Moyle v. United States

P R E L I M I N A R Y P R I N T
Volume 603 U. S. Part 1
Pages 324–368
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T H E S U P R E M E C O U R T
June 27, 2024
REBECCA A. WOMELDORF
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324 OCTOBER
TERM, 2023
Syllabus
MOYLE, SPEAKER OF THE IDAHO HOUSE OF REP-
RESENT
ATIVES, et al. v. UNITED STATES
certiorari before judgment to the united states
court of appeals for the ninth circuit
No. 23–726. Argued April 24, 2024—Decided June 27, 2024*
Certiorari dismissed and stays vacated.
Joshua N. Turner, Deputy Solicitor General of Idaho,
argued the cause for petitioners in both cases. On the briefs
in No. 23–726 were Taylor A. R. Meehan, Brandon Haase,
and Daniel W. Bower. Raúl R. Labrador, Attorney General
of Idaho, Alan M. Hurst, Solicitor General, Joshua N.
Turner, James E. M. Craig, Charles J. Cooper, David
H. Thompson, Peter A. Patterson, Megan M. Wold, John
J. Bursch, Erin M. Hawley, Matthew S. Bowman, Lin-
coln Davis Wilson, Jacob P. Warner, James A. Camp-
bell, Julie Marie Blake, and Rory Gray fled briefs in No.
23–727.
Solicitor General Prelogar argued the cause for the
United States in both cases. With her on the brief were
Principal Deputy Assistant Attorney General Boynton,
Deputy Solicitor General Fletcher, Yaira Dubin, Michael S.
Raab, Nicholas S. Crown, Samuel R. Bagenstos, and Paul
R. Rodríguez.†
*Together with No. 23–727, Idaho v. United States, on certiorari before
judgment to the same Court.
†Briefs of amici curiae urging reversal in both cases were fled for the
State of Indiana et al. by Theodore E. Rokita, Attorney General of Indi-
ana, James A. Barta, Solicitor General, and Melinda R. Holmes, Deputy
Attorney General, and by the Attorneys General for their respective
States as follows: Steve Marshall of Alabama, Treg Taylor of Alaska, Tim
Griffn of Arkansas, Ashley Moody of Florida, Christopher M. Carr of
Georgia, Brenna Bird of Iowa, Kris Kobach of Kansas, Liz Murrill of
Louisiana, Lynn Fitch of Mississippi, Andrew Bailey of Missouri, Austin
Knudsen of Montana, Michael T. Hilgers of Nebraska, Drew Wrigley of
North Dakota, Gentner F. Drummond of Oklahoma, Alan Wilson of South
Carolina, Marty Jackley of South Dakota, Jonathan Skrmetti of Tennes-
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Cite
as: 603 U. S. 324 (2024)
325
Kagan, J., concurring
Per Curiam.
The
writs of certiorari before judgment are dismissed as
improvidently granted, and the stays entered by the Court
on January 5, 2024, are vacated.
It is so ordered.
Justice Kagan, with whom Justice Sotomayor joins, and
with whom Justice Jackson joins as to Part II, concurring.
An Idaho law prohibits abortions unless necessary to pre-
vent a pregnant woman's death; the law makes no exception
see, Ken Paxton of Texas, Sean Reyes of Utah, Patrick Morrisey of West
Virginia, and Bridget Hill of Wyoming; for the American Association of
Pro-Life Obstetricians and Gynecologists by Judd E. Stone II and Ari
Cuenin; for the American Center for Law and Justice by Jay Alan Seku-
low, Stuart J. Roth, Colby M. May, Jordan A. Sekulow, and Laura B.
Hernandez; for the Christian Medical & Dental Associations by Lori H.
Windham and Rebekah P. Ricketts; for the Institute for Faith and Family
by Deborah J. Dewart and Tami Fitzgerald; for the Manhattan Institute
by Ilya Shapiro; for the Minnesota Family Council et al. by Nicholas J.
Nelson and Renee K. Carlson; for the National Right to Life Committee
by James Bopp, Jr.; for the Prolife Center at the University of St. Thomas
by Christopher E. Mills; for Stanton International by William Wagner
and Erin Elizabeth Mersino; for the United States Conference of Catholic
Bishops et al. by Thomas Brejcha and B. Tyler Brooks; and for 121 Members
of Congress by Steven H. Aden. William J. Olson, Jeremiah L. Morgan,
Robert J. Olson, and Phillip L. Jauregui fled a brief for America's Future
as amici curiae in No. 23–726 urging reversal. Gene C. Schaerr fled a brief
for the Charlotte Lozier Institute as amicus curiae urging vacatur.
Briefs of amici curiae urging affrmance in both cases were fled for the
State of California et al. by Letitia James, Attorney General of New York,
Barbara D. Underwood, Solicitor General, Ester Murdukhayeva, Deputy
Solicitor General, Galen Sherwin, Laura Etlinger, Assistant Solicitor
General, by Rob Bonta, Attorney General of California, Michael J.
Mongan, Solicitor General, Helen H. Hong and Julie Veroff, Deputy Solici-
tors General, Renu R. George, Senior Assistant Attorney General, Karli
Eisenberg, Supervising Deputy Attorney General, and Hayley Penan,
Deputy Attorney General, and by the Attorneys General for their respec-
tive jurisdictions as follows: Kris Mayes of Arizona, Philip J. Weiser
of Colorado, William Tong of Connecticut, Kathleen Jennings of Dela-
ware, Brian L. Schwalb of the District of Columbia, Anne E. Lopez
of Hawaii, Kwame Raoul of Illinois, Aaron M. Frey of Maine, Anthony

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YLE v. UNITED STATES
Kagan, J., concurring
for abortions necessary to prevent grave harms to the wom-
an'
s health, like the loss of her fertility. Before the law
could take effect, the Federal Government sued the State
under the Emergency Medical Treatment and Labor Act
(EMTALA). That law requires a Medicare-funded hospital
G. Brown of Maryland, Andrea Joy Campbell of Massachusetts, Dana Nes-
sel of Michigan, Keith Ellison of Minnesota, Aaron D. Ford of Nevada,
Matthew J. Platkin of New Jersey, Raúl Torrez of New Mexico, Joshua
H. Stein of North Carolina, Ellen F. Rosenblum of Oregon, Michelle A.
Henry of Pennsylvania, Peter F. Neronha of Rhode Island, Charity R.
Clark of Vermont, Robert W. Ferguson of Washington, and Joshua L. Kaul
of Wisconsin; for the County of Santa Clara et al. by Meredith A. Johnson,
Rachel A. Neil, Lyndsey M. Olson, and Sylvia O. Hinds-Radix; for the
American Civil Liberties Union et al. by Alexa Kolbi-Molinas, Jennifer
Dalven, David D. Cole, Kathleen R. Hartnett, and Angeline Chen; for the
American College of Obstetricians and Gynecologists et al. by Skye L.
Perryman, Carrie Y. Flaxman, Kaitlyn Golden, and Shannon Rose Sel-
den; for the American Hospital Association et al. by Charlotte H. Taylor
and Amanda K. Rice; for Amnesty International et al. by Christina G.
Hioureas; for Former HHS Offcials by Nicole Saharsky; for Legal Schol-
ars by John P. Elwood, Daphne O'Connor, Andrew T. Tutt, and William
T. Sharon; for the National Network of Abortion Funds by Jamie L. Lisa-
gor and Alanna Peterson; for Physicians for Human Rights by Gerson H.
Smoger; for Physicians for Reproductive Health by Janice Mac Avoy; for
Public Citizen by Nandan M. Joshi, Allison M. Zieve, and Scott L. Nelson;
for Sanctuary for Families et al. by Jennifer Kennedy Park; for Caitlin
Bernard et al. by Rupali Sharma and Tanya Pellegrini; for David S.
Cohen et al. by Susan Frietsche and David S. Cohen, pro se; and for 258
Members of Congress by Elizabeth B. Wydra and Brianne J. Gorod.
Briefs of amici curiae were fled in both cases for Advancing American
Freedom et al. by J. Marc Wheat; for the American Public Health Associa-
tion et al. by Thomas Barker; for the Center for Constitutional Jurispru-
dence by John C. Eastman and Anthony T. Caso; for the Chicago Abortion
Fund by Alexander M. Wol f and Drew Padley; for Disability Rights Advo-
cates et al. by Carolyn F. Corwin and Maria Michelle Uzeta; for the Foun-
dation for Moral Law et al. by John A. Eidsmoe and Roy S. Moore; for
the Idaho Coalition for Safe Healthcare, Inc., by Colleen R. Smith; for
Local Prosecutors et al. by Corey Stoughton, Rajat Rana, and Jonathan B.
Miller; for the National Women's Law Center et al. by Christine E. Webber,
Michelle Banker, Gretchen Borchelt, and Leila Abol fazli; for Pregnancy
Justice et al. by H. Rodgin Cohen and Sharon Cohen Levin; for St. Luke's
Health System, Ltd., by Lindsay C. Harrison; for the U. S. Women's Cham-

Cite
as: 603 U. S. 324 (2024)
327
Kagan, J., concurring
to provide essential care to patients experiencing medi-
c
al emergencies. The Government's suit contended that
EMTALA preempts the Idaho abortion law in a narrow class
of cases: when the state law bars a hospital from performing
an abortion needed to prevent serious health harms.
The District Court, believing the Government was likely
to prevail in its suit, entered a preliminary injunction. Dur-
ing the year that the injunction was in place, women in Idaho
were able to obt ai n abor ti ons i n medica l emergencies.
Idaho meanwhile sought to get the injunction lifted. When
the en banc Court of Appeals for the Ninth Circuit declined
to stay the injunction, Idaho fled an emergency application
here. This Court stayed the injunction and granted the
State's petition for certiorari before judgment. With that
stay in effect, Idaho could enforce its abortion ban even when
terminating a pregnancy was necessary to prevent grave
harm to the woman. The on-the-ground impact was im-
mediate. To ensure appropriate medical care, the State's
largest provider of emergency services had to airlift preg-
nant women out of Idaho roughly every other week, com-
pared to once in all of the prior year (when the injunction
was in effect). See Tr. of Oral Arg. 66, 113.
I concur in the Court's decision today to vacate its stay
and dismiss the writ of certiorari before judgment as im-
providently granted. I do so because Idaho's arguments
about EMTALA do not justify, and have never justifed,
either emergency relief or our early consideration of this dis-
pute. With this Court's writ of certiorari dismissed, the
lower courts can proceed with this litigation in the regular
course. And with this Court's stay dissolved, the District
Court's preliminary injunction will again take effect. That
ber of Commerce et al. by James C. Martin and M. Patrick Yingling; for
Women Hurt by Abortion by Mary J. Browning, R. Clayton Trotter,
Allan E. Parker, Jr., and Catherine Glenn Foster; for Kent Greenfeld
et al. by Emily Kanstroom Musgrave and Susan Finegan; and for
Amanda Zurawski et al. by Beth S. Brinkmann, Marc Hearron, and
Molly Duane.
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328 MO
YLE v. UNITED STATES
Kagan, J., concurring
will prevent Idaho from enforcing its abortion ban when the
ter
mination of a pregnancy is needed to prevent serious
harms to a woman's health.
I
EMTALA requires hospitals to provide abortions that Ida-
ho's law prohibits. When that is so, Idaho's law is preempted.
The Court's ruling today follows from those premises.
