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  1. When I first read about Gov Greg Abbott putting razor wire on the border, I was appalled. What is up with Republicans wanting to kill or maim people? It's like the Party of Death. As the saying goes "No hate like christian love" Juan R Gonzalez in USA Today ACLU re: Texas HB4 which died in the Texas Lege on Nov 7 2023
  2. that we have a good, decent man that is President, President Job Biden I had the enormous pleasure of being with my family, enjoying the companionship, conversation and laughs, as well as partaking of a delicious meal my daughter made. It was such a pleasant time. I noticed when I got back that the MAGA people also had their hero posting a thanksgiving message. It was like looking at a funhouse mirror, not a message lifting up Americans, celebrating our unity, but a petty diatribe blasting, bullying and scolding in ugly terms, one man's enemies and using his platform as a campaign in hopes, I believe, of winning the next election and continue what appears to be dementia on steroids. Can you see the contrast? One man, even if you don't agree with him about everything (and why should you, we are not a dictatorship but a democracy), gave us a message that appealed to our better natures, thanked all the people who work tirelessly in public service for this country and exhorted us to remember we are the United States of America. The other man used his pulpit to campaign for office, and, not just whine, but bitterly trash public service citizens, lie about the President, trash United States citizens that he doesn't happen to agree with, try to scare people who listen to him by implying that his sort of hateful bully should win. Make American Great Again? How is that? By encouraging people to be that kind of trash too? Admit it, if you had an old, going senile person at your Thanksgiving meal that started going on like this, unless you're a glutton for punishment and wanted to argue with him, you'd excuse yourself from the table and go watch football, all while whispering to your children to ignore what is being said. Except this old man is not gracious and presidential in old age. The above must be christian values. It's especially surprising to me when this hits the group of people that claim to somehow be better than anyone else on the basis of being brand *christian*. Sorry but I do not agree that the above list exemplifies good values nor want to join with anyone that thinks they do. Trump doesn't give two hoots about them, anyway, as long as they vote for him. To me, at least a large part of this election is about what kind of people we want to be, and, while not expecting perfection, at least not catering the extolling the bad behaviour and evil of those who want to divide our great country. Do US citizens who consider themselves patriots really want someone to be president who says that immigrants are *poisoning the blood of our country*? That[s what Hitler said, are there US citizens who believe in *blood purity* and are willing to exterminate other US citizens to do it? I'd sure like to see people ASK each other, especially in areas when gathered at supposed holy places, if they agree with this? Do US citizens believe that calling other US citizens that don't happen to agree with each other *vermin*? What does it mean when Trump says, as he did in New Hampshire recently, that he will *root out* the vermin? Deport US citizens he doesn't agree with? Throw them in jail? Murder them? Have his MAGA followers kill them? And, Trump called people vermin on Veteran's Day. Do we really want, in this great country, a person in charge who wants to dehumanize people and scare others doing so? It's truly disgusting. And, if a person makes being a US citizen being deported or not or attacked a loyalty test on whether they love one person and his family, rather than the constitution and the ideal of a united democracy, there is something unfit about that person being even near running the country. Here's Rude Pundit's profanity laced comment on this. Also, from NY Times Glass continued: If Trump — in adopting language that he cannot help knowing replicates that of Hitler (especially the references to opponents as “vermin” and “poisoning the blood of our country”), we have to wonder if he has crossed into “new terrain.” That terrain, driven by grandiosity and dread of exposure (e.g., at the trials) could signal the emergence of an even less constrained, more overtly vicious and remorseless Trump who, should he regain the presidency, would, indeed act like the authoritarians he praises. Absent conscientious aides who could contain him (as they barely did last time), this could lead to the literal shedding of American blood on American soil by a man who believes he is “the only one” and the one, some believe, is a purifying agent of God and in whom they see no evil nor do they doubt. Do US citizens really not want fair trials and everyone's day in court, and try to conduct government business that affects us all on on just, and open level? I believe in public entities like the courts and am glad that people don't run around just shooting people without the benefit of a fair trial process. That's unlike Trump, who said when someone robs a store, "you can full expect to be shot as you are leaving that store". He said this a day after he called for General Milley to be executed. What if the store got it wrong, or the people standing outside with a gun get it wrong? We are, I thought, a nation of laws, and a a process for law-breakers, not vigilante process or shooting somebody just because you have a gun, instead of calling the police to arrest lawbreakers. I've seen the movie "Purge" and the premise is supposed to be outrageous. Law and order processes are not perfect but seem for the most part to function well, and when they don't, in this day and age, it's usually public at least at some point so US citizens can call it out. Instead of Trump constantly trying to game the system over his own multitude of charges, begging suckers for money to pay for his attorneys so he can file endless lawsuits, and nastily attacking public servants who are following the law and giving him HIS day in court. He sure seems like a grifting coward to me, and that is not an ideal US citizens should try to live up to. From an article from plus.bulwark
  3. Yes, I realize Poor Poor Old Trump, who clearly is an awful man with growing dementia, is probably not a fit person to even be talking about. Certainly he's not a role model for anyone who cares about ethics, democracy and how to raise decent children, but here we are. This old conman keeps preying on suckers to pay his attorney bills, like a malevolent P T Barnum. It doesn't appear to these people Trump treats as chumps that Trump whining about so many cases against him might just be because he is deserving to be indicted. Trump the Rapist: Rape case. E Jean Carroll accused Trump of battery and defamation. On May 9 2023, Trump was found liable. (Not a surprise if you remember that creeps's grab-them-by-the-P*ssy remarks. What was surprising to me was so many people pretending to be morally superior by touting that they were so-called christians voted for him.) What was equally interesting about this is the judge said Trump was found to have raped E Jean Carroll. Filing Repeating that last part. Ms Carroll was awarded $2 million and $20,000 dollars. He set aside $5.5 million dollars in NY to pay E Jean Carroll as he awaits appeal response. Who helped this so-called billionaire get that much money? Probably chumps he sent beg-for-money emails to. 2nd case after Trump defamed her a second time, ie, what does Old Man Trump, who not only can't control his mouth but sure seems eager to be ugly to people, do? He decides to go defame Carrolll AGAIN. Now there's another trial in January 2024 that is not to determine IF he did it but to determine damages. And because, no doubt, the judge was concerned that Trump would either threaten or try to influence the jury, Judge orders anonymous jury for E Jean Carroll case against Trump Trump's obstruction case in Florida re: documents which includes some classified. When Presidents leave the White house after they lose, they are supposed to give all the documents to the National Archives, not take them home. Trump not only took boxes to Maralago, but lied about having them, kept at least some of them in a bathroom! and when it looked like they would be discovered, moved at least some of them to another one of his clubs in New Jersey. Timeline Here's the full indictment - Trump was charged with The Department of Justice released on Friday an unsealed federal indictment of former President Donald Trump, with 37 felony counts related to the mishandling of classified documents, obstructing justice and making false statements. note that Trump lies repeatedly about what actually this case is about, READ the indictment, which includes pictures of how he left boxes of documents in the ballroom, in the bathroom and all over the floor. Also, READ what the National Archives said about the documents, which includes this You know what kills me about this? Back when Hillary Clinton was running, the cries of "Lock her up" because she kept classified material on a home server were rampant.. I am not a Republican, but I felt that what Clinton was doing was wrong. So did a lot of people. Why, then, is there such a weird double standard from the "Lock her up" people not to think when Trump decided to put a bunch of documents he was not supposed to take, but were the property of the National Archives, in the BATHROOM! BY THE TOILET!!! and then played all kinds of games to try to avoid giving them back, is that okay? If he had accidentally taken them instead of following the National Archives law, and then given them back when asked, it would be a completely different story than obstruction, which is what he is charged with. He had employees MOVE the boxes to hide them, tried to wipe the server that had camera evidence. And we know he was showing classified documents to people without them having the right to see them. Is that all just about his ego? What about obeying the law? I have zip respect for anyone who supports Trump in this. Compare this with REAL president Joe Biden Election Interference Case Against Trump in DC Trial date set in March, 2024. Full Indictment here Part of the indictment. Trump is also lying to people about what is in this indictment, probably so he can get more money for his lawyers. Recent filling, Trump wanted the charges regarding Jan 6th to be removed. Judge Chutkan denied his motion From the Jan 6th House Select Committee about Trump's lie that he won the 2020 election Trump Fraud re: his corporations in New York (Civil) New York AG claimed in her lawsuit against Trump and business that Trump and his executive team engaged in fraudulent business practices including inflating the value of Trump's business and the market value of his real estate holdings in New York state and in Florida. Judge Engoron granted partial summary judgment against Trump back in 2023; this fraud lawsuit continues in order to check the other charges and determine the penalty amounts against Trump ...Let's repeat that. Trump ALREADY LOST the case. Engoron agreed with prosecutors that Trump and his associates exaggerated the former president's net worth in order to complete deals and receive more financing. As part of his decision, Engoron ordered the business licenses of the defendants to be canceled in New York — making it potentially difficult for them to continue working in the state. He also ordered the continuation of an independent monitor to oversee the Trump Organization. Factchecking Trump's claims about the fraud trial (Ie Trump's lies) Incidentally, this is a bench trial, meaning that the judge rather than a jury hears this and rules on it. From yesterday, I found this hilarious. The Trump team is doing their defense now and one of the people testifying is a guy named Steven Laposa, who is supposed to be a real estate expert. Read this and laugh with me. And here's another Brain Trust Trump called as an *expert* witness Latest frivolous filing in this case, which Trump is desperate to overcome, since Engoron has already ruled that his corporation has to be dissolved, is asking the judge for a mistrial. Here is Engoron's answer from yesterday. And here is an amusing part Trump Falsifying Business Records in NY criminal trial set for march 25, 2024 Time Line A lot of people know this as including Trump's falsifying records in order to cover up sex with Stormy Daniels (while his wife had recently given birth to another Trump son) Trump indictment and statement of facts Trump and 18 other defendants charged in Rico case in Georgia (racketeering, conspiracy and other charges. Indictment Fanni Willis asks for August 5 2024 trial date 4 people involved in this have taken plea deals, including recording statements and apologies to the citizens of Georgia. (Kenneth Chesboro, Sidney Powell, Jenna Ellis, Scott Hall). Fanni Willis has asked, as of today, for an August 2024 date for the trial. Mark Meadows, chief of staff for Trump, who faces two charges of violation of the state racketeering law and solicitation of violation of oath by a public officer, does not want the trial for him to be held in Georgia, so petitioned federal court to move his trial to US District Court. Got turned down I and now is on appeal. Oral arguments at appeals court to be held for this on Dec 15th. Meanwhile, he came out with a book in which he lied about the 2020 election, so the book publishers are suing him Trump and his family promoting a pyramid scheme - Case (civil) with multi-level marketing set to go to trial Jan 29 2024. First filed anonymously in 2018, the lawsuit alleges that the Trump Corporation promoted a multi-level marketing scheme — better known as a pyramid scheme — through the company ACN Opportunity, LLC, which operates under the name American Communications Network. The four named plaintiffs, suing under a proposed class action, have since agreed to go public. The case, which will finally see a jury more than half a decade after its initial filing, has encountered repeated delay over attempts to dismiss the case and publicly disclose its plaintiffs. They claim that Trump should be liable for lending his and his family’s names to a pyramid scheme through endorsements on The Celebrity Apprentice, and the lawsuit includes embedded advertisements on the show — one of which states, “Personally endorsed by renowned entrepreneur and multi-billionaire Donald J. Trump.” Capitol Police officers civil lawsuit against Trump and January rioters P. S. Just a couple more suits about Trump in the past. The lawsuit accusing Trump of raping a 13 year old girl. Trump admits misusing charity funds, settles lawsuit against Trump foundation As Law&Crime previously reported, James filed a recommendation in March that Trump personally pay $8.4 million in penalties and fines due to his family’s frequently improper use of the Trump Foundation. Also originally requested was an absolute bar on Trump himself serving on non-profit boards in New York for the next decade and a proposed one-year ban for Trump’s adult children. The settlement is significantly more lenient in both monetary and punitive terms. “The Trump Foundation has shut down, funds that were illegally misused are being restored, the president will be subject to ongoing supervision by my office, and the Trump children had to undergo compulsory training to ensure this type of illegal activity never takes place again,” James said. “The court’s decision, together with the settlements we negotiated, are a major victory in our efforts to protect charitable assets and hold accountable those who would abuse charities for personal gain. My office will continue to fight for accountability because no one is above the law — not a businessman, not a candidate for office, and not even the President of the United States.”
  4. Last week, Somervell County Commissioners Court went into executive session and then came out and the majority voted to fire Dwayne Johnson. Commissioner Richard Talavera made the motion, Jeff Harris seconded. When it came time to vote Danny Chambers voted with those two and Tammy Ray and Wade Busch voted against. No secret that I have had reservations about Dwayne Johnson for a long time, including when he was Precinct 2 commissioner. I was surprised that after he lost his commissioner election to Talavera that he was then hired in some position of authority over the Somervell County Expo Center in Glen Rose. Some items previously I found concerning. 1. He paid no rendering tax on his personal property 2. He showed disrespect for the Texas Open Meetings Act and used a commissioner meeting as an opportunity to brag on himself 3. Shifty about the process to build out the Rooster Bar and Grill at Squaw Valley Golf Course 4. Voted to okay Hidden Valley Ranch Subdivision without much pushback on potential problems (until later when the commissioners held another meeting about this due to community ire) 5. Part of voting to approve a Somervell County assistance district -sloppy and possible illegality of election 6. Somervell County now in the booze business 7. Sloppiness in following the law re: the 2022 budget All that I knew. What I did not know is that there were two criminal investigations into him this last year. 2023_06_05_13_43_23[1766].pdfIn the first one, from February 2023, Johnson was accused of Theft of Property >=$750<$2500. The complainant said she had evidence of mishandled funds within the county. Notice that the Show Barn was apparently built without any plans. Wade Busch didn't know of any and Danny Chambers said "county maintenance workers built the show barn so there most likely were not any permanent building plans (which would of course, IF they existed, would presumably show where the lighting would go instead of a fly by night seat of the pants install A few comments on this. Ooopsie, Johnson said he did not realize he had been overpaid by over $1400 (Really inspires confidence that Johnson was being a good steward and careful with taxpayer money, doesn't it -/s) Also, more generally, how is it that there are elected people that are just running out to do things without any kind of plan, using their buddies for a service (and maybe getting a kickback, who knows?) and aren't trying to be fair with competing services in the county. The commissioners decided, because the case was punted to Hill County DA which refused to look at the case, to just make Johnson pay back the money. As a side note on checks and balances, going to pull out again the fact that we have a felon who is the head of payroll. If this somehow missed through at least 3 levels of checks and balances, what confidence is there that a person doing payroll can't also escape notice should that person decide to commit theft. Also, because the commissioners kept it quiet, no one really knew about this double overpayment of funds. So, this first investigation was kept quiet. I don't know if this was discussed in an executive session after April 24th, but probably on the 5/8/2023 regular session. On to the second one and this one is very recent. EXPO 2301104.pdf EXPO 2301104 (2).pdf Somebody named MaKayla D'nell decided to go post about selling pallets, that Somervell County owns, on Facebook, taking cash. This isn't like you or me or a private business selling pallets, heck, I've gotten pallets for various projects. No, these are government property and not there to be taken for some unaccounted cash. Somebody must have tipped off the Sheriff who asked Trey Brown, the County Attorney to begin a live investigation, which then included Investigator Green. This was in June 2023. The investigator gave $250 cash (marked bills) to some guy named "Randy" with exchange of pallets. This last part of this was the reason why this case was not charged, because there was a difference between the money in the drawer and the money the investigator had given Makayla, since it went through a third person. That brings us to the 7th of November when the commissioners went into a special session and then came out and voted-Note who voted for and against. How many times did Johnson apparently lie?
  5. Somervell County has had at least three instances, that I know of, where an employee working for a public governmental entity, either embezzled money from the entity or worked with money while convicted of a felony. One, back in 2015, was Melanie Reese, former City Secretary of Glen Rose who plea bargained theft of government funds. A second was Janice Nickell who embezzled from Glen Rose Medical Center in 2013. And then there was Liz Morgan, who embezzled church money and spent at least part of it to take her child on a $20,000 Florida vacation. She worked for Glen Rose Medical Center in charge of patient records and HIPAA privacy officer, presumably taking off an hour or so every week to attend her probation officer hearing. Very recently a friend of mine told me that there is a felon working in payroll at Somervell County Courthouse, where Danny Chambers is judge. Although Treasurer is an elected position, payroll is not, and the felony this person plead guilty to was Theft of Property $20k>$100k. A couple of people did a background check on this person and found that the offense she was arrested for was a felony classification, offense code 23990010, with probation begin date of 20130617, sentence CommunitySupervisionCountySomervell. I have a few questions. When was she hired to work in payroll, ie, dealing with money, for Somervell County? Did anyone flag her activity when she was hired? Have heard that the former treasurer, Susie Graves, hired her, apparently without the benefit of doing a background check on her first. What are this payroll person's probation terms? If her probation terms were 10 years, then was she on probation for this felony when she was hired? Second, she was not hired for a Human Resourced job initially. When did that happen and why? Who is the person that oversees what she does? Is it the treasurer (Valerie Williams) ? The auditor (Nikky Weeden) ? Surely she's not a person, with a felony record, in a department with no oversight. Mentioning that I will be updating this post after the open records request I have done asking for her criminal record, including probation disposition. My personal opinion remains the same as it has been with the 3 previous incidents where someone stole money and had a job that dealt with money. Are there not plenty of other job either now or in the future that a person can apply for when one is a felon other than dealing with money and sensitive data? I think so. And apparently, at this moment, Danny Chambers and the commissioners know that this woman was convicted of being a felon. Why is she still there? Is there absolutely no one in the area who knows how to do payroll and is not a felon for the job? The taxpaying public deserves to have confidence that the people in charge of their money in ANY position do not have a theft felony and confidence that others in charge will not close their eyes and ignore that background. And it's not only money but other personal information dealing with payrolls. Even if one argues that this felon's work is being overseen by the auditor, Nikki Weeden, is that really the way that business should be conducted, having to scrupulously being on guard against theft from someone who is already convicted of same? (Maybe you would do this with family members, but this is dealing with public taxpayer money) Mentioning also that this is a Right To Work state, which is a deceptive misnomer for being able to fire someone at any time for any reason. From the Somervell County Personnel Policies Below is the audio of the County Commissioners coming out of executive session and voting on a new HR department. Apparently the person doing payroll also was given the job of human resources, without any salary bump. The new position for HR apparently cuts out the current payroll employee who "wears many hats". She was clearly not happy, even though she was NOT getting a salary change but is apparently being paid the same without having the duty of being *the* HR person, and carried on about it (listen below and you can hear). Why does someone care this much about a position for which she was not even being paid? Anyone know what this woman is referring to? Were there payroll problems already under her watch? What were those problems and how were they resolved? I'd also like to know why this week, her job of HR was cut off. What happened? Did the court finally realize this was a colossally bad idea or did something happen that made it imperative? Chambers makes the comment that back in 2019, the departments were changed. Some more timeline. Compare the 2023 budget and the 2022 budget First, I can find no entry for HR or Human Resources. Maybe sharper eyes can locate that but if this means, as the audio above shows, that they basically just tacked on that duty to the payroll person but now plan to create an HR department, that would explain why it's not there (and again, according to the audio, the commissioners were not paying the felon any extra money for this position). The Treasury job in 2022's budget showed 2022 010-405-101 TREASURER SALARY $56,055.00 $56,055.00 56,055.00 44,374.50 79.16 56,054.64 56,054.76 2022 010-405-103 TREASURER CHIEF DEPUTY $46,471.00 $46,471.00 38,700.28 13,096.86 33.84 53,907.90 43,752.06 2022 010-405-104 TREASURER PERSONNEL $42,500.00 $42,500.00 54,110.24 55,881.07 103.27 34,005.90 0 but in 2023, the Treasury Salary is $59,000 but the Chief Deputy, Personnel and Part time are 0 compare auditor 2022 010-404-101 AUDITOR SALARY $75,480.00 $75,480.00 75,480.00 59,755.00 79.17 75,480.00 75,480.00 2022 010-404-103 AUDITOR ASSISTANTS SALARIES $81,844.00 $81,844.00 81,683.49 50,604.88 61.95 79,324.40 72,791.52 for 2023 budget Auditor Salary is $79,254,00 with assistant auditor 89,118.75 Cannot find a payroll administrator in 2022 Payroll in 2023 Payroll Administrative $55,650.00 with Payroll Clerk 0 So the way this looks is that the Treasurer had additional staff cut for 2023, auditor still has salary and assistants both years and Payroll administrator was added for 2023. HR as a budget account does not appear in either 2022 or 2023.
  6. https://tlchouse.granicus.com/MediaPlayer.php?view_id=78&clip_id=24963 Here are the impeachment articles
  7. Wrote about this before on April 15th Here's the video from yesterday, the day before this hearing Here's the video for today (May 24 2023 before the Committee on General Investigating Here's an AP article showing what a crook this guy is. Chron Transcript of the hearing
  8. Texas Freedom Network Here's what I find ironic. These Texas Republicans are all about preventing children from learning about the diverse world as it is, and yet are trying to stuff 10 commandments posters into every classroom. If this jackass really feels this way, then why is he trying to put the Lege in the place of decision makers instead of parents with regard to the 10 commandments? Worse than a hypocrite. What is he, a christian nationalist instead of a normal person?
