 33, 78-81 (deposition of Dr. Willard Cates) (16 weeks latest D&E performed). Apparently Dr. Crist performed abortions only in Kansas, 3 Record 334, 368, 428, a State having no statutes comparable to § 188.030.1 and § 188.030.2. It is not clear whether he was operating under or familiar with the limitations imposed by Missouri law. Nor did he explain the circumstances when there were “contraindications” against the use of any of the procedures that could preserve viability, or whether his conclusory opinion was limited to emergency situations. Indeed, there is no record evidence that D&E ever will be the method that poses the least risk to the woman in those rare situations where there are compelling medical reasons for performing an abortion after viability. If there were such instances, they hardly would justify invalidating § 188.030.3.

In addition to citing Dr. Crist in its footnote, the District Court cited— with no elaboration — Dr. Schmidt. His testimony, reflecting no agreement with Dr. Crist, is enlightening. Although he conceded that the attendance of a second physician for a D&E abortion on a viable fetus was not necessary, he considered the point mostly theoretical, because he “simply [did] not believe that the question of viability comes up when D&E is an elected method of abortion.” 5 Record 836. When reminded of Dr. Crist’s earlier testimony, he conceded the remote possibility of third-trimester D&E abortions, but stated: “I personally cannot conceive that as a significant practical point. It may be important legally, but [not] from a medical standpoint. . . .” Ibid. Given that Dr. Crist’s discordant testimony is wholly unsupported, the State’s compelling interest in protecting a viable fetus justifies the second-physician requirement even though there may be the rare case when a physician may think honestly that D&E is required for the mother’s health. Legislation need not accommodate every conceivable contingency.

8 There is no clearly expressed exception on the face of the statute for the performance of an abortion of a viable fetus without the second physician in attendance. There may be emergency situations where, for example, the woman’s health may be endangered by delay. Section § 188.030.3 is qualified, at least in part, by the phrase “provided that it does not pose an increased risk to the life or health of the woman.” This clause reasonably could be construed to apply to such a situation. Cf. H. L. v. Matheson, 450 U. S. 398, 407, n. 14 (1981) (rejecting argument that Utah statute might apply to individuals with emergency health care needs).

9 See American College of Obstetricians and Gynecologists (ACOG) Technical Bulletin No. 56, p. 4 (Dec. 1979) (as high as 7% live-birth rate for intrauterine instillation of uterotonic agents); Stroh & Hinman, Reported Live Births Following Induced Abortion: Two and One-Half Years' Experience in Upstate New York, 126 Am. J. Obstet. Gynecol. 83, 83-84 (1976) (26 live births following saline induced-abortions; 9 following hysterotomy; 1 following oxtyocin-induced abortion) (1 survival out of 38 live births); 5 Record 728 (50-62% mortality rate for fetuses 26 and 27 weeks); id., at 729 (25-92% mortality rate for fetuses 28 and 29 weeks); id., at 837 (50% mortality rate at 34 weeks).

10 A pathological examination is designed to assist in the detection of fatal ectopic pregnancies, hydatidiform moles or other preeancerous growths, and a variety of other problems that can be discovered only through a pathological examination. The general medical utility of pathological examinations is clear. See, e. g., ACOG, Standards for Obstetric-Gynecologic Services 52 (5th ed. 1982) (1982 ACOG Standards); National Abortion Federation (NAF) Standards 6 (1981) (compliance with standards obligatory for NAF member facilities to remain in good standing); Brief for American Public Health Association as Amicus Curiae, O. T. 1982, Nos. 81-185, 81-746, 81-1172, p. 29, n. 6 (supporting the NAF standards for nonhospital abortion facilities as constituting “minimum standards”).