Federal law and Idaho law are in confict about the treat-
ment of preg nant women faci ng hea lth emergencies.
EMTALA requires a Medicare-funded hospital to offer an
abortion when needed to stabilize a medical condition that
seriously threatens a pregnant woman's life or health. See
42 U. S. C. § 1395dd. Idaho allows abortions only when “nec-
essary to prevent” a pregnant woman's “death.” Idaho Code
Ann. § 18–622(2)(a)(i) (Supp. 2023). By their terms, the two
laws differ. What falls in the gap between them are cases in
which continuing a pregnancy does not put a woman's life in
danger, but still places her at risk of grave health conse-
quences, including loss of fertility. In that situation, federal
law requires a hospital to offer an abortion, whereas Idaho law
prohibits that emergency care. And the record shows that,
as a matter of medical reality, such cases exist. For example,
when a woman comes to an emergency room with preterm pre-
mature rupture of membranes (PPROM), the serious risk she
faces may not be of death but of damage to her uterus, prevent-
ing her from having children in the future. See 2 App. 594;
see also id., at 615–616 (similar for preeclampsia). Idaho has
never suggested that its law would allow an abortion in those
circumstances. See Tr. of Oral Arg. 23 (stating that although
the threat of death need not be “imminen[t],” only that threat
can justify an abortion); see also id., at 25–28, 33–34. That is
why hospitals in Idaho have had to airlift medically fragile
women to other States to receive abortions needed to prevent
serious harms to their health. See id., at 66, 103–104, 113–
115. Those transfers measure the difference between the
life-threatening conditions Idaho will allow hospitals to treat
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as: 603 U. S. 324 (2024)
329
Kagan, J., concurring
and the health-threatening conditions it will not, despite
EMT
ALA's command.
Given that confict, I agree with the Court's decision today
to step back from its early intervention in this dispute. In
the frst stage of this suit, the District Court considered both
sides' medical evidence and entered a preliminary injunction
against Idaho's law on the ground of preemption. See 623
F. Supp. 3d 1096, 1103–1105, 1110, 1117 (2022). After the
Idaho Supreme Court construed the law, the District Court
revisited its fndings, and reaffrmed its entry of the injunc-
tion. See 2023 WL 3284977, *1, *5 (May 4, 2023). In line
with standard practice, that decision now can go to the Court
of Appeals, and the District Court can afterward consider
further evidence and arguments for the purpose of fnal judg-
ment. Idaho is not entitled to anything more. It mainly
argues that EMTALA never requires a hospital to “offer
medical treatments that violate state law,” even when they
are needed to prevent substantial health harms. Tr. of Oral
Arg. 4. In my view, that understanding of EMTALA is not
“likely to succeed on the merits,” and so cannot support a
stay of the injunction. Nken v. Holder, 556 U. S. 418, 434
(2009). Neither does the State's argument provide any basis
for this Court to short-circuit the proceedings below. To-
day's ruling thus puts the case back where it belongs, and
with the preliminary injunction in place.
II
Justice Alito's dissenting opinion requires a brief re-
sponse. His primary argument is that although EMTALA
generally obligates hospitals to provide emergency medical
care, it never demands that they offer an abortion—no mat-
ter how much that procedure is needed to prevent grave
physical harm, or even death. See post, at 348–359. That
view has no basis in the statute.
EMTALA unambiguously requires that a Medicare-funded
hospital provide whatever medical treatment is necessary to
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330 MO
YLE v. UNITED STATES
Kagan, J., concurring
stabilize a health emergency—and an abortion, in rare situa-
ti
ons, is such a treatment. The statutory obligation kicks in
when an individual arrives at a hospital with an “emergency
medical condition,” which is one involving serious jeopardy
to health. § 1395dd(e)(1)(A). The hospital must then “sta-
bilize” the condition. § 1395dd(b)(1)(A). That means offer-
ing the medical treatment necessary to ensure that “no ma-
ter ia l deter i orati on of the conditi on” is likely to occur.
§ 1395dd(e)(3)(A). The statute does not list particular treat-
ments—for example, defbrillation, blood transfusion, or me-
chanical ventilation. What it instead requires is the treat-
ment that is medically appropriate to stabilize the patient.
And when a pregnancy goes terribly wrong, that treatment
may be an abortion. Termination of the pregnancy (which
is often of a non-viable fetus) may be the only way to prevent
a woman's death or serious injury, including kidney failure
or loss of fertility. See 623 F. Supp. 3d, at 1101, 1103–1105.
I do not understand Justice Alito to dispute that medical
fact. And from that fact, a statutory obligation arises. It
does not matter that EMTALA “does not mention abortion.”
Post, at 356; see post, at 349. Neither, as just noted, does
EMTALA mention any other treatment. The statute sim-
ply requires the hospital to offer the treatment necessary to
prevent the emergency condition from spiraling downward.
And on rare occasions that means providing an abortion.
The statute's references to protecting an “unborn child” do
not lead to a different result. Contrary to Justice Alito's
view, none alters EMTALA's command when a pregnancy
threatens the woman's life or health. Three of the four pro-
visions Justice Alito cites concern the treatment of women
in labor ( including a ll those with healthy preg nancies).
Those provisions ensure that a hospital, in considering
the transfer of a woman to another facility, takes account of
risks to not only the woman but also her “unborn child.”
§ 1395dd(c)(1)(A)(ii), (2)(A), (e)(1)(B)(ii). The provisions
have no application to women who are not in labor, but in-
stead are experiencing a different pregnancy-related condi-
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331
Barrett, J., concurring
tion. The fourth provision (included within the defnition of
“emergency
medical condition”) specifes that a hospital must
treat a condition that “plac[es] the health of the individ-
ual (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy.”
§ 1395dd(e)(1)(A)(i). The parenthetical there, added in an
amendment to EMTALA, ensures that a woman with no
health risks of her own can demand emergency-room treat-
ment if her fetus is in peril. It does not displace the hos-
pital's duty to a woman whose life or health is in jeop-
ardy, and who needs an abortion to stabilize her condition.
Then, the statute requires offering that treatment to the
woman.
1
Because the Idaho law conficts with that requirement—
prevents hospitals from doing what EMTALA commands—
the Court is right to dissolve its stay of the District Court's
injunction. Doing so will again give Idaho women access to
all the needed medical treatments that EMTALA guarantees.
Justice Barrett, with whom The Chief Justice and
Justice Kavanaugh join, concurring.
We granted certiorari before judgment in these cases to
decide whether the Emergency Medical Treatment and
Labor Act (EMTALA) preempts a provision of Idaho law
that prohibits abortions except when necessary to save the
1
The amendment's history confrms that understanding. As originally
enacted, EMTALA did not obligate hospitals to provide medical care when
a woman's fetus, but not the woman herself, was in peril. See Tr. of Oral
Arg. 105 (Solicitor General describing “well-publicized cases” where
women's “own health and life were not in danger, but the fetus was in
grave distress and hospitals weren't treating them”). To fx that problem,
very large bipartisan majorities in both the House and the Senate elected
to broaden the provision, entitling a woman to demand care for her un-
born child as well as herself. See 103 Stat. 2248; 135 Cong. Rec. 31431
(1989); id., at 31127; id., at 24605; id., at 23393. The amendment would
likely have sparked far more opposition if it somehow tacitly withdrew
EMTALA's requirement that hospitals treat women who need an abortion
to prevent death or serious harm.
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YLE v. UNITED STATES
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life of the mother. 601 U. S. ––– (2024). Because the shape
of
these cases has substantially shifted since we granted cer-
tiorari, I concur in the Court's judgment dismissing the writ
as improvidently granted.
I
In 2022, the Department of Health and Human Services
issued guidance to “remind hospitals of their existing obliga-
tion to comply with EMTALA.” Centers for Medicare &
Medicaid Services, Reinforcement of EMTALA Obligations
Specifc to Patients Who Are Pregnant or Are Experiencing
Pregnancy Loss, Note, p. 1 (July 11, 2022) (rev. Aug. 25, 2022)
(italics deleted). The guidance tells physicians that if they
believe that “abortion is the stabilizing treatment necessary
to resolve” a pregnant woman's emergency medical condi-
tion, they “must provide that treatment.” Id., at 1 (italics
and emphasis deleted). Any contrary state law, the guid-
ance continues, is “preempted.” Ibid. (italics and emphasis
deleted).
Idaho's Defense of Life Act criminalizes the performance
of most abortions. Idaho Code Ann. § 18–622 (Supp. 2023).
As originally enacted, the Act allowed accused physicians to
raise an affrmative defense that “the abortion was necessary
to prevent the death of the pregnant woman.” § 18–622(2)
(a)(i). Soon before the Act was set to take effect, the United
States sued Idaho, seeking to enjoin Idaho's law “to the ex-
tent it conficts with EMTALA.” 1 App. 5. EMTALA, the
United States argued, requires physicians to perform abor-
tions under certain circumstances that Idaho's Act would
forbid.
After holding an evidentiary hearing, the District Court
identifed a confict and granted a preliminary injunction.
623 F. Supp. 3d 1096 (Idaho 2022). The court based its con-
clusion on three key assumptions: (1) The Act prohibits the
termination of ectopic pregnancies; (2) the pregnant woman's
death must be objectively “imminent” or “certain” before a
physician can perform an abortion; and (3) the “necessary to
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333
Barrett, J., concurring
prevent death” exception is only an affrmative defense. Id.,
at
1109–1114. The Government's witnesses, whose testi-
mony the court credited, made similar assumptions. Id., at
1104–1105. They claimed that the Act might prohibit abor-
tions as treatment for conditions including severe heart fail-
ure, preeclampsia, preterm premature rupture of membranes
(PPROM), sepsis, and placental abruption, because a physi-
cian could not know, “with certainty,” that an abortion is
necessary to save the mother's life in those circumstances.
See, e. g., 1 App. 30–38. They also assumed that the Act
only permitted abortions where death was “imminent.”
See, e. g., 2 id., at 608.
After the District Court ruled, the Idaho Supreme Court
construed the Act. That court explained that the Act “does
not require objective certainty, or a particular level of imme-
diacy, before the abortion can be `necessary' to save the
woman's life.” Planned Parenthood Great Northwest v.
State, 171 Idaho 374, 445, 522 P. 3d 1132, 1203 (2023). And
“treating an ectopic pregnancy, by removing the fetus,” the
court concluded, does not count as an “ `abortion' ” under the
Act. Ibid.
Without holding a new evidentiary hearing, the District
Court denied Idaho's motion for reconsideration. 2023 WL
3284977 (May 4, 2023). The Idaho Leg islature later
amended the defnition of “abortion” to exclude “[t]he re-
moval of a dead unborn child” and “[t]he removal of an ec-
topic or molar pregnancy.” § 18–604(1)(b), (c). It also
changed the “life of the mother” affrmative defense into an
exception from the prohibition on criminal abortions. § 18–
622(2).
The Ninth Circuit initially stayed the District Court's in-
junction, 83 F. 4th 1130 (2023), but the en banc court vacated
the panel's stay, declined to stay the injunction, and sched-
uled oral argument on the merits, 82 F. 4th 1296 (2023). We
granted Idaho's and the Legislature's applications to stay the
District Court's injunction pending appeal, treated the appli-

334 MO
YLE v. UNITED STATES
Barrett, J., concurring
cations as petitions for a writ of certiorari before judgment,
and
granted the petitions. 601 U. S. 1109 (2024).