  9. Continuing from would not survive to birth. She was advised that continuing her pregnancy put her at a higher risk of developing preeclampsia, placental abruption, and deadly blood clots. Yet, she was denied an abortion because the hospital said it was unsure whether her conditions satisfied Ohio’s abortion- ban exceptions. She and her husband immediately scheduled an abortion at a hospital in Michigan. But, soon after, a Michigan appeals court allowed the state’s 1931 abortion ban to go into effect and, as a result, Tara was denied abortion care for the second time in under a week. After struggling to find care in other states, she received a call from a doctor in Michigan who told her that they could go ahead with the procedure as a judge had issued a temporary restraining order, blocking the ban’s enforcement. That same day, she rushed to Michigan where she was finally able to receive the care she needed.72 381. Beth Long, an Ohio resident, was around 17 weeks pregnant when she learned her baby had limb body wall complex, a rare condition where the baby’s organs develop outside its body. Beth, who had undergone extensive and expensive fertility treatment to get pregnant, was told that the condition posed health risks for her too, including dangerous bleeding that could necessitate a hysterectomy. Beth was advised to terminate the pregnancy as soon as possible. But because her life was not “imminently in danger,” her state-issued insurance would not cover the $20,000-$30,000 procedure in Ohio, and Beth was forced to delay abortion care for weeks and ultimately travel to an out of state hospital that would do the procedure for a discounted rate. Beth called it “the most dehumanizing experience of my life.”73 72 Abigail Abrams, ‘Never-Ending Nightmare.’ An Ohio Woman Was Forced to Travel Out of State for an Abortion, Time (Aug. 29, 2022), https://time.com/6208860/ohio-woman-forced-travel-abortion. 73 Elizabeth Cohen & Amanda Musa, Ohio Abortion Law Meant Weeks of “Anguish,” “Agony” for Couple Whose Unborn Child Had Organs Outside Her Body, CNN (Feb. 8, 2023), https://www.cnn.com/ 2023/02/08/health/ohio-abortion-long/index.html. 382. Kayla Smith, an Idaho resident, was 20 weeks pregnant when she learned her baby had critical aortic stenosis and hypoplastic left heart syndrome, both serious heart defects. Kayla had been diagnosed with preeclampsia when she was pregnant with her older child and worried she would develop it again. Kayla ultimately decided to travel to Washington State for an induction abortion.74 383. Jennifer Adkins, an Idaho resident, was 12 weeks pregnant when she learned that her fetus had hydrops fetalis, a severe form of swelling, and likely had Turner syndrome. Jennifer was told that her fetus was unlikely to survive but due to Idaho’s abortion bans, there was nothing her doctors could do. Seeking abortion care in another state made Jennifer feel like a criminal and a medical refugee, but she ultimately traveled to Oregon for an abortion.75 384. Carmen Broesder, an Idaho resident, was 6 weeks pregnant when she began experiencing heavy bleeding and intense pain and cramps. Despite multiple trips to emergency rooms at different hospitals, Carmen was repeatedly denied abortion care, with her physicians citing trepidation regarding Idaho’s abortion ban. Carmen documented her 19-day miscarriage on social media.76 385. Kelly Shannon, an Alabama resident, was midway through her pregnancy when she learned her baby had Down syndrome and further testing revealed swelling in the baby’s head and body wall, a heart defect, and a tumor in the baby’s abdomen. Kelly was told it was unlikely the 74 Abby Davis, ‘I Don’t Wish This on Anyone:’ Idaho Couple Travel Out of State for Abortion, KTVB7 (April 5, 2023), https://www.ktvb.com/article/news/local/capitol-watch/idaho-couple-travels-out-of-state-for-abortion- kayla-smith-james-smith-baby-brooks/277-f6d5cdca-7d1e-421b-8758-88495a1154d2. 75 Kelcie Moseley-Morris, Her Fetus Had 1% Chance of Survival. Idaho’s Ban Forced Her to Travel for an Abortion, Idaho Capital Sun (May 10, 2023), https://idahocapitalsun.com/2023/05/10/her-fetus-had-1-chance-of- survival-idahos-ban-forced-her-to-travel-for-an-abortion. 76 Mary Kekatos, Idaho Woman Shares 19-Day Miscarriage on TikTok, Says State’s Abortion Laws Prevented Her from Getting Care, ABC News (Jan. 21, 2023), https://abcnews.go.com/Health/idaho-woman-shares- 19-day-miscarriage-tiktok-states/story?id=96363578 baby would survive to birth. Her doctors tried to get permission to perform her abortion, but while one committee approved the procedure, a higher-level committee denied permission based on Alabama’s laws. Kelly traveled to Virginia to access abortion care.77 386. Alyssa Gonzales, an Alabama resident, was heartbroken when her second baby was diagnosed with trisomy 18. Yet in her words, “the worst was yet to come,” as Alabama’s trigger law had taken effect weeks earlier and Alyssa was told she did not qualify for an exception. Alyssa did not have the money to travel for an abortion, but after connecting with an abortion fund who offered financial support, Alyssa loaded her infant son, her fiancé, and his parents in the car, and they drove 11 hours to an abortion provider in Washington, D.C.78 387. Jill Hartle, a resident of South Carolina, was 22 weeks pregnant when her fetus was diagnosed with hypoplastic left heart syndrome, a condition where the fetal heart does not properly develop. But Jill was told there was nothing doctors could do for her at home because Roe v. Wade had been overturned weeks earlier and South Carolina’s 6-week abortion ban was in effect. Jill was ultimately able to get an appointment for an abortion in Washington, D.C. but had to wait two weeks for an appointment due to the influx of patients.79 388. Mylissa Farmer, a Missouri resident, was nearly 18 weeks pregnant when her water broke. Her doctor diagnosed her with PPROM and advised her to terminate the pregnancy to protect her health. Due to Missouri’s abortion ban, however, she was advised that doctors could 77 Nadine El-Bawab, Alabama Mother Denied Abortion Despite Fetus’ ‘Negligible’ Chance of Survival, ABC News (May 2, 2023), https://abcnews.go.com/US/alabama-mother-denied-abortion-despite-fetus-negligible- chance/story?id=98962378. 78 Alyssa Gonzales, I Live in Alabama. Our Cruel New Abortion Law Has Made My Life Absolute Hell, Huffpost Personal (Oct. 21, 2022), https://www.huffpost.com/entry/supreme-court-roe-v-wade- alabama_n_63486af5e4b0b7f89f546712. 79 Andrea Michelson, Former Ms. South Carolina Says She Was Forced to Carry Her Fetus Until 25 Weeks— 2 Months After Doctors Detected a Deadly Heart Defect, Insider (Nov. 14, 2022), https://www.insider.com/former- pageant-winner-describes-abortion-at-25-weeks-post-roe-2022-11. only intervene if her vitals plummeted, infection set in, or the fetus’s cardiac activity stopped. Mylissa worried that by the time there was an emergency, it would be too late for her, as she was already at higher risk of maternal thrombosis, infection, and severe blood loss. After struggling to find an abortion provider in three other states, she eventually found a clinic in Illinois and traveled hundreds of miles to receive the care she needed.80 Upon information and belief, Mylissa is the first patient since Roe was overturned to submit an EMTALA complaint based on being denied an abortion for an emergent medical condition.81 The U.S. Department of Health and Human Services recently cited hospitals in Kansas and Missouri for violating EMTALA by failing to provide Mylissa with proper abortion care.82 389. “R,” a Missouri resident, found out she was pregnant a week after Roe v. Wade was overturned. R had previously been diagnosed with a “bicornate uterus,” a congenital abnormality that creates significant risks for carrying a child to term. R immediately knew that she wanted an abortion. Missouri’s trigger ban had just taken effect, so R started calling clinics out of state, but they were all booked up. It took seven weeks before she was able to get an appointment in Illinois.83 390. Deborah Dorbert, a Florida resident, was 24 weeks pregnant when her fetus was diagnosed with Potter syndrome, a condition where the kidneys do not develop properly and do not produce a sufficient amount of amniotic fluid. Deborah was told that the condition is 80 Susan Szuch, After Missouri Banned Abortions, She Was Left ‘With a Baby Dying Inside.’ Doctors Said They Could Do Nothing, Springfield News-Leader (Oct. 19, 2022), https://www.news-leader.com/story/ news/local/ozarks/2022/10/19/missouri-laws-abortion-ban-left-her-with-a-baby-dying-inside-pprom/10366865002. 81 Admin. Compl. (Mylissa Farmer), U.S. Dep’t of Health & Human Servs. (Nov. 8, 2022), https://nwlc.org/wp-content/uploads/2022/11/2022.11.08-Mylissa-Farmer-EMTALA-complaint.pdf. 82 HHS Secretary Xavier Becerra Statement on EMTALA Enforcement (May 1, 2023), https://www.hhs.gov/about/news/2023/05/01/hhs-secretary-xavier-becerra-statement-on-emtala-enforcement.html; Press Release: NWLC Applauds CMS’ Action on Mylissa Farmer’s Emergency Abortion Complaint, Finding Hospitals Violated Federal Law, Nat’l Women’s Law Ctr. (May 1, 2023), https://nwlc.org/press-release/nwlc- applauds-cms-action-on-mylissa-farmers-emergency-abortion-complaint-finding-hospitals-violated-federal-law. 83 Carter Sherman, She Feared Giving Birth Would Kill Her. She Fled Her State for an Abortion., Vice (Oct. 26, 2022), https://www.vice.com/en/article/m7gx4v/abortion-missouri 89 incompatible with life as babies born with Potter syndrome are both unable to breathe and go into renal failure at birth, and that the risks to Deborah will increase as her pregnancy continues. Deborah and her husband decided that they wanted an abortion as soon as possible due to concern for Deborah’s physical and mental health, worries about the baby suffering, and their desire to begin the grieving process. But because no one in Florida would perform the abortion under the state’s medical exception, and it was too difficult to leave the state, Deborah carried the pregnancy to term. Her baby lived for only 99 minutes. Florida has a 15-week abortion ban that has been in effect since shortly after Roe was overturned—it has been challenged but is in effect while appeals continue.84 391. Anya Cook and Shanae Smith-Cunningham, two close friends in Florida, were both pregnant at the same time when they experienced the same pregnancy complication just days apart. Anya was around 16 weeks pregnant when her water broke and Shanae was 19 weeks pregnant. Anya was diagnosed with PPROM at an emergency room then sent home to wait. She ultimately gave birth in the bathroom of a hair salon, started bleeding profusely, and was rushed to the hospital for emergency surgery. Shanae was in Jamaica when her water broke and took the risk to fly back to Florida, thinking she would get better care at home. But Shanae was sent home from the hospital multiple times before she eventually went into labor on her own. Both women are now suffering from fertility problems.85 84 Frances Stead Sellers, Thomas Simonetti, & Maggie Penman, The Short Life of Baby Milo (May 19, 2023), https://www.washingtonpost.com/health/interactive/2023/florida-abortion-law-deborah-dorbert; Frances Stead Sellers, Her Baby Has a Deadly Diagnosis. Her Florida Doctors Refused an Abortion, Washington Post (Feb. 18, 2023), https://www.washingtonpost.com/health/2023/02/18/florida-abortion-ban-unviable-pregnancy-potter- syndrome; Maya Yang, Florida Couple Unable to Get Abortion Will See Baby Die After Delivery, The Guardian (Feb. 18, 2023), https://www.theguardian.com/world/2023/feb/18/florida-abortion-law-couple-birth. 85 Caroline Kitchener, Two Friends Were Denied Care After Florida Banned Abortion. One Almost Died, Washington Post (April 10, 2023), https://www.washingtonpost.com/politics/2023/04/10/pprom-florida-abortion- ban 392. Anabely Lopes, a Florida resident, was 15 weeks pregnant when her fetus was diagnosed with trisomy 18. Florida’s 15-week ban had gone into effect just days earlier, and Anabely was forced to travel to Washington, D.C. for an abortion. The experience was so painful and devastating that Anabely had thoughts of suicide.86 393. Heather Maberry, a Kentucky resident, was 20 weeks pregnant when she learned her baby had anencephaly. Heather was already struggling with hyperemesis gravidarum and on bedrest. Now she must decide if she will travel out of state for an abortion or give birth to a child who will not survive. She is currently trying to raise the funds she needs on GoFundMe to travel for an abortion.87 394. Amy English, a Kentucky resident, was 20 weeks pregnant when she learned her baby had acrania and anencephaly and would not survive to birth. Amy wanted an abortion but erupted into sobs when her doctor told her that it was illegal in Kentucky and she should call hospitals in Illinois. Amy remembers thinking, “Am I just supposed to Google the number, call the front desk and ask, ‘How do I get an abortion at your hospital?’” Amy, her husband, and her sister-in-law called multiple clinics, but due to abortion laws in Indiana and Ohio, she had trouble finding a provider who could do a D&E. Eventually, she found a hospital 400 miles away in Illinois that agreed to give her an induction abortion.88 86 Timothy Bella, Fla. Woman Forced to Fly to D.C. for Abortion Returns for State of the Union, Washington Post (Feb. 7, 2023), https://www.washingtonpost.com/politics/2023/02/07/state-of-union-abortion-florida-anabely- lopes. 87 Kelsey Souto, Powell Co. Woman Forced to Travel out of State for Abortion, WKYT (May 8, 2023), https://www.wkyt.com/2023/05/08/powell-co-woman-forced-travel-out-state-abortion. 88 Alex Acquisto, A ‘Twisted’ Experience: How KY’s Abortion Bans Are Depriving Pregnant Patients of Health Care, Lexington Herald Leader (Feb. 22, 2023), https://www.kentucky.com/news/politics- government/article271925592.html 395. Leah Martin, a Kentucky resident, was 12 weeks pregnant when she learned her fetus had triploidy and she was diagnosed with a partial molar pregnancy. She was told that her pregnancy could give her cancer if she did not get an abortion. But Kentucky’s abortion bans had taken effect two weeks earlier and the hospital told Leah that they could not perform the abortion while litigation of the abortion bans continued. But Leah got lucky. Shortly after her diagnosis, a Kentucky judge temporarily enjoined the abortion bans, and Leah got an appointment at Kentucky’s sole abortion clinic. The injunction was lifted just days after her procedure and the abortion bans remain in effect today.89 396. Chloe, an Arizona resident, was 23 weeks pregnant when she learned her baby had holoprosencephaly. She was told her baby would only survive for days, if at all, but that due to the state’s 15-week abortion ban, she could not receive an abortion in Arizona. Chloe considered traveling out of state, but the clinic where she was scheduled to receive care canceled her appointment after they received threats to the clinic and to her safety based on a story regarding her experience that she had shared on social media. Chloe was forced to carry the pregnancy to term and her daughter lived for only 2 days.90 Chloe continues to suffer mental health effects from the experience. 397. Jaci Statton, an Oklahoma resident, was in her first trimester when she learned she had a partial molar pregnancy. Heavy bleeding and severe nausea first sent her to the emergency room. She was told that continuing the pregnancy was extremely dangerous to her health and could lead to cancer. But three different hospitals turned her away, saying that due to Oklahoma’s 89 Id. 90 Katie Kindelan, Woman Has 44 Hours with her Baby Born After a Nonviable Pregnancy, Good Morning America (May 11, 2023), https://www.goodmorningamerica.com/wellness/story/44-hours-baby-carried-nonviable- pregnancy-term-after-97451344. abortion laws, they could not provide her with abortion care. One hospital told her to wait in the parking lot of the hospital to see if she got worse. Jaci eventually traveled to Kansas for an abortion. She continues to suffer negative health effects form the pregnancy.91 A study and associated commentary published in the Lancet shows that Jaci’s experience is not unique: confusion about the state’s abortions laws is widespread at the hospitals throughout Oklahoma.92 398. Additional stories of pregnant people not publicly named have appeared constantly in the news since Roe v. Wade was overturned. For example: a Texas woman whose fetus was diagnosed with acrania spent six weeks putting together the resources to travel out of state for an abortion, and she ended up needing a hysterectomy that likely would not have been necessary if she had been able to get an abortion sooner;93 a Tennessee woman whose fetus was diagnosed with a genetic condition putting her at risk of preeclampsia was forced to take a 6-hour ambulance ride to North Carolina where, on arrival, her blood pressure was dangerously high and she was showing signs of kidney failure;94 a Tennessee woman was diagnosed with a cesarean scar ectopic pregnancy and traveled to Georgia which, though it has its own abortion ban, at least has an explicit exception for ectopic pregnancies, unlike Tennessee;95 a Florida woman pregnant with twins was 91 Selena Simmons-Duffin, In Oklahoma, a Woman was Told to Wait Until She’s ‘Crashing’ for Abortion Care, NPR (April 25, 2023), https://www.npr.org/sections/health-shots/2023/04/25/1171851775/oklahoma-woman- abortion-ban-study-shows-confusion-at-hospitals. 92 Michele Heisler et al., US Abortion Bans Violate Patients’ Right to Information and to Health, Lancet (April 25, 2023), https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00808-5/fulltext; Physicians for Human Rights, the Oklahoma Call for Reproductive Justice, and the Center for Reproductive Rights, No One Could Say: Assessing Emergency Obstetrics Information as a Prospective Prenatal Patient in Post-Roe Oklahoma (April 2023), https://phr.org/wp-content/uploads/2023/04/Oklahoma-Abortion-Ban-Report-2023.pdf. 93 Selena Simmons-Duffin, 3 Abortion Bans in Texas Leave Doctors ‘Talking in Code’ to Pregnant Patients, NPR (March 1, 2023), https://www.npr.org/sections/health-shots/2023/03/01/1158364163/3-abortion-bans-in-texas- leave-doctors-talking-in-code-to-pregnant-patients. 94 Susan Rinkunas, A Tennessee Woman Had to Take a 6-Hour Ambulance Ride to Get an Abortion, Jezebel (Oct. 17, 2022), https://jezebel.com/a-tennessee-woman-had-to-take-a-6-hour-ambulance-ride-t-1849668907. 95 Poppy Noor, ‘I Cried With Her’: The Diary of a Doctor Navigating a Total Abortion Ban, The Guardian (Feb. 22, 2023), https://www.theguardian.com/world/2023/feb/22/diary-doctor-navigating-total-abortion-ban- tennessee. 20 weeks pregnant when her water broke and she partially delivered one of the fetuses, but she was forced to wait a week until both fetuses’ hearts stopped to receive medical care;96 people whose fetuses were diagnosed with fatal conditions like anencephaly, some of whom were able to travel out of state for abortion care, while others were forced to carry the pregnancies to term and suffer through the emotional trauma of a stillbirth;97 and people who have been denied or delayed in receiving treatment for ectopic pregnancies or miscarriage despite intense pain and bleeding.98 B. Confusion and Fear Throughout the Medical Community Regarding Texas’s Abortion Bans and Similar Bans Around the Country 399. The stories of pregnant people described above reflect the widespread confusion among the medical community regarding the proper application of the Emergent Medical Condition Exception, combined with fear that a physician’s good faith reliance on the exception could nonetheless result in disciplinary sanctions, civil penalties, and/or a lengthy prison sentence. 400. After S.B. 8 took effect, researchers from Texas Policy Evaluation Project, the University of Texas at Austin, Baylor College of Medicine, and the Pegasus Health Justice Center interviewed 25 clinicians in general obstetrics and gynecology, maternal and fetal medicine, and genetic counseling regarding the impact S.B. 8 has had on their practice. The results of these 96 Rachel Rapkin, Here’s the Harrowing Story of One of My Patients After Florida’s 15-Week Abortion Ban, Tampa Bay Times (Jan. 21, 2023), https://www.tampabay.com/opinion/2023/01/21/heres-harrowing-story-one-my- patients-after-floridas-15-week-abortion-ban-column. 97 Nilo Tabrizy et al., “Do No Harm”: OB-GYNs Weigh the Legal Impact of Abortion Bans, N.Y. Times (Sept. 10, 2022), https://www.nytimes.com/video/us/100000008489880/abortion-bans-maternal-health.html? searchResultPosition=14; Noor, supra n.95. 98 Confusion Post-Roe Spurs Delays, Denials for Some Lifesaving Pregnancy Care, Washington Post (July 16, 2022), https://www.washingtonpost.com/health/2022/07/16/abortion-miscarriage-ectopic-pregnancy-care; Stephanie Wenger, Tennessee Doctor Details Patient's Experience Being Unable to Get Pills to Complete Her Miscarriage, People (July 8, 2022), https://people.com/health/tenn-doctor-details-patients-experience-being-unable- to-get-pills-to-complete-her-miscarriage interviews were published in the New England Journal of Medicine99 and show that fear and confusion among the medical profession regarding abortion bans is widespread: 401. There is no consensus view among physicians on the meaning of the Emergent Medical Condition Exception, leading to significant chilling in the provision of pregnancy-related care that involves abortion. 402. Some physicians believe that “[p]eople have to be on death’s door to qualify for maternal exemptions to SB8.” Accordingly, some clinicians force patients with “pregnancy complications or preexisting medical conditions that may be exacerbated by pregnancy” to “delay an abortion until their conditions become life-threatening,” i.e., until the patient is in crisis, and thus “qualify as medical emergencies.”100 In other words, instead of being offered expectant management or termination of pregnancy when the emergent conditions present themselves, pregnant people are given one option: wait to miscarry without medical intervention or until the emergent conditions have made them so horribly ill that they are at risk of imminent death. 403. For example, “[s]ome clinicians believe that patients with rupture of membranes before fetal viability are eligible for a medical exemption under SB8, while others believe these patients cannot receive an abortion so long as there is fetal cardiac activity.” Physicians who believe they cannot intervene before a patient falls sick with infection will send patients home, 99 Whitney Arey et al., A Preview of the Dangerous Future of Abortion Bans – Texas Senate Bill 8, 387 N. Engl. J. Med. 388, 388-89 (Aug. 4, 2022); see also Charlotte Huff, In Texas, Abortion Laws Inhibit Care for Miscarriages, NPR (May 10, 2022), https://www.npr.org/sections/health-shots/2022/05/10/1097734167/in-texas- abortion-laws-inhibit-care-for-miscarriages; María Méndez, Texas Laws Say Treatments for Miscarriages, Ectopic Pregnancies Remain Legal But Leave Lots of Space for Confusion, Tex. Tribune (July 20, 2022), https://www.texastribune.org/2022/07/20/texas-abortion-law-miscarriages-ectopic-pregnancies. 100 Arey et al., supra n.99 at 389 95 “only to see them return with signs of sepsis.” Another patient received an abortion only after her “severe cardiac condition” caused her to be admitted to the ICU.101 404. All of the hospitals where the interviewees practice prohibited fetal reduction, “even though in some cases (e.g., complications of monochorionic twins) failure to perform the procedure could result in the loss of both twins.”102 This reflects Lauren M. and Ashley’s personal experiences. 405. Some of the interviewed clinicians reported that, based on legal guidance, they do not believe they can even counsel patients regarding “the availability of abortion in cases of increased maternal risks or poor fetal prognosis, although before SB8 they would have done so.”103 Again, this reflects the experiences of Amanda, Lauren M., Lauren H., Anna, Ashley, Kylie, Jessica, Samantha, Dr. Dennard, Taylor, Kiersten, Lauren V., and Elizabeth, who sensed that their medical providers felt muzzled. 406. Fear of liability under the abortion bans is so great that some physicians have even changed their standard treatment methods from D&E to induction or hysterotomy (a procedure similar to caesarean).104 407. The confusion extends to physicians who do not perform abortions but are involved in advising on the appropriate treatment or in providing sedation, such as anesthesiologists who place epidurals during labor inductions. These physicians reportedly worry about potential liability for “aiding and abetting” an illegal abortion and thus decline to participate 408. Confusion over the Emergent Medical Condition Exception extends to ectopic pregnancies as well. At least one Texas hospital no longer treats patients with ectopic pregnancies implanted in cesarean scars, even though ectopic pregnancies are excluded from Texas’s definition of abortion and leading experts at the Society for Maternal-Fetal Medicine recommend treating these “life-threatening pregnancies” with “surgical or medical” termination.106 409. Because of the law’s severe restrictions on maternal health and wellbeing, some doctors have departed Texas for states without equally strict abortion bans. The result is fewer doctors who are fully equipped to treat patients suffering from serious pregnancy complications and challenges with training the next generation of doctors.107 410. Another study was conducted at two large hospitals in Dallas County, Parkland Hospital and the William P. Clements Jr. University Hospital after S.B. 8 took effect. The study documented a significant increase in maternal morbidity among patients with preterm labor who would have been promptly offered induction abortions before the law but, due to fear regarding S.B. 8, were not offered such treatment until their physicians determined that an emergent condition posed “an immediate threat to maternal life.” The study followed 28 patients (26 with PPROM, 2 with pregnancy tissue prolapsed into the vagina). Among these patients, 43% (12 of 28) experienced infection or hemorrhage and one patient required a hysterectomy. Other maternal morbidities included ICU admissions, blood transfusions, postpartum emergency room visits, and postpartum readmission.108 106 Id. at 389 (citing Russell Miller et al., Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean Scar Pregnancy, 222 Am. J. Obstetrics & Gynecology B2-B14 (May 2020); see also Patricia Santiago- Munoz, M.D., Cesarean Scar Ectopic Pregnancy: Facts and Treatment Options, U.T. Sw. Med. Ctr. (Aug. 23, 2022), https://utswmed.org/medblog/cesarean-scar-ectopic-pregnancy (explaining that a CSEP “may result in hemorrhage” and “potentially lead[] to a hysterectomy, damage to surrounding organs, or death of the pregnant patient”). 107 Arey et al., supra n.99 at 390. 108 Anjali Nambiar, et al., Maternal Morbidity and Fetal Outcomes Among Pregnant Women at 22 Week 411. The Dallas hospitals study concluded that “state-mandated expectant management” is associated with “significant maternal morbidity.”109 412. State-mandated expectant management under Texas’s abortion bans resulted in a lapse of nine days on average between first diagnosis and the development of “complications that qualified as an immediate threat to maternal life.”110 413. The Dallas hospitals study examined practices prior to the overturning of Roe and the triggering of Texas’s complete ban on abortion. It also examined practices at level IV designated maternal care facilities in large urban centers. On information and belief, delays and maternal morbidities are worse for patients who first present to non-level IV designated maternal care facilities, for patients who live far from large urban centers, and for patients after the Trigger Ban sprung into effect. 414. An additional study focused on patients with lethal or life-limiting fetal diagnoses in Texas after S.B. 8 took effect. The study documented self-censoring among health care providers regarding abortion because of a fear of potential liability under S.B. 8, and a resulting lack of information for patients about their pregnancy options, including abortion. The study followed 16 patients who received lethal or life-limiting fetal diagnoses in Texas after S.B. 8 took effect and ultimately pursued an abortion out of state. Patients reported feeling isolated after receiving their diagnoses as their health care providers were unable to speak openly with them about their options, including abortion. Instead, the study documented that patients were forced to rely on Google and their own knowledge about abortion, all the while stating that they would have Gestation or Less with Complications in Two Texas Hospitals After Legislation on Abortion, 227 Am. J. Obstetrics & Gynecology 648 (2022), https://doi.org/10.1016/j.ajog.2022.06.060. preferred to receive information straight from their Texas doctor. The study concluded that restrictions like S.B. 8 “erode the patient–physician relationship, evoke fear and safety concerns, and create a significant burden on patients to understand pregnancy options and navigate the process of abortion alone.”111 415. The patients study concluded that restrictions like S.B. 8 “erode the patient– physician relationship, evoke fear and safety concerns, and create a significant burden on patients to understand pregnancy options and navigate the process of abortion alone.” 