“a law . . . does not violate the Constitution solely because it directly or indirectly results in economic hardship”
How later courts described this case
- “a law . . . does not violate the Constitution solely because it directly or indirectly results in economic hardship”
- noting that our trial courts need not wait until an irreversible impairment occurs before acting
Written by the judges who cited it.
The opinion
FILED
Aug 11 2025, 8:56 am
CLERK
Indiana Supreme Court
Court of Appeals
and Tax Court
IN THE
Court of Appeals of Indiana
Planned Parenthood Great Northwest, Hawai’i, Alaska,
Indiana, Kentucky, Inc., et al.,
Appellants-Plaintiffs
v.
Members of the Medical Licensing Board of Indiana, in their
official capacities, et al.,
Appellees-Defendants
August 11, 2025
Court of Appeals Case No.
24A-PL-2467
Appeal from the Monroe Circuit Court
The Honorable Kelsey B. Hanlon, Special Judge
Trial Court Cause No.
53C06-2208-PL-1756
Opinion by Judge Mathias
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 1 of 31
Chief Judge Altice and Judge DeBoer concur.
Mathias, Judge.
[1] Following the Supreme Court of the United States’s decision on abortion rights
in Dobbs v. Jackson Women’s Health Organization, 597 U.S. 215 (2022), the
Indiana General Assembly enacted a revised version of Indiana Code section
16-34-2-1 (2022), 1 which is commonly referred to as Indiana’s abortion ban.
According to that statute, performing an abortion in Indiana “shall in all
instances be a criminal act,” 2 except when performed in one of three
circumstances: (1) when an abortion is necessary either to save the woman’s life
or to prevent a serious health risk to her; (2) when there is a lethal fetal
anomaly; or (3) when the pregnancy resulted from rape or incest. I.C. § 16-34-2-
1(a).
[2] The first exception (the “statutory Life or Health Exception”) may apply at any
time during the pregnancy so long as the decision is based on a “reasonable
medical judgment” and certain procedural requirements are satisfied. I.C. § 16-
1
The parties refer to the relevant statutes as Senate Bill 1 (or S.B. 1), which was the initial legislative vehicle
that resulted in the revised versions of the statutes relevant to this appeal. The finalized legislative vehicle that
resulted in the revised statutes consisted of fifty-four enumerated sections. Pub. L. 179-2022 (ss) (eff. Sept. 15,
2022). However, only the revised version of Indiana Code section 16-34-2-1, and its incorporated definitions,
is relevant to this appeal.
2
Indiana Code section 16-34-2-7(a) generally provides that “a person who knowingly or intentionally
performs an abortion prohibited by [section 16-34-2-1] commits a Level 5 felony.”
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 2 of 31
34-2-1(a)(1)(A)(i) (“before the earlier of viability of the fetus or twenty (20)
weeks of postfertilization age[3] of the fetus”), (a)(3)(A) (“and any time after”).
The Indiana Code further defines a “serious health risk” under the statutory
Life or Health Exception to be “a condition . . . that has complicated the
mother’s medical condition and necessitates an abortion to prevent death or a
serious risk of substantial and irreversible physical impairment of a major bodily
function.” I.C. § 16-18-2-327.9. That definition expressly excludes
“psychological or emotional conditions” as well as “a claim or diagnosis that
the woman will engage in conduct that she intends to result in her death or in
physical harm.” Id.
[3] Planned Parenthood and other medical-care providers challenged the facial
validity of Indiana’s abortion ban under Article 1, Section 1 of the Indiana
Constitution, which provides that “all people” are endowed “with certain
inalienable rights,” including “life, liberty, and the pursuit of happiness.” The
trial court entered a preliminary injunction on behalf of the medical-care
providers. On the State’s appeal from that injunction, our Supreme Court held
that Article 1, Section 1 of the Indiana Constitution affirmatively “protects a
woman’s right to an abortion that is necessary to protect her life or to protect
3
The Indiana Code defines “postfertilization age” to mean “the age of the fetus calculated from the date of
the fertilization of the ovum.” I.C. § 16-18-2-287.5. This is in contrast to the gestational age, which is
commonly used by medical-care providers and is based on the number of weeks since a woman’s last
menstrual period. See Appellants’ App. Vol. 2, p. 143 n.4. Fertilization typically occurs two weeks after a
woman’s last menstrual period, and, thus, the “postfertilization age” is typically two weeks shorter than the
gestational age (e.g., twenty-two weeks gestational age would be twenty weeks postfertilization age). Id.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 3 of 31
her from a serious health risk,” although the Court did not define “serious
health risk” in the constitutional context. Members of the Med. Licensing Bd. of Ind.
v. Planned Parenthood Great Nw., Haw., Alaska, Ind., Ky., Inc., 211 N.E.3d 957,
962 (Ind. 2023) (“Planned Parenthood I”). And, that baseline aside, our Supreme
Court held that our General Assembly “otherwise retains broad legislative
discretion for determining whether and the extent to which to prohibit
abortions.” Id. Thus, in reviewing the trial court’s entry of the preliminary
injunction, our Supreme Court concluded that a facial challenge to the statute
could not succeed but as-applied relief might be justified. Id. at 976-77. The
Court therefore vacated the preliminary injunction and remanded for further
proceedings. Id. at 985.