II
Before the Ninth Circuit had the opportunity to review
the Distr ict Cour t's preliminary in juncti on, th is Cour t
stayed the injunction and granted certiorari before judg-
ment. Both decisions were premised on the belief that
Idaho would suffer irreparable harm under the injunction
and that these cases were ready for the Court's immediate
determination. Since then, briefng and oral argument have
“shed more light on this case than in the nature of things
was afforded at the time” the Court considered petitioners'
emergency applications. Belcher v. Stengel, 429 U. S. 118,
119 (1976) (pe r cur i am) (dismissed as i mprov idently
granted). I am now convinced that these cases are no longer
appropriate for early resolution.
The parties dispute whether EMTALA requires hospitals
to provide abortions—or any other treatment forbidden by
state law—as necessary stabilizing care. They also disagree
about whether EMTALA, as a statute enacted under Con-
gress's spending power and that operates on private parties,
can preempt state law (an issue aired for the frst time in
this Court). In my judgment, it would be imprudent to an-
swer these important questions now. Since this suit began
in the District Court, Idaho law has signifcantly changed—
twice. And since we granted certiorari, the parties' litigat-
ing positions have rendered the scope of the dispute unclear,
at best.
In its stay application, Idaho argued that the Govern-
ment's interpretation of EMTALA would render Idaho's Act
virtually unenforceable. As Idaho understood it, the Gov-
ernment's theory would allow physicians to perform abor-
tions whenever necessary to avoid “ `serious jeopardy' ”
to the mother 's men ta l hea lth. St ay Reply Br ief i n
No. 23A470, p. 6. On that broad reading, Idaho projected
that emergency rooms would function as “federal abortion
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335
Barrett, J., concurring
enclaves governed not by state law, but by physician judg-
ment,
as enforced by the United States's mandate to per-
form abortions on demand.” Ibid. (citation omitted). Idaho
also warned that the Government's interpretation would
“threate[n] religious healthcare providers” by forcing doc-
tors and hospitals to perform abortions regardless of con-
science objections. Id., at 15. Both of these points were
relevant to the Court's assessment of the irreparable harm
that Idaho would suffer from the preliminary injunction,
Nken v. Holder, 556 U. S. 418, 434 (2009), as well as the need
for “immediate determination in this Court,” Supreme Court
Rule 11.
At the merits stage, however, the United States disclaimed
these interpretations of EMTALA. First, it emphatically
disavowed the notion that an abortion is ever required as
stabilizing treatment for mental health conditions. Brief for
United States 26, n. 5; Tr. of Oral Arg. 76–78. That is an
important concession: If restricted to conditions posing seri-
ous jeopardy to a woman's physical health, the Government's
reading of EMTALA does not gut Idaho's Act.* Second, the
United States clarifed that federal conscience protections,
for both hospitals and individual physicians, apply in the
EMTALA context. Tr. of Oral Arg. 87–89. That is another
critical point: It alleviates Idaho's concern that the Govern-
ment's interpretation of EMTALA would strip healthcare
providers of conscience protections.
Narrowing happened from the other direction too. The
United States identifed PPROM, placental abruption, pre-
eclampsia, and eclampsia as conditions for which EMTALA
*The United States also clarifed that if pregnancy seriously jeopardizes
the woman's health postviability, EMTALA requires delivery, not abor-
tion. Brief for United States 10; Tr. of Oral Arg. 75. And it emphasized
that EMTALA requires abortion only in an “emergency acute medical sit-
uation,” where a woman's health is in jeopardy if she does not receive an
abortion “then and there.” Tr. of Oral Arg. 79–80. These two temporal
points also narrow the scope of EMTALA's potential confict with Idaho's
Act.
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YLE v. UNITED STATES
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requires an emergency abortion to be available. (The same
conditi
ons that the Government's witnesses identifed—be-
fore Idaho's law changed.) But in this Court, petitioners
represent that the Act permits physicians to treat each
of these conditions with emergency abortions, even if the
threat to the woman's life is not imminent. Reply Brief in
No. 23–726, pp. 21–22; Reply Brief in No. 23–727, pp. 8–9; Tr.
of Oral Arg. 23. The same is true for the conditions identi-
fed by the Government's witnesses (severe heart failure and
sepsis). Reply Brief in No. 23–727, pp. 8–9.
A grant of certiorari before judgment presumes that fur-
ther proceedings below are unnecessary to the Court's reso-
lution of the question presented. That was a miscalculation
in these cases, because the parties' positions are still evolv-
ing. The United States has clarifed that EMTALA's reach
is far more modest than it appeared when we granted certio-
rari and a stay. Idaho law has materially changed since the
District Court entered the preliminary injunction, and,
based on the parties' arguments before us, it seems that the
framing of these cases has not had suffcient opportunity to
catch up. Cf. The Monrosa v. Carbon Black Export, Inc.,
359 U. S. 180, 184 (1959) (“Examination of a case on the mer-
its, on oral argument, may bring into `proper focus' a consid-
eration which, though present in the record at the time of
granting the writ, only later indicates that the grant was
improvident”).
On top of that, petitioners have raised a diffcult and conse-
quential argument, which they did not discuss in their stay
applications, about whether Congress, in reliance on the
Spending Clause, can obligate recipients of federal funds to
violate state criminal law. Brief for Petitioners in No. 23–
726, pp. 48–51; Reply Brief in No. 23–727, pp. 3–4; see also
Brief for Prolife Center at the University of St. Thomas as
Amicus Curiae. The District Court did not address this
issue below—nor did the Ninth Circuit, which we bypassed.
We should not jump ahead of the lower courts, particularly
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Barrett, J., concurring
on an issue of such importance. Cutter v. Wilkinson, 544
U
. S. 709, 718, n. 7 (2005) (“[W]e are a court of review, not
of frst view”); New York v. Uplinger, 467 U. S. 246, 251
(1984) (Stevens, J., concurring) (dismissing as improvidently
granted where “constitutional questions” would otherwise be
considered “premature[ly]”). The lower courts should ad-
dress the Spending Clause issue in the frst instance.
For these reasons, a “deviation from normal appellate
practice” in these cases has proved to be unwise. Supreme
Court Rule 11. I therefore agree that we should dismiss
the writ of certiorari as improvidently granted and permit
proceedings to run their course in the courts below.
Having dismissed the writ, I also agree that we should
vacate the stay. As the party seeking emergency relief
from this Court, Idaho bore the burden of showing that it
would be “ `irreparably injured' ” if the preliminary injunc-
tion remained in effect. Nken, 556 U. S., at 434. The
Court's grant of a stay refected, among other things, its de-
termination that Idaho had satisfed that burden. Now,
based on the parties' representations, it appears that the in-
junction will not stop Idaho from enforcing its law in the vast
majority of circumstances.
To be sure, the text of the two laws differs: Idaho's Act
allows abortion only when “necessary to prevent the death
of the pregnant woman,” Idaho Code Ann. § 18–622(2)(a)(i),
while EMTALA requires stabilizing care to prevent “se-
r i ous jeopardy” to the woman's hea lth, 42 U. S. C.
§ 1395dd(e)(1)(A)(i). But Idaho represents that its exception
is broader than the United States fears, and the United
States represents that EMTALA's requirement is narrower
than Idaho fears. That matters in assessing Idaho's irrepa-
rable harm for purposes of the stay. The dramatic narrow-
ing of the dispute—especially the Government's position on
abortions to address mental health and conscience exemp-
tions for healthcare providers—has undercut the conclusion
that Idaho would suffer irreparable harm under the prelimi-

338 MO
YLE v. UNITED STATES
Opinion of Jackson, J.
nary injunction. Contrary to Idaho's concerns at the stay
st
age, the Government's interpretation of EMTALA does not
purport to transform emergency rooms into “federal abor-
tion enclaves governed not by state law, but by physician
judgment, as enforced by the United States's mandate to
perform abortions on demand.” Stay Reply Brief in
No. 23A470, p. 6 (citation omitted). Nor does it purport to
deprive doctors and hospitals of conscience protections. Cf.
id., at 15. Thus, even with the preliminary injunction in
place, Idaho's ability to enforce its law remains almost en-
tirely intact.
Justice Jackson, concurring in part and dissenting in
part.
In 1986, Congress passed the Emergency Medical Treat-
ment and Labor Act (EMTALA), which requires hospitals
to provide stabilizing treatment when patients present with
emergency medical conditions. See 42 U. S. C. § 1395dd.
Sometimes, an abortion is the only way to stabilize a patient
and, therefore, comply with EMTALA. But Idaho law pro-
hibits abortions unless the treating physician believes that
the abortion is “necessary to prevent the [patient's] death.”
Idaho Code Ann. § 18–622(2)(a)(i) (Supp. 2023).
Recognizing the clear confict between EMTALA and
Idaho law, a Federal District Judge issued an injunction that
had the effect of ensuring that Idaho physicians would be
able to provide the abortion care EMTALA requires. Five
months ago, this Court stayed that injunction. As a legal
matter, this Court's stay meant that unless a doctor could
actually say that the abortion was necessary to prevent a
patient's death, that doctor could no longer provide abortion
care that she viewed as reasonably necessary to keep a pa-
tient from losing her uterus, going into organ failure, or
avoiding any number of other serious health risks. Com-
pare § 18–622(2)(a)(i) with 42 U. S. C. § 1395dd(e)(1)(A). As a
practical matter, this Court's intervention meant that Idaho
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physicians were forced to step back and watch as their pa-
tients
suffered, or arrange for their patients to be airlifted
out of Idaho.
This months-long catastrophe was completely unnecessary.
More to the point, it directly violated federal law, which in
our system of government is supreme. See Art. VI, cl. 2.
As Justice Kagan explains, EMTALA plainly requires doc-
tors to provide medically necessary stabilizing abortions in
limited situations. See ante, at 329–331 (concurring opin-
ion). To the extent that Idaho law conficts with EMTALA,
the State's law must give way. I join in Justice Kagan's
statutory analysis, see ibid., and I concur in the Court's per
curiam decision to lift its stay, which should not have been
entered in the frst place. I dissent in part because, in my
view, the Court is wrong to dismiss these cases as improvi-
dently granted.
I
This Court typically dismisses cases as improvidently
granted based on “circumstances . . . which `were not . . .
fully apprehended at the time certiorari was granted.' ”
The Monrosa v. Carbon Black Export, Inc., 359 U. S. 180,
183 (1959) (some alterations in original). This procedural
mechanism should be reserved for that end—not turned into
a tool for the Court to use to avoid issues that it does not
wish to decide.
The reasons that justifed our grant of certiorari in these
cases still hold true today. See this Court's Rule 11. The
importance of recognizing Congress's judgments in EMTALA
remains as imperative as ever. The United States is still
hamstrung in its ability to enforce federal law while States
pass laws that effectively nullify EMTALA's requirements.
And, on the ground, healthcare providers “have been all but
paralyzed by legal uncertainties,” placing pregnant patients
at risk while they are waiting to be transferred out of State
to receive the care they need. Brief for St. Luke's Health
System as Amicus Curiae 14–15.
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If anything, the need for a clear answer to the Supremacy
C
lause questi on has only i ncreased i n the i nterveni ng
months. Other States across the country have enacted leg-
islation that gives rise to the same sort of legal confict that
Idaho has created. This pre-emption issue is not going away
anytime soon and will most certainly return to this Court.