416. In the months since Roe v. Wade was overturned and other state bans have taken effect, confusion over the scope of exceptions to abortion bans has extended beyond Texas. For example, another article in the New England Journal of Medicine explained that physicians and other medical professionals nationwide have struggled to translate legislative exceptions to abortion bans into actionable clinical guidelines, with disastrous impacts on patient care. Without further explanation, physicians do not know if, for example, “a patient with pulmonary hypertension, for whom we cite a 30-to-50% chance of dying with ongoing pregnancy,” is sufficiently at risk of death or substantial impairment of a major bodily function to permit abortion.112 417. Other studies of the impact on the medical profession of reversing Roe v. Wade are ongoing, including a study out of the University of California San Francisco designed to examine how making abortion illegal is forcing clinical care for pregnant patients to deviate from the usual 111 Courtney C. Baker et al., Texas Senate Bill 8 and Abortion Experiences in Patients with Fetal Diagnoses, 141 Obstetrics & Gynecology 602 (2023), https://pubmed.ncbi.nlm.nih.gov/36735418. 112 Lisa H. Harris, Navigating Loss of Abortion Services—A Large Academic Medical Center Prepares for the Overturn of Roe v. Wade, 386 N. Engl. J. Med. 2061, 2061 (June 2, 2022) (describing a Michigan hospital’s efforts to interpret a state law permitting abortions to “preserve the life” of the pregnant person). standard of care.113 Preliminary findings of this study document horrifying outcomes for patients with emergent medical conditions that, like the Plaintiffs here, were denied or delayed abortion care due to confusion in the medical profession regarding the exceptions to abortion bans nationwide.114 418. In legal challenges to state abortion bans since Roe was overturned, medical professionals around the country have testified about the challenges of complying with state abortion bans, telling harrowing stories about their patients. These include: a 16-year-old girl who had such debilitating hyperemesis that she lost over 20 pounds and was forced to travel out of state twice to receive the care she needed after being denied an abortion; a patient with stage III melanoma who could not receive treatment until her pregnancy was terminated but was told she would have to travel out of state to receive an abortion, causing her to break down and cry inconsolably; and multiple patients diagnosed with PPROM but denied abortion care.115 In one case, a PPROM patient was forced to endure an excruciating, hours-long delivery of a non-viable fetus that eventually caused her to hemorrhage.116 Physicians have also testified about patients with mental health conditions that necessitated abortion care, including attempted suicide.117 419. These physicians have also testified about patients they treated before Roe was 113 Dobbs Impact Study, Univ. Cal. S.F., https://carepostroe.ucsf.edu. 114 Daniel Grossman et al., Preliminary Findings: Care Post-Roe: Documenting Cases of Poor-Quality Care Since the Dobbs Decision, Advancing New Standards in Reproductive Health (ANSIRH) (May 2023), https://www.ansirh.org/sites/default/files/2023-05/Care%20Post-Roe%20Preliminary%20Findings.pdf. 115 Aff. of Aeran Trick ¶¶ 6, 9, 11, Preterm Cleveland v. Yost, No. A2203203, 2022 WL 4279758 (Ohio Ct. Com. Pl. Sept. 2, 2022); Aff. of Valerie Williams, M.D. ¶¶ 10-11, June Med. Servs., LLC v. Landry, No. C-720988, 2022 WL 2902625 (La. Dist. Ct. July 13, 2022) (hereinafter “Williams Aff.”). 116 Williams Aff. ¶ 11. 117 See, e.g., Aff. of Dr. Sharon Liner ¶ 11, Preterm Cleveland v. Yost, No. A2203203 (Ohio Ct. Com. Pl. Sept. 2, 2022) (“We have had at least 3 patients threaten to commit suicide. Another patient stated that she would attempt to terminate her pregnancy by drinking bleach.”); Aff. of David Burkons, M.D. ¶ 9, Preterm Cleveland v. Yost, No. A2203203, 2022 WL 4279758 (Ohio Ct. Com. Pl. Sept. 2, 2022). overturned who they may not be able to help under the new state abortion bans if the same patient presented for care today. For example: patients whose fetuses were diagnosed with triploidy, causing some to develop HELLP syndrome and others preeclampsia with severe features; a patient who developed disseminated intravascular coagulation (“DIC”)—a condition that causes pregnant patients to lose large volumes of blood—due to placental abruption; a patient with preeclampsia with severe features that caused fluid to accumulate between the tissues lining her lungs and chest; a patient with preeclampsia with severe features caused by a partial molar pregnancy; a patient who experienced a septic abortion; a patient who went into hypovolemic shock after experiencing uncontrollable vaginal bleeding at 19 weeks of pregnancy; a patient with bipolar disorder at risk of developing postpartum psychosis; and patients with panic disorders that lead to attempted suicide.118 420. Physicians have also provided compelling hypotheticals in their testimony that highlight the practical ramifications of unclear abortion ban exceptions. For instance, one physician asked: “If a pregnant patient is experiencing renal failure, does she have to be on dialysis before a physician may perform an abortion that would otherwise be prohibited by the Ban? If a pregnant patient has a cardiac lesion, does a physician have to wait until she experiences heart 118 Decl. of Kylie Cooper, M.D. ¶¶ 6-12, United States v. Idaho, No. 1:22-cv-00329 (D. Idaho Aug. 8, 2022), ECF No. 17-7; Decl. of Dr. Emily Corrigan ¶¶ 20-30, United States v. Idaho, No. 1:22-cv-00329 (D. Idaho Aug. 8, 2022), ECF No. 17-6; Decl. of Stacy T. Seyb, M.D. ¶¶ 7-14, United States v. Idaho, No. 1:22-cv-00329 (D. Idaho Aug. 8, 2022), ECF No. 17-8; Aff. of Samantha Meltzer-Brody, M.D. ¶¶ 40-41, SisterSong Women of Color Reprod. Just. Collective v. Georgia, No. 2022CV367796, 2022 WL 3335938 (Ga. Super. Ct. July 23, 2022) (“I recall one patient who came to me with debilitating postpartum psychosis, a condition related to bipolar disorder that is often characterized by delusional thinking, typically focused on the infant. . . . The symptoms are excruciating . . . and there is a strong association between postpartum psychosis and maternal suicide. This patient was still in my treatment— no longer experiencing postpartum psychosis but still navigating her bipolar disorder—when she learned of an accidental pregnancy. She was gravely concerned about either stopping her medication during pregnancy and experiencing a worsening of her bipolar disorder, or continuing her medication and exposing the fetus to serious teratogenic risks. But even more than that, she was terrified at the thought of experiencing postpartum psychosis again and potentially hurting her child or herself. This patient told me repeatedly that she felt such overwhelming distress at the thought of continuing the pregnancy that she would rather die than go on.”). failure to intervene? If a pregnant patient has a clogged blood vessel, does a physician have to wait until she experiences chest pain before terminating the pregnancy to prevent pulmonary embolism?” Aff. of Martina Badell, M.D. ¶ 30, SisterSong Women of Color Reprod. Just. Collective v. Georgia, No. 2022CV367796, 2022 WL 3335933 (Ga. Super. Ct. July 25, 2022). Another physician queried: “[I]f I and another physician judge that a woman’s neurological condition is so complicated by pregnancy that she might lose entirely the ability to breathe, and I perform a procedure, could another physician look at the patient’s chart after the fact and think that we overestimated the danger, or that we should have delayed the abortion to see whether the patient’s condition deteriorated?” Decl. of Nikki Zite, M.D., M.P.H. ¶ 21, Memphis Ctr. for Reprod. Health v. Slatery, No. 3:20-cv-00501 (M.D. Tenn. June 22, 2020), ECF No. 8-3. III. THE TEXAS CONSTITUTION PROTECTS PREGNANT PEOPLE WITH EMERGENT MEDICIAL CONDITIONS AND THEIR PHYSICIANS FROM STATE DEPRIVATION OF THEIR RIGHTS A. Pregnant People Have Fundamental and Equal Rights Under the Texas Constitution 421. The Supreme Court may have stripped pregnant people of their federal constitutional right to abortion, Dobbs v. Jackson Women’s Health Organization, 142 S. Ct. 2228 (2022), but that does not mean that Plaintiffs are without Constitutional Rights. 422. The Texas Constitution guarantees its citizens certain fundamental rights, specifically: “[n]o citizen of this State shall be deprived of life, liberty, property, privileges, or immunities, or in any manner disfranchised, except by the due course of the law of the land.” Tex. Const. art. I, § 19. People do not lose these rights simply because they are pregnant. Moreover, Texas law cannot demand that a pregnant person sacrifice their life, their fertility, or their health for any reason, let alone in service of “unborn life,” particularly where a pregnancy will not or is unlikely to result in the birth of a living child with sustained life 102 423. The Texas Constitution also prohibits Texas law from excluding pregnant people with certain kinds of emergent conditions—for example, pregnant people whose health risks are not imminently “life-threatening”—from receiving appropriate and/or life-saving medical care. 424. The Texas Constitution also guarantees “equal rights” under the law and prohibits the law from “den[ying] or abridg[ing rights] because of sex.” Tex. Const. art. I, §§ 3, 3a. To deny a “woman known to be pregnant” equal access to life-saving and health-preserving medical care, simply because she is pregnant, would violate this foundational premise of equality under Texas law. 425. To the extent Texas’s abortion bans bar the provision of abortion to pregnant people to treat medical conditions that pose a risk to the pregnant person’s life or a significant risk to their health, the bans violate pregnant people’s fundamental rights under § 19 and their rights to equality under the law under §§ 3, 3a. 426. Indeed, Texas’s abortion bans fail any level of constitutional review when applied to such pregnant people. “If the Texas [pre-Roe ban] statute were to prohibit an abortion even where the mother’s life is in jeopardy, I have little doubt that such a statute would lack a rational relation to a valid state objective under the test stated in Williamson . . . .” Roe v. Wade, 410 U.S. 113, 173 (1973) (Rehnquist, J., dissenting). Because the abortion bans force pregnant people with emergent medical conditions to surrender their lives, health, and/or fertility, they have no rational relationship to protecting life, health, or any other legitimate state interest. B. Texas-Licensed Physicians Have Liberty and Property Rights to Provide Care to Pregnant People with Emergent Conditions 427. The Texas Constitution guarantees that “[n]o citizen of this State shall be deprived of life, liberty, property, privileges, or immunities, or in any manner disfranchised, except by the due course of the law of the land.” Tex. Const. art. I, § 19. The threatened enforcement of the abortion bans against physicians who in good faith provide abortions for pregnant people suffering emergent medical conditions infringes this constitutional guarantee. 428. Section 19 guarantees Texas-licensed physicians the right to practice their profession by providing abortion to their pregnant patients to treat emergent medical conditions that the physician determines poses a risk to the patient’s life or health. 429. To fulfill this guarantee, physicians must be able to exercise their good faith judgment in the care of their patients with emergent conditions without threat that the state will take their license and/or liberty if a prosecutor or jury second guesses their medical judgment. 430. Texas law authorizes Defendant TMB to institute disciplinary and licensing proceedings against any physician who performs an abortion that the TMB determines did not meet the Emergent Medical Condition Exception. See, e.g., Tex. Occ. Code §§ 165.001, 164.052(a)(5), 164.053(a), 164.055; Tex. Health & Safety Code § 170A.007. These proceedings may result in a provider losing their license to practice medicine. See, e.g., Tex. Health & Safety Code § 170A.007. 431. Disciplinary actions are reported to the National Practitioner Data Bank119 and can have collateral consequences on a physician’s ability to practice in other U.S. states.120 Defendant TMB, for example, requires physicians to make timely reports of any disciplinary actions taken by other jurisdictions against the physician, 22 Tex. Admin. Code § 173.3, and has taken disciplinary 119 See 42 U.S.C. § 11132 (requiring state medical boards to report all revocations or suspensions of physician licenses); see also Nat’l Practitioner Data Bank, Guidebook, at Ch. E: Reports, Table E-1 (Oct. 2018), https://www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp (explaining state medical boards and hospitals have mandatory reporting obligations). 120 See, e.g., Tex. Admin. Code § 173.3(d) (requiring reporting within 30 days of any actions issued by another state); Tex. Med. Bd. Press Release at 4-5, TMB Disciplines 27 Physicians at June Meeting, Adopts Rule Changes (June 30, 2022), https://www.tmb.state.tx.us/dl/2B28AF92-02B2-0425-2295-86E2DEAD1C51 (describing “other states’ [disciplinary] actions”). action against physicians based on conduct occurring in other states.121 Upon information and belief, disciplinary sanctions may also result in loss of employment. 432. Physicians must make a substantial investment to obtain a medical license in Texas. 433. According to the TMB, to be eligible for a physician’s license in Texas, individuals must: graduate from an accredited medical school, having gained admission through a highly competitive application process which often necessitates incurring significant amounts of debt (in 2019, an average of between $94,399 and $142,797 for students at medical schools in Texas);122 complete at least one continuous year of graduate medical training or a fellowship; pass rigorous state examinations; practice medicine full-time for one year; and, inter alia, have no relevant disciplinary or criminal history. 22 Tex. Admin Code § 163.2. 434. If physicians meet these requirements and incur the substantial associated costs, they are eligible for full licensure in Texas for which they must apply. 22 Tex. Admin Code §§ 163.2, 163.4. Once granted, a physician may practice medicine within Texas and has a vested property interest in their license. 435. Revoking or suspending a physician’s license based on a flawed interpretation of the Emergent Medical Condition Exception is improper interference with the physician’s vested property interest in their license. 436. Further, sending a physician to prison for up to 99 years for providing timely and appropriate medical care to a pregnant person with an emergent medical condition is improper interference with the physician’s liberty. 121 Tex. Med. Bd. Press Release at 4-5, TMB Disciplines 27 Physicians at June Meeting, Adopts Rule Changes (June 30, 2022), https://www.tmb.state.tx.us/dl/2B28AF92-02B2-0425-2295-86E2DEAD1C51. 122 See, e.g., Medical School Debt Keeps Climbing, Tex. Med. Ass’n (April 2020), https://app.texmed.org/ tma.archive.search/files/53049/april_20_tm_educationinfographic.pdf. 105 437. Physicians have constitutional rights under § 19 of the Texas Constitution including rights to liberty, property, and substantive due course of law. Even for laws that only touch on economic rights, § 19 requires a rational relationship to the purpose of the law. 438. As applied to pregnant people with emergent medical conditions and the physicians treating them, Texas’s abortion bans fail to comply with the Texas Constitution. They do not serve a proper legislative purpose because far from furthering life, they harm pregnant people’s lives, and the lives of their children, without furthering potential life at all. Texas law also demands that there be a real and substantial connection between a legislative purpose and the language of the law as it functions in practice. For pregnant people with emergent medical conditions, there is none. Further, for patients with emergent conditions, Texas’s abortion bans work an excessive burden on physicians treating such patients relative to their purported purpose. See, e.g., Patel v. Tex. Dep’t of Licensing & Reg., 469 S.W.3d 69, 80-81 (Tex. 2015). CLAIMS CLAIM I: DECLARATORY JUDGMENT 439. The allegations in paragraphs 1 through 438 above are incorporated as if fully set forth herein. 440. Plaintiffs hereby petition the Court pursuant to the UDJA. 441. Section 37.002 of the UDJA provides that it is remedial and its purpose is to settle and to afford relief from uncertainty and insecurity with respect to rights, status, and other legal relations; and it is to be liberally construed and administered. 442. Under Section 37.003 of the UDJA, a court of proper jurisdiction has the power to declare rights, status, and other legal relations, whether or not further relief is or could be claimed. The declaration may be either affirmative or negative in form and effect and the declaration has the force and effect of a final judgment or decree 443. Plaintiffs thus seek a declaratory judgment that the exception to Texas’s abortion bans, codified at Tex. Health & Safety Code §§ 170A.001-002, 171.002(3), 171.203-205, permits physicians to provide a pregnant person with abortion care when the physician determines, in their good faith judgment and in consultation with the pregnant person, that the pregnant person has a physical emergent medical condition that poses a risk of death or a risk to their health (including their fertility). 444. Plaintiffs also seek a declaratory judgment that, at a minimum, Texas’s abortion bans do not preclude a physician from providing abortion care where, in the physician’s good faith judgment and in consultation with the pregnant person, a pregnant person has: a physical medical condition or complication of pregnancy that poses a risk of infection, bleeding, or otherwise makes continuing a pregnancy unsafe for the pregnant person; a physical medical condition that is exacerbated by pregnancy, cannot be effectively treated during pregnancy, or requires recurrent invasive intervention; and/or a fetal condition where the fetus is unlikely to survive the pregnancy and sustain life after birth. 445. Plaintiffs have sued the State and the relevant state agencies, and that they seek to have this Court determine the validity of Texas’s abortion bans as applied in circumstances arising from emergent medical conditions. Therefore, the State and its agencies are necessary parties to this suit and governmental immunity does not apply. CLAIM II: ULTRA VIRES 446. The allegations in paragraphs 1 through 445 above are incorporated as if fully set forth herein. 447. A state office may not act without legal authority. See, e.g., City of El Paso v. Heinrich, 284 S.W.3d 366, 372 (Tex. 2009) 448. Any official’s enforcement of Texas’s abortion bans against any physician who provides an abortion to a pregnant person after determining that, in the physician’s medical judgment, the pregnant person has a physical emergent medical condition for which abortion would prevent or alleviate a risk of death or risk to their health (including their fertility) would be inconsistent with the Emergent Medical Condition Exception to Texas’s abortion bans and therefore would be ultra vires. 449. Plaintiffs have sued the Defendant state officials in their official capacities, and they seek prospective relief other than the recovery of monetary damages. Therefore, governmental immunity does not apply. CLAIM III: SECTION 19 RIGHTS OF PREGNANT PEOPLE 450. The allegations in paragraphs 1 through 449 above are incorporated as if fully set forth herein. 451. Under the Texas Constitution, “[n]o citizen of this State shall be deprived of life, liberty, property, privileges, or immunities, or in any manner disfranchised, except by the due course of the law of the land.” Tex. Const. art. I, § 19. 452. To the extent Texas’s abortion bans bar the provision of abortion to pregnant people to treat emergent medical conditions that pose a risk to pregnant people’s lives or health (including their fertility), the bans violate pregnant people’s fundamental rights under Article I, § 19 of the Texas Constitution. 453. Thus applied, Texas’s abortion bans do not serve a compelling or important state interest and are not sufficiently tailored to serve any compelling interest. 454. Thus applied, Texas’s abortion bans also lack any rational relationship to protecting life, health, or any other legitimate state interest 455. Plaintiffs seek a declaratory judgment that Article I, § 19 of the Texas Constitution guarantees a pregnant person the right to an abortion where the pregnant person has an emergent medical condition that poses a risk of death or risk to their health (including their fertility), and an abortion would prevent or alleviate such risk. 456. Any official’s enforcement of Texas’s abortion bans as applied to a pregnant person with an emergent medical condition for whom an abortion would prevent or alleviate a risk of death or risk to their health (including their fertility) would be inconsistent with Article I, § 19 of the Texas Constitution and therefore would be ultra vires. CLAIM IV: EQUAL RIGHTS OF PREGNANT PEOPLE 457. The allegations in paragraphs 1 through 456 above are incorporated as if fully set forth herein. 458. Under the Texas Constitution, “[a]ll freemen, when they form a social compact, have equal rights, and no man, or set of men, is entitled to exclusive separate public emoluments, or privileges, but in consideration of public services.” Tex. Const. art. I, § 3. 459. Texas does not prevent non-pregnant people or people unable to get pregnant from accessing critical medical treatment nor force them to unnecessarily suffer severe illnesses and injuries and undergo mental anguish. 460. To the extent Texas’s abortion bans bar or delay the provision of abortion to a pregnant person with an emergent medical condition that poses a risk of death or risk to their health (including their fertility), while allowing non-pregnant people and people unable to get pregnant to access medical treatment for emergent medical conditions, Texas’s abortion bans violate pregnant people’s right to equal rights. 461. Thus applied, Texas’s abortion bans do not serve a compelling or important state interest and are not sufficiently tailored to serve any compelling interest. 462. Thus applied, Texas’s abortion bans also lack any rational relationship to protecting life, health, or any other legitimate state interest. 463. Plaintiffs seek a declaratory judgment that Article I, § 3 of the Texas Constitution guarantees a pregnant person the right to an abortion where the pregnant person has an emergent medical condition that poses a risk of death or risk to their health (including their fertility), and an abortion would prevent or alleviate such risk. 464. Any official’s enforcement of Texas’s abortion bans as applied to a pregnant person with an emergent medical condition for whom an abortion would prevent or alleviate a risk of death or risk to their health (including their fertility) would be inconsistent with Article I, § 3 of the Texas Constitution and therefore would be ultra vires. CLAIM V: EQUALITY BASED ON SEX FOR PREGNANT PEOPLE 465. The allegations in paragraphs 1 through 464 above are incorporated as if fully set forth herein. 466. Under the Texas Constitution, “[e]quality under the law shall not be denied or abridged because of sex, race, color, creed, or national origin.” Tex. Const. art. I, § 3a. 467. To the extent Texas’s abortion bans bar or delay the provision of abortion to a “woman known to be pregnant” to treat an emergent medical condition that poses a risk of death or risk to their health (including their fertility), while allowing other people to access medical treatment for emergent medical conditions, Texas’s abortion bans deny pregnant women equality because of sex. 468. To the extent the Texas’s abortion bans are based on gender stereotypes that a woman’s primary role is to birth children and be a mother, they constitute discrimination because of sex. 469. Thus applied, Texas’s abortion bans do not serve a compelling or important state interest and are not sufficiently tailored to serve any compelling interest. 470. Thus applied, Texas’s abortion bans also lack any rational relationship to protecting life, health, or any other legitimate state interest. 471. Plaintiffs seek a declaratory judgment that Article I, § 3a of the Texas Constitution guarantees a pregnant person the right to an abortion where the pregnant person has an emergent medical condition that poses a risk of death or risk to their health (including their fertility), and an abortion would prevent or alleviate such risk. 472. Any official’s enforcement of Texas’s abortion bans as applied to a pregnant person with an emergent medical condition for whom an abortion would prevent or alleviate a risk of death or risk to their health (including their fertility) would be inconsistent with Article I, § 3a of the Texas Constitution and therefore would be ultra vires. CLAIM VI: SECTION 19 RIGHTS OF PHYSICIANS 473. The allegations in paragraphs 1 through 472 above are incorporated as if fully set forth herein. 474. Under the Texas Constitution, “[n]o citizen of this State shall be deprived of life, liberty, property, privileges, or immunities, or in any manner disfranchised, except by the due course of the law of the land.” Tex. Const. art. I, § 19. 475. Section 19 guarantees Texas-licensed physicians the right to practice their profession by providing abortion to their pregnant patients to treat emergent medical conditions that the physician determines pose a risk to the pregnant person’s life or health (including their fertility). 476. To the extent Texas’s abortions bans bar or delay physicians from providing abortion to treat emergent medical conditions that pose a risk to a pregnant person’s life or health 111 (including their fertility), Texas’s abortion bans violate Texas-licensed physicians’ rights under Section 19. 477. Thus applied, Texas’s abortion bans do not serve a proper legislative purpose, there is no real and substantial connection between a legislative purpose and the language of the abortion bans as those bans function in practice for patients with emergent medical conditions, and Texas’s abortion bans work an excessive burden on Texas-licensed physicians treating such patients relative to their purpose. 478. Thus applied, Texas’s abortion bans also lack any rational basis. 479. Plaintiffs seek a declaratory judgment that Article I, § 19 of the Texas Constitution guarantees Texas-licensed physicians the right to provide an abortion to a pregnant person to treat an emergent medical condition that the physician determines poses a risk to the pregnant person’s life or health (including their fertility). 480. Any official’s enforcement of Texas’s abortion bans as applied to a Texas-licensed physician who provides an abortion to a pregnant person to treat an emergent medical condition that the physician determines poses a risk to the pregnant person’s life or health (including their fertility) would be inconsistent with Article I, § 19 of the Texas Constitution and therefore would be ultra vires. CLAIM VII: APPLICATION FOR TEMPORARY INJUNCTION 481. The allegations in paragraphs 1 through 480 above are incorporated as if fully set forth herein. 482. Pursuant to Texas Civil Practice and Remedies Code Section 65.011 et seq., Plaintiffs are entitled to temporary injunctive relief against Defendants pending the full resolution of the merits. 483. Defendants’ threatened enforcement of Texas’s abortion bans is causing imminent, irreparable injury to Plaintiffs. 484. Plaintiffs are likely to prevail on the merits of this case and receive the requested declaratory judgment, as well as equitable relief. 485. Plaintiffs also have no adequate remedy at law for Defendants’ threatened actions. Specifically, money damages are insufficient to redress the threatened injury to Plaintiffs. 486. The threatened injury to Plaintiffs far outweighs any possible damages to Defendants. Plaintiffs include women who are currently pregnant and physicians who treat pregnant patients every day. There is no state interest that can outweigh the harm caused to patients by being denied or delayed in accessing abortion care that could save their lives, their fertility, or the health. 487. Accordingly, in order to preserve the status quo, Plaintiffs request that Defendants be cited to appear, and, after a full hearing, further request that the Court enter a temporary injunction pursuant to Texas Rule of Civil Procedure 680 et seq. and Texas Civil Practice and Remedies Code Section 65.011 et seq. 488. Plaintiffs are willing to post a bond for any temporary injunction if ordered to do so by the Court, but request that the bond be minimal because Defendants are acting in a governmental capacity, have no pecuniary interest in the suit, and no monetary damages can be shown. Tex. R. Civ. P. 684. PRAYER FOR RELIEF WHEREFORE, Plaintiffs ask this Court: A. To enter a judgment against Defendants granting appropriate declaratory relief to clarify the scope of the exception to Texas’s abortion bans consistent with the Texas Constitution 113 B. To enter a judgment against the Defendant state officials that enforcing Texas’s abortion bans contrary to the Court’s declaration regarding their scope would be ultra vires; C. To enter a judgment that Texas’s abortion bans, as applied to pregnant people with emergent medical conditions and Texas-licensed physicians treating such patients, violate the Texas Constitution; D. To issue temporary and permanent injunctive relief that restrains Defendants, their agents, servants, employees, attorneys, and any persons in active concert or participation with Defendants, from enforcing Texas’s abortion bans or instituting disciplinary actions related to alleged violations of the abortion bans in a manner violating the court’s judgment; E. To retain jurisdiction after judgment for the purposes of issuing further appropriate injunctive relief if the Court’s declaratory judgment is violated; and F. To such other and further relief as the Court deems just and proper.