11 ACOG’s standards at the time of the District Court’s trial recommended that a “tissue or operative review committee” should examine “all tissue removed at obstetric-gynecologic operations.” ACOG, Standards for Obstetric-Gynecologic Services 13 (4th ed. 1974). The current ACOG Standards also state as a general rule that, for all surgical services performed on an ambulatory basis, “[t]issue removed should be submitted to a pathologist for examination.” 1982 ACOG Standards, at 52. Justice Blackmun’s partial dissent, however, relies on the recent modification of these Standards as they apply to abortions. ACOG now provides an “exception to the practice” of mandatory examination by a pathologist and makes such examination for abortion tissue permissive. Ibid. Not surprisingly, this change in policy was controversial within the College. See 5 Record 799-800. ACOG found that “[n]o consensus exists regarding routine microscopic examination of aspirated tissue in every case,” though it recognized — on the basis of inquiries made in 29 institutions — that in a majority of them a microscopic examination is performed in all cases. ACOG, Report of Committee on Gynecologic Practice, Item #6.2.1 (June 27-28, 1980).

12 The professional views that the plaintiffs find to support their position do not disclose whether consideration was given to the fact that not all abortion clinics, particularly inadequately regulated clinics, conform to ethical or generally accepted medical standards. See Bellotti v. Baird, 448 U. S. 622, 641, n. 21 (1979) (Bellotti II) (minors may resort to “incompetent or unethical” abortion clinics); Planned Parenthood of Central Missouri v. Danforth, 428 U. S. 52, 91, n. 2 (1976) (Stewart, J., concurring). The Sun-Times of Chicago, in a series of special reports, disclosed widespread questionable practices in abortion clinics in Chicago, including the failure to obtain proper pathology reports. See The Abortion Profiteers, Chicago Sun-Times 25-26 (Special Reprint 1978). It is clear, therefore, that a State reasonably could conclude that a pathology requirement is necessary in abortion clinics as well as in general hospitals.

In suggesting that we make from a “comfortable perspective” the judgment that a State constitutionally can require the additional cost of a pathology examination, Justice Blackmun’s partial dissent suggests that we disregard the interests of the “woman on welfare or the unemployed teenager.” Post, at 498. But these women may be those most likely to seek the least expensive clinic available. As the standards of medical practice in such clinics may not be the highest, a State may conclude reasonably that a pathologist’s examination of tissue is particularly important for their protection.

13 Justice Blackmun’s partial dissent appears to suggest that § 188.047 is constitutionally infirm because it does not require microscopic examination, post, at 496-497, but that misses the point of the regulation. The need is for someone other than the performing clinic to make an independent medical judgment on the tissue. See n. 12, supra; 5 Record 750 (Dr. Pierre Keitges, a pathologist). It is reasonable for the State to assume that an independent pathologist is more likely to perform a microscopic examination than the performing doctor. See H. Cove, Surgical Pathology of the Endometrium 28 (1981) (“To the pathologist, abortions of any sort are evaluated grossly and microscopically for the primary purpose of establishing a diagnosis of intrauterine pregnancy”) (emphasis added).

14 The Danforth Court also noted that “[t]he added requirements for confidentiality, with the sole exception for public health officers, and for retention for seven years, a period not unreasonable in length, assist and persuade us in our determination of the constitutional limits.” 428 U. S., at 81. Missouri extends the identical safeguards found reassuring in Danforth to the pathology reports at issue here. See Mo. Rev. Stat. §§ 188.055.2, 188.060 (Supp. 1982).

15 The dissenters apparently believe that the issue here is an open one, and adhere to the views they expressed in Bellotti II. Post, at 503-504. But those views have never been adopted by a majority of this Court, while a majority have expressed quite differing views. See H. L. v. Matheson, 450 U. S. 398 (1981); Bellotti II (plurality opinion); 443 U. S., at 656-657 (White, J., dissenting).