Indeed, it already has. Just three days before we granted
this petition, the Fifth Circuit decided a similar case, affrm-
ing a permanent injunction that prevents the United States
from enforcing EMTALA's requirements with respect to sta-
bilizing emergency abortions prohibited by Texas law. See
Texas v. Becerra, 89 F. 4th 529, 533 (2024). The United
States has already petitioned for certiorari in that case. See
Pet. for Cert. in Becerra v. Texas, O. T. 2023, No. 23–
1076.
Nor has there been any change in today's cases that might
eliminate or undermine the need for this Court's review.
The Government continues to maintain (correctly, in my
view) that EMTALA's plain text requires hospitals to pro-
vide certain emergency abortions when doing so is the only
way to stabilize an emergency condition. Brief for United
States 12–20. Idaho continues to criminalize the provision
of such abortions unless doing so is necessary to prevent the
patient's death. Idaho Code Ann. § 18–622(2)(a)(i). And
both Idaho and the United States still agree that Idaho law
directly criminalizes emergency care that the Federal Gov-
ernment reads EMTALA to require. See Tr. of Oral Arg.
16–17, 65–66. Idaho's lawyers may have changed their tune
about the exact types of medical care that fall in the gap
between state and federal law, but the fundamentals of this
dispute remain the same.
II
Most importantly, as Justice Kagan observes, the con-
fict between the state and federal law—as they are actually
being interpreted and applied on the ground—is both sub-
stantial and signifcant. Ante, at 329–331. It is a clash that
clearly exists despite the attempt by Idaho's counsel to
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Opinion of Jackson, J.
muddy the waters concer ni ng the scope of the St ate's
law
.
The textual confict is plain. EMTALA requires stabiliz-
ing treatment if a patient has an acute medical condition
that is so severe “that the absence of immediate medical at-
tention could be reasonably expected to” either result in a
serious health risk, or seriously threaten bodily functions
or organs. 42 U. S. C. §§ 1395dd(b)(1), (e)(1)(A). In such
cases, EMTALA requires hospitals “to provide such medical
treatment of the condition as may be necessary to assure,
within reasonable medical probability, that no material
deterioration of the condition is likely to . . . occur.”
§ 1395dd(e)(3)(A). Idaho's broad criminalization of abor-
tion—unless the treating physician believes that the abortion
is “necessary to prevent the [patient's] death,” Idaho Code
Ann. § 18–622(2)(a)(i)—conficts with the text of EMTALA.
Put simply, under federal law, a hospital must provide an
emergency abortion that is reasonably necessary to preserve
a patient's health within the meaning of EMTALA. But,
under Idaho law, a doctor cannot provide this care (required
by federal law) without committing a criminal act.
From the beginning of this litigation, the United States
has emphasized the host of emergency medical conditions
that require stabilizing abortions—even when the proce-
dure is not necessarily life saving. That list includes pre-
eclampsia, preterm premature rupture of membranes
(PPROM), sepsis, and placental abruption, to name just a
few examples. Having now been sued over its interference
with EMTALA's protections for people experiencing these
conditions, Idaho has shifted its position, both here and be-
fore the District Court, recharacterizing abortions in these
scenarios as life-saving care permitted under Idaho law.
Some of my colleagues appear to view this convenient rhe-
torical maneuver as a material change that (also conven-
iently) reduces the confict between state and federal law to
the point that a ruling from this Court is no longer warranted.
See ante, at 337–338 (Barrett, J., concurring). But it
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YLE v. UNITED STATES
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is both legally and factually implausible to say that Idaho's
current
litigating position actually mitigates the confict be-
tween that State's law and EMTALA.
The confict between state and federal law still exists—in
real life. Idaho cannot credibly maintain that its law always
permits abortions in cases of PPROM or preeclampsia such
that its mandate never conficts with federal law. The same
medical condition can present with different risks in differ-
ent patients. See, e. g., Brief for Physicians for Reproduc-
tive Health as Amicus Curiae 10–11; Brief for Physicians for
Human Rights as Amicus Curiae 11–19. And, often, a doc-
tor simply does not know what the risks are or whether a
patient might face death. See Tr. of Oral Arg. 103–104; 2
App. 615–617. Such a doctor, observing the different legal
thresholds for action under state and federal law—not to
mention the severe criminal penalties for a miscalculation—
would surely be cowed into not providing abortion care that
medical standards warrant and federal law requires. Do not
take my word for this; it is already happening.* So it is
strange, to say the least, that this Court would shirk its duty
to resolve a pressing legal issue on the basis of representa-
tions that defy medical realities.
In any event, the representations Idaho's counsel made
during oral argument and in the State's briefs fled in this
Court are not a defnitive interpretation of Idaho law. That
authority remains with the Idaho Supreme Court, which has
never endorsed the State's position. To the contrary, the
Idaho Supreme Court has emphasized that, to avoid criminal
liability, a doctor must subjectively believe that an abortion
is necessary to prevent death. Planned Parenthood Great
*See Brief for Idaho Coalition for Safe Healthcare, Inc., as Amicus Cu-
riae 7–13 (providing examples in Idaho where doctors' lack of certainty
prevented them from providing medically necessary abortions); see also
Brief for St. Luke's Health System as Amicus Curiae 14–16 (same); Brief
for Amanda Zurawski et al. as Amici Curiae 29–30 (same); Brief for Phy-
sicians for Human Rights as Amicus Curiae 12–17 (same).
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Northwest v. State, 171 Idaho 374, 445–446, 522 P. 3d 1132,
1203
–1204 (2023). And that is to say nothing of local prose-
cutors, who may not be aware of (or care about) Idaho's new-
found interpretation of its abortion ban, and who are highly
incentivized to enforce the law to the hilt. See Idaho Code
Ann. § 63–3642 (Supp. 2023) (withholding funding from local
governments if their offcials decline to enforce Idaho felony
laws, which include these felony abortion laws); see also
Brief for Idaho Coalition for Safe Healthcare, Inc., as Amicus
Curiae 14–24 (discussing myriad ways in which state and
local offcials in Idaho have targeted physicians). Still, some
of my colleagues latch onto the bald representations of Ida-
ho's counsel, using them as an escape hatch that justifes our
dispensing with having to issue a merits ruling in these
cases.
We cannot simply wind back the clock to how things were
before the Court injected itself into this matter. Our inter-
vention has already d storted this litigation process. We
permitted Idaho's law to go into effect by staying the Dis-
trict Court's injunction in the frst place, then allowed this
matter to sit on our merits docket for fve months while we
considered the question presented. It is too little, too late
for the Court to take a mulligan and just tell the lower courts
to carry on as if none of this has happened. As the old adage
goes: The Court has made this bed so now it must lie in it—
by proceeding to decide the merits of the critical pre-emption
issue these cases present.
We have granted certiorari and heard argument. We
have had ample opportunity to consider the issues. The par-
ties were well represented on both sides, and dozens of amici
have weighed in. What is more, the necessary legal reason-
ing is straightforward, and the answer to the question pre-
sented is—or at least should be—quite clear: Idaho law pro-
hibits what federal law requires, so to that extent, under the
Supremacy Clause, Idaho's law is pre-empted. See Mutual
Pharmaceutical Co. v. Bartlett, 570 U. S. 472, 479–480 (2013)
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YLE v. UNITED STATES
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(“[I]t has long been settled that state laws that confict with
federa
l law are `without effect' ” (quoting Maryland v. Loui-
siana, 451 U. S. 725, 746 (1981))). There is simply no good
reason not to resolve this confict now.
***
Despite the clarity of the legal issue and the dire need
for an answer from this Court, today six Justices refuse to
recognize the rights that EMTALA protects. See ante, at
334–338 (Barrett, J., concurring); post, at 348–355
(Alito, J., dissenting). The majority opts, instead, to dis-
miss these cases. But storm clouds loom ahead. Three
Justices suggest, at least in this context, that States have
free rein to nullify federal law. See post, at 355–358
(Alito, J., dissenting). And three more decline to disagree
with those dissenters on the merits. See ante, at 334–338
(Barrett, J., concurring). The latter group offers only
murmurs that “petitioners have raised a diffcult and conse-
quential argument” about Congress's authority under the
Spending Clause. Ante, at 336 (Barrett, J., concurring).
So, as of today, the Court has not adopted Idaho's farfetched
theories—but it has not rejected them either.
Instead, the Court puts off the decision. But how long
must pregnant patients wait for an answer? Until we con-
front the pending petition that the Government fled with us
after the Fifth Circuit enabled Texas's fouting of EMTALA?
Until these very cases return to us in a few years? Will
this Court just have a do-over, rehearing and rehashing the
same arguments we are considering now, just at a compara-
tively more convenient point in time? Or maybe we will
keep punting on this issue altogether, allowing chaos to reign
wherever lower courts enable States to fagrantly undercut
federal law, facilitating the suffering of people in need of ur-
gent medical treatment.
After today, there will be a few months—maybe a few
years—during which doctors may no longer need to airlift
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Alito, J., dissenting
pregnant patients out of Idaho. As Justice Kagan empha-
si
zes, portions of Idaho's law will be preliminarily enjoined
(at least for now). Ante, at 327, 329. But having not heard
from this Court on the ultimate pre-emption issue, Idaho's
doctors will still have to decide whether to provide emer-
gency medical care in the midst of highly charged legal cir-
cumstances with no guarantee that this fragile detente over
the State's categorical prohibitions will be maintained. Cf.
ante, at 338 (Barrett, J., concurring) (“[E]ven with the pre-
liminary injunction in place, Idaho's ability to enforce its law
remains almost entirely intact”).
So, to be clear: Today's decision is not a victory for preg-
nant patients in Idaho. It is delay. While this Court daw-
dles and the country waits, pregnant people experiencing
emergency medical conditions remain in a precarious posi-
tion, as their doctors are kept in the dark about what the
law requires. This Court had a chance to bring clarity and
certainty to this tragic situation, and we have squandered it.
And for as long as we refuse to declare what the law re-
quires, pregnant patients in Idaho, Texas, and elsewhere will
be paying the price. Because we owe them—and the Na-
tion—an answer to the straightforward pre-emption ques-
tion presented in these cases, I respectfully dissent.
Justice Alito, with whom Justice Thomas joins, and
with whom Justice Gorsuch joins as to Parts I and II,
dissenting.
This case presents an important and unsettled question
of federal statutory law: whether the Emergency Medical
Treatment and Labor Act (EMTALA), 42 U. S. C. § 1395dd,
sometimes demands that hospitals perform abortions and
thereby preempts Idaho's recently adopted Defense of Life
Act, Idaho Code Ann. § 18–622 (Supp. 2023). Enacted nearly
40 years ago, EMTALA requires hospitals participating in
Medicare to “scree[n]” and “stabilize” “any individual”
who comes to an emergency room with an “emergency medi-

346 MO
YLE v. UNITED STATES
Alito, J., dissenting
ca l conditi on” that jeopardi zes the patient's “ hea lth. ”
§
§ 1395dd(a), (b)(1)(A), (e)(1)(A). And if the patient is a
pregnant woman, the hospital must stabilize both “the
woman” and “her unborn child.” § 1395dd(e)(1)(A)(i).