[4] On remand, the medical-care providers amended their complaint to request
declaratory and injunctive relief on the theory that there are numerous, specific
circumstances in which the life or health of a woman is at serious risk by a
pregnancy, but the abortion ban would appear to prohibit a woman in those
circumstances from obtaining an abortion to resolve those risks. The providers
also challenged additional amendments to Indiana Code section 16-34-2-1 that
now require all abortions to be performed in a licensed hospital or an
ambulatory outpatient surgical center that is majority owned by a licensed
hospital. See I.C. § 16-34-2-1(a)(1)(B), (a)(2)(C), (a)(3)(C) (“the Hospital
Requirement”). The parties agreed to accelerate the proceedings on the
amended complaint to a final hearing. After receiving significant amounts of
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 4 of 31
evidence, the trial court entered a final judgment denying the medical-care
providers their requested relief.
[5] On appeal from that judgment, we hold as follows:
1. The constitutional right to an abortion under Article 1, Section
1 is limited to circumstances in which an abortion is the only
reasonable medical option to protect a woman from a risk to her
life or to protect her from a serious health risk. The circumstances
argued by the medical-care providers here generally do not
necessitate an abortion to treat those risks. Thus, the medical-care
providers have not shown that their patients’ constitutional
abortion rights are available in circumstances that would not
qualify them for a legal abortion under the statutory Life or
Health Exception.
2. The constitutional right to an abortion under Article 1, Section
1 requires the determination that an abortion is necessary to be a
reasonable medical judgment, which is consistent with the
statutory Life or Health Exception. There is therefore no material
burden on the constitutional right to an abortion under that
statutory language.
3. Because the constitutional right to an abortion requires an
extreme medical scenario where the woman’s life or health is at
serious risk, performing a constitutionally protected abortion in
Indiana is a procedure that nearly always will be done in a
hospital. Thus, the statutory Hospital Requirement is not a
material burden on the constitutional right to an abortion.
[6] We affirm the trial court’s judgment.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 5 of 31
Facts and Procedural History
[7] This is the second round of trial and appellate proceedings between the parties
regarding the validity of Indiana’s abortion ban. The first round of proceedings
is described below, followed by the proceedings on remand.
The initial round of proceedings and Planned Parenthood I
[8] Prior to the effective date of Indiana’s abortion ban, the medical-care providers
sought declaratory and injunctive relief to prohibit the enforcement of the
statute. Following a hearing on the facial validity of the ban, the trial court
entered a preliminary injunction in favor of the medical-care providers under
Article 1, Section 1. The State appealed the trial court’s injunction directly to
our Supreme Court.
[9] On appeal, our Supreme Court first held that the medical-care providers had
standing to seek their requested relief because the abortion ban “criminalizes
their work.” Planned Parenthood I, 211 N.E.3d at 965. In reaching that initial
conclusion, the Court rejected the State’s assertion that the medical-care
providers were simply attempting “to vindicate their patients’ constitutional
rights rather than their own.” Id. And the Court noted that, in any event, it has
“repeatedly reviewed the constitutionality of abortion laws based on abortion
providers’ claims that the laws are unconstitutional because they violate their
patients’ rights.” Id. at 966 (citing cases).
[10] The Court then held that, although written broadly, Article 1, Section 1
contains unenumerated and judicially enforceable rights. Id. The Court
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 6 of 31
explained that Article 1, Section 1 is a “Lockean Natural Rights Guarantee”
that derives from our constitutional founders agreeing to “giv[e] up some
natural rights . . . to better secure the remainder,” which, in turn, implies that
the founders did not “relinquish natural rights beyond what [wa]s reasonably
necessary to secure the natural rights of the broader community.” Id. at 968.
Thus, the Court concluded that Article 1, Section 1 necessarily “include[s]
unenumerated rights under the umbrella of ‘life, liberty, and the pursuit of
happiness,’” which rights the founders would have considered “beyond the
reach of government.” Id. at 968-69.
[11] The Court also recognized that its understanding of Article 1, Section 1
displayed a “symmetry” between the unenumerated rights reserved to the
people and the police power of the State:
While the State worries judicial enforcement of unenumerated
rights may overreach, most of the State’s police powers are
unenumerated too, so there should be equal concern that the
State might view its own powers too generously. After all, our
Constitution’s language in delegating authority to the State for
promoting the “peace, safety, and well-being” of Hoosiers is no
less capacious than its language guaranteeing Hoosiers’ rights to
“life, liberty, and the pursuit of happiness.” Ind. Const. art. 1, §
1. So, Article 1, Section 1 strikes a balance: it allows the State
broad authority to promote the peace, safety, and well-being of
Hoosiers, but that authority goes no farther than reasonably
necessary to advance the police power, and not at the expense of
alienating what Hoosiers have commonly understood to be
certain fundamental rights.
Id. at 970.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 7 of 31
[12] The Court then applied its understanding of Article 1, Section 1 to abortion as
follows:
[The providers] emphasize that abortion procedures are
sometimes their only means to save their patients’ lives. That is
undisputed, and we agree the Constitution—including Article 1,
Section 1—does not permit the General Assembly to prohibit
abortion in those circumstances. . . .
Article 1, Section 1 expressly protects an “inalienable” right to
“life,” which was a firmly established right long before Indiana
became a state. See generally Eugene Volokh, State Constitutional
Rights of Self-Defense and Defense of Property, 11 Tex. Rev. L. & Pol.
399, 401-07 (2007). That right to protect one’s own life extends
beyond just protecting against imminent death, and it includes
protecting against “great bodily harm.” Larkin v. State, 173
N.E.3d 662, 670 (Ind. 2021). Although the State disputes that
Article 1, Section 1 is judicially enforceable, it recognizes that
governmental authority is limited to the police power, and it
acknowledges “grave doubt” that the police power would permit
the State to prohibit an abortion that was necessary to save a
woman’s life.