  10. Why, it was only a couple of weeks ago that some Republicans were telling women to just move on and forget about that they were doing re: abortion bans. Yeah, forget that some states were STILL passing laws to limit abortion to 6 weeks, make women have multiple appointments over several days before they cold even get on, maybe forced to have a sonogram, or having to leave the state if, god forbid, they have to get an abortion for any reason AFTER 6 weeks. (At which point, incidentally, a lot of women, dare I say most, don't even know if they're pregnant yet. And what if there is a birth defect? The CDC (Centers for Disease Control and Prevention) says tha screening tests are done, in the first trimester, between 11 and 13 weeks The screen that checks for downs syndrome isn't till between weeks 15 and 20. Give me a BREAK on the 6 weeks, it's effectively an abortion ban while pretending women have choices. Nope Because Republicans are trying to bamboozle women about what they're doing, since not allowing women to control their own healthcare and have decisions be between them and their doctor, their newest lie is to pretend a 12 week ban (oh, they don't call it a ban, but it is) is reasonable and just common sense. Nope, but you're a fool if you believe this. Read this about what North Carolina Republicans are doing. Read about the unnecessary sonograms, the baloney doctors are forced to say and show while telling lies. But this is the cake Republicans are LYING. Do not elect them any more at all if you think women should be in charge of their own heath care. Here's some videos to watch on Tik Tok AND the Abortion Every Day newsletter by Jessica Valenti
  11. Don't know if everyone is following how utterly corrupt and bribe-able Clarence Thomas is, but the most amazing part is that Harlan Crow put Thomas on the gravy train and Thomas not only took all the spiffs, but didn't fill out his ethics reports about all the gifts. That tells me Thomas knew is was shameful but liked those free trips too much plus it was too much work to recuse himself from any court cases involving Crows pet projects. (Harlan Crow doesn[t want anyone to know how much bribes gifts he gave to Thomas) If you look at this picture, you'll see Clarence Thomas AND Harlan Crow at the swearing in of James Ho, who is now on the 5th circuit. Oh, and the slimy guy on the left is cowardly Ted Cruz, who ran away from Texas to go to Cancun for a vacay during the Big Winter Freeze that killed some Texans and spends his time drumming up anti-*woke* battles instead of doing things that benefit Texans. Cruz and Ho apparently also had no problems getting shuttled around on billionarie H Crow's private jet. What? Flying commercial must be just for ordinary peasants. Anyway, Hoi is a real extremist who is anti-abortion and if you want to read a great article that pokes fun at how nuts Ho is, read this from Jezebel. The ridiculous abortion pill lawsuit is still ongoing, and its latest stop was a Wednesday hearing at the ultraconservative Fifth Circuit Court of Appeals. The three judges drawn at random to hear the case were all appointed by Republicans—and two by Donald Trump—so we knew it was going to be bad. But it was truly something to behold. What a right-wing idiot Ho is. Now read this. You will laugh
  12. 2nd part Everyone has read the horror stories of women who are being affected by the draconian and cruel law passed by Texas to prevent women from getting abortions past a certain date (not to mention how awful it was to take away someone's rights to their own health care and treat them like non-citizens who need to be guided by ignorant politicians rather than qualified doctors. What happens if a women needs emergency care because the fetus dies or otherwise has an issue? The law in Texas is written in such a way that it is not only not specific about what should happen but puts doctors in fear they will go to jail if they help in any way, which healthcare could include an abortion. Side note that this is no way addressed the very real issues of what to do if you're female and you are raped or get pregnant through incents. That's the basis for this lawsuit which I am going to, after putting the link to it, copy and paste in full Lawsuit CAUSE NO. D-1-GN-23-000968 AMANDA ZURAWSKI; LAUREN MILLER; LAUREN HALL; ANNA ZARGARIAN; ASHLEY BRANDT; KYLIE BEATON; JESSICA BERNARDO; SAMANTHA CASIANO; AUSTIN DENNARD, D.O.; TAYLOR EDWARDS; KIERSTEN HOGAN; LAUREN VAN VLEET; ELIZABETH WELLER; DAMLA KARSAN, M.D., on behalf of herself and her patients; and JUDY LEVISON, M.D., M.P.H., on behalf of herself and her patients, Plaintiffs, v. STATE OF TEXAS; ATTORNEY GENERAL OF TEXAS; KEN PAXTON, in his official capacity as Attorney General of Texas; TEXAS MEDICAL BOARD; and STEPHEN BRINT CARLTON, in his official capacity as Executive Director of the Texas Medical Board, Defendants. IN THE DISTRICT COURT OF TRAVIS COUNTY, TEXAS 353RD JUDICIAL DISTRICT PLAINTIFFS’ FIRST AMENDED VERIFIED PETITION FOR DECLARATORY JUDGMENT AND APPLICATION FOR TEMPORARY AND PERMANENT INJUNCTION As a direct result of Texas’s abortion bans, Texas is in the midst of a health care crisis. Amanda Zurawski, Lauren Miller, Lauren Hall, Anna Zargarian, Ashley Brandt, Kylie Beaton, Jessica Bernardo, Samantha Casiano, Austin Dennard, D.O., Taylor Edwards, Kiersten Hogan, Lauren Van Vleet, and Elizabeth Weller, and countless other pregnant people have been denied necessary and potentially life-saving obstetrical care because medical professionals throughout the state fear liability under Texas’s abortion bans. Amanda was forced to wait until she was septic to receive abortion care, causing one of her fallopian tubes to become permanently closed. When Lauren M. learned one of her twins was not viable, she was forced to travel out of state for the abortion she needed to save her and her other baby’s life. Her baby was born several weeks after this case was filed. Lauren H. received a devastating fetal diagnosis two weeks after Roe was overturned, and in the chaos that followed, she was forced to travel to Seattle for an abortion. Pregnant again now, Lauren H. fears that Texas is not safe for her or her family. Anna was forced to fly across multiple states after her water broke, risking that she would go into labor or septic shock on the journey. Ashley had to travel out of state for an abortion to save the life of one of her twins, and afterwards, fearful of documenting Ashley’s abortion, her Texas physician instead described her condition as “vanishing twin syndrome.” Yet with the threat of losing their medical licenses, fines of hundreds of thousands of dollars, and up to 99 years in prison lingering over their heads, it is no wonder that doctors and hospitals are turning patients away—even patients in medical emergencies like Amanda, Lauren M., Lauren H., Anna, Ashley, Kylie, Jessica, Samantha, Dr. Dennard, Taylor, Kiersten, Lauren V., and Elizabeth. Plaintiffs file this First Amended Verified Petition for Declaratory Judgment and Application for a Temporary and Permanent Injunction because uncertainty surrounding the meaning of the exception to Texas’s abortion bans, codified at Tex. Health & Safety Code §§ 170A.001-002 (the exception to the Trigger Ban) and Tex. Health & Safety Code §§ 171.002(3), 171.203-205 (the “medical emergency” exception to Senate Bill 8 of 2021) (collectively, the “Emergent Medical Condition Exception”), has caused and threatens to cause irreparable injury to Plaintiffs and the Physician Plaintiffs’ patients Since the filing of Plaintiffs’ Original Petition on March 6, 2023, many women have reached out to Plaintiffs and/or Plaintiffs’ counsel to say, in the words of one, “your story is my story.” Plaintiffs’ bravery has encouraged many of these women to publicly tell their own stories of being denied abortion care. In fact, Lauren Miller’s obstetrician, Dr. Austin Dennard, was inspired to share her own story about having to travel out of state for a medically indicated abortion only after her patient joined this lawsuit. Because Texas’s abortion bans continue to harm pregnant people every day, Plaintiffs amend their petition to add 8 additional plaintiffs and to urgently request temporary injunctive relief. The new plaintiffs represent a cross section of the pregnant people who need abortion care in Texas: they include women of color, women with disabilities, survivors of intimate partner violence, and women who struggle to make ends meet. Specifically: Dr. Dennard, Jessica, Taylor, and Lauren V. received devastating fetal diagnoses and were forced to travel out of state for abortion care, even while the risks to their own health increased. Dr. Dennard is pregnant again now and continues to fear for her safety being a pregnant woman in Texas. Kiersten and Elizabeth’s water broke prematurely, and they were both told to wait until they were sick enough to be eligible for abortion care. In Kiersten’s case, she was told that if she tried to leave the hospital to seek care elsewhere, she could be arrested for trying to kill her baby. Samantha and Kylie were forced to carry non-viable pregnancies to term. Samantha’s daughter passed four hours after birth, and Samantha was only able to afford a gravestone after NPR wrote a story about her and members of the public contributed to her GoFundMe. Kylie was forced to undergo a Cesarean surgery because, due to the delays in her care caused by Texas’s abortion bans, she was no longer eligible for abortion care even out of state. Kylie’s son passed the same day they were discharged from the hospital. The harms to pregnant Texans from the state’s abortion bans grow every day and should not continue. In support of their petition, Plaintiffs respectfully show the following: INTRODUCTION 1. Abortion bans harm the health of women and pregnant people. In September 2021, Senate Bill 8 (“S.B. 8”) effectively imposed a statewide ban on abortion after approximately 6 weeks of pregnancy.1 After the U.S. Supreme Court overturned Roe v. Wade in June 2022, Texas’s near-total abortion ban took effect. Texans have suffered catastrophic harms because of those bans. Pregnant people in Texas and throughout the country have suffered unnecessary physical and emotional pain and harm, including loss of their fertility. These pregnant people are not hypothetical. They are not unknown. They are real people with families, many with children already, and some of them are plaintiffs in this action. 2. Local newspapers and social media abound with stories of abortion bans harming pregnant people and their families, a large number of whom live in Texas. In every person’s story, the same themes emerge: First, abortion is necessary health care that is being denied under Texas’s civil and criminal abortion bans. Second, abortion bans are preventing pregnant people from receiving the standard of care from their medical professionals in times of crisis. And third, pervasive fear and uncertainty throughout the medical community regarding the scope of the life and health exceptions have put patients’ lives and physicians’ liberty at grave risk. 3. Abortion bans are hindering or delaying necessary obstetrical care. And, contrary to their stated purpose of furthering life, the bans are exposing pregnant people to risks of death, injury, and illness, including loss of fertility—making it less likely that every family who wants to bring children into the world will be able to do so and survive the experience. Medical professionals are now telling their patients that if they want to become pregnant, they should leave Texas. 4. Plaintiffs represent only the tip of the iceberg. Since September 2021, millions of people of reproductive capacity in Texas and beyond have been denied dignified treatment as equal 1 Consistent with standard medical practice, gestational ages as used in this petition are dated from the first day of the patient’s last menstrual period (“LMP”), which is typically approximately two weeks before the estimated date of fertilization of a pregnancy. human beings. This Court need not guess at the impact that abortion bans have. Each day, in states across the country, pregnant people like Amanda, Lauren M., Lauren H., Anna, Ashley, Kylie, Jessica, Samantha, Dr. Dennard, Taylor, Kiersten, Lauren V., and Elizabeth are being denied their ability to control their reproductive lives and to build their families according to their own values and beliefs. Medical professionals are being forced to forgo practicing their profession and fulfilling their ethical duties to patients in the face of catastrophic risks to their liberty and livelihood. Plaintiffs’ experiences illustrate that while the stated purpose of Texas’s abortion bans may have been to promote healthy babies and families, the bans have done the opposite. 5. Plaintiffs respectfully ask this Court for a declaratory judgment clarifying the scope of Texas’s Emergent Medical Condition Exception to its abortion bans, and any and all declaratory or injunctive relief necessary to protect the health and lives of pregnant Texans with emergent medical conditions. DISCOVERY CONTROL PLAN 6. Plaintiffs request that this case be conducted as a Level 3 case for the purposes of discovery in accordance with Texas Rule of Civil Procedure 190.4. In addition, pursuant to Texas Rule of Civil Procedure 47(c)(5), Plaintiffs state that they seek non-monetary relief only. PARTIES I. PLAINTIFFS A. Amanda Zurawski 7. Amanda Zurawski is 36 years old and lives in Austin, Texas. 8. Amanda and her husband have known each other since preschool and were married in 2019. They have long wanted to have children. When they started trying for a baby, however, Amanda learned she was not ovulating. After a year and a half of fertility treatments—which included exploratory procedures, use of multiple medications, one misdiagnosis, and treatment with intrauterine insemination or IUI—Amanda finally got pregnant for the first time. 9. Amanda’s pregnancy proceeded without incident until, at 17 weeks, 6 days, she was diagnosed with an “incompetent cervix”—weakening of the cervical tissue that causes premature dilation of the cervix. Because her pregnancy was still so many weeks before viability, she was told that her baby2 would not survive. 10. Amanda and her husband were devastated and kept asking if there was something, anything, her doctors could do. Amanda specifically asked if she was a candidate for cerclage, a procedure where a patient’s cervix is stitched closed to prevent preterm birth. Her doctors told her that unfortunately, her membranes were already prolapsing, meaning that a cerclage procedure would be too risky and, in any event, would not be successful. 11. Amanda was sent home, and that night, her water broke. It was Tuesday, August 23, 2022. 12. Amanda returned to the emergency room that night and was diagnosed with preterm prelabor rupture of membranes (also known as preterm premature rupture of membranes, or “PPROM”). Because all of Amanda’s amniotic fluid drained when her water broke, the emergency room kept her overnight in hopes that she would go into labor on her own. In the morning, however, she had not gone into labor, her baby still had cardiac activity, and her vitals were still “stable,” meaning she was not yet showing signs of acute infection. 13. Amanda was told that under Texas’s abortion ban, there was no other medical care the hospital could provide. At this point, absent Texas’s abortion bans, a patient in Amanda’s 2 This petition describes pregnancy using medical terminology, unless describing a particular patient’s pregnancy, in which case, consistent with principles of medical ethics, it adopts the terminology preferred by the individual patient.situation would have been offered an abortion or transferred to a facility that could offer the procedure. But Amanda was offered neither because the hospital was concerned that providing an abortion without signs of acute infection may not fall within the Emergent Medical Condition Exception in Texas’s abortion bans. 14. Amanda was told that delivery could take hours, days, or weeks. Once Amanda heard it could take hours, she decided there was no time to travel to another state for an abortion. She looked it up, and the drive to the closest abortion provider, in Albuquerque, New Mexico, would be 11 hours. The specialist at the hospital also urged Amanda to stay within a 15-minute drive of the hospital, in case her health deteriorated quickly. 15. On Wednesday morning, Amanda was sent home with instructions to monitor herself for signs of infection. 16. Amanda spent Wednesday and Thursday at home, grieving her inevitable loss and worrying about her own health. 17. On Thursday morning, Texas’s Trigger Ban went into effect. 18. On Friday morning, Amanda went for a check-up at her obstetrician’s office. At her appointment, her vitals were still “stable.” 19. On the drive home from her obstetrician’s office, however, Amanda developed chills and started shivering, and by the time she got home, she had a temperature of 101 degrees and was not responding to her husband’s questions—all signs of sepsis. 20. Amanda’s husband called their obstetrician’s office and while he was waiting for a call-back, decided he could wait no longer and needed to take her to the emergency room immediately 21. By the time Amanda was admitted to the labor and delivery unit, her temperature was 102 degrees and peaked at 103.2 degrees. Her medical team confirmed she was indeed septic and put her on antibiotics. The hospital finally agreed she was sick enough that inducing labor would clearly not violate Texas’s abortion bans. 22. Amanda delivered, and her baby, Willow, did not survive. 23. That night, Friday, Amanda’s fever subsided but her blood pressure and platelet levels remained abnormally low. Amanda was told that while the first infection had cleared, she had developed a secondary infection, chorioamnionitis, and septic shock. The subsequent bout of sepsis landed her in the intensive care unit (“ICU”). 24. Amanda spent three days in the ICU while her infection was treated. Amanda’s family flew to Austin from across the country because they worried it would be the last time they would see her. 25. Amanda was eventually discharged and returned home, but her suffering was far from over. The infections had caused such severe scar tissue to develop in her uterus and on her fallopian tubes that it obscured x-ray imaging of her reproductive organs. She had a procedure to attempt to remove the scar tissue, and while her physicians were able to clear her uterus and one of her fallopian tubes, the other fallopian tube remains permanently closed. 26. Amanda has been advised by her reproductive specialist that to get pregnant again, she should start in vitro fertilization (“IVF”), which involves its own invasive procedures and uncertain success. 27. Amanda has already begun IVF treatments. 28. Once a pregnant person has been diagnosed with an incompetent cervix in one pregnancy, the risk is high that they will develop the same condition in future pregnancies. 29. Amanda and her husband have been trying to have children for years, and she not only lost her first pregnancy, but because of Texas’s abortion bans, she nearly lost her own life and spent days in the ICU for septic infections whose lasting impacts threaten her fertility and, at a minimum, make it more difficult, if not impossible, to get pregnant again in the future. 30. Amanda’s claims are capable of repetition but evading review. Amanda sues on her own behalf. B. Lauren Miller 31. Lauren Miller is 35 years old and lives in Dallas, Texas. 32. Lauren M. first learned she was pregnant from a pharmacy urine test in July 2022, and quickly realized that the first day of her last menstrual period, the date from which her pregnancy would be dated, was June 24, 2022, the same day Roe v. Wade was overturned. 33. Lauren M. already had, at the time, a one-year-old son, and she and her husband were excited to have another child join their family. She started keeping a pregnancy journal to document the details of her pregnancy and her emotions about her pregnancy. Lauren M. scheduled her first prenatal visit for approximately 8 weeks. 34. Before her first prenatal visit, however, Lauren M.’s health took a turn for the worse. She experienced horrible nausea and vomiting and could not keep food or even water down. After 36 hours of continuous vomiting, Lauren M. went to the emergency room for treatment for dehydration. At the emergency room, Lauren M. had her first ultrasound and learned she was pregnant with twins. She and her husband were shocked but thrilled. 35. At the emergency room, Lauren M. was also diagnosed with hyperemesis gravidarum, a severe form of persistent nausea that can last throughout pregnancy and cause significant risks for pregnant people and their babies. 36. Lauren M. began treatment for hyperemesis gravidarum but did not respond to medications and continued to struggle with nausea and vomiting as her pregnancy progressed. 37. At Lauren M.’s 12-week ultrasound appointment, she learned that one of her twins—who her doctors referred to as Baby B because it was farther away from her cervix—was not growing as fast as the other twin—who her doctors referred to as Baby A because it was closer to her cervix. While that was a cause for potential concern, obtaining a diagnosis would require additional monitoring and testing. Lauren M. provided a blood sample for noninvasive prenatal blood testing (“NIPT”), which can be done between 10 and 13 weeks to screen for some fetal conditions. While Lauren M. was still waiting for the NIPT results, she returned a week later for another ultrasound and learned that Baby B had developed two cystic hygromas, fluid filled sacs near the brain. While worrisome, Lauren M.’s physicians still could not yet diagnose Baby B’s medical condition and recommended additional testing, specifically chorionic villus sampling (“CVS”) or amniocentesis, which involves a needle procedure into the placenta or amniotic fluid. 38. Several days later, Lauren M. received the results from her NIPT test, which indicated that Baby B likely had trisomy 18, a condition with a very high likelihood of miscarriage or stillbirth and low survival rates beyond the first year of life. 39. Lauren M. met with a genetic counselor who struggled to give clear information regarding what this result meant for her pregnancy under Texas’s new abortion bans. After receiving a referral to a maternal-fetal medicine (“MFM”) specialist who could perform CVS testing, Lauren M. scheduled the first available appointment, which was for the following day. 40. The following day, Lauren M. visited an MFM specialist who performed a high- resolution ultrasound and attempted CVS testing. The MFM confirmed via ultrasound that Baby B had multiple fetal structural abnormalities—cystic hygromas where much of the brain should have been developing, a single artery umbilical cord, incomplete abdominal wall, abnormal heart, abnormal nuchal translucency—and told Lauren M. and her husband that Baby B would likely not survive to birth. Because the ultrasound alone was so conclusive, and because Lauren M.’s uterus was contracting and preventing the needle from reaching the placenta of Baby B, the MFM did not ultimately complete the CVS test. 41. The MFM told Lauren M. and her husband that, before S.B. 8, he would have been able to offer Lauren M. a single fetal reduction (an abortion of Baby B) to give Baby A and Lauren M. the best chance to avert a health crisis. Now, all he could do was suggest that she travel out of state. 42. In every interaction with their medical team in Texas, Lauren M. and her husband felt confused and frustrated and could not get direct answers. It was apparent that their doctors, nurses, and counselors were all fearful of speaking directly and openly about abortion for fear of liability under Texas’s abortion bans. 43. A few days after Lauren M.’s visit with the MFM, she was hospitalized again with complications from hyperemesis gravidarum. Lauren M. was vomiting so violently that she was unable to drive herself to the emergency room and had debilitating chills and severe dehydration requiring hospitalization. If not for Texas’s abortion bans, Lauren M. would have had the single fetal reduction before her subsequent emergency room visit. 44. Lauren M. and her husband remained deeply concerned about her health as well as that of Baby A. They ultimately decided to travel out of state to receive a selective fetal reduction abortion procedure. They named their son, Baby B, “Thomas” and started to say goodbye. 45. At 15 weeks at a clinic in Colorado, Lauren M. underwent the selective reduction abortion procedure. It was quick, taking approximately 15 minutes, and uncomplicated. Yet the procedure, plus the associated travel, cost thousands of dollars and required Lauren M. and her husband to be away from their toddler for two days. 46. After the procedure, Lauren M.’s hyperemesis gravidarum symptoms immediately subsided, and her pregnancy with Baby A has since progressed without complications. Lauren M. lost so much weight from hyperemesis gravidarum that she did not return to her pre-pregnancy weight until 29 weeks gestation. 47. After the procedure, Lauren M.’s pregnancy with Baby A progressed without complications. 48. Lauren M. gave birth in late March 2023 to a healthy baby boy who she and her husband named Henry. 49. Lauren M. is thankful that she had the funds and support from family, friends, and employers to allow her and her husband to travel for the health care she needed. She has friends in the medical field who helped her connect with doctors out of state. She knows that many other pregnant people have not been so fortunate. 50. Lauren M. was overjoyed to discover she was pregnant with twins, but after suffering from extreme hyperemesis gravidarum and a devastating fetal diagnosis for Thomas, she believes that Texas’s abortion laws made it less likely that both she and Henry would survive her pregnancy. 51. At the time this lawsuit was filed, Lauren M. was still pregnant with Henry and continued to fear for her safety as a pregnant woman in Texas. She continues to fear for her safety should she get pregnant in the future.52. Lauren M.’s claims relate both to her pregnancy at the time of filing this suit and to any future pregnancies and are capable of repetition but evading review. Lauren M. sues on her own behalf. C. Dr. Austin Dennard 53. Dr. Austin Dennard is 38 years old and lives in Dallas, Texas. 54. Dr. Dennard is a doctor of osteopathic medicine (“D.O.”) and works in general obstetrics and gynecology. She specializes in obstetrics, robotic gynecology surgery, and pelvic floor dysfunction. Dr. Dennard is also trained to provide miscarriage care in the first trimester. 55. Lauren M. is one of Dr. Dennard’s obstetrical patients. 56. Dr. Dennard and her husband, who is also an OB/GYN, have two children, but they had always wanted a third. In July of 2022, Dr. Dennard was excited to be pregnant, particularly because before this pregnancy, she had had a miscarriage. 57. At Dr. Dennard’s 11-week ultrasound visit, however, her baby was diagnosed with anencephaly. Dr. Dennard knew immediately the prognosis for both her and her baby. Her doctor confirmed that the condition was not compatible with survival and that in Texas, all they could offer her was additional ultrasound scans. Dr. Dennard decided she wanted an abortion. 58. Dr. Dennard had been through this before. In her first pregnancy, Dr. Dennard’s baby was diagnosed at 18 weeks with a rare genetic condition associated with heart disorders and other medical comorbidities—and she and her husband made the difficult choice to end the pregnancy. At the time, abortion was legal in the state of Texas, and Dr. Dennard was able to get the abortion at a clinic in her home community. 59. This time, however, Dr. Dennard knew that due to Texas’s abortion bans, she would need to travel out of state. Dr. Dennard immediately started researching her options and calling friends and colleagues for advice. She decided to travel to the east coast for her care 60. As soon as she got the diagnosis, Dr Dennard immediately felt silenced and marginalized. She felt like she was in an alternate universe, as a 6th generation Texan, fleeing her own state for basic medical care. She paid out of pocket for her abortion procedure, as well as her travel expenses. Family stayed at home with her children. Colleagues covered her shifts at the hospital. While traveling out of state was traumatic, she was relieved she had the resources to access the care she needed. 61. Dr. Dennard initially considered sharing her story publicly but was nervous to do so. Colleagues in family planning warned Dr. Dennard that there were political consequences associated with being outspoken on abortion. 62. But Dr. Dennard’s personal and professional lives collided when months later, one of her patients, Lauren M., faced a similar devastating diagnosis. Dr. Dennard watched Lauren M. go through exactly the same experience—researching abortion providers out of state on her own, traveling to get care, finding childcare, and more. Just like Dr. Dennard, Lauren M. was trying to grieve while being plagued by medical trauma, fear, and confusion. 63. When this lawsuit was filed and Dr. Dennard saw that Lauren M. was one of the plaintiffs, Dr. Dennard knew this was the moment for her to tell her story as well, and she reached out to Plaintiffs’ counsel. 64. Dr. Dennard is pregnant again now with her long-awaited third child. She is due in the fall. 65. Dr. Dennard’s claims are capable of repetition but evading review. Dr. Dennard sues on her own behalf. D. Lauren Hall 66. Lauren Hall is 28 years old and lives outside of Dallas, Texas 67. Lauren H. and her husband were thrilled when they found out she was pregnant. At her first ultrasound at around 8 weeks, everything looked great. Because her pregnancy was uncomplicated, Lauren H. would not have another ultrasound until her anatomy scan, which is usually scheduled later than 16 weeks. In the meantime, Lauren H. started planning, telling friends and family the news, buying baby clothes and furniture, and even selected a name—Amelia. 68. Lauren H. knew that her OB/GYN was opposed to abortion. But at the time, it did not seem like a big deal. 69. Two weeks after Roe v. Wade was overturned, however, Lauren H. went to an appointment with an MFM specialist for her 18-week anatomy scan. Lauren H. is a nurse, and as the ultrasound began, she knew immediately that something was wrong. 70. Lauren H. was told that her baby had anencephaly, a condition where the baby does not develop a skull and has a severely underdeveloped brain. Lauren H. knew that with such a diagnosis, the baby had no chance of survival. Her MFM specialist told her that anencephaly is incompatible with life. 71. Lauren H. was told that there were many physical and mental risks to her if she continued the pregnancy, including hemorrhage and preterm birth. Lauren H. remembers thinking that she did not want to end up bleeding to death on the bathroom floor. She was scared that when something inevitably went wrong, she would not get proper care for this pregnancy in Texas. She decided that she wanted an abortion. 72. Lauren H.’s MFM specialist said she couldn’t help her and was even fearful to give her information about her options. Roe had just been overturned and everyone Lauren H. encountered was terrified. Her MFM urged her to go out of state and tell no one—not her family, not anyone at the airport—where she was going or what she was doing. Lauren H.’s MFM said she could not provide a referral or even transfer her medical records to an abortion provider. No one knew how far the politicians in Texas would go to prosecute people involved in abortion care. 73. Lauren H. and her husband were grieving, were desperate for help, and they were made to feel like everything they needed was illegal. 74. Lauren H. tried to get an appointment with her OB/GYN, but he was out of town, and no one from the office was responding. Lauren H. even drove to her OB/GYN’s office to ask for help in person, but no one would see her. Eventually, someone from the office called back but only offered her information about support groups for patients who give birth to babies with anencephaly. Lauren H. realized she was on her own to figure out what to do. 75. Lauren H. called clinics in Colorado and New Mexico. Because Roe had just been overturned and abortion bans were taking effect in states throughout the South, the Colorado and New Mexico clinics were inundated with patients. They didn’t have appointments. 76. Lauren H. has struggled with depression, and the stress of searching for care took a huge toll. Her mental health spiraled to the point that she considered checking herself into the hospital. But she was afraid to tell anyone what was going on because she worried what would happen to her if people knew she wanted an abortion. 77. Because she was already 18 weeks pregnant, Lauren H. worried that she was too far along to be seen by most clinics. Eventually, Lauren H. got an appointment at a clinic in Seattle that specializes in cases like hers. Lauren H. and her husband’s family sent them money to help pay for the extremely expensive last-minute trip. On her way into the clinic for her appointment, protesters shouted at her that she was a baby killer. 