After this Court's decision in Dobbs v. Jackson Women's
Health Organization, 597 U. S. 215 (2022), Idaho and other
States enacted new laws restricting the performance of abor-
tions. To protect both “maternal health and safety” and
“ `the life of preborn children,' ” Planned Parenthood Great
Northwest v. State, 171 Idaho 374, 438, 522 P. 3d 1132, 1196
(2023) (quoting Idaho Code Ann. § 18–601), Idaho's law per-
mits an abortion only when “necessary to prevent the death
of the pregnant woman,” § 18–622(2)(a)(i).
Shortly before Idaho's law took effect, President Biden in-
structed members of his administration to fnd ways to limit
Dobbs's reach. Protecting Access to Reproductive Health-
care Services, Exec. Order No. 14076, 87 Fed. Reg. 42053
(2022) In response, Government lawyers hit upon the novel
argument that, under EMTALA, all Medicare-funded hospi-
tals—that is, the vast majority of hospitals
1
—must perform
abortions on request when the “health” of a pregnant woman
is in serious jeopardy. § 1395dd(e)(1)(A)(i). In the Govern-
ment's view, EMTALA trumps laws like Idaho's, which allow
abortions only to preserve the life of the pregnant woman.
See Dept. of Health & Human Servs. (HHS), Reinforcement
of EMTALA Obligations Specifc to Patients Who Are Preg-
nant or Are Experiencing Pregnancy Loss 1 (QSO–22–22–
Hospitals, July 11, 2022). The Government sued Idaho on
this preemption theory and obtained a preliminary injunc-
tion against enforcement of the state law “to the extent
it conficts with EMTALA.” 623 F. Supp. 3d 1096, 1117
(Idaho 2022).
1
For instance, the American Hospital Association (AHA) calculates that
96% of hospitals have at least 50% of their inpatient days paid by Medicare
and Medicaid. AHA, Fact Sheet: Majority of Hospital Payments Depend-
ent on Medicare or Medicaid (Mar. 2024).
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Alito, J., dissenting
The Government's preemption theory is plainly unsound.
F
ar from requir i ng hospit a ls to per for m abor ti ons,
EMTALA's text unambiguously demands that Medicare-
funded hospitals protect the health of both a pregnant
woman and her “unborn child.” § 1395dd(e)(1)(A)(i). And
even if there were some ambiguity in the statutory text, we
would be obligated to resolve that ambiguity in favor of the
State because EMTALA was enacted under the Spending
Clause, and as we have held time and again, conditions
attached to the receipt of federal funds must be unambigu-
ous. Arlington Central School Dist. Bd. of Ed. v. Murphy,
548 U. S. 291, 296 (2006); Pennhurst State School and Hospi-
tal v. Halderman, 451 U. S. 1, 17 (1981). Here, no one who
has any respect for statutory language can plausibly say that
the Government's interpretation is unambiguously correct.
And in any event, Idaho never consented to any conditions
imposed by EMTALA and certainly did not surrender con-
trol of the practice of medicine and the regulation of abor-
tions within its territory.
Recognizing the faws in the Government's theory and Ida-
ho's “strong ” likelihood of success, this Court stayed the pre-
liminary injunction pending appeal on January 5. And,
wisely or not, the Court also took the unusual step of grant-
ing certiorari before Idaho's appeal was heard by the Ninth
Circuit. See this Court's Rule 11. Now the Court dis-
misses the writ and, what is worse, vacates the stay.
This about-face is baffing. Nothing legally relevant has
occurred since January 5. And the underlying issue in
this case—whether EMTALA requires hospitals to perform
abortions in some circumstances—is a straightforward ques-
tion of statutory interpretation. It is squarely presented by
the decision below, and it has been exhaustively briefed and
argued. In addition to the parties' briefs, we received 46
amicus briefs, including briefs submitted by 44 States and
the District of Columbia; briefs expressing the views of 379
Members of Congress; and briefs from prominent medical or-
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YLE v. UNITED STATES
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ganizations. Altogether, we have more than 1,300 pages of
br
iefng to assist us, and we heard nearly two hours of argu-
ment. Everything there is to say about the statutory inter-
pretation question has probably been said many times over.
That question is as ripe for decision as it ever will be. Ap-
parently, the Court has simply lost the will to decide the easy
but emotional and highly politicized question that the case
presents. That is regrettable.
Having already taken the extraordinary step of granting
certiorari before judgment in order to decide whether the
Government's new interpretation of EMTALA is correct, we
have no good reason to change course now. This is espe-
cially so because the Court's decision to reexamine the stay
issued in January makes it necessary to reassess whether
Idaho showed a likelihood of success on the merits, a ques-
tion that is closely related to the question whether Idaho or
the Government has correctly interpreted EMTALA. I will
therefore proceed to analyze what EMTALA means.
I
A
The text of EMTALA shows clearly that it does not re-
quire hospitals to perform abortions in violation of Idaho law.
To the contrary, EMTALA obligates Medicare-funded hospi-
tals to treat, not abort, an “unborn child.”
EMTALA imposes two main obligations on covered hos-
pitals. First, a hospital must, within its “capabilit[ies],”
“screen” “any individual” arriving at the emergency room
w ithout regard to the i ndiv idua l's abi l ity to pay.
§§ 1395dd(a), (h). The purpose of this screening is to deter-
mine whether the individual has an “emergency medical con-
dition,” which EMTALA defnes as follows:
“a medical condition manifesting itself by acute symp-
toms of suffcient severity (including severe pain) such
that the absence of immediate medical attention could
reasonably be expected to result in—
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Alito, J., dissenting
“(i) placing the health of the individual (or, with re-
spec
t to a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy,
“(ii) serious impairment to bodily functions, or
“( i i i) ser i ous dysfunc ti on of any bodi ly organ or
part.” § 1395dd(e)(1)(A) (emphasis added).
2
When a hospital determines that an “emergency medical
condition” exists, it has two options. It may provide “treat-
ment” within the capability of its “staff and facilities.”
§ 1395dd(b)(1)(A). Or it may “transfer . . . the individual”
to another hospital that “has available space and qualifed
personnel for the treatment” as long as the transfer would ef-
fec t a net benefit for the patient. §§ 1395dd( b)(1)(B),
(c)(2)(B)(i).
At no point in its elaboration of the screening, stabiliza-
tion, and transfer requirements does EMTALA mention
abortion. Just the opposite is true: EMTALA requires the
hospital at every stage to protect an “unborn child” from
harm.
Begin with the screening provision, which requires a hos-
pital “to determine whether or not an emergency medical
condition (within the meaning of subsection (e)(1)) exists.”
§ 1395dd(a). “[W]ith respect to a pregnant woman,” sub-
section (e)(1) defnes an emergency medical condition as one
that is suffciently serious to “plac[e] . . . the health of the
woman or her unborn child . . . in serious jeopardy.”
§ 1395dd(e)(1)(A)(i) (emphasis added). Thus, if the hospi-
tal identifes an emergency medical condition threatening
the child, it must “stabilize” that condition to ensure that
t h e c h i l d 's h e a l t h d o e s n o t r e m a i n i n “ j e o p a r d y. ”
§§ 1395dd(b)(1)(A), (e)(1)(A)(i). It goes without saying that
aborting an “unborn child” does not protect it from jeopardy.
2
At oral argument, the Solicitor General stated that, in the Govern-
ment's view, an “impairment” or “dysfunction” under §§ 1395dd(e)(1)(A)(i)
and (ii) may be temporary. Tr. of Oral Arg. 80.
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YLE v. UNITED STATES
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Similarly, if a hospital wants to transfer a pregnant woman
to
another facility, it may not do so unless, among other
things, a physician certifes directly or through an intermedi-
ary that the medical benefts of transfer outweigh any “in-
creased risks” to the woman “and, in the case of labor, to the
unborn child.” §§ 1395dd(c)(1)(A)(ii), (e)(1)(B). Thus, re-
gardless of whether a hospital chooses to treat or transfer a
pregnant woman, it must strive to protect her “unborn child”
from harm.
The Government struggles mightily—but unsuccessfully—
to get around this language. First, the Government argues
that EMTALA's repeated use of the term “individual,” cou-
pled with the Dictionary Act's defnition of that term, which
does not include an “unborn child,”
3
shows that “[a]ll of
EMTALA's duties—screening, stabilization, and transfer—
run to the `individual' seeking care.” Brief for United
States 41. That assertion falls fat in light of EMTALA's
express protection of the unborn child.
Besides, there is a simple explanation for EMTALA's re-
peated use of the term “individual,” and it provides no sup-
port for the Government's interpretation. Most of those
references involve conduct in which only the pregnant
woman can engage, such as going to an emergency room,
4
receiving medical information,
5
consenting to or refusing
treatment,
6
or fling suit.
7
Many references concern trans-
fer to another facility,
8
and when a pregnant woman is trans-
3
The Dictionary Act defnes an “individual” to “include every infant
member of the species homo sapiens who is born alive at any stage of
development.” 1 U. S. C. § 8(a). But it goes on to provide that this def-
nition is not to “be construed to . . . deny . . . any legal status or legal
right applicable to any member of the species homo sapiens at any point
prior to being `born alive.' ” § 8(c). Thus, the Act itself provides no sup-
port for the Government's position.
4
§ 1395dd(a).
5
§ 1395dd(c)(1)(A)(i).
6
§ 1395dd(b)(2).
7
§ 1395dd(d)(2)(A).
8
§§ 1395dd(b)(3), (c), (e)(4).
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Alito, J., dissenting
ferred, her “unborn child” obviously goes with her. Another
reference
concerns a woman's “emergency medical condi-
tion,” which, as noted, includes conditions that jeopardize
her “unborn child.”
9
And some references expressly men-
tion both the “individual” and “the unborn child.”
10
No use
of the ter m “ i ndiv idua l” suppor ts the Gover nment's
interpretation.
Second, based on a provision stating that an individual
may not be treated without consent, § 1395dd(b)(2), the Gov-
ernment infers that “it is for the pregnant woman, not state
law, to decide how to proceed” when her health is at risk.
Brief for United States 43. The Government's logic is
faulty. The right to withhold consent does not necessarily
carry with it the right to demand whatever cannot be done
without consent. X may withhold consent to a contract with
Y, but that does not mean that X may demand to enter into
such a contract. A person may not be forced to assume the
duties of the Presidency without consent, but it does not
follow that this person may demand to be sworn in as
President.
Or, to provide an example that is more closely related to
the matter at hand, the right to refuse medical treatment
without consent does not entail the right to demand treat-
ment that is prohibited by law. Cancer patients have the
right to refuse treatment that their doctors recommend, but
they do not have a right to obtain whatever treatment they
want, such as the administration of a drug that cannot legally
be used in this country. Cf. 21 U. S. C. § 360bbb–0a (grant-
ing terminal patients the right to try experimental drugs).
Likewise here, a woman's right to withhold consent to treat-
ment related to her pregnancy does not mean that she can
demand an abortion.
For these reasons, the text of EMTALA conclusively
shows that it does not require hospitals to perform abortions.
9
§ 1395dd(e)(1)(A)(i).
10
§§ 1395dd(c)(1)(A)(ii) and (2)(A), (e)(1)(A)(i).