Because this fundamental right of self-protection—whether
considered as an exercise of the right to life, an exercise of the
right to liberty, a limitation on the scope of the police power, or
as a matter of equal treatment—is so firmly rooted in Indiana’s
history and traditions, it is a relatively uncontroversial legal
proposition that the General Assembly cannot prohibit an
abortion procedure that is necessary to protect a woman’s life or
to protect her from a serious health risk. See, e.g., Dobbs v. Jackson
Women’s Health Org., 597 U.S. [215], 142 S. Ct. 2228, 2305 n.2,
213 L. Ed. 2d 545 (2022) (Kavanaugh, J., concurring) (“Abortion
statutes traditionally and currently provide for an exception when
an abortion is necessary to protect the life of the mother.”); see
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 8 of 31
generally Eugene Volokh, Medical Self-Defense, Prohibited
Experimental Therapies, and Payment for Organs, 120 Harv. L. Rev.
1813, 1825 (2007) (demonstrating that, and explaining why, “the
abortion-as-self-defense right is largely uncontroversial”).
Reflecting that understanding, all of Indiana’s abortion statutes
since 1851 have recognized an exception for abortions that are
required to protect a woman’s life. Even when the General
Assembly revised the abortion laws in response to Roe [v. Wade]
and made clear it was not agreeing there is “a constitutional right
to abortion on demand” or that it “approves of abortion,” it also
made clear that it continued to conclude that abortion should
remain available “to save the life of the mother.” Pub. L. No.
322, § 1, 1973 Ind. Acts 1740, 1740. And now that the United
States Supreme Court has returned broad discretion to the states
to determine the legality of abortion, [Indiana’s] general abortion
ban continues to recognize an exception for “when reasonable
medical judgment dictates that performing the abortion is
necessary to prevent any serious health risk to the pregnant
woman or to save the pregnant woman's life.” Ind. Code § 16-34-
2-1(a)(1)(A)(i); see also id. § -1(a)(3)(A).
Accordingly, Article 1, Section 1 protects a woman’s right to an
abortion that is necessary to protect her life or to protect her from
a serious health risk. . . .
Id. at 975-76 (record citation omitted).
[13] The Court then concluded that its holding under Article 1, Section 1 did not
support the providers’ claim for a preliminary injunction “because they framed
their claim as a facial challenge to the entire statute in all conceivable
circumstances rather than an as-applied challenge to the law’s application in
any particular set of circumstances where a pregnancy endangers a woman’s life
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 9 of 31
or health.” Id. at 976. Thus, the appeal in Planned Parenthood I did not “present
an opportunity to establish the precise contours of a constitutionally required
life or health exception and the extent to which that exception may be broader
than the current statutory exceptions.” Id. at 976-77. And the Court further held
that our General Assembly retains legislative discretion to prohibit abortions
that are unnecessary to protect a woman’s life or to protect her from a serious
health risk. Id. at 977. The Court therefore vacated the preliminary injunction
and remanded for further proceedings. Id. at 984-85.
[14] The medical-care providers petitioned our Supreme Court for rehearing, which
the Court summarily denied. Chief Justice Rush, who had joined the majority
in Planned Parenthood I, concurred in the denial of rehearing with opinion. She
noted that Article 1, Section 1 “could protect a woman’s right to obtain an
abortion under circumstances that extend beyond the current law,” but she
concluded that rehearing was inappropriate because the providers had not “put
[any such] concerns before us.” Members of Med. Licensing Bd. of Ind. v. Planned
Parenthood Great Nw., Haw., Alaska, Ind., Ky., Inc., 214 N.E.3d 348, 349 (Ind.
2023) (Rush, C.J., concurring in the denial of reh’g).
Proceedings on remand
[15] Following Planned Parenthood I, the medical-care providers 4 amended their
complaint. In that complaint, the medical-care providers sought declaratory and
4
There was some change in the named plaintiffs on remand, but those changes are immaterial to this appeal.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 10 of 31
injunctive relief prohibiting the enforcement of the abortion ban in the
following six circumstances where the medical-care providers argued Article 1,
Section 1 would allow for an abortion but the abortion ban would appear to
prohibit an abortion:
(1) health conditions requiring treatment that would endanger the
fetus, meaning that continuing the pregnancy could require
forgoing needed treatment; (2) health conditions that cause
extended and/or debilitating symptoms during the course of a
pregnancy; (3) health conditions that are likely to worsen over
the course of the pregnancy to eventually become life-
threatening; . . . (4) health conditions that are likely to cause
lasting damage to the patient’s health or seriously increase the
patient’s future health risk, even after giving birth;
. . . ([5]) mental health conditions treated with medications that
do not have an established safety profile in pregnancy or that
pose risks to the fetus, meaning that continuing the pregnancy
could require forgoing needed treatment; and ([6]) severe and/or
debilitating mental health conditions (including conditions that a
patient has previously experienced and risk recurrence due to
pregnancy)[.]
Appellants’ App. Vol. 2, pp. 157-58.