78. Lauren H. and her family grieved their loss but are still processing the trauma of what happened to her and needing to travel so far from home during such a time of chaos and confusion, just to receive necessary health care. 79. Lauren H. is now pregnant again and due in September. She is both excited and scared because she fears that it is not safe for her or for anyone to be pregnant in Texas. 80. Lauren H.’s claims relate both to her current pregnancy and any future pregnancies and are capable of repetition but evading review. Lauren H. sues on her own behalf. E. Anna Zargarian 81. Anna Zargarian is 33 years old and lives in Austin, Texas. 82. In September 2021, just a few weeks after S.B. 8 took effect, Anna realized that her period was two weeks late. 83. Anna and her now-husband were surprised to learn she was pregnant, but they were excited about having a baby. Anna remembers thinking that it was a good thing she did not want an abortion, as she may have already been past the cutoff for abortion care under S.B. 8. 84. Anna’s pregnancy proceeded without incident until, at 19 and a half weeks, she felt a sensation like something was starting to come out of her body. Anna had some cramping but tried to put it out of her mind. Hours later, Anna felt a gush of liquid leave her body, then a second gush left a puddle on the floor. Anna knew something was wrong. 85. Anna and her husband went to the emergency room that night and learned that her water had broken prematurely, and her cervix had started dilating. She was diagnosed with PPROM. Anna was told that because all of the amniotic fluid had drained when her water broke, her baby would not survive to birth. 86. Doctors in the emergency room told Anna that for patients in her situation, they would usually recommend termination of the pregnancy. If she continued the pregnancy, she was at high risk of developing a septic infection or hemorrhaging. Anna works in health care, and as soon as she heard that she was at risk of sepsis, she panicked. 87. The doctors told her that the safest treatment for her was a D&E. But because of S.B. 8, as long as her baby had detectible cardiac activity, Texas law barred them from performing an abortion, unless and until her life was in imminent danger. 88. Anna tried to reason with the doctors in the emergency room. She asked if, instead of a D&E, they could induce her. But the doctors explained that an induction at this stage was also an abortion prohibited by law. When Anna asked for guidance, the medical staff at the hospital were scared to give Anna any information about where to seek abortion care. Instead, one of the doctors typed a generic abortion finder resource into her cell phone and showed the webpage to Anna. 89. Anna was told that she could be admitted to the hospital for “expectant management”—where she would wait either to go into labor naturally, or for her health to deteriorate sufficiently for the hospital to be able to intervene. She was also told that she could wait until the morning to speak to an MFM specialist, but that the MFM would not be able to offer any different treatment. 90. Anna and her husband decided to go home so they could begin researching abortion options on their own. They debated what seemed less risky—an 11 hour drive to New Mexico, or a 2 hour flight to Colorado? Anna wanted to make sure the state she chose did not have a mandatory waiting period that would delay her care further. That night, Anna continued to leak amniotic fluid and experience cramping. 91. The next morning, Anna spoke to her longtime OB/GYN. Anna was concerned that if she went into labor while driving through rural Texas, there would be no hospital where she could access care. While she might go into labor or septic shock on the plane as well, at least the trip would be shorter and she could get to a doctor more quickly. Anna and her OB/GYN agreed: the best option given the circumstances was for Anna was to leave Texas for an abortion, and that a short flight was less risky than a long drive. 92. Anna called clinics in Colorado, but they were still being inundated by the influx of patients from Texas. A clinic in Denver was able to squeeze her in once she explained why she would not be able to wait weeks for an appointment. Anna bought a plane ticket and paid extra for a seat at the front of the plane near the bathroom. Thankfully, Anna arrived safely. 93. The morning of her procedure, Anna had a fever of 101, but she received an abortion and recovered well. 94. Since this experience, Anna has suffered from stress and anxiety, specifically related to the fear for her life she felt during the trip to Denver. She grieves the loss of a wanted pregnancy and still relives the trauma of being forced to leave Texas in the middle of a medical emergency. 95. Anna still wants to have children, but she is afraid of being pregnant again in Texas. Her doctors have told her that she will be at high risk for developing conditions associated with PPROM in future pregnancies. 96. Anna’s claims are capable of repetition but evading review. Anna sues on her own behalf. F. Ashley Brandt 97. Ashley Brandt is 31 years old and recently moved from Houston to Dallas, Texas. 98. Ashley and her husband got married in 2018 and already have a 3-year-old child. Ashley always wanted to have three children, so when she learned in May of 2022 that she was pregnant with twins, Ashley and her husband were thrilled. 99. During early prenatal visits, Ashley was told she was having identical twin girls, and that each had their own placenta and amniotic sac. Ashley and her husband love being parents and were excited about having twins. They began to tell their friends and family. 100. At her 12-week ultrasound, however, Ashley was told that Twin A’s skull was much smaller than Twin B’s, and Twin A did not appear to be developing normally. Ashley’s OB/GYN explained that Twin A likely had acrania, a condition where the fetus does not develop a skull, and referred her to an MFM specialist for further testing. 101. For over a week, Ashley waited for her insurance to approve a visit with the MFM. She spent much of that week crying in bed. Still reeling from the news, and without guidance from her Texas physicians, Ashley started researching her options online and calling doctors in other states. A doctor in Colorado explained selective fetal reduction, and Ashley realized that an abortion of Twin A could help her save Twin B and herself. 102. Finally at the appointment, Ashley’s Texas MFM confirmed that Twin A’s skull was not properly developing and that the acrania had progressed to exencephaly, a precursor to anencephaly. The MFM warned Ashley that as long as Twin A continued growing, her chances of miscarriage or premature labor were high. Twin A’s amniotic fluid would continue to break down brain tissue until she went into labor, at which point, she could lose both babies. Twin B might survive if born prematurely, but would require intensive neonatal care for months or longer. Further, if Twin A continued growing, there was also a risk of polyhydramnios, or excessive accumulation of amniotic fluid, which put Twin B at risk for fetal growth restriction. 103. Ashley did not want one stillborn, but she definitely did not want two. 104. There were significant risks for Ashley as well, particularly because she had a cesarean delivery with her first pregnancy. Ashley learned that polyhydramnios can lead toPPROM and/or placental abruption, meaning that Ashley was at risk of infection, bleeding, and hemorrhage. These risks were especially high because Twin A was the twin closest to her cervix. 105. Ashley asked her MFM about selective fetal reduction. Her MFM said that in another world, it would be simple, but this was Texas. And in Texas, abortion is illegal even if it means saving the life of a healthy baby. If Ashley wanted to go out of state for an abortion, that was her right and her MFM would send her medical records. But in Texas, all her physicians could do was monitor her at weekly appointments. Ashley was on her own. 106. Ashley made an appointment with the doctor in Colorado. 107. Ashley and her husband arranged for childcare, took time off work, and made the journey to Colorado. Her abortion procedure went smoothly, and Ashley and her husband flew home. 108. The day she returned home, however, Twin A’s amniotic sac ruptured in the middle of the night and the bleeding and leaking fluid sent her to the emergency room. She was terrified that she would lose both babies and that she would somehow be in trouble for going out of state for the fetal reduction procedure. Thankfully, Twin B had a separate amniotic sac which was still intact. 109. In the emergency room, Ashley felt a distinct uneasiness and confusion. It appeared that the medical staff thought they were not supposed to know about Ashley’s abortion or discuss it with her. To Ashley, everything felt secretive and icky. 110. The remainder of Ashley’s pregnancy was plagued by fear and stress. Ashley’s physicians recommended pelvic rest until her third trimester, as well as weekly ultrasounds that she had to pay for out of pocket. Ashley and her husband kept extra money in savings in case they had to leave the state again for medical care. 111. When Ashley reviewed her medical records, she saw a noticeable absence of documentation of her abortion. Her MFM’s records contained no reference to their conversations about fetal reduction and at her appointment after the abortion, stated simply “SAB of Twin A,” meaning “spontaneous abortion.” At every one of her regular appointments with her OB/GYN following the abortion, her OB/GYN’s records listed her diagnosis as “vanishing twin syndrome.”3 It was not until she was a few weeks from her due date that her OB/GYN added the following note to her chart: “one twin with acrania and was electively terminated.” 112. At 38 weeks, Ashley gave birth to a healthy baby. 113. Ashley feels fortunate that she could leave Texas for an abortion and thankful for the support of family and friends. While she had always planned to have more children, Texas’s abortion bans make it hard for her to imagine getting pregnant again. 114. Ashley’s claims are capable of repetition but evading review. Ashley sues on her own behalf. G. Kylie Beaton 115. Kylie Beaton is 33 years old and lives near Fort Worth, Texas. 116. Kylie and her husband have a 4-and-a-half-year-old and have wanted to have more children for years. But it has not been easy. Kylie has a history of polycystic ovary syndrome (“PCOS”), a condition that interferes with ovulation. Also, Kylie’s husband was hospitalized for 4 months in 2021 with COVID pneumonia. When he recovered, the couple immediately started trying to get pregnant again but faced challenges. After trying several different fertility medications, Kylie was thrilled to learn she was pregnant. 3 “Vanishing twin syndrome” is a type of miscarriage where one fetus in a multi-fetal pregnancy stops growing spontaneously and is absorbed into either the body of the pregnant person or (one of) the other fetus(es). See Vanishing Twin Syndrome, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/23023-vanishing-twin- syndrome. 117. At Kylie’s 20-week anatomy scan in early January of 2023, however, Kylie’s obstetrician told her that something did not look right with the baby’s head. Her obstetrician diagnosed the baby with alobar holoprosencephaly, a condition in which the brain does not develop into two hemispheres as it normally would, and the major structures of the brain remain fused in the middle. He referred Kylie to a specialist. 118. The next week, an MFM specialist confirmed the diagnosis and explained that the baby would likely only survive for several days or weeks past birth, if at all. In the meantime, the baby’s head would continue to be abnormally large for its gestational age. The specialist told Kylie that due to Texas’s abortion laws, there was nothing he could do unless Kylie became severely ill or the baby’s heart stopped, and that Kylie would either have to carry to term or she could look for care outside of Texas. Before the law changed, her doctors would have been able to perform a D&E or an induction abortion before the baby’s head got too big, but that was no longer legally possible. 119. Unsure what to do or where to go, Kylie and her husband began researching their options. They called a couple of abortion clinics and made an appointment at a clinic in New Mexico for the beginning of February. The procedure would cost $3,500. In advance of traveling to New Mexico, however, an ultrasound revealed that the baby’s head was already measuring at close to 24 weeks, abnormally large, meaning its size was past the gestational cutoff for the New Mexico clinic. Kylie and her husband were devastated. 120. They quickly learned that very few clinics in the country provide abortions past this cutoff. Kylie called a few of those clinics, but the procedure would cost between $10,000 and $15,000, which was far beyond their means. Kylie realized that she would have no choice but to continue the pregnancy. 121. At an ultrasound appointment in early March, the baby’s head was measuring at 39 weeks even though Kylie was only 28 weeks. Kylie was told this would be the last point at which she would be able to deliver vaginally. She begged the doctors to induce her. Her doctor told her that if not for Texas’s abortion bans, he would induce her for a vaginal delivery that day. But because of the law, she was told that no doctor could induce her until 37 weeks. 122. Kylie preferred to deliver vaginally, so her specialist called other doctors to make sure there was nothing more they could do. But her specialist was told that her baby’s large head size alone was not enough of a reason to justify an induction abortion under Texas law. 123. Kylie was scheduled for a Cesarean in early May, when she would be 37 weeks. 124. When Kylie was 35 weeks pregnant, however, she started having horrible pain in the right side of her abdomen. It did not feel like labor contractions to Kylie, but she knew something was wrong. After talking with her OB/GYN, she decided to go to the hospital to get checked out. Kylie and her family live an hour from the hospital, and her husband was at work, but another family member was able to drive her. She was in excruciating pain for the entire drive. 125. At the hospital, the medical staff could not determine if she was experiencing unusual labor pains due to the size of her baby’s head or if the pain was originating from her gallbladder, appendix, or some other internal organ. Kylie was told that before they could induce her, they would need to rule out her gallbladder and appendix as the source of her pain. 126. By this point, her baby’s head circumference was measuring at 49 cm. The average head circumference for a newborn is 35 cm. 127. Tests of her gallbladder and appendix came back normal. Kylie was only a couple centimeters dilated, and due to the size of her baby’s head, the staff did not believe she would dilate further. Finally, the hospital agreed to send her for an emergency cesarean. 128. Kylie’s OB/GYN performed the cesarean surgery, making a larger incision than normal to accommodate the baby’s head. The baby was born at the end of April. 129. Kylie and her husband wanted to donate their baby’s heart valves. They named their son Grant, hoping that he could grant other children life. 130. The first day in the hospital, Grant ate relatively well and at times, almost seemed normal. But over the next three days, his condition deteriorated. He cried constantly. He stopped eating. His core temperature gradually decreased. He could not be held upright or it would put too much pressure on his head. The medical staff was unsure if he was experiencing pain, but gave him morphine. Kylie understood he was slowly dying, day by day. 131. On day 4, Kylie’s insurance required her to be discharged from the hospital. She and her husband set up hospice care to meet them at home. 132. They were discharged in the early afternoon. The medical staff told Kylie that Grant could not sit in a car seat because it would put too much pressure on his head. So Kylie held Grant in her arms for the hour long car ride home. 133. Kylie’s daughter wanted to have a movie night with her brother, so the family watched movies together for a few hours. After her daughter went to bed, however, Grant’s breathing became more labored. A hospice nurse came to establish care. For hours, Kylie and her husband watched as their son grew cold in their arms. Late that night, Grant passed. 134. Kylie and her family are still waiting for Grant’s cremated ashes to be returned to them. They plan to plant a tree outside their house along with the ashes. 135. Many challenges remain for Kylie and her family. Kylie’s milk came in while she was at the hospital and it took weeks to dry up, long after Grant was gone. She is still recovering from the cesarean surgery and struggles to resume normal physical activity. The hardest part, however, is explaining to their daughter what happened and why. She still says she misses her brother and draws him pictures. Each time, it brings Kylie and her husband a new wave of grief. 136. Kylie will need to wait many months before trying to get pregnant again. Doctors recommend waiting at least 12-18 months after a cesarean to get pregnant again to give the uterus time to heal. Kylie does not want to have another cesarean delivery, but doctors have told her it will be challenging to deliver vaginally in the future, and the risk of another cesarean is higher the sooner she gets pregnant again. 137. When Kylie read about this lawsuit in the news in March of 2023, she decided she wanted to tell her story too, so she contacted a reporter and connected with Plaintiffs’ counsel. 138. Kylie believes that the government should not dictate the choices families like hers have to make. Having to go through the birth and death of Grant made losing him so much harder. Kylie wants to fight for other women, so they do not have to experience the same grief and pain. 139. Kylie continues to fear for her health and safety and her ability to get pregnant again in the future. She also fears for her safety as a pregnant woman in Texas if she gets pregnant again. 140. Kylie’s claims are capable of repetition but evading review. Kylie sues on her own behalf. H. Jessica Bernardo 141. Jessica Bernardo is 38 years old and lives near Frisco, Texas. 142. Jessica met her now husband in 2011 and they married in 2018. In 2020, they started trying to get pregnant but ran into challenges, so she started seeing a reproductive specialist. Jessica went through extensive testing and even a medical procedure to improve their chances of conceiving. 143. Jessica finally got pregnant in July of 2022. Jessica and her husband were ecstatic about their pregnancy and they shared the news with family around the world. 144. At around 14 weeks, Jessica received the results from her NIPT genetic testing and learned that there was a high likelihood that their baby had trisomy 21, or Down syndrome. Jessica and her husband were in disbelief, but they both agreed that they would love the baby no matter what. Jessica began researching how to support a baby with a disability, including special schools. She also started reading about and supporting small businesses started by adults with Down syndrome. 145. Jessica and her husband learned the baby was a girl and decided to name her Emma, meaning “whole.” They believed that she would be whole, with or without Down syndrome. They also started telling their friends and family the exciting news. 146. Because of the NIPT screening results, Jessica’s OB/GYN referred her to an MFM specialist and advised her to make an appointment as soon as possible. When making the appointment, she believes she was told about the option of having an amniocentesis. She researched amniocentesis and determined that she would not elect to have the testing performed because of the small risk of miscarriage. She knew she would keep the baby no matter what. 147. At the visit with the MFM in October 2022, they received devastating news. The scan revealed that the baby had fetal anasarca, which is the end stages of hydrops fetalis otherwise known as extreme full-body edema signifying end of life; other structural abnormalities; and was already showing signs of significant heart failure. Her MFM specialist told her that the baby would not survive to birth. The MFM instructed Jessica to monitor herself for complications like coughing, swelling, and high blood pressure, which could be signs of Mirror syndrome. She had already developed a cough starting at week seven of her pregnancy and her blood pressure had also increased. The MFM did not mention abortion. 148. Afterwards, Jessica did her own research to understand what Mirror syndromemeant and how serious it was. She came to understand that Mirror syndrome is a severe condition in which the pregnant person and fetus both experience severe fluid retention that can lead to both fetal and maternal demise, and that she was at a high risk for developing it. She realized just how risky it would be for her to continue her pregnancy. 149. That same day, Jessica’s OB/GYN called her to follow up. Jessica told her doctor she did not want to be left waiting for her baby’s heart to stop on its own, that it was cruel and would be detrimental to Jessica’s mental health, and that she was also scared of her health deteriorating. She wanted to be able to grieve, start healing, and ultimately, try to get pregnant again. Her OB/GYN told her that before Texas’s new laws, she would have been able to provide a “therapeutic birthing” to induce Jessica in the hospital but could no longer do so. Her doctor contacted the ethics committee at her hospital for an exclusion but was not granted one. 150. Jessica felt like her doctor was hesitant to tell Jessica what her options were, other than talk in code. She told her doctor that they had a residence in Colorado and asked her doctor if they should go there. Her doctor responded that yes, Jessica should go to Colorado. Her doctor never mentioned the word abortion. 151. Unfortunately, the clinics in Colorado were all booked—the soonest appointment was two months away. Jessica started looking for other options. She used private browser mode for fear that she would be prosecuted for looking for abortion services out of state. Jessica was eventually able to get an appointment for an abortion in Seattle, and she booked expensive, last- minute flights and a hotel room. 152. At the clinic in Seattle, Jessica was told she was the third patient from Texas that week alone. One of Jessica’s doctors told Jessica that she had moved away from Texas due to its restrictive laws. At 16 weeks and 6 days, and on the same day her nursery furniture was supposed to be delivered, Jessica received her abortion. Jessica wished that she could have been at home while she was going through the worst trauma of her life. 153. After this lawsuit was filed, Jessica reached out to Plaintiffs’ counsel. She wanted to tell her story and be part of changing the law. She wants people to know that abortion is healthcare and that these laws are not protecting women. 154. Jessica continues to grieve, but she is terrified to get pregnant naturally again in Texas. Because she and her husband still really want a child, she has started IVF. 155. Jessica’s claims are capable of repetition but evading review. Jessica sues on her own behalf. I. Samantha Casiano 156. Samantha Casiano is 29 years old and lives in East Texas. 157. Samantha and her partner live in a mobile home with their four children and their goddaughter. Samantha is a busy working mom with a large extended family. 158. Samantha’s youngest child was only around 3 months old when she found out she was pregnant again. Samantha was initially excited, but at her 20-week anatomy scan in December of 2022, everything changed. After a long pause during her ultrasound, the doctor entered the room. Without providing Samantha with much explanation of the condition, Samantha’s doctor told her that her baby had anencephaly and that the condition was incompatible with life. Samantha was devastated. 159. Samantha immediately asked what her options were. But her doctor’s response was, “You have no options. You will have to go through with your pregnancy.” Her doctor gave her a prescription for an anti-depressant. 160. Samantha’s doctor did not mention the option of leaving the state for abortion care. She assumed her doctor was legally prohibited from doing so. Samantha and her partner investigated their options and called clinics in New Mexico and Arizona but quickly realized it would be financially impossible to make the trip. She would need somewhere to stay, a car, and a way to pay for the procedure, none of which she had. Her family only has one car, which her partner uses to drive an hour and a half to work every day. She also could not miss work or find childcare for her five children. 161. Samantha realized she would have to carry the pregnancy to term. 162. In January, Samantha’s doctor wrote her employer a letter, saying that Samantha would need to work from home until she delivered. The doctor’s letter said that Samantha’s baby had been diagnosed with anencephaly, which is incompatible with life, and that her pregnancy was high risk. Samantha was relieved, as it was excruciating to have people congratulating her, rubbing her belly, and asking questions about her plans for the new baby. Repeatedly having to tell people her baby would not survive made everything worse. 163. As the months wore on, Samantha tried to focus on something positive. She wanted to donate her baby’s organs because then there might be a purpose to this pregnancy. But she learned that babies with anencephaly are not eligible for donation. 164. Eventually, all she could think about was that she and her partner needed to bury their daughter and she did not know how they would be able to afford a funeral. She reached out to a Christian pro-life non-profit that paid for professional maternity photos and said they would help her raise the money. They generated almost no donations. She also started a GoFundMe to pay for the funeral, but that too did not yield much money. Samantha started her own fundraising campaign, including selling menudo, a spicy Mexican soup, by the bowl. 165. Samantha grew weary of hearing the phrase “I’m sorry.” 166. Samantha read about this lawsuit after it was filed, and she reached out to both a reporter and Plaintiffs’ counsel. She wanted people to know her story. 167. At the end of April, Samantha went into labor several weeks early. She panicked. She had not had enough time to raise the money she needed for the funeral. 168. At the hospital, Samantha learned her baby was breech, meaning the fetus was positioned backwards for delivery. Because vaginal delivery can be complicated and dangerous and risk injuring the baby, Cesarean section is recommended for a breech baby. But there was no talk of a Cesarean here. Samantha noted the hypocrisy of treating her daughter like a healthy baby only while she was in utero. 169. Samantha gave birth to her daughter and named her Halo. Halo only lived for 4 hours. During those hours, as Samantha watched her daughter gasp for air, she knew for sure she wanted to tell her story publicly. 170. After Halo passed, Samantha’s milk came in. 171. Samantha received multiple calls from Texas Women, Infants, and Children (“WIC”) to congratulate her on the birth of her baby and update her Medicaid. Each time, Samantha had to tell them that Halo had passed. 172. When it came time to plan Halo’s funeral, Samantha and her partner got multiple quotes for thousands of dollars. They found a simple graveside service they could afford and scheduled it for a Friday morning. When the funeral home tried to charge them an additional $1,100 because it was Good Friday, Samantha cried until they agreed to waive the extra fee. 173. Samantha also connected with an NPR reporter, and after they published a story about her, people donated to her GoFundMe. By then, the simple funeral was already over. But Samantha is thankful she will now be able to buy a headstone. 174. Samantha believes that she should have had the choice and the right over her body and her daughter Halo’s body. She wanted to be able to put her daughter to rest earlier, since she was going to have to rest either way. Samantha hopes that the law will change and no one, including her children, will have to go through this again. 175. Samantha’s claims are capable of repetition but evading review. Samantha sues on her own behalf. J. Taylor Edwards 176. Taylor Edwards is 30 years old and lives in Austin, Texas. 177. Taylor and her husband have always wanted to have kids but struggled to get pregnant. Taylor has PCOS, which interferes with ovulation, so they began fertility treatments and IVF. After two years of treatments, Taylor finally got pregnant in November 2022. 178. At first, everything was fine. Taylor had some bleeding at 12 weeks, but ultrasounds showed that the pregnancy was developing normally. Taylor did NIPT genetic testing that came back normal. Taylor and her husband learned they were having a girl and named her Phoebe. 179. Because Taylor had conceived with IVF, her doctor recommended that she do her anatomy scan early, at 17 weeks. That is when everything changed. In February 2023, her MFM specialist told her the baby was measuring unusually small and diagnosed the baby with encephalocele, a bubble-like protrusion on the base of the skull that causes the brain matter to herniate out of the skull. Taylor’s MFM told her that no fetal surgery could correct the issue and that her baby would die at birth and may not even survive the pregnancy. The MFM gave her the name of an abortion clinic in New Mexico but could not advise her further. 180. Taylor sought a second opinion from another MFM who confirmed the diagnosis. Taylor also spoke to her OB/GYN, who said the baby would never be able to breathe on her own. 181. Her doctors counseled her that there was a high risk her baby would not survive to birth and that continuing the pregnancy carried risks for her. Taylor decided she needed an abortion. Her doctors told her that if this had happened a year and a half ago, they could have offered her the care she needed in Texas, but not anymore. 182. The logistics were daunting. Taylor could not use her medical insurance to pay for the abortion. They had to sort out flights, hotels, and transfer of medical records. She and her husband felt like they were completely on their own. 183. Taylor made an appointment at a clinic in New Mexico recommended by her doctor, and she and her husband booked plane tickets. But three hours before their flight was scheduled to leave, the clinic called to say that due to a shortage of medication needed for the procedure, they had to cancel her appointment. Taylor was shocked. She tried to get an appointment at another clinic in New Mexico, but none were available. 184. Taylor started to panic. She worried that by the time she got an appointment, she would be too far along to get an abortion. She started vomiting every day and struggled with the physical and emotional weight of her situation. She also felt like a fraud, walking around pregnant with a baby that would never live. 185. She searched for help online and eventually found a clinic in Colorado with appointments. She traveled to Colorado to receive her abortion. 186. When Taylor returned from Colorado, she saw news about this lawsuit. She was connected to a reporter and Plaintiffs’ counsel and decided she needed to tell her story too. 187. Now, Taylor is back at square one with IVF. She and her husband still want a child, but trying again is complex, especially in Texas, where she fears being pregnant again. 188. Taylor’s claims are capable of repetition but evading review. Taylor sues on her own behalf. K. Kiersten Hogan 189. Kiersten Hogan is 30 years old and lives in the Dallas-Fort Worth area of Texas. 190. Kiersten was living in Oklahoma in June 2021 when she found out she was pregnant. She had long-ago been diagnosed with PCOS, had a history of miscarriages, and had been told when she was a teenager that she could not have children. So, after she missed her period and got a positive pregnancy test, she was surprised but excited. 191. Soon after learning she was pregnant, however, Kiersten started bleeding. She went to the emergency room at a hospital near her home in Oklahoma. After an ultrasound, Kiersten was told that everything looked normal, and that she should rest and abstain from sexual activity. She was relieved. 192. Kiersten lived with her boyfriend, who was physically and emotionally abusive. When he found out she was pregnant, he became violent with her and told her they would have to leave the state for her to get an abortion. Kiersten did not want an abortion. She wanted the baby. So she decided to wait until her boyfriend was traveling for work, then packed up her things and left. 193. After staying with family briefly, Kiersten came to Waco, Texas, to stay with a friend. She immediately started looking for a job and a place to live. Things were looking up. 194. In August 2021, when she was around 13 weeks pregnant, she started bleeding again, this time passing large clots. She rushed to the emergency room and explained that she had a history of miscarriages and bleeding during this pregnancy. Once again, she was told that everything looked normal, and that she should go home, rest, and abstain from sexual activity. 