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B
F
or those who fnd it appropriate to look beyond the statu-
tory text, the context in which EMTALA was enacted re-
inforces what the text makes clear. Congress designed
EMTALA to solve a particular problem—preventing private
hospitals from turning away patients who are unable to pay
for medical care. H. R. Rep. No. 99–241, pt. 1, p. 27 (1985);
K. Treiger, Preventing Patient Dumping: Sharpening the
COBRA's Fangs, 61 N. Y. U. L. Rev. 1186, 1188 (1986). And
none of the many briefs submitted in this suit has found any
suggestion in the proceedings leading up to EMTALA's pas-
sage that the Act might also use the carrot of federal funds
to entice hospitals to perform abortions. To the contrary,
EMTALA garnered broad support in both Houses of Con-
gress, including the support of Members such as Representa-
tive Henry Hyde who adamantly opposed the use of federal
funds to abet abortion.
11
It is also telling that the Congress that initially enacted
EMTALA in 1986 and the one that amended it in 1989 also
passed appropriations riders under what is now known as
the Hyde Amendment (named after Representative Hyde)
to prevent federal funds from facilitating abortions, except
in limited circumstances. See Harris v. McRae, 448 U. S.
297, 302 (1980). Between 1981 and 1993—the very period
when EMTALA was enac ted and amended—the Hyde
Amendment contained only one exception: for abortions nec-
essary to save the life of the pregnant woman. Congres-
sional Research Service, E. Liu & W. Shen, The Hyde
Amendment: An Overview 1 (2022); see § 204, 99 Stat. 1119
(1986 Hyde Amendment). The Hyde Amendment thus pro-
hibited federal funds from paying for the health-related
abortions that the Government says EMTALA mandates.
11
See House Vote #499 in 1986 (99th Cong.), GovTrack.US (Mar. 20,
1986), https://www.govtrack.us/congress/votes/99-1986/h499; Senate Vote
#379 in 1985 (99th Cong.), GovTrack.US (Dec. 19, 1985), https://www.
govtrack.us/congress/votes/99-1985/s379.

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It would have been strange indeed if a Congress that repeat-
edly
sought to prevent federal funding of abortions simulta-
neously enacted a law that, as interpreted by the Govern-
ment, requires hospitals and physicians to perform that very
same procedure.
The Government's reading of EMTALA is doubly strange
given that the President who signed that law repeatedly
promised not to use federal funds to subsidize or require the
provision of abortions. Less than three months before sign-
ing EMTALA, President Reagan told participants in the an-
nual March for Life that “the resources of government are
not [to be] used to promote or perform abortions.” The
American Presidency Project, Remarks to Participants in
the March for Life Rally (Jan. 22, 1986). The next year, he
touted his administration's work “to restrict the use of Fed-
eral funds to perform abortions.” Id., Remarks to Partici-
pants in the March for Life Rally (Jan. 22, 1987). In another
1987 speech, he promised that his administration would “op-
pose any legislation that would require individuals or institu-
tions, public or private, to fnance or perform abortions.”
Id., Remarks at a White House Briefng for Right to Life
Activists (July 30, 1987). And his 1986 and 1987 messages
to Congress repeated that promise. See id., Message to the
Congress on “A Quest for Excellence” (Jan. 27, 1987); id.,
Message to the Congress on America's Agenda for the Fu-
ture (Feb. 6, 1986).
Around the same time, President Reagan's HHS Secretary
testifed before Congress that “the Administration stead-
fastly opposes [the] creation of [a] program which would en-
courage, promote or fnance the performance of abortions.”
Statement of the Hon. Margaret M. Heckler, in Budget Rec-
onciliation: Hearings before the Senate Committee on Fi-
nance, 99th Cong., 1st Sess., pt. 1, p. 273 (1985). It beggars
belief that President Reagan would have happily signed
EMTALA into law if it did what he “steadfastly oppose[d].”
Ibid.
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C
D
esperate to fnd some crumb of support for its interpreta-
tion, the Government scrapes together a handful of sources
that it says evidence a general understanding that EMTALA
requires hospitals to perform health-related abortions pro-
hibited by Idaho law. None of these sources stands for
that proposition.
First, the Government searched a vast database of HHS
enforcement decisions and located six occurring between
2010 and 2023 that it fnds helpful. It is not obvious why
those enforcement decisions—which postdate EMTALA by
more than 20 years—shed light on its original meaning.
And it is even less clear why they justify the Government's
claim that EMTALA preempts Idaho law. Five of the six
cases involved ectopic pregnancies, which the Idaho law does
not cover. See Idaho Code Ann. § 18–604(1)(c) (excluding ec-
topic pregnancies from the defnition of “abortion”). In the
remaining case, the hospital was faulted, not for failing to
perform an abortion, but for discharging a sick pregnant
woman without calling for an ambulance to transport her to
another hospital.
12
The Government also seizes upon a provision in the Af-
fordable Care Act stating that “[n]othing in this Act shall be
construed to relieve any health care provider from providing
emergency services as required by State or Federal law, in-
cluding . . . EMTALA.” 42 U. S. C. § 18023(d) (internal quo-
tation marks omitted). Because this provision was placed
in a section of the Act concerning abortion, the Government
12
Additionally, it is doubtful that Idaho law would have prevented an
abortion in this suit. The woman was diagnosed with “[i]nevitable abor-
tion.” Centers for Medicare and Medicaid Services, Hospital Surveys
With 2567 Statement of Defciencies—2024Q1 (2010–2016 fle) Row 16,961.
But Idaho law does not apply to “non-viable pregnancies . . . where the
unborn child is no longer developing.” Planned Parenthood Great North-
west v. State, 171 Idaho 374, 445, 522 P. 3d 1132, 1203 (2023); see also Idaho
Code Ann. §§ 18–604(1), (11).
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Alito, J., dissenting
infers that it refects a congressional understanding that
EMT
ALA sometimes requires abortions. Brief for United
States 19–20. That inference is totally unwarranted. The
provision in question refers to the entire massive Afford-
able Care Act, not just the relatively few provisions concern-
ing abortion. Compare § 18023(d), with § 18023(c) (referring
more narrowly to “this subsection”). It reaffrms the duty
of participating hospitals to comply with EMTALA, but it
does not expand what the text of EMTALA requires.
13
So
this provision cannot support the Government's interpreta-
tion of EMTALA either.
II
As the previous Part shows, EMTALA's text and con-
text decisively refute the Government's interpretation. But
there is a third strike against the Government's position:
EMTALA is an exercise of Congress's spending power. And
when Congress relies on its authority to attach conditions to
the receipt of federal funds special rules apply
Spending Clause legislation operates “much in the nature
of a contract: in return for federal funds, the [recipients]
agree to comply with federally imposed conditions.” Penn-
hurst, 451 U. S., at 17. These conditions do not bind unless
and until they are accepted, and private parties “can opt out
of spending programs” at will, “completely nullifying what-
ever force the spending conditions once had.” Health and
Hospital Corporation of Marion Cty. v. Talevski, 599 U. S.
166, 201 (2023) (Thomas, J., dissenting); accord, Townsend v.
Swank, 404 U. S. 282, 292 (1971) (Burger, C. J., concurring in
result) (“[A]herence to [Spending Clause] provisions . . . is in
no way mandatory”). “[T]he `legitimacy of Congress'
power' ” to enforce conditions tied to federal funds depends
on whether the parties who accepted federal funds also “ `vol-
13
Section 18023(d) also demands compliance with state emergency care
requirements, and laws like Idaho's impose requirements regarding per-
missible emergency care for pregnant women.
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untarily and knowingly' ” accepted the conditions. Cum-
mings
v. Premier Rehab Keller, 596 U. S. 212, 219 (2022)
(quoting Barnes v. Gorman, 536 U. S. 181, 186 (2002)).
Because the enforcement of conditions attached to the re-
ceipt of federal money depends on a recipient's knowing and
voluntary consent, “the conditions must be set out `unam-
biguously.' ” Arlington Central, 548 U. S., at 296 (quoting
Pennhurst, 451 U. S., at 17). And recipients must be given a
“legitimate choice whether to accept the federal conditions.”
National Federation of Independent Business v. Sebelius,
567 U. S. 519, 578 (2012) (opinion of Roberts, C. J.); accord,
Steward Machine Co. v. Davis, 301 U. S. 548, 590 (1937).
The Government's interpretation founders at both points.
First, consider the requirement that EMTALA speak un-
ambiguously. Even if it were possible to read EMTALA as
requiring abortions prohibited by Idaho law, it is beyond dis-
pute that such a requirement is not unambiguously clear.
The statute does not mention abortion, let alone expressly
bind hospitals to perform abortions contrary to state law.
The need for clear statutory language is especially impor-
tant in this suit because the Government's interpretation
would intrude on an area traditionally left to state control,
namely, the practice of medicine. We typically expect Con-
gress to “ `make its intention “clear and manifest” if it
intends to pre-empt the historic powers of the States.' ”
Gregory v. Ashcroft, 501 U. S. 452, 461 (1991) (quoting Rice
v. Santa Fe Elevator Corp., 331 U. S. 218, 230 (1947)); see
also Gonzales v. Oregon, 546 U. S. 243, 274 (2006) (“[T]he
background principles of our federal system also belie the
notion that Congress would use such an obscure grant of
authority to regulate areas traditionally supervised by the
States' police power”).
Second, consider the requirement that parties be given a
choice before being bound by Spending Clause conditions.
The Government's interpretation purports to limit Idaho's
choices about what conduct to criminalize. But Idaho never
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Alito, J., dissenting
“agree[d]” to be bound by EMTALA,
14
Cummings
, 596 U. S.,
at 219, let alone to surrender its historic power to regulate
the practice of medicine or the performance of abortions
within its borders.
The Idaho Legislature takes its argument against preemp-
tion even further. It contends that EMTALA cannot pre-
empt the State's abortion regulations because Idaho is not a
party to the agreement between the Federal Government
and the hospitals that take Medicare funds. See Brief for
Petitioners in No. 23–726, pp. 50–51. As it explains, States
cannot be bound by terms that they never accepted, so it is
hard to see how a third party's agreement with the Federal
Government can deprive a State of the ability to enforce its
criminal laws. Accord, Talevski, 599 U. S., at 212 (Thomas,
J., dissenting) (“[E]ven those who held the broadest concep-
tion of the spending power recognized that it was only a
power to spend, not a power to impose binding requirements
with the force of federal law”).
The potential implications of permitting preemption here
are far-reaching. Under the Government's view, Congress
could apparently pay doctors to perform not only emergency
abortions but also third-trimester elective abortions or eu-
genic abortions. It could condition Medicare funds on hospi-
tals' offering assisted suicide even in the vast majority of
States that ban the practice. It could authorize the practice
of medicine by any doctor who accepts Medicare payments
even if he or she does not meet the State's licensing
requirements.
While the Government is not troubled by the potential
consequences of its preemption argument, Congress was sen-
sitive to state prerogatives. The Medicare Act, in which
EMTALA is situated, disclaims any construction that would
“authorize any Federal offcer or employee to exercise any
supervision or control over the practice of medicine or the
14
Only one state psychiatric hospital accepts Medicare funds, and it does
not have an emergency room. 2 App. 531.
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YLE v. UNITED STATES
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manner in which medical services are provided” in a particu-
lar
State. 42 U. S. C. § 1395. This disclaimer evidences a
desire to “minimize federal intrusion” into state healthcare
regulation. Massachusetts Medical Soc. v. Dukakis, 815
F. 2d 790, 791 (CA1 1987) (opinion of Breyer, J.). EMTALA's
narrow preemption clause also respects core state powers by
providing that the Act “do[es] not preempt any State or local
law requirement, except to the extent that the requirement
direc tly confl ic ts w ith a requirement of th is sec ti on. ”
§ 1395dd(f ). This phrasing signals that EMTALA's default
position is coexistence with state law.