[16] The medical-care providers likewise sought to enjoin the Hospital Requirement
on the theory that it materially burdened their patients’ rights under Article 1,
Section 1 “by making abortion care prohibitively expensive and otherwise
erecting insurmountable barriers to access for pregnant Hoosiers who are
entitled to abortion care . . . .” Id. at 157. The medical-care providers alleged
that, in 2021, the year before the abortion ban was enacted, “8,414 abortions
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 11 of 31
were performed in Indiana,” with “[o]ver 98[%] of [them] . . . performed at
[licensed] abortion clinics” that are now prohibited by the Hospital
Requirement. Id. at 151-52. The medical-care providers further alleged that the
Hospital Requirement would reduce the number of locations in Indiana where
a woman could obtain an abortion to two Indianapolis hospitals. Id. at 152.
Thus, as to the Hospital Requirement, the medical-care providers requested
declaratory and injunctive relief allowing the operation of licensed abortion
clinics “to provide abortions in the limited circumstances in which abortions are
legal in Indiana.” Id. at 158.
[17] The parties agreed to accelerate the medical-care providers’ claims to a final
hearing on the merits. Following that evidentiary hearing, the trial court entered
numerous undisputed findings of fact. Those findings of fact include the
following undisputed findings with respect to the medical-care providers’ claims
that there are various physical-health conditions (the first four enumerated
circumstances in paragraph 15 above) that might create a risk to the life or
health of a woman and entitle her to an abortion under Article 1, Section 1 that
the statutory abortion ban would appear to prohibit:
47. Hyperemesis gravidarum is a severe form of nausea and
vomiting brought on by pregnancy. The most commonly cited
diagnostic criteria for the disease are persistent vomiting not
related to other causes, a measure of acute starvation . . . , and
some discrete measure of weight loss, most often at least 5% of
pre-pregnancy weight.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 12 of 31
48. Hyperemesis gravidarum is the most common indication for
admission to the hospital during the first part of pregnancy and is
second only to preterm labor as the most common reason for
hospitalization during pregnancy.
49. Hyperemesis gravidarum is typically confined to the first
trimester but it can occasionally extend into the second
trimester[] and rarely into the third trimester.
50. Hyperemesis gravidarum presents with different degrees of
severity in different pregnant patients, and, although rare, it can
become life-threatening. Some patients are unable to eat or drink
for weeks, if not months, on end, severely limiting their
nutritional intake. Severe hyperemesis can cause significant
electrolyte abnormalities, cardiac arrhythmias and heart attack,
kidney failure, liver damage, and even death.
51. Patients with hyperemesis gravidarum are at high risk of early
delivery and are at risk of infections and blood clots.
52. The impact of hyperemesis gravidarum on women can be
devastating[,] not only physically but also socially and
emotionally. Although not typically life-threatening, patients
with hyperemesis gravidarum may need to be admitted to
hospitals for multiple days or weeks.
53. Treatments for hyperemesis gravidarum symptoms can vary
significantly and can include nonpharmacologic options,
pharmacotherapy, hospitalization, tube-feeding, and/or
catheterization.
54. Given the significant range of clinical possibilities, it is
possible that different patients suffering from hyperemesis
gravidarum could qualify for a legal abortion under [Indiana
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 13 of 31
Code section 16-34-2-1], a constitutionally protected abortion
under [Article 1, Section 1,] both, or neither.
55. Deep vein thrombosis is a condition in which potentially
dangerous blood clots form in a patient’s veins. The condition
can have different levels of severity, including pulmonary failure
and death from thromboembolism.
56. Pregnancy is a risk factor for deep vein thrombosis. As [one
expert] testified . . . , “if you are predisposed to having deep vein
thrombosis, being pregnant is going to put you at higher risk.”
57. Doctors regularly expectantly manage a pregnant patient’s
deep vein thrombosis through anticoagulation medication (i.e.,
blood thinners). Most patients with deep vein thrombosis have
mild disease that can be managed but a small subset of women
suffer from severe embolic disease during pregnancy or in the
postpartum period.
58. Neither induced abortion nor termination of pregnancy are
mentioned as a management strategy for deep vein thrombosis in
the American College of Obstetricians and Gynecologist’s
Practice Bulletin on Thromboembolism in Pregnancy.
59. Thromboembolic disease is potentially life threatening and
accounts for 9% of pregnancy-related deaths.
60. Given the significant range of clinical possibilities, it is
possible that different patients suffering from thromboembolic
disease could qualify for a legal abortion under [Indiana Code
section 16-34-2-1], a constitutionally protected abortion under
[Article 1, Section 1,] both, or neither.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 14 of 31
61. Preeclampsia is a disorder of pregnancy associated with new-
onset hypertension, which occurs most often after twenty weeks
gestation and frequently near term.
62. Preeclampsia presents with different degrees of severity in
different women. If untreated, preeclampsia can develop into its
more serious form, Hemolysis, Elevated Liver Enzymes and Low
Platelets (“HELLP”) syndrome and can cause organ damage,
stroke, seizures, and death.
63. Preeclampsia is a progressive disease, and it can be difficult
for physicians to predict when the risks presented by
preeclampsia may become an emergency. Thus, it is consistent
with best practices to manage preeclampsia as soon as it is
detected, regardless of its severity at the time. Optimal
management strategies for preeclampsia can be different
depending on clinical maternal and fetal evaluation and
gestational age.
64. Before 37 weeks [gestational age], doctors may try to manage
preeclampsia symptoms by, for example, managing a pregnant
person’s blood pressure and monitoring for signs and symptoms
of worsening disease.
65. Because preeclampsia is a progressive disease, the longer a
patient remains pregnant, the worse the preeclampsia will get. As
such, expectant management of preeclampsia is not always the
safest option.
