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Singleton v. Wulff (1976)

In Depth

Background

Under a Missouri statute (subsequently repealed and replaced with another statute), only the costs of "medically indicated" abortions were reimbursable under the State's Medicaid program.  Two physicians brought a lawsuit in federal district court against the Chief of the Bureau of Medical Services, Department of Health and Welfare, alleging that the statute violated the constitutional rights of the physicians, as well as those of their patients.  The physicians claimed that the statute was vague, deprived them of their right to practice medicine "according to the highest standards of medical practice," deprived their patients of their "fundamental right" to choose an abortion, interfered with the physicians "right to render and their patients' right to receive safe and adequate medical advice and treatment," and denied both the physicians and their patients the equal protection of the laws. Singleton, 428 U.S. at 110 (reciting plaintiffs' claims).

The district court dismissed plaintiffs' action "for lack of standing," i.e., the physicians were not the proper parties to challenge the funding restriction.  The court of appeals reversed, determined that the physicians had standing to challenge the statute and went on to hold that the statute violated the Equal Protection Clause of the Fourteenth Amendment.

The Statute Under Review

The Missouri Medicaid plan includes a list of twelve categories of medical services that are eligible for Medicaid funding.  The final category, the subject of the litigation, provided:

Family planning services defined by federal rules and regulations; provided, however, that such family planning services shall not include abortions unless such abortions are medically indicated.

Mo. Rev. Stat. § 208.152(12).

The Court's Holding

All of the justices agreed that the physicians had standing to raise their own financial interests in seeking reimbursement for abortions that were not "medically indicated" under the statute.  The justices were sharply divided, however, on whether the physicians had standing to represent the interests of their Medicaid-eligible patients. Four justices expressed the view that the physicians had standing to represent their patients' interests, four justices disagreed and one justice

expressed no view on whether the physicians would have had standing to represent their patients' interests if they had not had any interests of their own to raise.  All of the justices agreed that the court of appeals had erred in reaching the merits of the plaintiffs' constitutional challenge.  Once the court of appeals had determined that the physicians had standing, it should have remanded the case to the district court for further proceedings on the merits of their underlying claim.

The Court's Reasoning

The Court quickly disposed of the issue of the physicians' standing to represent their own financial interests.  To maintain their standing, they needed to allege an "injury-in-fact," that is "a sufficiently concrete interest in the outcome of their suit to make it a case or controversy subject a federal court's Article III jurisdiction."  Singleton, 428 U.S. at 112.  That requirement was easily met because, if the physicians prevailed in their lawsuit, they would benefit financially "for they will then receive payment for the abortions" they perform on indigent women.  Id. at 113.

The Court expressed no opinion on whether the physicians had a constitutional right "to practice medicine," but added that, if they do, they could assert them in the underlying litigation.

The more difficult issue, and the one on which the Court was divided, was whether the physicians had standing to represent the interests of third parties, specifically, their women patients who were Medicaid-eligible and sought abortions that were not "medically indicated."

Justice Blackmun's plurality opinion on this aspect of the case, which was joined by Justices Brennan, White and Marshall, began by noting that third party standing involves prudential considerations as to whether a given plaintiff is the proper proponent of the legal rights of others.  Third party standing is not favored for two reasons:  First, the rights of third parties who are not before the court should not be adjudicated unnecessarily.  "It may be," the plurality said, that "the holders of those rights either do not wish to assert them, or will be able to enjoy them regardless of whether the in-court litigant is successful or not."  Singleton, 428 U.S. at 113-14.  Second, "third parties themselves usually will be the best proponents of their own rights."  Id. at 114.  "The courts depend on effective advocacy, and therefore should prefer to construe legal rights only when the most effective advocates of those rights are before them."  Id.

Notwithstanding these considerations, the plurality noted that in certain situations there may be countervailing considerations that allow for third party standing.  Two factors that the courts have looked at are the relationship of the litigant to the person whose right he seeks to assert and, the ability of the third party to assert his own rights.  Singleton, 428 U.S. at 114-16.  With respect to the former factor, "[i]f the enjoyment of the right is inextricably bound up with the activity the litigant wishes to pursue, the court at least can be sure that its construction of the right is not unnecessary in the sense that the right's enjoyment will be unaffected by the outcome of the case."  Id. at 114-15.  With respect to the latter factor, third party standing may be appropriate where "there is some genuine obstacle to [the] assertion [of the third party's rights]."  Id. at 115.