In response to the Legislature's argument, the Govern-
ment claims that a handful of our cases have held that Spend-
ing Clause statutes can preempt the laws of non-consenting
States, but those cases do not begin to settle the question
at hand. Two are entirely inapposite.
15
And the remaining
cases simply upheld the Federal Government's ability to pre-
vent the use of federal money for purposes other than those
intended by Congress.
16
The Government has not identifed
any decision holding that a federal law enacted under the
Spending Clause preempts a state criminal law or public
health regulation.
For present purposes, it is not necessary to decide whether
the Legislature's theory is correct. At a minimum, however,
15
Coventry Health Care of Mo., Inc. v. Nevils, 581 U. S. 87, 95–99
(2017), held that Missouri's anti-subrogation law was preempted by the
Federal Employee Health Benefts Act with regard to contracts for health
benefts negotiated between the Federal Government and insurance carri-
ers. It did not present the question whether Spending Clause conditions
placed on private parties could preempt States from enforcing their crimi-
nal statutes against any of their residents—including parties that did not
contract with the Federal Government. And in Townsend v. Swank, 404
U. S. 282 (1971), the State itself was the recipient of the funds in question.
16
See Philpott v. Essex County Wel fare Bd., 409 U. S. 413, 415 (1973)
(attachment of Social Security benefts); Bennett v. Arkansas, 485 U. S.
395, 398 (1988) (per curiam) (same); Lawrence County v. Lead-Deadwood
School Dist. No. 40–1, 469 U. S. 256, 268 (1985) (use of federal payments
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Alito, J., dissenting
it provides yet another reason to be wary about interpreting
EMT
ALA to displace the core powers of a non-consenting
State without unmistakable clarity regarding the meaning of
the federal law.
***
In sum, the Government's new interpretation of EMTALA
is refuted by the statutory text, the context in which the law
was enacted, and the rules of interpretation that we apply
to Spending Clause legislation. We should reject the Gov-
ernment's interpretation and put that matter to rest.
17
III
Even if the Court is unwilling to decide the statutory in-
terpretation question, there is no excuse for vacating the
stay of the preliminary injunction. In order to obtain that
injunction, the Government was required to make a strong
17
Justice Sotomayor, Justice Kagan, and Justice Jackson endorse
the Government's interpretation of EMTALA but barely bother to explain
why they think the interpretation is correct. Justice Kagan's opinion,
which Justice Sotomayor and Justice Jackson join, argues that
“EMTALA unambiguously requires that a Medicare-funded hospital pro-
vide whatever medical treatment is necessary to stabilize a health emer-
gency” and in some cases this may require an abortion. Ante, at 329–
330 (concurring opinion). Justice Kagan conveniently fails to note that
EMTALA defnes the term “emergency medical condition” and that this
defnition includes any condition that is suffciently serious to “plac[e] . . .
the health of [a pregnant] woman or her unborn child . . . in serious jeop-
ardy.” § 1395dd(e)(1)(A)(i). Therefore, as I have already explained,
EMTALA demands that a covered hospital stabilize any suffciently seri-
ous threat to the health of an “unborn child.”
Not only is Justice Kagan's analysis of the statutory language faulty,
but she fails to say anything about the special rules of interpretation that
apply to Spending Clause measures or how Idaho can be bound by condi-
tions to which it has never agreed.
Justice Jackson’s opinion adds nothing to Justice Kagan's legal anal-
ysis, but she reads my opinion to suggest “that States have free rein to
nullify federal law.” Ante, at 344 (opinion concurring in part and dissent-
ing in part). Anyone who reads my opinion can see that it makes no such
suggestion but simply explains what the federal law in question means.
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showing that it was likely to prevail on the merits. See
Mun
af v. Geren, 553 U. S. 674, 690 (2008). And as I have
explained, its argument was almost certain to lose. That in
itself is suffcient to preclude continuation of the prelimi-
nary injunction.
Why then have six Justices voted to vacate the stay? The
per curiam itself provides no explanation. In separate opin-
ions, three of the six agree with the Government's interpre-
tation of EMTALA, see supra, at 359, n. 17, and that at least
is an explanation that would make sense if the premise (the
correctness of the Government's interpretation) were sound.
As for the remaining three, their only explanation is that
“the injunction will not stop Idaho from enforcing its law in
the vast majority of circumstances” and that therefore Idaho
cannot show that it will be irreparably harmed by allowing
the injunction to remain in place during the pendency of the
appeal. Ante, at 337 (Barrett, J., joined by Roberts, C. J.,
and Kavanaugh, J., concurring). That justifcation is pat-
ently unsound. “ `[A]ny time a State is enjoined by a court
from effectuating statutes enacted by representatives of its
people, it suffers a form of irreparable injury.' ” Maryland
v. King, 567 U. S. 1301, 1303 (2012) (Roberts, C. J., in cham-
bers). And in this case, Idaho's injury is not abstract. As
I will explain, it is very likely that the preliminary injunction
will lead to more abortions, including in at least some cases
where the fetus is viable. The State of Idaho wants to pre-
vent that; the preliminary injunction stands in its way. Isn't
that enough to constitute irreparable harm?
The Justices who have joined Justice Barrett's concur-
rence claim that the parties' briefs and oral arguments seem
to have narrowed the degree to which EMTALA, as inter-
preted by the Government, conficts with the Idaho law, ante,
at 335–338, but all the parties continue to insist that the laws
conflict. The Solicitor General argued that EMTALA's
focus on a pregnant woman's health is broader than Idaho's
life-of-the-mother exception. In forceful terms, she told us:
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“In Idaho, doctors have to shut their eyes to everything ex-
cept
death,” whereas under EMTALA, a physician is sup-
posed to think about serious threats to a pregnant woman's
health. Tr. of Oral Arg. 102. In light of this perceived con-
fict, the Solicitor General said it was “gravely mistaken” to
suggest that “there really isn't in operation a difference be-
tween” EMTALA and Idaho law. Id., at 101–102.
Idaho agreed that the Government's interpretation of
EMTALA conficts with state law. In particular, the State
worried that “the United States' novel theory” would “au-
thorize emergency-room doctors to perform abortions” for
mental-health reasons and would thus “turn emergency
rooms into federal abortion enclaves governed not by state
law but by subjective physician judgment.” Brief for Peti-
tioner in No. 23–727, p. 30; see also Tr. of Oral Arg. 45–46.
Thus, whatever narrowing may have occurred during
briefng and argument in this Court, both the Government
and the State of Idaho fervently maintain that it matters
whether the Idaho law is enforced. Do any Justices in the
majority seriously disagree? Do any of them think that the
parties, not to mention their armies of amici, are fghting
about nothing?
Three of the six Justices in the majority also agree that
there is a confict—and judging from their fery rhetoric, a
big one. See ante, at 328 (Kagan, J., joined by Sotomayor,
J., and by Jackson, J., as to Part II, concurring); ante, at
340–341 (Jackson, J., concurring in part and dissenting in
part). And they are correct to this extent: there is a real
confict.
A
I begin with the Government's argument that “there are
numerous conditions” that may affict a pregnant woman
“where a doctor's immediate concern is not death.” Tr. of
Oral Arg. 103. In those cases, the Government explains, a
doctor might be worried about serious risks to the woman's
“health.” Ibid. In the Government's telling, EMTALA re-
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quires hospitals to perform an abortion on demand in these
circumst
ances.
Idaho law says otherwise. An Idaho doctor may not per-
form an abortion unless the doctor “determine[s], in his good
faith medical judgment . . . , that the abortion [is] necessary
to prevent the death of the pregnant woman.” Idaho Code
Ann. § 18–622(2)(a)(i). And even then, the doctor must “at-
temp[t] to perform the abortion in the manner that . . . pro-
vide[s] the best opportunity for the unborn child to survive,”
unless doing so “would . . . pos[e] a greater risk of the death
of the pregnant woman.” § 622(2)(a)(ii).
These standards do not require a doctor to be “objec-
tive[ly] certai[n]” that the abortion is “ `necessary' to save
the woman's life.” Planned Parenthood, 171 Idaho, at 445,
522 P. 3d, at 1203 (emphasis deleted). Nor does Idaho law
require that the risk of death be particularly immediate.
Ibid. Indeed, the Idaho Supreme Court has explained that
the law “leaves wide room for the physician's `good faith
medical judgment' on whether [an] abortion was `necessary.' ”
Ibid.; accord, id., at 446, 522 P. 3d, at 1204 (noting that the
Act “imposes a subjective standard based on the individual
physician's good faith medical judgment”). And any lati-
tude, it said, “ `operates for the beneft, not the disadvantage,
of the pregnant woman.' ” Id., at 445–446, 522 P. 3d, at
1203–1204. Even so, Idaho's law is focused on “death,” and
a doctor must be able to say in “good faith” that he or she
was acting to preserve the woman's life, not simply her
health. Idaho Code Ann. § 18–622(2)(a)(i).
These different considerations—health versus life—may
lead to different outcomes. For instance, consider the situa-
tion of a woman who experiences a condition that was dis-
cussed in the briefs and at argument: preterm premature
rupture of membranes (PPROM), which occurs when a wom-
an's amniotic sac breaks before the 37th week of pregnancy.
1 App. 295. The Members of this Court are not physicians
and should therefore be wary about expressing conclusions
about medical issues. But guidance provided by prominent

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363
Alito, J., dissenting
medical institutions is suffcient to show how Idaho law and
EMT
ALA, as interpreted by the Government, may confict
in such cases.
If a woman experiences PPROM between the 34th and
37th week of pregnancy and does not go into labor, her phy-
sician is likely to recommend that labor be induced.
18
In
that situation, it does not appear that the risk of confict is
high.
On the other hand, when PPROM occurs earlier than that,
the chances of confict are greatly increased. If PPROM oc-
curs before the 34th week and the woman's pregnancy con-
tinues, she may experience conditions such as an infection of
the amniotic fuid, infammation of the uterine lining, hemor-
rhage, or sepsis.
19
However, life-threatening complications
are not inevitable, and according to the PPROM Foundation,
death is “extremely rare.”
20
A physician may try to delay
labor by putting the woman on bed rest and administering
steroids to help the baby's lungs grow and antibiotics to pre-
vent infection.
21
18
See, e. g., 1 App. 306; Mount Sinai, Premature Rupture of Membranes,
https://www.mountsi nai.org/ hea lth-library/specia l-topic/premature-
r upture-of-membranes#:-:textSometimes%20the%20membranes%20-
break%20before,rupture%20of%20-membranes%20 (June 21, 2024).
19
One study found that 14% of women with PPROM before the point of
viability developed one or more of these complications, and approximately
1% to 5% developed life-threatening sepsis. 1 App. 298. A review of
studies after 1993 indicated that the most common maternal morbidity is
infection of the amniotic fuid, “with approximately 37% of women develop-
ing this complication.” T. Waters & B. Mercer, The Management of Pre-
term Premature Rupture of Membranes Near the Limit of Fetal Viability,
201 Am. J. Obstetrics & Gynecology 230, 231 (Sept. 2009) (A JOG); see also
Brief for Physicians for Reproductive Health as Amicus Curiae 18.