66. When preeclampsia occurs prior to viability, expectant
management may not be recommended as a treatment option
because it can pose a higher risk to the patient’s health and the
fetus may be unlikely to survive.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 15 of 31
67. Because expectant management is intended to provide
neonatal benefit at the expense of maternal risk, expectant
management is not advised when neonatal survival is not
anticipated.
68. The decision whether to manage a preeclamptic patient
expectantly versus moving toward delivery is nuanced.
69. Given the significant range of clinical possibilities, it is
possible that different patients suffering from preeclampsia could
qualify for a legal abortion under [Indiana Code section 16-34-2-
1], a constitutionally protected abortion under [Article 1, Section
1,] both, or neither.
70. Preterm premature rupture of the membranes (“PPROM”)
occurs when the sac (or amniotic membrane) surrounding the
fetus ruptures before the pregnancy is full-term. It is a serious
condition that places the pregnant woman at increased risk of
infection, including “clinically evident intraamniotic infection,”
which occurs in 15-35% of cases. If the infection progresses to
sepsis (infection in the bloodstream), the risk of severe morbidity
(loss of fingers, toes, limbs, or neurologic injury), need for
hysterectomy, or mortality becomes quite high.
71. PPROM occurs in approximately 2% to 3% of pregnancies in
the United States.
72. Management decisions for PPROM depend on gestational
age and evaluation of the relative risks of delivery versus the risks
of expectant management when pregnancy is allowed to progress
to a later gestational age. While expectant management is one
option for patients with PPROM, it has significant maternal
risks.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 16 of 31
73. The risks of PPROM are especially difficult to manage in the
mid-trimester—especially before 24 weeks [gestational age]—
because the prognosis for the fetus if the pregnancy continues is
usually poor, and, even in the best of circumstances, uncertain.
74. Delaying treatment when a patient has a mid-trimester
PPROM can have grave consequences, including maternal sepsis
and death.
75. IU Health and Eskenazi hospital systems have provided
guidance to their physicians that performing abortion care in
certain instances of PPROM fits within the [statutory Life or
Health Exception] and abortions have been provided under these
circumstances. [One medical expert] has treated patients with
PPROM that were transferred from other hospitals that were
unable or unwilling to provide abortion care.
76. Given the significant range of clinical possibilities, it is
possible that different patients suffering from PPROM could
qualify for a legal abortion under [Indiana Code section 16-34-2-
1], a constitutionally protected abortion under [Article 1, Section
1,] both, or neither.
77. [The medical-care providers] present[ed] additional evidence
regarding a range of other illnesses that they contend implicate
constitutionally protected abortions that are prevented by [the
statutory ban]. These include but were not limited to diabetes
(gestational and preexisting), kidney disease, cancer,
cardiovascular disease, molar pregnancy, auto-immune
disorders, and obstructive sleep apnea.
78. Sometimes ending a pregnancy is necessary to protect a
woman from a serious health risk or from a threat to her life.
There are, however, “very, very few” conditions for which
pregnancy is “contraindicated.” And even for those conditions,
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 17 of 31
both sides’ experts agree that abortion is not the only way to
manage the condition . . . .
Id. at 63-70 (citations and internal alterations omitted).
[18] The trial court’s findings of fact also include the following undisputed findings
with respect to the medical-care providers’ claims that there are various mental-
health conditions (the last two enumerated circumstances in paragraph 15
above) that might create a risk to the life or health of a woman and entitle her to
an abortion under Article 1, Section 1 that the statutory abortion ban would
appear to prohibit:
82. Pregnancy is a complex and dynamic time that can impact
mental health in a variety of ways, both biologically and
psychosocially.
83. These biological and psychosocial factors can cause new
mental health conditions to emerge in pregnant patients, can
cause recurrences or exacerbations of previously experienced or
current mental health conditions, and can force pregnant patients
who take teratogenic medications to manage mental health
conditions to face the decision to stop or adjust that medication
or to change medications.
84. Pregnant patients may experience a range of severe and
debilitating mental health conditions, including anxiety,
depressive, and psychotic disorders. The specific symptoms and
consequences of these conditions vary by both condition and
between specific patients with similar diagnoses.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 18 of 31
85. Pregnant patients experiencing severe anxiety disorders may
be unable to work or care for themselves or their families and
may require in-patient hospitalization.
86. Pregnant patients experiencing post-traumatic stress disorder
(“PTSD”) may suffer from nightmares, states of fear, and
flashbacks, causing these patients to withdraw from daily life and
relationships and possibly engage in self-harm.
87. Pregnant patients experiencing severe depressive disorder
may be unable to function—for example, by being unable to eat
or to care for themselves—and can suffer from escalating suicidal
ideation, which increases the risk for self-harm and may require
hospitalization.
88. Pregnant patients experiencing severe bipolar disorder can
experience an exacerbation in the manic pole, causing the patient
to become extremely agitated with excess energy, to feel
decreased need for sleep, and to engage in very risky behavior
that can evolve into psychosis and require psychiatric
hospitalization. Pregnant patients with severe bipolar disorder
may also experience an exacerbation of the depressive pole, the
risks of which are similar to those for patients experiencing severe
depressive disorder.
89. Pregnant patients experiencing severe schizophrenia can
experience psychosis characterized by delusions, paranoia, and
auditory hallucinations, which can tell the patient to do highly
risky things, leadings to psychiatric hospitalization and/or
increased medication for the patient’s safety.