16 The plurality in Bellotti II also required that the alternative to parental consent must “assure” that the resolution of this issue “will be completed with anonymity and sufficient expedition to provide an effective opportunity for an abortion to be obtained.” Id., at 644. Confidentiality here is assured by the statutory requirement that allows the minor to use her initials on the petition. Mo. Rev. Stat. § 188.028.2(1) (Supp. 1982). As to expedition of appeals, § 188.028.2(6) provides in relevant part:

“The notice of intent to appeal shall be given within twenty-four hours from the date of issuance of the order. The record on appeal shall be completed and the appeal shall be perfected within five days from the filing of notice to appeal. Because time may be of the essence regarding the performance of the abortion, the supreme court of this state shall, by court rule, provide for expedited appellate review of cases appealed under this section.”

We believe this section provides the framework for a constitutionally sufficient means of expediting judicial proceedings. Immediately after the effective date of this statutory enactment, the District Court enjoined enforcement. No unemancipated pregnant minor has been required to comply with this section. Thus, to this point in time, there has been no need for the State Supreme Court to promulgate rules concerning appellate review. There is no reason to believe that Missouri will not expedite any appeal consistent with the mandate in our prior opinions.

17 Cf. H. L. v. Matheson, supra, at 406-407, and n. 14, 411 (upholding a parental notification requirement but not extending the holding to mature or emancipated minors or to immature minors showing such notification detrimental to their best interests). The lower courts found that § 188.028’s notice requirement was unconstitutional. 655 F. 2d, at 873; 483 F. Supp., at 701. The State has not sought review of that judgment here. Thus, in the posture in which it appears before this Court for review, § 188.028 contains no requirement for parental notification.

18 The Missouri statute also exempts “emancipated” women under the age of 18 both from the requirement of parental consent and from the alternative requirement of a judicial proceeding. Plaintiffs argue that the word “emancipated” in this context is void for vagueness, but we disagree. Cf. H. L. v. Matheson, supra, at 407 (using word to describe a minor). Although the question whether a minor is emancipated turns upon the facts and circumstances of each individual case, the Missouri courts have adopted general rules to guide that determination, and the term is one of general usage and understanding in the Missouri common law. See Black v. Cole, 626 S. W. 2d 397, 398 (Mo. App. 1981) (quoting 67 C. J. S., Parent and Child § 86, p. 811 (1950)); In re Marriage of Heddy, 535 S. W. 2d 276, 279 (Mo. App. 1976) (same); Wurth v. Wurth, 313 S. W. 2d 161, 164 (Mo. App. 1958) (same), rev’d on other grounds, 322 S. W. 2d 745 (Mo. 1959).

19 See n. 4, supra. This Court in Danforth held unconstitutional Missouri’s parental-consent requirement for all unmarried minors under the age of 18. 428 U. S., at 75. In response to our decision, Missouri enacted the section challenged here. This new statute became effective shortly before our decision in Bellotti II.

20 We have indicated in prior opinions that a minor should have access to an “independent decisionmaker.” H. L. v. Matheson, supra, at 420 (Powell, J., concurring). Missouri has provided for a judicial decisionmaker. We therefore need not consider whether a qualified and independent nonjudicial decisionmaker would be appropriate. Cf. Bellotti II, 443 U.S., at 643, n. 22.

21 Plaintiffs also argue that, in light of the ambiguity of § 188.028.2(4), as evidenced by the differing interpretations placed upon it, the appropriate course of judicial restraint is abstention. This Court has found such an approach appropriate. See Bellotti v. Baird, 428 U. S. 132, 146-147 (1976) (Bellotti I). Plaintiffs did not, however, argue in. the Court of Appeals that the court should abstain, and Missouri has no certification procedure whereby this Court can refer questions of state statutory construction to the State Supreme Court. See 655 F. 2d, at 861, n. 20; 17 C. Wright, A. Miller, & E. Cooper, Federal Practice and Procedure § 4248, p. 525, n. 29 (1978 and Supp. 1982). Such a procedure “greatly simplified” our analysis in Bellotti I, supra, at 151. Moreover, where, as here, a statute is susceptible to a fair construction that obviates the need to have the state courts render the saving construction, there is no reason for federal courts to abstain.