195. Over the next several weeks, Kiersten tried to take it easy, though she continued to experience bleeding and cramping. She found a new job and a place to live and moved all of her possessions. Shortly after, she started her new job. 196. On September 30, 2021, just weeks after S.B. 8 had taken effect, and days after Kiersten had settled into her new life, she thought her water broke. She was only around 19 weeks pregnant and panicked. 197. Kiersten was rushed to the hospital and admitted where she learned that her amniotic sac was protruding out of her cervix. The diagnosis was cervical insufficiency, and she was told that if it had been diagnosed earlier, she could have had a cerclage procedure to prevent her cervix from dilating prematurely. Now it was too late. While she would likely lose the pregnancy, there was a small chance the sac would recede. In the meantime, they would keep her in the hospital for monitoring. 198. But her water broke a few hours after arriving at the hospital. Kiersten asked what her options were and was told that because of the new Texas law, as long as her baby had a heartbeat, she did not have any options. She would need to stay in the hospital on bedrest until she either went into labor or got sick enough for the hospital to give her an abortion. She was told that if she tried to leave the hospital, it would be used as evidence that she was trying to kill her baby; that if she tried to do anything to end her pregnancy, criminal charges could be brought against her. 199. On multiple occasions, religious counselors came to visit her, even though she had declined pastoral care. One nurse told her that because of the hospital’s religious affiliation, they cared more about fetuses than pregnant women. 200. Kiersten was terrified and felt trapped inside the hospital walls. She was afraid to even go to the bathroom for fear that she would cause herself to go into labor and be arrested. Four days later, on the afternoon of October 4, Kiersten went into labor in the hospital bathroom and delivered her son stillborn. 201. On the morning of October 5, Kiersten was discharged. 202. Texas law caused Kiersten to be detained against her will for four days and made to feel like a criminal, all during the biggest medical emergency of her life. 203. When Kiersten saw news reporting about this lawsuit, she reached out to Plaintiffs’ counsel because she wanted to tell her story too. 204. Kiersten’s claims are capable of repetition but evading review. Kiersten sues on her own behalf. L. Lauren Van Vleet 205. Lauren Van Vleet is 27 years old and lives in Jarrell, Texas. 206. Lauren V. and her husband have always wanted children, so they were excited when she got pregnant in October 2022. Her initial bloodwork and ultrasounds were all normal. They learned the baby was a boy and named him Rowan. 207. Lauren V. was scheduled to have her anatomy scan at 20 weeks. However, there was a terrible snow and ice storm that caused widespread power outages and several deaths throughout Texas. Lauren V.’s anatomy scan was rescheduled for two weeks later. 208. At her anatomy scan in February 2023, Lauren V. learned that her baby’s skull was not developing properly. Her OB/GYN said it was anencephaly. 209. Lauren V. had an appointment with a high-risk specialist the next day who confirmed the diagnosis and told her that her baby would not survive. Lauren V. was advised that she could either continue the pregnancy or she could go to Colorado or New Mexico for an abortion. Her doctor told her that due to Texas’s laws, there was nothing they could do but wait for the baby’s heart to stop beating or for her to carry the pregnancy to term. 210. Lauren V. was devastated and had a sudden and suffocating feeling of guilt. She feared that she had done something wrong. Nonetheless, Lauren V. knew that she wanted an abortion. 211. Due to the delay in getting her anatomy scan, Lauren V. was already 23 weeks pregnant and concerned that she would have trouble finding a clinic, even one out of state, with appointments and the ability to provide her with abortion care. 212. Lauren V.’s aunt lives in Maryland, so Lauren V. looked for a provider there. Her family helped her with the logistics, and she got financial support for the procedure. All the while, Lauren V. was terrified about legal liability and avoided texting anyone about her plans. 213. By the time Lauren V. arrived at the clinic for her abortion, she was 24 weeks pregnant. She received the abortion and has spent the last several months trying to heal. 214. When this lawsuit was filed, Lauren V. read about the case with keen interest, particularly because Lauren H.’s story was so similar to her own. 215. Lauren V. wrote a letter to Lauren H., sent it to Plaintiffs’ counsel, and asked them to pass it on to her. The letter read, in part: “[I]t wasn’t until I read your story on the news and then again in the lawsuit that I actually felt like I had made the right choice. I am so sorry for your loss but I am also very happy to see you fighting for our rights as mothers to make informed decisions as well.about our own bodies and health without feeling like we are committing a terrible crime. Know that you have so many people in your corner and I will be cheering you on as loudly as I can.” 216. Lauren V. decided to join this lawsuit because she still wants to have children but is scared to be pregnant again in Texas. 217. Lauren V.’s claims are capable of repetition but evading review. Lauren V. sues on her own behalf. M. Elizabeth Weller 218. Elizabeth is 27 years old and lives in Kingwood, Texas. 219. Elizabeth and her husband learned she was pregnant at the beginning of 2022. They had just started trying for a baby, so they were both taken aback and excited. They immediately started planning everything, from their pregnancy announcement to designing the nursery. 220. Elizabeth and her husband opted not to do any genetic testing during her pregnancy because she knew she would want to continue the pregnancy even if her baby had a disability. Elizabeth herself was born with a physical disability, brachial plexus Erb’s palsy, which causes partial paralysis of her right arm. 221. Elizabeth was diagnosed with gestational diabetes and began taking medication to control her blood sugar. Otherwise, her pregnancy progressed relatively smoothly. Her anatomy scan revealed no issues. They learned the baby was a girl. 222. But on May 10, 2022, Elizabeth was 19 weeks pregnant when her water broke. Immediately, she knew what it meant. Shocked and terrified, Elizabeth rushed to the emergency room. Once at the hospital, she was told that while her cervix was still closed, she had lost a lot of amniotic fluid. 223. Elizabeth was admitted to the hospital but felt extremely uneasy. Hospital staff told her: “At this point, we just have to hope and pray that it all comes together.” They told her to pray as well. Elizabeth felt like she was not getting information about the true severity of her situation and that some staff might even be lying to her. 224. Elizabeth called her OB/GYN who explained that at 19 weeks, the baby was not developed enough to survive and that if she chose to remain pregnant, the baby’s chances of survival were almost zero. Her OB/GYN also told her that if she did not terminate the pregnancy, she could get an infection that could cause her to lose her uterus or even her life. 225. That night, Elizabeth and her husband talked at length and decided they wanted to terminate the pregnancy. There was no reason to prolong their suffering and risk Elizabeth’s health when their baby would never survive. 226. In the morning, Elizabeth’s OB/GYN visited her in the hospital and Elizabeth confirmed that she wanted to terminate the pregnancy. Her OB/GYN said that she needed to clear the procedure with the hospital administration. At this point, Elizabeth was already passing blood clots and began taking a course of prophylactic antibiotics prescribed by the doctor. 227. But hours later, her OB/GYN returned and gave her the bad news: Elizabeth wasn’t sick enough to get an abortion. Specifically, because Elizabeth had started antibiotics that were already fending off any infection, she had put herself in a legal grey area. Elizabeth was told that she could either discontinue antibiotics and stay in the hospital to wait to develop an infection and get sicker, or she could go home and look out for signs of infection. Elizabeth chose to go home. 228. For the next three days, Elizabeth’s physical, mental, and emotional health deteriorated. She was vomiting constantly and in abdominal pain. Amniotic fluid would not stop leaking out of her body. She checked her temperature every hour and obsessively monitored the color and smell of her vaginal discharge. She was in a terrible mental state, grappling with the fact that her daughter was dying inside of her 229. On May 13, Elizabeth went to her OB/GYN’s office for an ultrasound to determine if the baby still had a heartbeat. The baby did. Elizabeth asked if she should leave the state to seek care, and her doctor said she could leave if she felt comfortable doing so, but that she might bleed out and risk death on the way. Dejected, Elizabeth was leaving her doctor’s office when she felt another gush of liquid. This time, her discharge was finally yellow and foul smelling. Elizabeth collected a sample to bring to the hospital as proof. 230. That night, Elizabeth was admitted again and diagnosed with chorioamnionitis. A medical board reviewed her case and finally approved her abortion. Elizabeth was given the medication to induce labor. Her daughter did not survive. 231. While Elizabeth recovered physically, she was outraged about what happened to her. She reached out to lawyers, reporters, and even the Texas Medical Board for help. The Texas Medical Board told her that she could submit a formal complaint against her doctor. But Elizabeth did not blame her doctor—to the contrary, Elizabeth felt her doctor was her only advocate throughout the traumatic incident. Ultimately, the complaint went nowhere. 232. Elizabeth’s experience made her feel like she was deserving of punishment and specifically, that the state of Texas wanted her to suffer. She felt emotionally traumatized, depressed, and inadequate. It was as though because she had failed to carry a wanted pregnancy to term, she deserved to be slowly tortured. This feeling of punishment only made the process of healing worse. It felt like a cruel and unusual reminder by the state that she was inadequate, and therefore deserved this punishment. 233. Elizabeth thought: if I don’t speak out, who will? But after telling her story to a reporter at NPR, Elizabeth was inundated with other media requests, and decided it was all too much. At the time, she was finishing graduate school and had to focus on healing and her graduate studies. 234. When Elizabeth saw news reports about this lawsuit, however, she knew she wanted to do something more and reached out to Plaintiffs’ counsel. 235. Elizabeth and her husband still want children, but they struggle to grapple with the idea as well as the serious risks associated with being pregnant again in Texas. 236. Elizabeth’s claims are capable of repetition but evading review. Elizabeth sues on her own behalf. N. Dr. Damla Karsan 237. Plaintiff Damla Karsan, M.D, is a board-certified OB/GYN in private practice at Comprehensive Women’s Healthcare in Houston, Texas who is licensed to practice medicine in the state of Texas. 238. Dr. Karsan has practiced obstetrics and gynecology in Houston since 2001. As part of her practice, Dr. Karsan provides gynecological care, prenatal care, and obstetric care to her patients and to her colleagues’ patients when she is on-call at the hospital where she has admitting privileges. 239. She is also trained to provide abortion care, and before S.B. 8, she routinely provided abortions to her patients as part of their comprehensive reproductive health care needs.4 240. Over her career, Dr. Karsan has personally treated pregnant patients with a wide variety of obstetrical and other health complications that develop during pregnancy, including but not limited to: miscarriage; ectopic pregnancy; management of fetal demise; complications of 4 Before S.B. 8, Texas law generally permitted physicians to provide a limited number of abortions per year up to 18 weeks LMP in their private practices, or up to 22 weeks LMP in a hospital or ambulatory surgical center. See Tex. Health & Safety Code §§ 171.004, 171.045, 245.004. pregnancy, including cervical insufficiency, PPROM, bleeding, preeclampsia, hyperemesis gravidarum; maternal comorbidities such as hypertension, diabetes, heart disease, kidney disease, cancer, rheumatologic disorders, psychiatric conditions, including those that may lead to suicide; complicated twin pregnancies; lethal fetal anomalies; various genetic diagnoses, including trisomy 13, 18, and 21; structural fetal abnormalities; and molar pregnancy. Dr. Karsan consults with specialists in the care of such patients—including but not limited to emergency medicine hospitalists, cardiologists, oncologists, anesthesiologists, and maternal fetal medicine doctors— and actively participates in the care of her patients who are treated for emergent health conditions during their pregnancies. Dr. Karsan intends to continue providing the full scope of care to her pregnant patients in the future. 241. Since S.B. 8 took effect, Dr. Karsan has seen the devastating impact of Texas’s abortion bans on her practice and on that of her colleagues. In Dr. Karsan’s experience, widespread fear and confusion regarding the scope of Texas’s abortion bans have chilled the provision of necessary obstetric care, including abortion care. Dr. Karsan and her colleagues fear that prosecutors and politicians will target them personally and threaten the state funding of the hospitals where they work if they provide abortion care to pregnant people with emergent medical conditions. 242. Dr. Karsan has seen that physicians in Texas are even afraid to speak out publicly about this issue for fear of retaliation. Dr. Karsan feels she is only able to speak out publicly because she is in private practice and not directly employed by a state-funded hospital. 243. Dr. Karsan has also personally treated pregnant patients with emergent medical conditions since S.B. 8 took effect and consulted with colleagues about the care of such patients. In Dr. Karsan’s experience, an emergent condition or emergency situation cannot be formulaically defined and will always depend on the patient’s unique situation. 244. Since Roe v. Wade was overturned, Dr. Karsan has treated patients with emergent medical conditions, including patients carrying pregnancies with lethal fetal conditions who needed treatment for complications like kidney stones, bipolar disorder, and hemorrhage. Before S.B. 8, Dr. Karsan would have offered abortion care to these patients. Now, Dr. Karsan instead has had to give them information about where to seek abortion care out of state. 245. Dr. Karsan sues on her own behalf and on behalf of her patients. O. Dr. Judy Levison 246. Plaintiff Judy Levison, M.D., M.P.H., is a board-certified OB/GYN licensed to practice medicine in the state of Texas. Dr. Levison is also a professor in the Department of Obstetrics and Gynecology at Baylor College of Medicine in Houston, Texas. 247. During her career, Dr. Levison has worked in private practice and in educational settings in Washington, California, and Texas providing obstetrical and gynecological care, including abortion, as well as teaching medical students, residents, and fellows. For the last 23 years, Dr. Levison has practiced obstetrics and gynecology in Houston and taught at Baylor College of Medicine, developing internationally recognized expertise in the treatment of pregnant people with HIV. Over her career, Dr. Levison has personally treated pregnant patients and consulted with relevant specialists regarding many different emergent conditions that arise during pregnancy, including, but not limited to: miscarriage; management of fetal demise; ectopic pregnancy; infections during pregnancy, including as a result of PPROM; bleeding and hemorrhage; comorbidities such as hypertension and diabetes; preeclampsia; hyperemesis gravidarum; heart conditions, including pulmonary hypertension and valve replacement; kidneydisease; cancer, including cervical and breast cancer; rheumatological problems like lupus or Sjogren’s syndrome; psychological conditions, including those that may lead to suicide; and various fetal diagnoses including trisomy 13, 18, and 21, neural tube defects like anencephaly, gastric and cardiac defects, Potter syndrome (where the baby does not properly develop kidneys), and molar pregnancy. 248. Since S.B. 8 took effect, Dr. Levison has seen the devastating impact of Texas’s abortion bans on her practice and on that of her colleagues. In Dr. Levison’s experience, widespread fear and confusion regarding the scope of Texas’s abortion bans has chilled the provision of the standard of practice of obstetric care, including counseling patients about the options for genetic screening for chromosomal diagnoses or neural tube defects and the options for abortion if a lethal fetal diagnosis was found. Dr. Levison and her colleagues fear that prosecutors and politicians will target them personally and threaten the state funding of their hospitals if they provide abortion care to pregnant people with emergent medical conditions. 249. Dr. Levison partially retired from the practice of medicine in July 2022 in part because, after the Supreme Court overturned Roe v. Wade and abortion became nearly completely banned in Texas, she felt she could no longer practice medicine the way she was trained and consistent with her ethical obligations as a physician. Texas’s abortion bans have made it impossible for her to provide comprehensive, high-quality reproductive care to her patients. 250. While she is partially retired, Dr. Levison can still see patients and regularly consults with colleagues regarding a wide array of pregnancy complications necessitating abortion care, including various specialists. She regularly consults with OB/GYN and MFM colleagues regarding the care of pregnant patients under Texas’s abortion bans. Specifically, since S.B. 8 went into effect, Dr. Levison has consulted with and assisted colleagues regarding patient cases that arguably fall under the Emergent Medical Condition Exception, including patients with PPROM, cancer, diabetes, hypertension, suicidal ideation, and who need fetal reduction procedures. Dr. Levison plans to continue to consult with her colleagues on these cases in the future. 251. Dr. Levison has seen that physicians in Texas are afraid to speak out publicly about Texas’s abortion bans for fear of retaliation. Dr. Levison feels she is only able to speak out publicly because she is in the process of retiring. 252. Dr. Levison sues on her own behalf and on behalf of her patients. 253. Plaintiffs Dr. Karsan and Dr. Levison are collectively referred to throughout this Complaint as the “Physician Plaintiffs.” II. DEFENDANTS 254. Defendant State of Texas is responsible for the enforcement of Texas laws, including its abortion bans and the Emergent Medical Condition Exception. The State of Texas includes private citizens that could potentially enforce S.B. 8. 255. Defendant Ken Paxton is the Attorney General of Texas. As Attorney General, he is empowered to institute an action for a civil penalty against physicians licensed in Texas who violate or threaten to violate any provision of the Texas Medical Practice Act, including provisions triggered by a violation of the Trigger Ban. Tex. Occ. Code § 165.101; id. § 164.053. The Attorney General is additionally empowered to file a civil action against any person who violates the Trigger Ban, seeking a civil penalty of at least $100,000, plus attorney’s fees and costs. Tex. Health & Safety Code § 170A.005. Defendant Paxton has threatened that he will “strictly enforce” the Trigger Ban.5 Defendant Paxton is sued in his official capacity and may be served with process at 300 West 15th Street, Austin, Texas 78701. 5 Ken Paxton, Tex. Att’y Gen., Advisory on Texas Law Upon Reversal of Roe v. Wade (June 24, 2022), https://www.texasattorneygeneral.gov/sites/default/files/images/executive-management/Post-Roe%20Advisory.pdf. 256. Defendant Texas Medical Board (“TMB”) is the state agency mandated to regulate the practice of medicine by licensed doctors in Texas. TMB must initiate disciplinary action against licensees who violate any provision of the Texas Medical Practice Act or Chapter 171 of the Texas Health and Safety Code. Tex. Occ. Code § 165.001; id. § 164.055. TMB may impose discipline on a doctor who violates any state law “connected with the physician’s practice of medicine” because such violation constitutes per se “unprofessional or dishonorable conduct.” Tex. Occ. Code § 164.053(a)(1); id. § 164.052(a)(5); see also id. § 164.053(b) (making clear that “[p]roof of the commission of the act while in the practice of medicine . . . is sufficient” for discipline). TMB “shall” also “revoke the license, permit, registration, certificate, or other authority” of a physician who violates the Trigger Ban. Tex. Health & Safety Code § 170A.007. TMB may be served with process at 1801 Congress Avenue, Suite 9.200, Austin, Texas 78701. 257. Defendant Stephen Brint Carlton is the Executive Director of TMB and in that capacity serves as the chief executive and administrative officer of TMB. Tex. Occ. Code § 152.051. Mr. Carlton is sued in his official capacity and may be served with process at 1801 Congress Avenue, Suite 9.200, Austin, Texas 78701. JURISDICTION AND VENUE 258. This action is brought pursuant to Texas Rules of Civil Procedure 680 to 693, Texas Civil Practice and Remedies Code Chapter 65, and the common law of Texas to obtain declaratory and injunctive relief against Defendants. 259. This Court has jurisdiction over this matter, pursuant to the Texas Uniform Declaratory Judgments Act, Texas Civil Practice and Remedies Code § 37.001, et seq. (“UDJA”), Sections 24.007 and 24.008 of the Texas Government Code, and Texas Constitution, Article V, 260. Further, this Court has jurisdiction over Plaintiffs’ request for declaratory and injunctive relief against Defendants because the UDJA waives sovereign and governmental immunity for challenges to the validity of statutes. 261. The Court also has jurisdiction over the Defendants sued in their official capacity because the Ultra Vires Doctrine permits claims brought against state officials for nondiscretionary acts unauthorized by law. See Tex. Civ. Prac. & Rem. Code §§ 37.003, 37.004, 37.006; Tex. Lottery Comm’n v. First State Bank of DeQueen, 325 S.W.3d 628, 634-635 (Tex. 2010); Tex. Dep’t of Transp. v. Sefzik, 355 S.W.3d 618, 621-22 (Tex. 2011). 262. Finally, Texas’s abortion bans are enforced through civil means, including steep civil penalties and disciplinary sanctions. See, e.g., Tex. Occ. Code §§ 165.001, 164.052(a)(5), 164.053(a), 164.055; Tex. Health & Safety Code §§ 170A.005, 170A.007. This Court has jurisdiction to render a declaratory judgment regarding a civil enforcement scheme. 263. Although there are also potential criminal penalties for providing a prohibited abortion in Texas, this Court has jurisdiction to enter declaratory and injunctive relief because of the bans’ civil penalties. Additionally, the Court has jurisdiction to enter declaratory and injunctive relief because criminal enforcement threatens irreparable injury to physicians’ vested property interests in their medical licenses and liberty interests in pursuit of their chosen profession. See Tex. Propane Gas Ass’n v. City of Houston, 622 S.W.3d 791, 798–99 (Tex. 2021) (holding that district court had jurisdiction to render declaratory judgment regarding municipal criminal ordinances because the ordinances threatened irreparable injury to the plaintiff’s property rights); TitleMax of Tex., Inc. v. City of Austin, 639 S.W.3d 240, 248 (Tex. Ct. App. 2021) (same). This Court also has jurisdiction because application of the abortion bans is causing pregnant people to face death, sustain physical injury, and endure extreme mental anguish, which is unconstitutional and threatens irreparable injury to Physician Plaintiffs’ and their patients’ rights. State v. Morales, 869 S.W.2d 941, 942 (Tex. 1994). 264. Venue is proper in Travis County because Defendants State of Texas, Paxton, TMB, and Carlton reside or have their principal office in Travis County. Tex. Civ. Prac. & Rem. Code § 15.002(a). 265. Plaintiffs’ request for prospective relief is specifically authorized as a request for a declaratory judgment under the UDJA. An action for a declaratory judgment is neither legal nor equitable but is sui generis—that is, of its own kind. Tex. Liquor Control Bd. v. Canyon Creek Land Corp., 456 S.W.2d 891, 895 (Tex. 1970). Without such declaratory judgment, Plaintiffs have no meaningful remedy for their state law claims in accordance with Texas Constitution Article I, § 13. FACTUAL ALLEGATIONS I. BACKGROUND A. Abortion is Health Care 266. Every major mainstream medical organization, including the American Medical Association (“AMA”), the American College of Obstetricians and Gynecologists (“ACOG”), the American College of Emergency Physicians (“ACEP”), and the Society for Maternal-Fetal Medicine (“SMFM”), recognizes that abortion is necessary health care. These organizations are all opposed to governmental interference into patient-physician relationships. Such interference is contrary to the appropriate exercise of professional judgment that medical professionals need to exercise to protect patients’ well-being. As the experiences of Amanda, Lauren M., Lauren H., Anna, Ashley, Kylie, Jessica, Samantha, Dr. Dennard, Taylor, Kiersten, Lauren V., and Elizabeth demonstrate, abortion bans are a paradigmatic example of such governmental interference. 270. While the medical treatment is generally the same, medical professionals may draw a distinction from the patient’s perspective between a “spontaneous abortion” or “miscarriage”— where the embryo or fetus has no discernable cardiac activity—and an “induced abortion”— where the embryo or fetus has cardiac activity. The pregnant person’s desire to have a baby or not, however, has no bearing on whether or not an abortion is considered spontaneous or induced.10 271. The majority of abortions in the United States are accomplished either through use of medications (medication abortion) or via an outpatient procedure (procedural abortion). Medication abortions are typically indicated up to 10.0 weeks and involve the ingestion of two medications to terminate the pregnancy, expelling the pregnancy via vaginal bleeding, akin to a heavy period or spontaneous miscarriage. Procedural abortions are possible throughout pregnancy and involve a two-step process where the medical provider first partially dilates the patient’s cervix (using medications and/or mechanical or osmotic dilators), then evacuates the uterus using suction aspiration, instruments, or some combination. Dilation is done either the same day or the day before, and the evacuation phase of a procedural abortion typically takes around 5 minutes in the first trimester of pregnancy and 10-20 minutes in the second trimester, depending on the patient’s response to the procedure and the complexity of the case.11 272. The only other medically proven abortion method is induction abortion, where a physician uses medication to induce labor and delivery of a non-viable fetus. Induction of labor accounts for only about 2% of second-trimester abortions nationally. Induction abortions must be performed in a hospital or similar facility that has the capacity to monitor a patient overnight and 10 See Practice Bulletin 200: Early Pregnancy Loss, ACOG (Nov. 2018) https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss; Andrew Moscrop, Miscarriage or Abortion? Understanding the Medical Language of Pregnancy Loss in Britain; A Historical Perspective, 39 Med. Humanities 98 (2013), https://mh.bmj.com/content/39/2/98. 11 See The Safety and Quality of Abortion Care in the United States, Nat’l Acads. of Sci., Eng’g, & Med. (2018) at 51-65. provide pain management (e.g., epidural). Induction abortions can last anywhere from five hours to three days; are extremely expensive; entail more pain, discomfort, and recovery time for the patient—similar to giving birth—than procedural abortion; and are medically contraindicated for some patients.12 273. While some people attempt to stigmatize abortion care by misusing or conflating pregnancy terminology—e.g., villainizing particular methods of abortion or attempting to distinguish “elective abortion” from “miscarriage”—mainstream medical professionals understand that patients in any number of circumstances need abortions and that pregnant people, in consultation with their medical providers, should be able to choose the method of abortion appropriate for their circumstances. B. Some Pregnancies Pose Emergent Medical Risks to Pregnant People’s Lives and Health 274. All pregnancy care, including abortion, is time sensitive. Medically unnecessary delays in access to abortion care always harm pregnant people. Yet pregnancy can lead to any number of urgent or emergent conditions, if not outright medical emergencies, where especially prompt termination of pregnancy is necessary to preserve the life, health, and/or future fertility of the pregnant person. The American Board of Emergency Medicine (“ABEM”) defines “emergent” conditions as cases where the “[p]atient presents with symptoms of an illness or injury that may progress in severity or result in complications with a high probability for morbidity if treatment is not begun quickly.”13 12 See id. at 5-8, 66-68. 13 Michael S. Beeson et al., The 2019 Model of the Clinical Practice of Emergency Medicine, 59 J. of Emergency Med. 96 (2020), https://www.jem-journal.com/article/S0736-4679(20)30154-2/fulltext. 275. ACOG has emphasized that “it is impossible to create an inclusive list of conditions that qualify” as emergent or emergencies and thus fall under an exception to a state’s abortion ban. Moreover, “it is dangerous to attempt to create a finite list of conditions to guide the practice of clinicians attempting to navigate their state’s abortion restrictions.” This is true for many reasons, including: “The practice of medicine is complex and requires individualization—it cannot be distilled down to a one-page document or list that is generalizable for every situation; No single patient’s condition progresses at the same pace; A patient may experience a combination of medical conditions or symptoms that, together, become life-threatening; Pregnancy often exacerbates conditions or symptoms that are stable in nonpregnant individuals; There is no uniform set of signs or symptoms that constitute an ‘emergency’; Patients may be lucid and appear to be in stable condition but demonstrate deteriorating health.”14 Nonetheless, medical organizations have described broad categories of types of conditions in pregnancy that are emergent. 276. ABEM’s Model of Clinical Practice of Emergency Medicine, the definitive source and guide to the core content found on emergency physicians’ board examinations, contains sections on “Complications of Pregnancy,” “Complications of Labor,” and “Complications of Delivery.” The conditions include: (1) ectopic pregnancy; (2) conditions that can lead to dangerous bleeding or hemorrhage, including placental issues; (3) severe forms of hypertension; (4) conditions that can lead to dangerous infection, including premature rupture of membranes; and (5) extreme hyperemesis gravidarum (dangerous nausea and vomiting leading to hospitalization).15 14 Understanding and Navigating Medical Emergency Exceptions in Abortion Bans and Restrictions, ACOG (Aug. 15, 2022), https://www.acog.org/news/news-articles/2022/08/understanding-medical-emergency-exceptions-in-abortion-bans-restrictions. 15 See Beeson et al., supra note 13. 