90. If the aforementioned mental health conditions go untreated,
they can significantly worsen throughout pregnancy[] and can
require psychiatric hospitalization.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 19 of 31
91. Suicidal ideation, which can present alongside any of the
aforementioned mental health conditions, can present as
thoughts of ending one’s life, developing active, specific plans to
end one’s life, and gathering means to end one’s life.
92. Mental health conditions can also emerge or worsen during
the postpartum period, which is a period complicated by many
physiologic and biological changes, including abrupt hormonal
changes, sleep disturbance, pain, recovery from delivery, and
additional psychosocial changes.
***
99. Certain medications can pose developmental risks for an
embryo or fetus. These teratogenic medications are sometimes
used to manage mental health disorders during pregnancy.
Teratogenic medications are not the only way to manage certain
mental health conditions during pregnancy. Most doctors avoid
teratogenic medications for women of childbearing age, whether
or not they are pregnant.
100. Doctors routinely adjust patients’ medications for a variety
of reasons, and this can occur during pregnancy as well.
101. Due to ethical limitations on study design and the extreme
difficulty in controlling for the innumerable confounding factors
impacting a person’s mental health, the scientific literature
presented on the mental health impacts of abortion does not
support definitive factual conclusions regarding abortion’s mental
health effects for a particular patient or class of patients.
102. The current scientific consensus is that abortion is not a
direct treatment for mental health conditions.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 20 of 31
103. The American College of Obstetricians and Gynecologists
has asserted that it is impossible to create an inclusive list of what
constitutes a medical emergency, and that creating a finite list is
dangerous.
Id. at 70-75 (citations omitted).
[19] And, with respect to the medical-care providers’ challenges to the Hospital
Requirement, the trial court entered the following undisputed findings of fact:
105. Until [the abortion ban] went into effect, clinics performed
the vast majority of abortions in Indiana, and they did so in
accordance with State law and with minimal complications.
106. Complications from medically uncomplex abortion care are
rare and can typically be treated in clinics.
107. Prior to [the abortion ban], clinics had policies and
procedures to safely refer or transfer patients needing higher
levels of care.
108. Before [the abortion ban] went into effect, and consistent
with Indiana law, [Planned Parenthood] provided procedural
abortions until 13 weeks and 6 days [gestational age] using oral
medications and local pain medications, not anesthesia.
Anesthesia is not required to provide abortion care, and, before
[the abortion ban], patients needing anesthesia to complete a
procedural abortion were transferred to hospitals as needed.
109. Because of the [new] legal limitations on abortions in
Indiana, the likelihood that an abortion will be performed at a
later gestational age and on a more medically complex patient
has increased.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 21 of 31
110. Hospitals and ambulatory surgical centers are better
equipped than clinics to address complications arising from a
constitutionally protected abortion implicating a serious health
risk. “While clinics . . . may have plenty of staff who . . . know a
lot about what . . . care they provide, they don’t have the same
type of emergency equipment that a . . . full-fledged hospital
would have.” For example, code carts, which have necessary
equipment “for cardiopulmonary resuscitation,” are “required
in . . . a hospital,” but not in a clinic. This is in part because
ambulatory surgical centers and hospitals can perform “more
complicated” procedures, including those requiring sedation or
anesthesia.
111. Similarly, for an abortion in the case of a lethal fatal
anomaly, hospitals are more likely than clinics to have genetic
counseling, perinatal hospice and/or bereavement counseling
services following abortion. And for abortions in the case of rape
or incest, hospitals employ trained Sexual Assault Nurse
Examiners who can investigate the circumstances leading to the
abortion and help women avoid potentially abusive situations.
112. The cost difference between abortion treatment in a clinic
versus a hospital is a significant one. . . .
***
115. Hospitals like IU Health and Eskenazi provide physicians
with extensive guidance regarding compliance with Indiana
abortion laws . . . . For example, IU Health provides its
physicians with a document that has “frequently asked
questions” regarding [the abortion ban and its exceptions]. IU
Health has also put together a “rapid response team” to “deal
with urgent provider questions regarding . . . termination of
pregnancy” under the [statutory Life or Health Exception]. This
team has “a clinical expert,” “an ethical expert,” and “a legal
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 22 of 31
expert,” reachable by “a phone number you can call twenty-four
seven.” The hospital encourages physicians to consult its
[abortion-ban] compliance resources and will defend its
physicians against any legal action . . . if they follow the
hospital’s protocols. Though abortions have been performed
there since [the abortion ban] went into effect, no civil or
criminal actions have been brough[t] against an IU Health
physician regarding whether an abortion was legally
performed . . . .
Id. at 75-79 (citations and internal alterations omitted; some ellipses in original).
[20] The trial court then concluded that the medical-care providers’ physical- and
mental-health conditions did not identify a condition that would be protected
by Article 1, Section 1 yet prohibited by Indiana Code section 16-34-2-1.
Regarding the range of physical-health conditions, the court concluded that the
medical-care providers “have not identified a specific situation in which [an]
abortion would both fall outside [the statutory Life or Health Exception] and be
‘necessary’ to guard against” a patient’s constitutionally protected interests. Id.
at 85 (emphasis in original). Regarding the mental-health conditions, the trial
court concluded that the medical-care providers “have not shown that there is a
single mental health concern that must be treated with abortion.” Id. at 86
(emphasis added). And, with respect to the Hospital Requirement, the court
concluded that “the evidence demonstrates that many women receiving
abortion care when they are seriously ill or at risk of becoming seriously ill will
likely be receiving in-hospital care irrespective of the Hospital Requirement,”
and, further, increased costs and travel are insufficient under Indiana law to
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 23 of 31
demonstrate a material burden of a constitutional right. 5 Id. at 93-94.