Applying these factors, the plurality concluded that the physicians could assert the rights of their patients.  First, the relationship between the physician and the patient is close because "[a] woman cannot safely secure an abortion without the aid of a physician, and an impecunious woman cannot easily secure an abortion without the physician's being paid by the State."  Id. at 117.  Accordingly, "[t]he woman's exercise of her right to an abortion . . . is therefore necessarily at stake."  Id. "Aside from the woman herself, . . . the physician is uniquely qualified to litigate the constitutionality of the State's interference with, or discrimination against, that decision."

Second, for reasons of privacy, the woman might not want to bring her own lawsuit.  Moreover, her case may become moot during the course of litigation once she is no longer pregnant.  Id.

The plurality recognized that a pregnant woman may file her suit under a pseudonym and also recognized that the mootness of her lawsuit (by giving birth or obtaining an abortion) would not prevent her from pursuing it to a final judgment.  And, certainly, a class may be assembled whose membership always included some women with "live claims."  Id. But if the assertion of her rights is representative to such an extent, "there seems little loss in terms of effective advocacy from allowing the its assertion by a physician."  Id. at 117-18.  The plurality concluded that "it generally is appropriate to allow a physician to assert the rights of women patients as against governmental interference with the abortion decision . . . ."   Id. at 118.  Finally, as, previously noted, the Court unanimously decided that the court of appeals had erred in reaching the merits of the physicians' constitutional claims once it determined that they had standing to pursue their own interests and to represent the interests of their women patients.  Id. at 119-21.  The court of appeals should have remanded the case to the district court for further proceedings.

The Concurring And Dissenting Opinions

In a short, two-paragraph opinion concurring in part, Justice Stevens agreed that the physicians had standing to sue to vindicate their own interests.  As a consequence, they also had standing to represent the interests of their patients.  Singleton, 428 U.S. at 121-22 (Stevens, J., concurring in part).  Justice Stevens, however, was not sure that, apart from their own asserted interests, the physicians would have standing to represent the interests of their patients.  Accordingly, he did not join the key part of the plurality opinion (Part II-B).  Id. at 122.  Nevertheless, because he agreed that, under the circumstances of the case, the physicians could assert the interests of their pregnant, Medicaid-eligible patients, his opinion provided the fifth vote needed to allow them to represent their patients in the subsequent proceedings in the district court.

Justice Powell, joined by Chief Justice Burger, Justice Stewart and Justice Rehnquist, dissented from the plurality's analysis of third party standing.  Justice Powell expressed the view that third party standing should be allowed only when litigation by the actual holders of the rights involved "is in all practicable terms impossible."  Singleton, 428 U.S. at 126 (Powell, J., concurring in part and dissenting in part).  No such impossibility was shown, however.  Moreover, even under the plurality's more expansive view of third party standing, the physicians should have been denied standing to represent the interests of their women patients.  The alleged "obstacles" to the patients' assertion of their own rights, Justice Powell concluded, were more apparent than real.  The women patients could have brought suit using pseudonyms and the "mootness" of their claims would not bar judicial review so long as the claims existed at the time they filed suit.  Id. Insofar as the "confidential relationship" between the holder of the right and the party seeking to assert her rights is concerned, Justice Powell emphasized that third party standing had been allowed only where "the State directly interdicted the normal functioning of the physician-patient relationship by criminalizing certain procedures." Id. at 128.  In those circumstances, "one party to the relationship should be permitted to assert the constitutional rights of the other, for a judicial rule of self-restraint should not preclude an attack on a State's proscription of constitutionally protected activity."  Id. But the statute at issue in Singleton-restricting public funding of abortions-did not directly interfere with the physician-patient relationship and imposed no criminal penalties.  Id.  Finally, Justice Powell expressed concern that the plurality's analysis of third party standing would open the door to allowing any provider of services to assert his client's or his customer's constitutional rights, if any, in an attack on a welfare statute that excludes from coverage his particular transaction."  Id. at 129-30.  "The Court's holding invites litigation by those who perhaps have the least legitimate ground for seeking to assert the rights of third parties." Id. at 130.

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