277. An ectopic pregnancy is a pregnancy where a fertilized egg implants and grows outside the uterine cavity, usually in the fallopian tube. Ectopic pregnancies cannot result in live births and are life-threatening to the pregnant person because the pregnancy can rupture and cause massive internal bleeding. Ectopic pregnancies must be terminated with medication or surgery as soon as possible after diagnosis.16 278. Cesarean-scar ectopic pregnancy, where a pregnancy implants in the scar from a previous cesarean delivery, is considered an emergent condition where, like any other ectopic pregnancy, the recommended treatment is termination of pregnancy.17 279. Hemorrhaging during pregnancy is particularly dangerous for patients, as it can lead to organ damage, organ failure, or even death. A variety of preexisting chronic health conditions and health conditions that develop during pregnancy can become emergent due to the risk of hemorrhage during pregnancy. These conditions include, but are not limited to: placenta previa (when the placenta covers the cervix); placental abruption (when the placenta prematurely detaches from the uterine lining); placenta accreta (when the placenta grows into the uterine wall); uterine fibroids (that inhibit the uterus from contracting effectively and stopping bleeding from the placental implantation site); and other forms of first or second trimester bleeding.18 280. Severe forms of hypertension in pregnancy can also lead to life-threatening conditions. For example, preeclampsia is a complication of pregnancy which, when severe, can 16 See Practice Bulletin 193: Tubal Ectopic Pregnancy, ACOG (Mar. 2018), https://www.fertilehealthexpert.com/wp-content/uploads/2021/11/Ectopic-Pregnancy-ACOG.pdf. 17 SMFM Consult Series #63: Cesarean Scar Ectopic Pregnancy, Soc’y for Maternal Fetal Med. (Sept. 2022), https://www.smfm.org/publications/448-smfm-consult-series-63-cesarean-scar-ectopic-pregnancy#:~:text=Cesarean %20scar%20ectopic%20pregnancy%20is,in%20securing%20a%20prompt%20diagnosis. 18 See Practice Bulletin 222: Gestational Hypertension and Preeclampsia, ACOG (June 2020), https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/06/gestational-hypertension-and-preeclampsia; Practice Bulletin 203: Chronic Hypertension in Pregnancy, ACOG (Jan. 2019), https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/01/chronic-hypertension-in-pregnancy cause seizures, injury to the pregnant person’s liver and kidneys, stroke, and death. HELLP (Hemolysis, Elevated Liver Enzymes and Low Platelets) syndrome is a particularly dangerous variant of preeclampsia. For some patients, other forms of hypertension (sometimes in conjunction with other chronic conditions like obesity and diabetes) can increase in severity and cause the same complications seen with severe preeclampsia. 281. Infection of the reproductive organs, which can lead to chorioamnionitis (infection of the placenta or amniotic fluid) or sepsis (where the body’s response to infection damages its own tissue), is another risk that can cause a pregnant person’s medical condition to become emergent. Premature dilation of the cervix, for example, dramatically increases a pregnant person’s risk of infection and can be caused by conditions like an incompetent cervix (weak cervical tissue) and/or PPROM before the onset of labor. PPROM has a relatively high incidence, occurring in approximately 2% to 3% of pregnancies in the United States, and is an emergent condition itself due to the high risk of infection it entails.19 282. Other medical conditions can become emergent during pregnancy, either because being pregnant causes or exacerbates a chronic condition or increases other health risks, or because treatment for the chronic condition is unsafe while pregnant. For example: certain cancers requiring radiation, chemotherapy, or major surgery; certain cardiac, autoimmune, respiratory, or endocrine diseases; certain cases of hyperemesis gravidarum; and certain psychiatric conditions like bipolar disorder, major depressive disorder, anxiety disorders, and psychotic disorders can all be emergent, depending on the circumstances. Intentional acts of violence or accidents, e.g., motor vehicle crashes, firearm violence, intimate partner violence, etc., and substance use disorder can 19 See Practice Bulletin 217: Prelabor Rupture of Membranes, ACOG (Mar. 2020), https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/03/prelabor-rupture-of-membranes.also lead to emergent conditions. Because each patient’s circumstances are unique, it is within the purview of the patient’s medical provider to determine whether the patient’s comorbidities and/or other circumstances make abortion part of the patient’s recommended course of treatment.20 283. Finally, certain fetal conditions or diagnoses can increase the risks to a pregnant person’s health such that, when combined with the patient’s other comorbidities, her medical provider may determine that an abortion is necessary or recommended to prevent serious jeopardy to the pregnant person’s health. 284. For example, neural tube defects (including anencephaly); certain trisomies like trisomy 13 and 18 (the presence of an extra chromosome); triploidy (the presence of an extra set of chromosomes); certain gastric and cardiac defects in the fetus; and Potter syndrome (where the fetus does not properly develop kidneys), are examples of conditions where the fetus either will not survive delivery or likely will not survive more than a few hours or days after birth. As in Lauren M.’s case, cystic hygromas may indicate the presence of one or more of these fetal conditions. Abortion is generally indicated for patients with such pregnancies, as abortion is typically medically safer for the pregnant person than carrying the pregnancy to term and delivering a baby with no meaningful chance of survival. 285. Some fetal conditions present particularly acute risks to the pregnant person. For example, partial molar pregnancy is a condition where the placenta transforms into an invasive cancer, thus creating an emergency for the pregnant person. Mirror syndrome is an emergent 20 See High-Risk Pregnancy, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/22190-high-risk-pregnancy (last updated Dec. 14, 2021) (describing how certain preexisting conditions exacerbate the risks of the pregnancy); Practice Bulletin 189: Nausea and Vomiting of Pregnancy, ACOG (Jan. 2018), https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/01/nausea-and-vomiting-of-pregnancy; Nicole T. Christian & Virginia F. Borges, What Dobbs Means for Patients with Breast Cancer, 387 N. Engl. J. Med. 765-67 (Sept. 1, 2022) complication of pregnancy where the pregnant person and fetus both experience severe fluid retention that can lead to both fetal and maternal demise. 286. In the case of multiple pregnancies (twins, triplets, etc.), a fetal condition in one or more of the fetuses, combined with the pregnant person’s other comorbidities, can lead to an emergent condition where selective abortion (sometimes called selective “fetal reduction” or “fetal termination”) of one (or more) fetus is necessary to give the pregnant person and the remaining fetus(es) the best chance of survival.21 287. The discussion above highlights some of the emergent medical conditions necessitating prompt abortion care, but the list is by no means exhaustive, nor could it be. Mainstream medical associations emphasize that physician discretion to diagnose and treat emergent conditions is paramount to patient health. 288. Thus, where state law seeks to create a statutory exception to its abortion ban to allow abortion care for the purpose of preserving the life or health (including fertility) of the pregnant person, it must recognize that it is within the purview of the medical provider to determine the appropriate course of treatment for the patient. When a physician determines that such treatment includes abortion, the physician must be able to provide that treatment without concern that a prosecutor, jury, or disciplinary board second guessing their medical judgment will send them to prison and/or revoke their medical license. 289. The nature of abortion as critical health care is all the more acute in Texas, where maternal mortality and morbidity rates are rising. Texas’s Maternal Mortality and Morbidity 21 Practice Bulletin 231: Multifetal Gestations Twin Triplet and Higher-Order Multifetal Pregnancies, ACOG (June 2021), https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2021/06/multifetal-gestations-twin-triplet-and-higher-order-multifetal-pregnancies. Review Committee and the Department of State Health Services recently released their joint biennial report, and the results are shocking and alarming: 290. Among the documented pregnancy-related deaths in Texas, a staggering 90% were preventable.22 291. According to the report, the maternal mortality ratio for Texas is higher than the national average—20.2 maternal deaths per 100,000 live births (in 2017, the latest year for which data is available), compared to the national average of 17.4 deaths per 100,000 live births (in 2018, the latest year for which data is available).23 292. The report finds that the leading cause of pregnancy-related deaths in Texas was obstetric hemorrhage, and the leading underlying causes of hemorrhage were ruptured ectopic pregnancy, uterine rupture, placental abruption, and placenta accreta—all conditions that are considered emergent. In 2019, at least 13 women in Texas died from a ruptured ectopic pregnancy.24 293. The report shows that Severe Maternal Morbidity (“SMM”)—defined as “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health” that “if left untreated, could result in death”—increased significantly between 2018 to 2020, surging from 58.2 to 72.7 cases per 10,000 delivery hospitalizations. The total rate of pregnancy-related illnesses and injuries is likely much higher, as 22 Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022 (“Texas MMRC 2022 Report”) at 8, https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Joint-Biennial-MMMRC-Report-2022.pdf. 23 Id. at 10; Maternal Mortality Rates in the United States, Ctrs. for Disease Control & Prevention, https://www.cdc.gov/nchs/data/hestat/maternal-mortality-2021/maternal-mortality-2021.htm. 24 Texas MMRC 2022 Report at 8 297. The Texas Maternal Mortality Report further notes that “delay in referring or access to treatment,” “lack of standardized policies/procedures,” “failure to screen/inadequate assessment of risk,” “lack of continuity of care,” and “lack of access/financial resources” are all contributing factors in maternal deaths in Texas.30 298. Barriers such as these disproportionately impact Black patients. Black patients face significant barriers to quality, equitable health care, including delays in care, systemic discrimination, and implicit biases in their interactions with health care providers.31 Black women in Texas also face disproportionate poverty: 19.5% of Black Texans live in poverty compared to 10.5% of white Texans. And 15.5% of Texan women live in poverty compared to 13% of Texan men.32 This, coupled with Texas’s restrictive Medicaid and insurance coverage policies, renders health care unaffordable for many.33ss7005a1.htm?s_cid=ss7005a1_w; The Facts, Stats, and Impacts of Diabetes, Ctrs. for Disease Control & Prevention (Jun. 20, 2022), https://www.cdc.gov/diabetes/library/spotlights/diabetes-facts-stats.html; Data & Statistics on Sickle Cell Disease, Ctrs. for Disease Control & Prevention (May 2, 2022), https://www.cdc.gov/ncbddd/sicklecell/ data.html; Maria Dall’Era, Systemic Lupus Erythematosus, in John B. Imboden et al., (eds.), Current Rheumatology Diagnosis and Treatment 3rd ed, New York, NY: McGraw-Hill (2013). 30 Texas MMRC 2022 Report at D-2, D-3. In fact, a report by March of Dimes found that 49.2% of Texas counties are “maternity care deserts” where maternity health services are entirely absent. It also found that an additional 22.8% of Texas counties have only low or moderate access where there are few hospitals or birth centers, few obstetric care providers, or a high proportion of women without insurance coverage. Maternity Care Desert: Texas, 2020, March of Dimes (last visited Mar. 2, 2023), https://www.marchofdimes.org/peristats/data?reg=99&top= 23&stop=641&lev=1&slev=4&obj=9&sreg=48. 31 Michael T. Halpern & Debra J. Holden, Disparities in Timeliness of Care for U.S. Medicare Patients Diagnosed with Cancer, 19(6) Current Oncology e404-13 (2012); Jasmine M. Miller-Kleinhenz et al., Racial Disparities in Diagnostic Delay Among Women with Breast Cancer, 18(10) J. Am. Coll. Radiol. 1384 (2021); Joe Feagin & Zinobia Bennfield, Systemic Racism and U.S. Health Care, 103 Soc. Sci. & Med. 7 (2013); Bani Saluja & Zenobia Bryant, How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States, 30(2) J. Women’s Health 270-273 (2021); Brenda Pereda & Margret Montoya, Addressing Implicit Bias to Improve Cross-Cultural Care, 61 Clinical Obstetrics & Gynecology 2, 3-5 (2018). 32 American Community Survey S107: Poverty Status in the Past 12 Months, United States Census Bureau (last visited Mar. 1, 2023), https://data.census.gov/table?q=gender+poverty+in+texas. 33 The State of Reproductive Health and Rights: A 50-State Report Card, Population Institute (Feb. 2021), https://www.populationinstitute.org/resource/the-state-of-reproductive-health-and-rights-a-50-state-report-card 299. The Texas Maternal Mortality Report ends with multiple recommendations that are at odds with the demonstrated impact of Texas’s abortion bans. For example: “[p]romote patient- centered care through shared decision-making recognizing women as experts in their values and preferences and supporting informed, collaborative approaches to making health care decisions”; “support health systems with implementing evidence-based standards, guidelines, and practices, increasing patient and family engagement, promoting health care quality improvement, and reducing maternal health disparities”; “[s]upport emergency and maternal health service coordination” as “[e]mergency health providers’ knowledge about maternal health, as well as communication and coordination with obstetric and women’s health professionals, are critical factors in preventing pregnancy-related deaths.”34 C. Texas’s Abortion Bans 300. Texas has several abortion bans relevant to Amanda, Lauren M., Lauren H., Anna, Ashley, Kylie, Jessica, Samantha, Dr. Dennard, Taylor, Kiersten, Lauren V., Elizabeth, and the Physician Plaintiffs and their patients. 1. Texas’s Definition of Abortion 301. Texas law does not define “abortion” using the medical definition. Rather, Texas law states: “‘Abortion’ means the act of using or prescribing an instrument, a drug, a medicine, or any other substance, device, or means with the intent to cause the death of an unborn child of a woman known to be pregnant. The term does not include birth control devices or oral contraceptives. An act is not an abortion if the act is done with the intent to: (A) save the life or preserve the health of an unborn child; (B) remove a dead, unborn child whose death was caused 34 Texas MMRC 2022 Report at 16, 17, 20 by spontaneous abortion; or (C) remove an ectopic pregnancy.” Tex. Health & Safety Code § 245.002(1). 302. Texas law defines “ectopic pregnancy” as “the implantation of a fertilized egg or embryo outside of the uterus.” Tex. Health & Safety Code § 245.002(4-a). 303. While there is no express definition, it is generally understood that in the context of Texas’s definition of abortion, “dead” means that there is no cardiac activity present in the embryo or fetus. See, e.g., Tex. Health & Safety Code §§ 171.201-203 (emphasizing importance of a “fetal heartbeat” or “cardiac activity” to “unborn life”). 304. Abortions done to “save the life or preserve the health of an unborn child” are not considered abortions under Texas law. Tex. Health & Safety Code § 245.002(1)(A) (emphasis added); see also Tex. Health & Safety Code § 170A.002(b) (applying exception to abortion ban where “the person performs, induces, or attempts the abortion in a manner that, in the exercise of reasonable medical judgment, provides the best opportunity for the unborn child to survive unless, in the reasonable medical judgment, that manner would create . . . a serious risk of substantial impairment of a major bodily function of the pregnant female.”). 305. Texas’s abortion bans cite back to Texas’s definition of abortion, meaning that neither medical care involving removal of an ectopic pregnancy, nor removal of pregnancy tissue where no cardiac activity is present, is an abortion under Texas law. 2. Trigger Ban 306. Texas’s criminal ban on abortion is often referred to as the Trigger Ban because, while signed into law in 2021, it specified a contingent effective date and did not take effect until August 25, 2022, 30 days after the Supreme Court issued its judgment overturning Roe v. Wade.35 35 Defendant Paxton published an “Advisory on Texas Law” after the U.S. Supreme Court issued its opinion 307. The Trigger Ban states that “[a] person may not knowingly perform, induce, or attempt an abortion,” citing to Texas’s longstanding definition of abortion. Tex. Health & Safety Code §§ 170A.001(a), 170A.002(a). 308. There are both criminal and civil penalties for violations of the Trigger Ban. 309. A person can be charged with either a first- or second-degree felony for violating the Trigger Ban. Tex. Health & Safety Code § 170A.004. First-degree felonies are subject to imprisonment for life, or a term of between 5 and 99 years. Tex. Penal Code § 12.32. Second- degree felonies are punishable by imprisonment for a term of between 2 and 20 years. Tex. Penal Code § 12.33. 310. Further, the Trigger Ban states that the relevant licensing authority, the Texas Medical Board, “shall revoke the license, permit, registration, certificate, or other authority of a physician or other health care professional who performs, induces, or attempts an abortion in violation” of the Trigger Ban. Tex. Health & Safety Code § 170A.007. 311. Finally, any person who violates the Trigger Ban “is subject to a civil penalty of not less than $100,000 for each violation,” and “[t]he attorney general shall file an action to recover a civil penalty assessed under this section and may recover attorney’s fees and costs incurred in bringing the action.” Tex. Health & Safety Code § 170A.005. 312. The only exception to the Trigger Ban is an abortion performed by a physician on a patient with an emergent medical condition (see infra ¶ 324). in Dobbs v. Jackson Women’s Health Org., Case No. 19-1392, on June 24, 2022, that correctly noted the effective date of the Trigger Ban as 30 days after issuance of the “judgment” in Dobbs. Ken Paxton, Tex. Att’y Gen., Advisory on Texas Law Upon Reversal of Roe v. Wade (June 24, 2022), https://www.texasattorneygeneral.gov/ sites/default/files/images/executive-management/Post-Roe%20Advisory.pdf. Defendant Paxton later published an “Updated Advisory on Texas Law” upon issuance of the Dobbs judgment that confirmed that the Trigger Ban would take effect August 25, 2022. Ken Paxton, Tex. Att’y Gen., Updated Advisory on Texas Law Upon Reversal of Roe v. Wade (July 27, 2022), https://texasattorneygeneral.gov/sites/default/files/images/executive-management/ Updated%20Post-Roe%20Advisory%20Upon%20Issuance%20of%20Dobbs%20Judgment%20(07.27.2022).pdf 3. Senate Bill 8 313. Senate Bill 8 of 2021 prohibits physicians from providing an abortion in Texas if the embryo or fetus has detectible cardiac activity. Tex. Health & Safety Code §§ 171.201-204. S.B. 8 took effect in September of 2021 and creates additional civil penalties for physicians who perform abortions prohibited by S.B. 8. 314. Violations of S.B. 8 are subject to a bounty-hunting civil enforcement scheme allowing any individual to seek “statutory damages in an amount of not less than $10,000 for each abortion that the defendant performed” and “injunctive relief sufficient to prevent the defendant from violating” S.B. 8 in the future. Tex. Health & Safety Code §§ 171.207-211. 315. Like the Trigger Ban, the only exception to S.B. 8’s ban on abortion in pregnancies with detectible cardiac activity is an abortion performed by a physician on a patient with an emergent medical condition (discussed in detail below). 316. S.B. 8 also created new state documentation and reporting requirements that apply to all abortions performed under the Emergent Medical Condition Exception. As of September 1, 2021, all abortions performed under the Emergent Medical Condition Exception must be documented in detail by the treating physician. Specifically, the physician must “execute a written document”: (1) that “certifies the abortion is necessary due to a medical emergency;” (2) that “specifies the medical condition the abortion is asserted to address;” (3) that “provides the medical rationale for the physician’s conclusion that the abortion is necessary to address the medical condition;” (4) “place the document . . . in the pregnant woman’s medical record” (5) and “maintain a copy of the document . . . in the physician’s practice records.” Tex. Health & Safety Code §§ 171.008, 171.205. 317. S.B. 8 also requires physicians who perform abortions at abortion facilities to report all abortions performed under the Emergent Medical Condition Exception to the state. Tex. Health & Safety Code § 245.011(c)(10), (11) (requiring reporting to include “whether the abortion was performed or induced because of a medical emergency and any medical condition of the pregnant woman that required the abortion”). 4. Pre-Roe Ban 318. The Texas abortion ban at issue in Roe v. Wade (the “pre-Roe Ban”)36 also contained an exception for the life of the pregnant person.37 After the pre-Roe Ban was held unconstitutional in 1973, it was removed from the Texas Penal Code and Texas Civil Code. The Texas Legislature then enacted a comprehensive statutory scheme permitting and regulating abortion. In light of those later enactments, the Fifth Circuit held that the pre-Roe Ban was impliedly repealed. McCorvey v. Hill, 385 F.3d 846 (5th Cir. 2004).38 319. On June 24, 2022, for the first time, the text of the pre-Roe Ban was placed on the Texas Legislature’s website, with the note that the relevant statutes were “held to have been impliedly repealed in McCorvey v. Hill, 385 F.3d 846 (5th Cir. 2004).”39 Despite that holding and subsequent litigation regarding the pre-Roe Ban, Defendant Paxton took the position that the pre- Roe Ban was immediately enforceable after Roe v. Wade was overturned. Courts addressing this 36 “If any person shall designedly administer to a pregnant woman or knowingly procure to be administered with her consent any drug or medicine, or shall use towards her any violence or means whatever externally or internally applied, and thereby procure an abortion, he shall be confined in the penitentiary not less than two nor more than five years; if it be done without her consent, the punishment shall be doubled. By ‘abortion’ is meant that the life of the fetus or embryo shall be destroyed in the woman’s womb or that a premature birth thereof be caused.” 1925 Tex. Crim. Stat. 1191. 37 “By medical advice. Nothing in this chapter applies to an abortion procured or attempted by medical advice for the purpose of saving the life of the mother.” 1925 Tex. Crim. Stat. 1196. 38 See also Whole Woman’s Health v. Paxton, Civil Cause No. 2022-38397, 2022 WL 2314499 (Harris Cnty. Dist. Ct. June 27, 2022), injunction lifted by In re Paxton, No. 22-0527, 2022 WL 2425619 (Tex. July 1, 2022), case dismissed (Harris Cnty. Dist. Ct. Oct. 5, 2022); Texas v. Becerra, No. 5:22-cv-185-H, 2022 WL 3639525 (N.D. Tex. Aug. 23, 2022), appeal docketed, No. 22-11037 (5th Cir. Oct. 25, 2022); Order, Fund Tex. Choice v. Paxton, No. 1:22-cv-00859 (W.D. Tex. Feb. 24, 2023), ECF No. 120. 39 Vernon’s Tex. Civ. Stats. ch. 6-1/2 (last updated Dec. 14, 2022), https://statutes.capitol.texas.gov/ Docs/SDocs/VERNON'SCIVILSTATUTES.pdf. issue after Roe was overturned, however, largely disagree. See Order at 1, Fund Tex. Choice v. Paxton, No. 1:22-CV-859-RP (W.D. Tex. Feb. 24, 2023), ECF No. 120 (“[T]he Court finds that the pre-Roe laws have been repealed by implication . . . .”); Texas v. Becerra, No. 5:22-CV-185- H, 2022 WL 3639525, at *2 (N.D. Tex. Aug. 23, 2022) (treating the pre-Roe Ban as enforceable but noting that the Trigger Ban “reflects a more recent, more specific regulation of abortion and, normally, a more recent enactment governing the same subject supersedes prior enactments”). D. Exception to Texas’s Abortion Bans for Emergent Medical Conditions 320. Texas’s abortion laws have long recognized that providing abortion care to pregnant people with emergent medical conditions is exempted from the state’s various restrictions on the provision of abortion. Yet inconsistencies in the language of these provisions, the use of non-medical terminology, and sloppy legislative drafting have resulted in understandable confusion throughout the medical profession regarding the scope of the exception. 1. History of the Emergent Medical Condition Exception 321. Texas’s Emergent Medical Condition Exception first appeared in the Texas Code in 2011, when Texas updated its informed consent requirements for abortion and created certain exceptions for cases of so-called “medical emergency.” It defined “medical emergency” as “a life- threatening physical condition aggravated by, caused by, or arising from a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed.” Tex. Health & Safety Code § 171.002(3) (hereinafter the “Definition Provision”). 322. Over the last ten years, Texas has added numerous requirements to its abortion code that, utilizing this definition, have exceptions for “medical emergencies.”40 For example, in 2017 Texas passed a ban on “dismemberment abortion”—essentially a ban on dilation and evacuation (“D&E”) abortions—that has an exception for “medical emergencies.” Tex. Health & Safety Code § 171.152(a). 323. S.B. 8 is another example. The only exception to S.B. 8’s abortion ban and its associated civil penalties is for patients where “a physician believes a medical emergency exists.” Tex. Health & Safety Code § 171.205. 324. The same language in the Definition Provision appears as the sole exception to the Trigger Ban. Specifically, Texas’s criminal ban on abortion “does not apply if: (1) the person performing, inducing, or attempting the abortion is a licensed physician; (2) in the exercise of reasonable medical judgment, the pregnant female on whom the abortion is performed, induced, or attempted has a life-threatening physical condition aggravated by, caused by, or arising from a pregnancy that places the female at risk of death or poses a serious risk of substantial impairment of a major bodily function unless the abortion is performed or induced; and (3) the person performs, induces, or attempts the abortion in a manner that, in the exercise of reasonable medical judgment, provides the best opportunity for the unborn child to survive unless, in the reasonable medical judgment, that manner would create: (A) a greater risk of the pregnant female’s death; or (B) a serious risk of substantial impairment of a major bodily function of the pregnant female.”Tex. Health & Safety Code § 170A.002(b). 40 See Tex. Health & Safety Code § 171.0124 (informed consent); Tex. Fam. Code §§ 33.002, 33.0022 (informed consent for minors); Tex. Ins. Code §§ 1218.001, 1696.001 (insurance coverage); Tex. Gov’t Code § 2273.002 (facility licensing); Tex. Health & Safety Code § 171.152(a) (ban on “dismemberment abortions”); Tex.Occ. Code § 164.052 (physician licensing) 328. Yet the Trigger Ban also prohibits a physician from “knowingly” providing a prohibited abortion. Thus, a physician does not violate the Trigger Ban by providing an abortion in reliance on the exception unless the physician subjectively knows that in the exercise of reasonable medical judgment, the patient does not have a condition qualifying for the exception. When a physician relies on the exception in good faith, the physician does not know that the exception does not apply. Stated differently, a physician cannot knowingly violate the ban if she acts in good faith reliance on the exception. 329. Meanwhile, the Definition Provision’s language, which applies to S.B. 8, does not explicitly mention intent. Instead, the language “as certified by a physician” modifies the exception language, suggesting that the treating physician’s good faith certification, buttressed by the documentation and reporting requirements for medical emergencies added to the code by S.B. 8, governs the assessment of a patient’s circumstances. 330. Physicians confronted with the question of whether or not a patient qualifies for the Emergent Medical Condition Exception must consider not only their ethical responsibilities as physicians and potential medical malpractice liability if they do not follow the standard of care, but the risk of loss of liberty and prison sentence they will face, Tex. Health & Safety Code § 170A.004, Tex. Penal Code §§ 12.32-12.33, and the potential loss of their license to practice medicine and pursue their chosen profession if they are found guilty of violating an abortion ban, Tex. Occ. Code §§ 165.001, 164.052(a)(5), 164.053(a), 164.055; Tex. Health & Safety Code § 170A.007. 331. Understandable confusion regarding physicians’ level of discretion under Texas’s abortion bans and fear for the legal consequences if they are wrong, is leading to physicians denying care to patients—including patients presenting with emergent conditions—even when such care likely would fall within the exception. As Plaintiffs’ experiences show, because of the laws’ uncertainty, physicians are over-complying with the laws to the detriment of their patients’ lives and health. 332. Texas has failed to provide clarification or guidance on the meaning of the exception, despite being asked repeatedly. See infra ¶¶ 352-64. 333. Texas’s abortion bans can and should be read to ensure that physicians have wide discretion to determine the appropriate course of treatment, including abortion care, for their patients who present with emergent medical conditions—without being second guessed by the Attorney General, the Texas Medical Board, a prosecutor, or a jury. 3. Conditions Included in the Emergent Medical Condition Exception 334. In addition to the conflicting language regarding physician intent, Texas law provides scant guidance for what the rest of the language in the Emergent Medical Condition Exception means. Nowhere in the code does Texas law define any of the following distinctions: “risk” versus “serious risk”; “insubstantial impairment” versus “substantial impairment”; or “minor bodily function” versus “major bodily function.” Nor does Texas law define what it means to have “a serious risk of a substantial impairment” or “a substantial impairment of a major bodily function.” 335. None of this terminology has standardized meaning in the medical profession, leaving physicians to guess at how to translate it into clinical practice. The lack of clarity is preventing medical professionals from providing the care that their patients need. 336. The best reading of Texas law’s plain text in the context of supporting patient and physician autonomy requires, at a minimum, that: (1) measurement of risk is left to physician judgment; (2) impairment of a “major bodily function” includes harm to reproductive functions and fertility (3) acute risk need not be already present or imminent; and (4) the patient’s condition need not be presently “life-threatening.” 337. A condition placing the pregnant person at “risk” or “serious risk” includes any condition that, in the physician’s judgment, merits intervention to prevent “death” or “substantial impairment of a major bodily function,” given the patient’s symptoms, medical history, and the physician’s experience and training. 338. While “major bodily function” is not defined in the Texas Health and Safety Code, the Texas Labor Code defines the term to include “reproductive functions.” Tex. Labor Code § 21.002(11-a) (“[M]ajor bodily function, includ[es], but [is] not limited to, functions of the immune system, normal cell growth, and digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.”). 339. Accordingly, any physical condition that presents a serious risk of substantially impairing the patient’s future fertility falls within the exception. This includes any condition that poses a serious risk of substantial impairment or loss of the patient’s uterus, ovaries, or other reproductive organs. 340. The exception does not require that any of the risks to the pregnant person be imminent. To the contrary, the exception only requires that a physician certify that the patient is “in danger of death” or has a condition that creates “a serious risk of substantial impairment of a major bodily function.” 341. Nor does the best reading of the exception require that the pregnant person have a condition that is imminently and/or definitively “life-threatening.” While the exception references a “life-threatening physical condition,” this phrase must be read together with the full language of the exception, which permits physicians to provide an abortion if the patient’s condition would pose a serious risk to her health (specifically, a “serious risk of substantial impairment of a major bodily function”) if left untreated. 342. The Trigger Ban states that the Emergent Medical Condition Exception does not apply to abortions performed to prevent a pregnant person from harming themself: “A physician may not” provide an abortion “if, at the time the abortion was performed, induced, or attempted, the person knew the risk of death or a substantial impairment of a major bodily function described by [the Emergent Medical Condition Exception] arose from a claim or diagnosis that the female would engage in conduct that might result in the female’s death or in substantial impairment of a major bodily function.” Tex. Health & Safety Code § 170A.002(c). The Definition Provision (and thus S.B. 