Accordingly, the trial court denied the medical-care providers their requested
relief.
[21] This appeal ensued.
Standards of Review
[22] The medical-care providers appeal the trial court’s entry of a final judgment
supported by findings of fact and conclusions thereon following an evidentiary
hearing.6 In such appeals, we review the trial court’s judgment under our clearly
erroneous standard. E.g., Town of Linden v. Birge, 204 N.E.3d 229, 233-34 (Ind.
2023). Under that standard, we “determin[e] whether the evidence supports the
findings and, if so, whether the findings support the judgment.” Id. at 233. We
5
The medical-care providers do not challenge the trial court’s assessment that Indiana law does not permit
increased costs to demonstrate a material burden of a constitutional right. See Clinic for Women, Inc. v. Brizzi,
837 N.E.2d 973, 981 (Ind. 2005) (“a law . . . does not violate the Constitution solely because it directly or
indirectly results in economic hardship”) (quotation marks omitted).
6
The parties dispute whether the trial court actually assessed the medical-care providers’ claims under an as-
applied standard and whether the trial court could have construed their claims as facial challenges. We
conclude that the trial court plainly and correctly considered the medical-care providers’ claims under an as-
applied standard.
The State also suggests that the medical-care providers lack standing to present their challenges to
the abortion ban because they have not identified by name any patients in present need of abortion care. But
the State’s suggestion is directly contrary to our Supreme Court’s holding in Planned Parenthood I that the
medical-care providers have standing to challenge Indiana’s abortion laws both in their own right and
derivatively on behalf of their patients. 211 N.E.3d at 965-66. We reject the State’s position accordingly. We
further note that the State’s corollary assertion that the medical-care providers’ claims are not ripe for review
for the same reason—i.e., that there is no named patient in imminent need of care—is an understanding of
ripeness that is unreasonable under Indiana law and, in the context of emergency medical care, invites
mootness issues. Cf. K.E. v. Ind. Dep’t of Child Servs., 39 N.E.3d 641, 649 (Ind. 2015) (noting that our trial
courts need not wait until an irreversible impairment occurs before acting). We therefore also reject those
arguments.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 24 of 31
will not reweigh the evidence or reassess the credibility of the witnesses. Id. at
234.
[23] That said, the parties do not dispute the trial court’s findings, and, thus, the
issues argued in this appeal all are questions of law surrounding the meaning or
application of constitutional and statutory provisions. Our review of such issues
is de novo, and we owe no deference to the trial court’s assessment of what the
law is. See, e.g., Russell v. State, 234 N.E.3d 829, 857 (Ind. 2024). “A statute
challenged under the Indiana Constitution stands before this Court clothed with
the presumption of constitutionality until clearly overcome by a contrary
showing.” Planned Parenthood I, 211 N.E.3d at 975 (quotation marks omitted).
Further, when construing a statute, our “primary task is to give effect to the
intent of the legislature” by giving the statute’s words their “plain meaning” and
by considering “the structure of the statute as a whole.” Nardi v. King, 253
N.E.3d 1098, 1104 (Ind. 2025) (quotation marks omitted).
1. The right to an abortion that is protected under Article 1,
Section 1 requires the abortion to be a necessary procedure to
protect the woman’s life or to protect her from a serious
health risk.
[24] On appeal, we first address the medical-care providers’ arguments that the trial
court’s judgment is clearly erroneous on their theory that the undisputed
findings demonstrate numerous circumstances in which an abortion would
resolve a serious health risk to the mother but the statutory ban would appear to
prohibit such an abortion. The medical-care providers frame these arguments as
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 25 of 31
falling within a legal space where the constitutional definition of a “serious
health risk” is greater than the statutory definition. See Appellants’ Br. at 37-38.
The medical-care providers’ arguments are especially notable with respect to
mental-health conditions, which are expressly excluded under the definitions
relevant to the statutory Life or Health Exception. See I.C. § 16-18-2-327.9.
[25] But whether there is a conceptual gap between the constitutional understanding
of a “serious health risk” and the statutory definition of it is beside the point on
this record. The constitutional right to an abortion is limited to circumstances in
which an abortion is “necessary” to protect the life of the woman or to protect
her from a serious health risk. Planned Parenthood I, 211 N.E.3d at 975-76.
“[O]therwise,” our General Assembly “retains broad legislative discretion for
determining whether and the extent to which to prohibit abortions.” Id. at 962.
Stated another way, if both an abortion and a reasonable medical alternative to
an abortion exist to treat a given condition, the patient’s constitutional right to
an abortion is not available. See id. at 975-76.
[26] And here the record demonstrates that all of the physical-health conditions
identified by the medical-care providers can be treated by reasonable medical
means other than an abortion up until a given condition becomes so extreme that
an abortion is necessary to either save the woman’s life or to prevent a serious
risk to her of organ damage. And once one of those extreme scenarios is met,
an abortion becomes legal both under Article 1, Section 1 and under the
statutory Life and Health Exception. See id.; see also I.C. § 16-43-2-1. Similarly,
the record here demonstrates that the medical-care providers’ identified mental-
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 26 of 31
health conditions can also be treated by reasonable medical alternatives to
abortions.
