23-726 6jgm

(Slip Opinion) Cite as: 603 U. S.
____ (2024) 1
Per Curiam
NOTICE: This opinion is subject to formal revision before publication in the

United States Reports. Readers are requested to notify the Reporter of
Decisions, Supreme Court of the United States, Washington, D. C. 20543,
pio@supremecourt.gov, of any typographical or other formal errors.
SUPREME COURT OF THE UNITED STATES

_________________
Nos. 23–726 and 23–727

_________________
MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF

REPRESENTATIVES, ET AL., PETITIONERS
23–726 v.
UNITED STATES
IDAHO, PETITIONER
23–727 v.
UNITED STATES
ON WRITS OF CERTIORARI TO THE UNITED STATES COURT OF
APPEALS FOR THE NINTH CIRCUIT
[June 27, 2024]
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.
Cite as: 603 U. S. ____ (2024) 1
KAGAN, J., concurring

_________________
Nos. 23–726 and 23–727

_________________

23–726 v.
UNITED STATES
IDAHO, PETITIONER
23–727 v.
UNITED STATES
[June 27, 2024]
JUSTICE KAGAN, with whom JUSTICE SOTOMAYOR joins,

and with whom JUSTICE JACKSON joins as to Part II, con-
curring.
An Idaho law prohibits abortions unless necessary to pre-
vent a pregnant woman’s death; the law makes no excep-
tion for abortions necessary to prevent grave harms to the
woman’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
to provide essential care to patients experiencing medical
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 per-
forming an abortion needed to prevent serious health
harms.
The District Court, believing the Government was likely
2 MOYLE v. UNITED STATES
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 obtain abortions in medical 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 filed 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
immediate. 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 justified, ei-
ther 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
will prevent Idaho from enforcing its abortion ban when the
termination of a pregnancy is needed to prevent serious
harms to a woman’s health.
I
EMTALA requires hospitals to provide abortions that
Idaho’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 conflict about the treat-
ment of pregnant women facing health emergencies.
Cite as: 603 U. S. ____ (2024) 3
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
“necessary 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 consequences, including loss of fertility. In that sit-
uation, 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 PPROM, the serious risk she faces may not be of
death but of damage to her uterus, preventing her from
having children in the future. See 2 App. 594; see also id.,
at 615–616 (similar for pre-eclampsia). Idaho has never
suggested that its law would allow an abortion in those cir-
cumstances. 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 med-
ically 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 differ-
ence between the life-threatening conditions Idaho will al-
low hospitals to treat and the health-threatening conditions
it will not, despite EMTALA’s command.
Given that conflict, I agree with the Court’s decision to-
day to step back from its early intervention in this dispute.
In the first stage of this suit, the District Court considered
both sides’ medical evidence and entered a preliminary in-
junction 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 Dis-
trict Court revisited its findings, and reaffirmed its entry of
the injunction. 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
final judgment. 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 sup-
port 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.
Today’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 4–15. That view
has no basis in the statute.
EMTALA unambiguously requires that a Medicare-
funded hospital provide whatever medical treatment is nec-
essary to stabilize a health emergency—and an abortion, in
rare situations, is such a treatment. The statutory obliga-
tion 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 “stabilize” the condition. §1395dd(b)(1)(A). That
means offering the medical treatment necessary to ensure
that “no material deterioration of the condition” is likely to
Cite as: 603 U. S. ____ (2024) 5
occur. §1395dd(e)(3)(A). The statute does not list particu-