20
PPROM Foundati on, PPROM Fac ts, https://www.aapprom.org/
community/ppromfacts (June 21, 2024) (PPROM Facts).
21
Ibid.; see also Children's Hospital of Philadelphia, Premature Rupture
of Membranes (PROM)/ Preter m Premature Rupture of Membranes
(PPROM), https://www.chop.edu/conditions-diseases/premature-rupture-
membranes-prompreterm-premature-rupture-membranes-pprom (June 21,
2024).
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When PPROM occurs before the 24th week of pregnancy,
the
potential for confict appears to be even higher. But in
that situation, it may still be possible to manage the situation
until the baby can be delivered,
22
and there is a chance of a
good outcome for both the mother and child, although studies
have yielded different results.
23
Thus, when PPROM occurs
before the 34th week of pregnancy, there is a risk to the
health of both the woman and her unborn child.
In these situations, the Defense of Life Act requires doc-
tors to consider whether performing an abortion is necessary
to prevent the woman's death. Because this is a “subjec-
tive” standard, Planned Parenthood, 171 Idaho, at 446, 522
P. 3d, at 1204, different doctors may reach different conclu-
sions about when PPROM endangers the woman's life. At
least some may conclude in some cases of PPROM occurring
before the 34th week of pregnancy that the woman's life is
not endangered since she may never develop a serious infec-
tion, let alone life-threatening sepsis or any other potentially
22
See, e. g., S. Dayal & P. Hong, Premature Rupture of Membranes (July
17, 2023), https://www.ncbi.nlm.nih.gov/ books/NBK532888.
23
“A recent study reports a 90% survival rate for infants exposed to
prolonged PPROM occurring between 18–24 weeks who were delivered
after 24 weeks.” PPROM Facts (citing J. Brumbaugh et al., Neonatal
Survival After Prolonged Preterm Premature Rupture of Membranes Be-
fore 24 Weeks of Gestation, 124 Obstetrics & Gynecology 992 (2014); see
also A. Özel et al., Outcomes of Pregnancies Complicated by Preterm Pre-
mature Rupture of Membranes Before and After 24 Gestational Weeks: A
Retrospective Analysis, 33 J. Clinical Obstetrics & Gynecology 228, 231
(Nov. 2023) (reporting that one-third of unborn children survived PPROM
before viability at a hospital between 2018–2020); E. Lorthe et al., Preterm
Premature Rupture of Membranes and 22–25 Weeks' Gestation, 219 A JOG
298.e1, 298.e5–298.e6 (Sept. 2018) (determining that, when PPROM oc-
curred between weeks 22 and 25, about half of the children survived, and
roughly three-quarters of the survivors did not have severe morbidities);
P. Wagner et al., Outcome of Pregnancies With Spontaneous PPROM Be-
fore 24+0 Weeks' Gestation (2016) (reporting that “[a]bout half ” of fetuses
in PPROM pregnancies that make it to viability “will be discharged alive
without major complications”).
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365
Alito, J., dissenting
fatal condition, if she receives proper treatment. See 1 App.
306
–307. Rather, those doctors may believe that Idaho law
requires them to try to delay delivery long enough to save
the child's life, unless PPROM becomes suffciently “severe”
to cause “infection and serious risk of sepsis.” See, e. g., 2
id., at 547.
24
Accordi ng to the Gover nment's exper ts, however,
EMTALA requires a hospital to perform an abortion at the
woman's request whenever PPROM is diagnosed, even if the
woman has not yet developed an infection or any other
health complications. That is because, they assert, it can
be “reasonably expected” that, in “the absence of immediate
medical attention,” PPROM would “plac[e] the health” of the
pregnant woman “in serious jeopardy” or cause “serious dys-
function” to her reproductive organs. §§ 1395dd(c)(1)(A)(ii),
(e)(1)(A)(i) and (iii); see, e. g., 2 App. 594 (“Providing stabiliz-
ing treatment in the form of termination of pregnancy at
the point of diagnosis would be an appropriate means to
preserve the patient's reproductive organs at that time”).
Thus, in PPROM cases, there may be an important confict
between what Idaho law permits and what EMTALA, as in-
terpreted by the Government, demands. And the same may
be true with respect to other conditions that a pregnant
woman may experience.
This gap between the Idaho law and the Government's in-
terpretation of EMTALA matters. Idaho has always per-
24
It has been estimated that PPROM occurs in about 2% of all pregnan-
cies involving a single fetus and in 7% of all pregnancies involving twins.
See PPROM Facts. It is reported that in 2022, there were 22,391 live
births in Idaho. March of Dimes, Fertility Rate: Idaho, 2012–2022, https://
www.marchofdimes.org/peristats/data?reg=99&top=2&stop=1&lev=slev=
4&obj=1&sreg=16 (Jan. 2024). These statistics suggest that PPROM may
have occurred in as many as 500 cases. In some of these cases, the fetus
may not have been viable, and in some, the pregnant woman may not have
chosen to have an abortion even if the law allowed. Nevertheless, it
would not be surprising if the Idaho law, if allowed to be enforced, would
result in fewer abortions and more live births.
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YLE v. UNITED STATES
Alito, J., dissenting
mitted abortions that are necessary to preserve the life of a
preg
nant woman, but it has not allowed abortions for other
non-life-threatening medical conditions. Planned Parent-
hood, 171 Idaho, at 391–394, 522 P. 3d, at 1149–1152 (summariz-
ing Idaho's historical restrictions); see also Dobbs, 597 U. S., at
302–330 (appendixes to opinion of the Court) (compiling other
state statutes with identical exceptions). This balance re-
fects Idaho's judgment about a diffcult and important moral
question. See Planned Parenthood, 171 Idaho, at 437–438,
522 P. 3d, at 1195–1196. By requiring Idaho hospitals to
strike a different balance, the preliminary injunction thwarts
the will of the people of Idaho as expressed in law by their
elected representatives.
B
I now turn to Idaho's claim that the Government's reading
of EMTALA would authorize abortions for mental-health
reasons. My colleagues dismiss this concern because at ar-
gument, the Solicitor General “emphatically disavowed the
notion that an abortion is ever required as stabilizing treat-
ment for mental health conditions.” Ante, at 335 (Barrett,
J., concurring). But it is hard to see how the Government
could reach that conclusion. At oral argument, the Solicitor
General conceded that the term “health” in EMTALA in-
cludes mental health, Tr. of Oral Arg. 77–78, and if that is
so, it is not diffcult to imagine a situation in which the Gov-
ernment's interpretation of EMTALA could require an
abortion.
Suppose, for example, that a woman in the 10th week of
gestation experiences serious depression due to her preg-
nancy. If she asks emergency medical professionals for
treatment, her medical care providers might conclude that
her continued pregnancy could “reasonably be expected” to
seriously jeopardize the woman's mental health. § 1395dd(e)
(1)(A). Under the Government's reading of EMTALA, the
woman would then have the right to “make an informed deci-
sion” about the treatment she received. Brief for United
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367
Alito, J., dissenting
States 41. If the woman preferred to abort rather than
manage
her depression alongside her pregnancy, it is not ap-
parent why the Government's reading of EMTALA would
not require that abortion.
We have seen where a rule permitting abortions to protect
the psychological health of pregnant women may lead. In
Roe, the Court held that a woman had the right to obtain a
post-viability abortion that was deemed “necessary, in appro-
priate medical judgment, for the preservation of the life or
health of the mother.” Roe v. Wade, 410 U. S. 113, 165
(1973). In the companion case Doe v. Bolton, 410 U. S. 179
(1973), the Court wrote that a doctor, in judging whether an
abortion was needed to preserve a pregnant woman's health,
could consider “all factors—physical, emotional, psychologi-
cal, familial, and the woman's age—relevant to the well-being
of the patient.” Id., at 192. That decision was viewed by
many as essentially preventing States from restricting post-
viability abortions
25
As Harvard Law School Professor
Mary Ann Glendon put it: “[W]hen Roe is read with Doe,
third-trimester restrictions are effectively ruled out as
well—for Roe's dictum that such restrictions might be per-
missible if they did not interfere with the mother's health
was negated by Doe's defnition of `health' as `well-being.' ”
The Women of Roe v. Wade (2003).
The Solicitor General tried to explain why the Govern-
ment's interpretation would not lead down this path, but her
explanation is hard to understand. She said that mental-
health emergencies “could never lead to pregnancy termina-
25
See, e. g., J. Ely, The Wages of Crying Wolf: A Comment on Roe v.
Wade, 82 Yale L. J. 920, 921, and n. 19 (1973); J. Dellapenna, Dispelling the
Myths of Abortion History 695 (2006) (“Blackmun's defnition of women's
`health' in Doe as encompassing anything affecting her `well-being ' virtu-
ally precluded any possible regulation of abortion during the entire
months of pregnancy”); R. Ponnuru, The Party of Death 10 (2006) (“Roe
required that any ban on late-term abortion include an exception allowing
abortion to protect a woman's health; Doe defned that exception so
broadly that it swallowed up any possibility of a ban”).
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YLE v. UNITED STATES
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tion” because abortion “is not the accepted standard of prac-
tice
to treat any mental health emergency.” Tr. of Oral Arg.
77–78; accord, Brief for United States 26, n. 5.
That assertion appears to be inconsistent with the position
taken by prominent medical associations that endorse abor-
tion for mental-health reasons as an accepted standard of
practice. See, e. g., American Psychiatric Association, Po-
sition Statement on Abortion and Women's Reproductive
Healthcare Rights (Mar. 2023) (“Freedom to act to interrupt
pregnancy must be considered a mental health imperative”);
American Psychological Association, Resolution Affrming
and Building on APA's History of Support for Reproductive
Rights (Feb. 2022).
For these reasons, there is a real potential for confict be-
tween the Idaho law and the Government's interpretation of
EMTALA, and in my judgment, the Court seriously errs by
vacating the stay we issued earlier this year.
***
Today's decision is puzzling. Having taken the unusual
step of granting certiorari before Idaho's appeal could be
heard by the Ninth Circuit, the Court decides it does not
want to tackle this case after all and thus returns the appeal
to the Ninth Circuit, which will have to decide the issue that
this Court now ducks. What is more, the Court vacates the
stay it issued earlier this year even though the majority fails
to provide any facially plausible explanation for doing so.
I cannot endorse this turn of events and therefore respect-
fully dissent.
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Reporter’s Note
The attached opinion has been revised to refect the usual publication
and citation style of the United States Reports. The revised pagination
makes available the offcial United States Reports citation in advance of
publication. The syllabus has been prepared by the Reporter of Decisions
for the convenience of the reader and constitutes no part of the opinion of
the Court. A list of counsel who argued or fled briefs in this case, and
who were members of the bar of this Court at the time this case was
argued, has been inserted following the syllabus. Other revisions may
include adjustments to formatting, captions, citation form, and any errant
punctuation. The following additional edits were made:
p. 328, line 13 from bottom: “preterm premature rupture of membranes“
is inserted before PPROM
p. 333, line 6: “the” is deleted
p. 341, line 12 from bottom: “the” is deleted
p. 343, line 10 from bottom: “this case presents” is replaced with “these
cases present”
p. 352, line 9: “the” is inserted after “of ”
p. 362, line 6 from bottom: “prelabor” is replaced with “premature”
p. 366, line 6: “(appendixes to opinion of the Court)” is inserted after “330”