[27] We acknowledge that the physical- and mental-health conditions identified by
the medical-care providers all demonstrate some measure of a “serious health
risk” as that phrase might be used colloquially, regardless of whether those risks
are within our statutory or constitutional uses of the phrase. And we
acknowledge the medical-care providers’ concerns that our Supreme Court’s
articulation of the right to an abortion under Article 1, Section 1 might
“compel[] physicians to wait until a patient’s condition is desperate before
performing an abortion.” Appellants’ Br. at 37. But that is the balance struck
between the unenumerated, reserved right to the people under Article 1, Section
1 and the State’s police power under the Indiana Constitution. See Planned
Parenthood I, 211 N.E.3d at 970. Accordingly, the trial court did not err when it
concluded that the physical- and mental-health conditions identified by the
medical-care providers fail to show a scenario where the right to an abortion is
available under Article 1, Section 1 but prohibited by the statutory abortion
ban.
2. The constitutional right to an abortion under Article 1,
Section 1 requires the determination that an abortion is
necessary to be a reasonable medical judgment, which is
consistent with the statutory Life or Health Exception.
[28] The medical-care providers next contend that the Life or Health Exception
imposes a material burden on the constitutional right to an abortion by
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 27 of 31
requiring an invocation of the statutory exception to be based on a “reasonable
medical judgment.” Appellants’ Br. at 42-43. Under our Supreme Court’s
precedents, a constitutional right “is impermissibly alienated when the State
materially burdens one of the core values which it embodies.” Clinic for Women,
Inc. v. Brizzi, 837 N.E.2d 973, 983 (Ind. 2005) (quotation marks omitted). This
analysis looks to whether “the right, as impaired, would no longer serve the
purpose for which it was designed . . . .” Id.
[29] The medical-care providers argue that “[t]he ‘reasonable medical judgment’
standard” under the statutory Life or Health Exception “is tethered to such
narrow and ambiguous circumstances that physicians are hesitant to rely on it.”
Appellants’ Br. at 43. The medical-care providers further assert that “physicians
using their reasonable medical judgment can, and often do, reach different
conclusions on proposed treatments,” and the fear of prosecution for
performing an abortion has had a chilling effect on physicians who might have
otherwise done so. Id.
[30] We acknowledge that the fear of prosecution is real and potentially chilling to
medical-care providers. However, we reject the medical-care providers’
suggestion that the “reasonable medical judgment” standard is amorphous
simply because reasonable physicians can come to different judgments as to the
best course of care to provide to a patient. That reasonable minds may differ is
typically a basis for leeway in how one might proceed and is not a basis for
strict compliance to a singular approach in all circumstances.
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 28 of 31
[31] That said, we discern no impairment of the constitutional right to an abortion
by the statutory “reasonable medical judgment” standard. As explained above,
the constitutional right to an abortion is available only where that procedure is
“necessary” to protect the life of the woman or to protect her from a serious
health risk. Planned Parenthood I, 211 N.E.3d at 975-76. Those circumstances are
medical circumstances and determining whether they exist requires a
reasonable medical judgment. The statutory Life or Health Exception thus does
not impose a material burden on the constitutional right to an abortion at all as
both the constitutional right and the statutory exception require a reasonable
medical judgment.
3. The statutory Hospital Requirement also does not impair
the constitutional right to an abortion.
[32] The final issue in this appeal is the medical-care providers’ challenge to the
Hospital Requirement. Specifically, the medical-care providers argue that the
Hospital Requirement has substantially reduced access to abortion care
throughout the State and made it exceedingly more difficult for women who
might need such care to protect their lives or to protect themselves from serious
health risks.
[33] We do not agree that the Hospital Requirement specifically, rather than the
statutory ban itself, is to blame for the reduced access to abortion care in
Indiana. And, the medical-care providers’ assertions aside, the Hospital
Requirement does not impair the constitutional right to an abortion. A woman
in need of exercising her constitutional right to an abortion is, by definition,
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 29 of 31
facing a risk to her life or a serious health risk. Planned Parenthood I, 211 N.E.3d
at 975-76. As the trial court expressly found, a woman facing such a substantial
medical risk “will likely be receiving in-hospital care” with or without the
Hospital Requirement. Appellants’ App. Vol. 2, p. 93. Thus, the medical-care
providers cannot show that the Hospital Requirement imposes a material
burden on the constitutional right to an abortion.
Conclusion
[34] For all of these reasons, we affirm the trial court’s denial of the medical-care
providers’ claims for declaratory and injunctive relief.
[35] Affirmed.
Altice, C.J., and DeBoer, J., concur.
ATTORNEYS FOR APPELLANTS
Kenneth J. Falk
Gavin M. Rose
Stevie J. Pactor
ACLU of Indiana
Indianapolis, Indiana
Catherine Peyton Humphreville
Melissa Shube
Planned Parenthood Federation of America
New York, New York
Rupali Sharma
Lawyering Project
South Portland, Maine
Allison Zimmer
Lawyering Project
New Orleans, Louisiana
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 30 of 31
Katherine V. Mackey
Wilmer Cutler Pickering Hale and Dorr LLP
Boston, Massachusetts
Alan E. Schoenfeld
Lori A. Martin
Wilmer Cutler Pickering Hale and Dorr LLP
New York, New York
ATTORNEYS FOR APPELLEES
Theodore E. Rokita
Attorney General of Indiana
James A. Barta
Solicitor General
Jenna M. Lorence
Deputy Solicitor General
Katelyn E. Doering
John M. Vastag
Deputy Attorneys General
Indianapolis, Indiana
Court of Appeals of Indiana | Opinion 24A-PL-2467 | August 11, 2025 Page 31 of 31