😎 does not contain the same carve out. 343. Notwithstanding the Definition Provision’s use of the term “medical emergency,” the language of the exception—which also appears in the Trigger Ban without the use of the term “medical emergency”—is broader than the type of medical conditions that physicians would consider “emergencies” under, for example, the Emergency Medical Treatment & Labor Act (“EMTALA”).41 344. An analysis of Texas’s Emergent Medical Condition Exception and similar exceptions in other states’ abortion bans shows that Texas’s language is comparatively broad. Some states do not contain “emergency” exceptions at all, but only provide affirmative defenses to be used in prosecutions.42 Some states do not explicitly exclude ectopic pregnancies and/or treatment for miscarriage from their definitions of abortion.43 Some states mention “impairment 41 See 42 U.S.C. § 1395dd(e)(1) (defining medical emergency to involve, among other things, “acute symptoms of sufficient severity (including severe pain)” that create a need for “immediate medical attention”). 42 See, e.g., Idaho Code § 18-622(3); N.D. Cent. Code § 12.1-31-12; Tenn. Code § 39-15-213(c). 43 See, e.g., Mo. Rev. Stat. § 188.015(1); Miss. Code § 41-41-45(1); Tenn. Code § 39-15-213(a)(1). of a major bodily function” but require such impairment to be “irreversible” in addition to “substantial,” while other states limit their exception to life-threatening conditions.44 And some states require a second physician to confirm that an exception applies.45 345. Reading the provisions of the Emergent Medical Condition Exception together, they permit physicians to provide an abortion to a patient where, in the physician’s good faith judgment, the patient has a physical condition posing a risk of death or a serious risk to the patient’s health. Such conditions include, but are not limited to, the following: conditions that can lead to dangerous bleeding or hemorrhage, including placental conditions; dangerous forms of hypertension; conditions that can lead to dangerous infection, including premature rupture of membranes; other medical conditions that can become emergent during pregnancy, either because being pregnant causes or exacerbates a chronic condition or increases other health risks, or because 44 See, e.g., Ark. Code § 5-61-303(3) (“‘Medical emergency’ means a condition in which an abortion is necessary to preserve the life of a pregnant woman whose life is endangered by a physical disorder, physical illness, or physical injury, including a life-endangering physical condition caused by or arising from the pregnancy itself.”); Ky. Rev. Stat. § 311.772(4)(a) (An abortion may be performed “to prevent the death or substantial risk of death due to a physical condition, or to prevent the serious, permanent impairment of a life-sustaining organ of a pregnant woman.”); Okla. Stat. tit. 63, § 1-731.4(A)(2) (“‘Medical emergency’ means a condition which cannot be remedied by delivery of the child in which an abortion is necessary to preserve the life of a pregnant woman whose life is endangered by a physical disorder, physical illness or physical injury including a life-endangering physical condition caused by or arising from the pregnancy itself.”); La. Stat. § 40:1061(F) (Abortion may be performed where “necessary in reasonable medical judgment to prevent the death or substantial risk of death due to a physical condition, or to prevent the serious, permanent impairment of a life-sustaining organ of a pregnant woman.”); Miss. Code § 41- 41-45(2) (“No abortion shall be performed or induced in the State of Mississippi, except in the case where necessary for the preservation of the mother’s life.”); Mo. Rev. Stat. § 188.015(7) (“‘Medical emergency,’ a condition which, based on reasonable medical judgment, so complicates the medical condition of a pregnant woman as to necessitate the immediate abortion of her pregnancy to avert the death of the pregnant woman or for which a delay will create a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant woman.”); S.D. Codified Laws § 22-17-5.1 (Abortion prohibited “unless there is appropriate and reasonable medical judgment that performance of an abortion is necessary to preserve the life of the pregnant female.”); Tenn. Code § 39-15-213(c)(2) (An abortion may be performed where “the abortion was necessary to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman.”); Utah Code § 76-7a-201(1)(a) (An abortion may be performed where “necessary to avert: (i) the death of the woman on whom the abortion is performed; or (ii) a serious risk of substantial and irreversible impairment of a major bodily function of the woman on whom the abortion is performed.”); H.B. 481 sec. 4(2), 2019 Leg., Reg. Sess. (Ga. 2019) (“‘Medical emergency’ means a condition in which an abortion is necessary in order to prevent the death of the pregnant woman or the substantial and irreversible physical impairment of a major bodily function of the pregnant woman.”). 45 See, e.g., Ala. Code § 26-23H-4; Utah Code § 76-7a-201(1)(b). treatment for the chronic condition is unsafe while pregnant (with the exception of conditions whose emergent nature stems from the risk of self-harm, which are statutorily excluded); and certain fetal conditions or diagnoses that can increase the risks to a pregnant person’s health such that, when combined with the patient’s other comorbidities, a patient’s medical provider may determine that the patient has an emergent condition necessitating abortion.46 4. Legislative Intent Regarding the Scope of the Emergent Medical Condition Exception 346. In interpreting the Emergent Medical Condition Exception language, the intent of the legislature and lawmakers who make and enforce Texas’s abortion bans, while sparce, is instructive. 347. In 2021, Senator Angela Paxton was the primary sponsor of the Trigger Ban in the Senate. During a debate on the Senate floor regarding the bill, Senator Paxton explained to her Senate colleagues that it “would be the determination of the physician and the woman” whether or not the woman has “a physical condition” that meets the requirements of the Emergent Medical Condition Exception.47 348. In 2013, then-Representative Jodie Laubenberg was one of the primary sponsors on a bill banning abortion after 20 weeks of pregnancy that also contained the Emergent Medical Condition Exception. The 20-week ban was ultimately passed into law as part of omnibus anti- abortion legislation, House Bill 2. During a debate on the House floor regarding House Bill 2, Representative Laubenberg explained to her House colleagues that the Bill “gives the physician full authority to know what condition his patient is in and to have that authority to make that 46 Other emergent conditions, like ectopic pregnancy, are not included here because the necessary abortion care they require is explicitly excluded from Texas’s definition of abortion. See supra ¶¶ 301-02. 47 Senate Session, 87th Leg., Reg. Sess. (Tex. Mar. 29, 2021) (floor debate on Senate Bill 9, the companion bill to House Bill 1280, the Trigger Ban), https://tlcsenate.granicus.com/MediaPlayer.php?view_id=49&clip_ id=15566 (beginning at 4:47:18). determination.”48 She then repeated this understanding of what she described as a “very broad” exception eight more times during the floor debate.49 349. Representative Laubenberg also stated that she “would disagree” with a reading of the bill that blocked physicians from performing an abortion until “an infection has become so severe [that it poses an immediate risk of death].” Consistent with this position, she agreed that “toxemia” and “ruptured membranes” (PPROM) “would be covered under [the] exception.”50 350. Yet the legislators who supported these bills and other politicians in Texas who championed them have largely remained silent since S.B. 8 took effect and Roe was overturned. 351. Meanwhile, confusion among the medical profession over the last year and a half regarding the scope and meaning of the exception has been widely reported, showing that Plaintiffs’ experiences are the norm, not the exception. 352. Shortly after Roe v. Wade was overturned, the Texas Medical Association (“TMA”) asked state regulators to provide guidance to the state’s physicians on the scope of the exception. Public reporting indicates that in July 2022, TMA sent a letter to the Texas Medical Board (“TMB”) saying it had received complaints that hospitals, administrators, and their attorneys are prohibiting doctors from providing abortion services to patients with major pregnancy complications for fear of violating Texas’s abortion bans. The letter, which is not public, is said to 48 House Session, 83d Leg., 2d Called Sess., House Journal Suppl. S4–S6 (Tex. July 9, 2013) (floor debate on House Bill 2), https://journals.house.texas.gov/HJRNL/832/PDF/83C2DAY02SUPPLEMENTFINAL.PDF. 49 See id. (“This bill does give the physician the full autonomy and full authority to take care of his patient.”), id. (The exception language “places the physician at the center of this [determination],” so that “[i]t will be his judgment” whether the patient has met the threshold for an abortion under the exception.), id. (The bill “gives the physician full control” over determining whether the “threshold” for the emergent medical condition exception is met.), id. (“By this language, we’re allowing whatever the physician determines to be the condition that would impair the physical life of the woman” to control.), id. (“[T]his language actually gives broad coverage by allowing the physician, the physician, to have that authority.”), id. (“Actually, it’s not [tying the physician’s hands]” because “[i]t’s very broad to give that physician the authority.”), id. (“It’s whatever the doctor believes is in the best interest for the health of the pregnant mom.”), id. (“I would not want to limit the physician’s authority.”). have asked the TMB to “swiftly act to prevent any wrongful intrusion into the practice of medicine.”51 353. Upon information and belief, to date, the TMB has not responded to TMA. 354. Similarly, Texas Senator Bryan Hughes, the author of S.B. 8, sent a letter to the TMB on August 4, 2022, regarding reported complaints that hospitals “may be wrongfully prohibiting or seriously delaying physicians from providing medically appropriate and possibly life saving services to patients who have various pregnancy complications. These complaints arise from confusion or disregard of the law in Texas since [Roe was overturned] and must be corrected.” Letter from Bryan Hughes to Executive Director Brint Carlton (Aug. 4, 2022) (attached hereto as Exhibit A).52 355. Senator Hughes’s letter mentions many of the emergent medical conditions Plaintiffs argue are included in the Emergent Medical Condition Exception, and notes that his list is “non-exhaustive.” Senator Hughes explicitly mentions PPROM, the same condition for which Amanda would be denied care three weeks later. See Ex. A at 1 n.3 (“[P]regnancy complication[s] that a physician could determine rise to the level of a ‘medical emergency’ are ectopic pregnancies, preterm premature rupture of membranes, pre-eclampsia, hemorrhaging, strain on the mother’s heart, or peripartum cardiomyopathy. This is a non-exhaustive list.”). 356. Senator Hughes’s Letter concludes by saying, “Texas law makes it clear that a mother’s life and major bodily function should be protected.” Ex. A at 2. 51 Allie Morris, Texas Hospitals Fearing Abortion Law Delay Pregnant Women’s Care, Medical Association Says, Dallas Morning News (July 14, 2022), https://www.dallasnews.com/news/politics/2022/07/14/texas-hospitals- fearing-abortion-law-delay-pregnant-womens-care-medical-association-says/. 52 The letter was made public in a news report regarding Texas’s interpretation of EMTALA after Roe was overturned. Dan Vergano, The Federal Law Against Patient Dumping—EMTALA—Is the Latest Front in the Abortion Battle, Grid (Aug. 29, 2022), https://www.grid.news/story/science/2022/08/29/the-federal-law-against-patient- dumping-emtala-is-the-latest-front-in-the-abortion-battle. because neither of those two are abortions. But that said, I’ve even seen some other situations that some women are going through where they’re not getting the health care they need to protect their life. . . . [T]he point is this, our goal is to make sure we protect the lives of both the mother and the baby. And there’s been too many allegations that have been made about ways in which the livesn of the mother are not being protected. And so that must be clarified.”55 362. When Jonathan Mitchell, a former Texas Solicitor General who helped draft S.B. 8, was asked if he was concerned about the patient stories told in this case, he said the following: “It concerns me, yeah, because the statute was never intended to restrict access to medically necessary abortions, and the statute specifically says that it’s not restricting access to medically necessary abortions. So that shouldn't be happening. The statute was written to draw a clear distinction between abortions that are medically necessary and abortions that are purely elective. Only the purely elective abortions are unlawful under SB 8.”56 Mitchell was sitting next to Senator Hughes in Senator Hughes’s office when he made this statement. 363. Defendant Paxton sued Secretary of Health and Human Services Xavier Becerra over legal guidance that the Biden administration’s HHS issued after Roe v. Wade was overturned. That guidance reiterated that the federal EMTALA law obligates hospitals and physicians to provide abortion care to a patient who presents to the hospital’s emergency department if a physician or other qualified medical provider determines that the patient has an emergency medical condition and that an abortion is needed to prevent serious jeopardy to the patient’s health. The 55 Michael McCardel, Race for Texas Governor: Full interview with Governor Greg Abbott, WFAA (Oct. 16, 2022) at 1:42-2:26, https://www.wfaa.com/article/news/politics/inside-politics/texas-politics/inside-texas- politics-governor-greg-abbott-full-interview/287-e3aa0d2f-d204-46a9-8d4e-7dc442e5e6fa 56 Sarah McCammon, He Helped Craft the ‘Bounty Hunter’ Abortion Law in Texas. He’s Just Getting Started, NPR (May 8, 2023), https://www.npr.org/2023/05/08/1174552727/jonathan-mitchell-abortion-texas-sb8-roe-v-wade- dobbs guidance states that physicians and hospitals have a legal obligation to follow EMTALA even if doing so involves providing treatment—including abortion—that is prohibited in the state where the hospital is located. After receiving a preliminary injunction blocking part of the guidance in Texas, Paxton issued a press release lauding the decision, stating: “We’re not going to allow left- wing bureaucrats in Washington to transform our hospitals and emergency rooms into walk-in abortion clinics” and “I will fight back to defend our pro-life laws and Texas mothers and children.”57 364. As Plaintiffs’ experiences show, Texas law is not “pro-life” when it comes to pregnant people’s lives, and the State of Texas has failed to give physicians any meaningful guidance on how to interpret its laws consistent with that goal. II. IN THE ABSENCE OF STATE GUIDANCE REGARDING THE EXCEPTION, TEXAS’S ABORTION BANS ARE HARMING PREGNANT PEOPLE WITH EMERGENT MEDICAL CONDITIONS AND THEIR PHYSICIANS A. Impact of Texas’ Abortion Bans on Pregnant People 365. Amanda, Lauren M., Lauren H., Anna, Ashley, Kylie, Jessica, Samantha, Dr. Dennard, Taylor, Kiersten, Lauren V., and Elizabeth’s experiences are not isolated. Reports from around Texas reveal that pregnant people with emergent conditions are being denied appropriate counseling and abortion care in Texas altogether or are being forced to wait until they are clearly hemorrhaging or showing active signs of infection before they will be offered abortions. Media reports of these incidents have continued to accumulate since Plaintiffs first filed this case. Each person’s medical circumstances are unique, but in every case, Texas’s abortion bans radically decreased the quality of their medical care during pregnancy, often with devastating results. 57 Ken Paxton, Tex. Att’y Gen., Paxton Secures Victory Against Biden Administration, Blocks HHS from Forcing Healthcare Providers to Perform Abortions in Texas (Aug. 24, 2022), https://www.texasattorneygeneral.gov/ news/releases/paxton-secures-victory-against-biden-administration-blocks-hhs-forcing-healthcare-providers- perform. 366. While some pregnant people have only shared their stories anonymously, many have used their names: 367. Kristen Anaya, a Texas resident, was four months pregnant in January 2023 when her water broke. Kristen and her husband went through two rounds of IVF that yielded only one healthy embryo, so she was thrilled when she finally got pregnant. When her water broke prematurely, however, Kristen rushed to the emergency room where she learned she had already lost nearly all of her amniotic fluid. While she was being examined, she spiked a fever and began shaking uncontrollably, both signs of sepsis. Yet her care was delayed for 22 hours while her doctors consulted with “the termination committee” and an ethics committee at the hospital. Kristen continues to experience health complications due to the delay in her abortion care.58 368. Kristina Cruickshank, a Houston resident, was 12 weeks pregnant with her first child when abdominal pain and heavy bleeding sent her to the emergency room. Kristina was told that her fetus had a cystic hygroma of unknown cause so large that her fetus was unlikely to survive. Yet because of S.B. 8, all her obstetrician was willing to offer her was weekly check-in appointments. Over the next three weeks, Kristina’s condition dramatically deteriorated: she was in so much abdominal pain she could not walk; she had severe nausea and vomiting; she lost 15 pounds; she developed hyperthyroidism and was put on multiple thyroid medications. It was not until another emergency room visit at 15 weeks that she finally received a diagnosis: she had a partial molar pregnancy, a rare condition in which the fetus is not viable but that can cause the pregnant person to develop cancer. The condition had also led to massive cysts on her ovaries, explaining her pain. Yet because her fetus had cardiac activity, multiple ethics committees refused 58 Nadine El-Bawab, Woman Said She Went into Sepsis Before She Could Get Lifesaving Abortion Care in Texas, ABC News (May 15, 2023), https://abcnews.go.com/US/woman-sepsis-life-saving-abortion-care- texas/story?id=99294313. to provide her abortion care. Kristina lay in agony for three days until her obstetrician finally found a hospital that would accept her case and a doctor who would perform a D&E. Kristina continues to battle the physical and emotional impact of her pregnancy, including rapid heart rate, shortness of breath, anxiety, and concerns for developing cancer.59 369. Kailee DeSpain, a resident of Cleburne, was 19 weeks pregnant when she learned her baby had triploidy, or an extra set of chromosomes, leading to heart, lung, brain, and kidney anomalies that made it highly unlikely he would survive to birth. Kailee had already had two miscarriages, a stillborn, and uterine cancer, and was desperately hoping this pregnancy would “stick.” She was counseled that continuing the pregnancy would put her at high risk of multiple complications including blood clots, preeclampsia, placental abnormalities, and cancer, but that her only option for abortion care was to leave the state. Kailee was docked pay at work because she had already taken too many sick days, and she and her husband struggled to find the money to travel and pay for an abortion in New Mexico. Kailee’s obstetrician has now advised her not to get pregnant again, not in Texas.60 370. A League City resident was 15 weeks pregnant with her first child when she learned her baby had fetal hydrops condition, Turner syndrome, and other genetic conditions, and likely would not survive to birth. The woman was suffering from severe swelling, high blood pressure, severely elevated liver enzymes, and her doctors worried that she was also developing Mirror syndrome, a life-threatening condition involving severe hypertension and swelling. Yet she was 59 Julian Gill, Texas' Abortion Laws Led to 3-Day Delay for Houston Woman's Pregnancy Loss Treatment, Doctor Says, Houston Chronicle (Sept. 7, 2022), https://www.houstonchronicle.com/news/houston-texas/health/ article/Waiting-in-vain-Texas-abortion-laws-stymie-17424262.php. 60 Elizabeth Cohen & Danielle Herman, Why a Woman’s Doctor Warned Her Not to Get Pregnant in Texas, CNN (Sept. 10, 2022), https://www.cnn.com/2022/09/09/health/abortion-restrictions-texas/index.html; Brian Scott, ‘What About Women Like Me?’: North Texas Couple's Post About Pregnancy Struggle, Abortion Goes Viral, Spectrum News 1 (May 19, 2022), https://spectrumlocalnews.com/tx/south-texas-el-paso/news/2022/05/18/tx- couple-shares-tough-time-under-new-abortion-law. told that anything short of liver failure or a stroke would not be enough to warrant an abortion procedure.61 371. Other accounts of anonymous pregnant people in Texas denied care include: a woman with a twin pregnancy delivered one stillborn at 15 weeks and continued pregnancy of the remaining baby put her at high risk of infection, but she was denied an abortion and returned two weeks later with sepsis and an acute kidney injury; a woman at a small rural hospital was 17 weeks pregnant when her water broke, and after being denied care, she was forced to travel to New Mexico for abortion care;62 a woman whose cancer was in remission before pregnancy saw it come back aggressively after she got pregnant with her second child, and she was forced to travel out of state for the abortion that would allow her to resume cancer treatments;63 a woman in San Antonio started to miscarry and was denied care until the fetus’s heartbeat stopped, but in the meantime, the woman developed a dangerous womb infection, lost multiple liters of blood, and was put on a breathing machine.64 372. These stories are not unique to Texas. Since Roe v. Wade was overturned last year, multiple state abortion bans have gone into effect, and pregnant people in these states with emergent health conditions are facing similar barriers to care: 373. Mayron Hollis, a Tennessee resident, was 8 weeks pregnant when she was diagnosed with a cesarean scar ectopic pregnancy. It was just days before Tennessee’s trigger ban 61 Courtney Carpenter, League City Family in ‘Nightmare’ Situation Under Texas Abortion Law, ABC13 (Sept. 29, 2022), https://abc13.com/texas-abortion-laws-heartbeat-act-senate-bill-8-pregnant-woman/12277047. 62 J. David Goodman & Azeen Ghorayshi, Women Face Risks as Doctors Struggle with Medical Exceptions on Abortion, N.Y. Times (July 20, 2022), https://www.nytimes.com/2022/07/20/us/abortion-save-mothers-life.html. 63 Laura Ungar & Heather Hollingsworth, Despite Dangerous Pregnancy Complications, Abortions Denied, AP News (Nov. 20, 2022), https://apnews.com/article/abortion-science-health-business-890e813d855b57cf8e 92ff799580e7e8. 64 Lindsey Tanner, Abortion Laws Spark Profound Changes in Other Medical Care, AP News (July 16, 2022), https://apnews.com/article/abortion-science-health-medication-lupus-e4042947e4cc0c45e38837d394199033 took effect. Mayron was told that continuing the pregnancy was extremely dangerous and could lead to hemorrhage or a life-threatening placenta disorder. Mayron’s doctors offered an abortion before the new law took effect, but Mayron needed time to think. By the time she decided she wanted an abortion, Tennessee’s abortion ban had gone into effect and there was nothing her doctors could do. Mayron had no choice but to continue the pregnancy. At 26 weeks, Mayron started bleeding. Doctors were able to save Mayron’s life but had to remove her uterus in the process. Her baby survived but has been in and out of the hospital ever since with severe health problems. Mayron now struggles to balance her job, care for her older children, and the frequent hospital stays.65 374. Madison Underwood, a Tennessee resident, was nearly 17 weeks pregnant when, during a routine ultrasound, she was informed that her fetus had not formed a skull. She was advised that continuing the pregnancy could lead to sepsis, critical illness, or even death. Madison postponed her wedding to schedule her abortion. But while undergoing a pre-abortion ultrasound, Madison was informed that her procedure had been canceled because it had been determined that the legal risks in Tennessee were too high. Madison remembered wondering: “They’re just going to let me die?” Madison was forced to travel hundreds of miles to receive care in Georgia, where, at the time, abortion was legal until 20 weeks.66 Presently a 6-week ban is in effect in Georgia. 375. Allie Phillips, a Tennessee resident, was 19 weeks pregnant when her baby was diagnosed with holoprosencephaly, a congenital defect where the brain does not develop properly, and other structural abnormalities. Allie was told that her baby would not survive to birth, and that 65 Kavitha Surana, Doctors Warned Her Pregnancy Could Kill Her. Then Tennessee Outlawed Abortion, ProPublica (March 14, 2023), https://www.propublica.org/article/tennessee-abortion-ban-doctors-ectopic- pregnancy?utm_source=sailthru&utm_medium=email&utm_campaign=majorinvestigations&utm_content=feature. 66 Neelam Bohra, ‘They’re Just Going to Let Me Die?’ One Woman’s Abortion Odyssey, N.Y. Times (Aug. 1, 2022), https://www.nytimes.com/2022/08/01/us/abortion-journey-crossing-states.html?referringSource= articleShare. the problems would only get worse the longer she continued her pregnancy. Her doctor said that due to Tennessee’s law, she could not offer Allie advice on abortion, and if it was something Allie wanted to do, she would have to do her own research. To make things worse, Allie and her husband had to explain the situation to their 5-year-old daughter. Allie has been documenting her journey on Tik Tok and is planning to travel to New York for an abortion.67 376. “Sarah,” a Tennessee resident, went to the emergency room with severe abdominal pain. Even though she had an IUD, tests revealed that she had an ectopic pregnancy—a relatively common occurrence when an IUD fails—and was bleeding internally. Instead of receiving the immediate treatment she needed, however, Sarah was forced to endure hours of pain and severe bleeding while hospital attorneys attempted to determine whether providing her with abortion care would be prohibited under the state’s ban. Almost 10 hours later, after drafting 20 paragraphs of rationale for why an abortion was necessary, the hospital finally performed an abortion and was forced to remove part of one of her fallopian tubes to save her life.68 377. Kaitlyn Joshua, a Louisiana resident, was nearly 11 weeks pregnant when she started bleeding heavily, passing clots and tissue, and experiencing pain that she described as being worse than childbirth. Kaitlyn learned that her fetus had stopped growing past 7 or 8 weeks and that it only had faint cardiac activity, but despite two emergency room visits at two different 67 Michael Daly, Tennessee Abortion Ban a ‘Nightmare’ for Woman With Doomed Pregnancy, Daily Beast (Feb. 28, 2023), https://www.thedailybeast.com/tennessee-abortion-ban-a-living-nightmare-for-woman-with- doomed-pregnancy. 68 Steve Cavendish, Sarah Needed an Abortion. Her Doctors Needed Lawyers, Nashville Scene (Dec. 20, 2022), https://www.nashvillescene.com/news/citylimits/sarah-needed-an-abortion-her-doctors-needed- lawyers/article_472a621e-7fdb-11ed-bf8d-0797b6012be2.html. Unlike Texas, Tennessee’s abortion bans do not explicitly exclude ectopic pregnancy or miscarriage care from the definition of “abortion.” hospitals, she was repeatedly denied a D&C due to fear regarding Louisiana’s abortion bans. After this experience, she and her husband have decided not to have any more children for now.69 378. Nancy Davis, a Louisiana resident, was around 10 weeks pregnant when an ultrasound revealed that her fetus had acrania, a condition where the fetus is missing part of its skull. Nancy was counseled that her fetus would die shortly after birth but was refused abortion care because hospital officials were unsure whether the exceptions to Louisiana’s abortion-bans applied to her case. Nancy was eventually forced to make an arduous, 1,400-mile journey to New York to receive the care she needed.70 379. Christina Zielke was visiting Ohio when she started bleeding. A few weeks earlier, doctors in Washington D.C. told her that she was likely miscarrying because her fetus had no cardiac activity, so when she started bleeding, she assumed that she was simply passing the pregnancy. The next day, however, she started bleeding profusely and passing large clots. In the emergency room, an ultrasound confirmed that the fetus had no cardiac activity, and even though she was informed that an abortion is often required to stop such bleeding, she was not offered an abortion procedure. Instead, she was discharged with blood running down her shoes.71 380. Tara George, an Ohio resident, was 20 weeks pregnant with her first child when she learned that her baby had multiple conditions in its bladder, heart, and kidneys, and likely 69 Rosemary Westwood, Bleeding and in Pain, She Couldn't Get 2 Louisiana ERs to Answer: Is It a Miscarriage?, NPR (Dec. 29, 2022), https://www.npr.org/sections/health-shots/2022/12/29/1143823727/bleeding-and-in-pain-she-couldnt-get-2-louisiana-ers-to-answer-is-it-a-miscarria. There are multiple overlapping and inconsistent abortion bans currently in effect in Louisiana, contributing to the confusion regarding the scope of the state’s abortion exceptions. See June Med. Servs., LLC v. Landry, No. C-720988, 2022 WL 2824316 (La. Dist. Ct.July 7, 2022). 70 Ramon Antonio Vargas, Louisiana Woman Carrying Unviable Fetus Forced to Travel to New York for Abortion, The Guardian (Sept. 14, 2022), https://www.theguardian.com/us-news/2022/sep/14/louisiana-woman-skull- less-fetus-new-york-abortion. 71 Selena Simmons-Duffin, Her Miscarriage Left Her Bleeding Profusely. An Ohio ER Sent Her Home to Wait, NPR (Nov. 15, 2022), https://www.npr.org/sections/health-shots/2022/11/15/1135882310/miscarriage-hemorrhage-abortion-law-ohio.
  13. Makes ya wonder how many christian nationalists are actually in office that don't give a hoot about either the US constitution or the Texas constitution. Anyway, this is absurd and waiting for a lawsuit to happen, not to mention how bigoted this idea is. What is it? That Texas public schools can decide, rather than hire a qualified guidance counselor, to hire a chaplain instead. Because where every public school being paid for tax dollars wants is some pushy religious types using an office in the school to evangelize. And not even as qualified as what one would hope for their child. Here's really why Texas Lege wants this (cough cough Dan Patrick) Note that the kook whose idea this was led a group whose purpose was to evangelize children in schools Suppose there are students, and there really only has to be one, that does not want to be counseled, prayed with, guided by religions, etc but that is the ONLY counselor in a given school. Unfair and students not being treated equally. Suppose a student were to go to one of these *counselors* and counseled according to the religious beliefs, which quite often are racist and bigoted but had no other possible counselor to go to. Surely an interested parent would want to vocally and actively stop this from happening. Have to assume this is for the purpose of pushing christianity in schools, as opposed to judaism, islam, buddhism or some other flavor of religion. Well, then, which sect of christianity, assuming that having a religious countselor is a good thing that doesn't violate the constitution. Maybe the kind that likes to pray in tongues and handle snakes? Or a religious counselor that believes that gay people should be lined up against a wall and shot ? Or this bigot that told his congregation to punch their kids? The Southern Baptist Convention released a lit of alleged abusers in 2022. Anyone that wrongly thinks that just because there's some underqualified religious chaplain in a school their children will be safer is kidding themselves. Guidepost Here's just one of them, go look at the list So, assuming this isn't Abbott signing this bill into law isn't quickly followed up with a lawsuit, what are the provisions a public school would make for a guidance counselor for kids who did not or whose parents did not want to go to a chaplain? They just miss out on a guidance counselor? P.S. Side notes about bigot chaplains
  14. DemocracyNow An interesting part of the video with this article regarding the process of getting a pardon So, what in the world is the Office of the US Pardon Attorney for if people can just go around it, probably have no investigation but instead possibly under the table pardons given out to those with lots of money. Feels like everything was a grift under the table with the Trump administration. Anyone, I believe, should be able to go to the OPA and ask to see the papers for WHY someone was granted a pardon. Also side note that it is creepy that Trump is throwing out, as a carrot to get elected again, that he would pardon the lawbreakers on Jan 6th. A lot of Republican lawmakers also asked Trump for pardons. Now why would they do that if they didn[t think what they were doing was aboveboard?
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