lar treatments—for example, defibrillation, blood transfu-
sion, or mechanical ventilation. What it instead requires is
the treatment that is medically appropriate to stabilize the
patient. And when a pregnancy goes terribly wrong, that
treatment may be an abortion. Termination of the preg-
nancy (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 12; see post, at 5. Neither,
as just noted, does EMTALA mention any other treatment.
The statute simply requires the hospital to offer the treat-
ment 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 provisions JUSTICE ALITO cites concern the treat-
ment of women in labor (including all those with healthy
pregnancies). 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 instead are experiencing a different pregnancy-
related condition. The fourth provision (included within the
definition of “emergency medical condition”) specifies that
a hospital must treat a condition that “plac[es] the health
of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeop-
ardy.” §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
treatment if her fetus is in peril. It does not displace the
hospital’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.*
Because the Idaho law conflicts 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 guaran-
tees.
——————
*The amendment’s history confirms 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 fix that
problem, very large bipartisan majorities in both the House and the Sen-
ate elected to broaden the provision, entitling a woman to demand care
for her unborn child as well as herself. See 103 Stat. 2248; 135 Cong.
Rec. 31431 (1989); id., at 31127; id., at 24605; id., at 23393. The amend-
ment 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.
Cite as: 603 U. S. ____ (2024) 1
BARRETT, J., concurring

_________________
Nos. 23–726 and 23–727

_________________

23–726 v.
UNITED STATES
IDAHO, PETITIONER
23–727 v.
UNITED STATES
[June 27, 2024]
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 La-
bor Act (EMTALA) preempts a provision of Idaho law that
prohibits abortions except when necessary to save the 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 obli-
gation to comply with EMTALA.” Centers for Medicare &
Medicaid Services, Reinforcement of EMTALA Obligations
Specific 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 nec-

essary to resolve” a pregnant woman’s emergency medical
condition, they “must provide that treatment.” Id., at 1
(italics and emphasis deleted). Any contrary state law, the
guidance continues, is “preempted.” Ibid. (italics and em-
phasis 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 affirmative defense that “the abortion was nec-
essary 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 extent it conflicts with EMTALA.” 1 App. 5. EMTALA,
the United States argued, requires physicians to perform
abortions under certain circumstances that Idaho’s Act
would forbid.
After holding an evidentiary hearing, the District Court
identified a conflict 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 prevent death” exception is only an affirma-
tive defense. Id., at 1109–1114. The Government’s wit-
nesses, whose testimony the court credited, made similar
assumptions. Id., at 1104–1105. They claimed that the Act
might prohibit abortions as treatment for conditions includ-
ing severe heart failure, pre-eclampsia, preterm premature
rupture of the membranes (PPROM), sepsis, and placental
abruption, because a physician could not know, “with cer-
tainty,” 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.
Cite as: 603 U. S. ____ (2024) 3
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 im-
mediacy, before the abortion can be ‘necessary’ to save the
woman’s life.” Planned Parenthood Great Nw. v. State, 171
Idaho 374, 445, 522 P. 3d 1132, 1203 (2023). And “treating
an ectopic pregnancy, by removing the fetus,” the court con-
cluded, 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 Legislature later
amended the definition 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” affirmative 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 va-
cated the panel’s stay, declined to stay the injunction, and
scheduled oral argument on the merits, 82 F. 4th 1296
(2023). We granted Idaho’s and the Legislature’s applica-
tions to stay the District Court’s injunction pending appeal,
treated the applications as petitions for a writ of certiorari
before judgment, and granted the petitions. 601 U. S. ___
(2024).
II
Before the Ninth Circuit had the opportunity to review
the District Court’s preliminary injunction, this Court
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, briefing and oral argument
have “shed more light on this case than in the nature of

things was afforded at the time” the Court considered peti-
tioners’ emergency applications. Belcher v. Stengel, 429
U. S. 118, 119 (1976) (per curiam) (dismissed as improvi-
dently 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 disa-
gree about whether EMTALA, as a statute enacted under
Congress’s spending power and that operates on private
parties, can preempt state law (an issue aired for the first
time in this Court). In my judgment, it would be imprudent
to answer these important questions now. Since this suit
began in the District Court, Idaho law has significantly
changed—twice. And since we granted certiorari, the par-
ties’ litigating positions have rendered the scope of the dis-
pute 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 mental health. Stay Reply Brief in No.
23A470, p. 6. On that broad reading, Idaho projected that
emergency rooms would function as “federal abortion en-
claves 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 rel-
evant 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
Cite as: 603 U. S. ____ (2024) 5
need for “immediate determination in this Court,” Supreme

Court Rule 11.
At the merits stage, however, the United States dis-
claimed these interpretations of EMTALA. First, it em-
phatically disavowed the notion that an abortion is ever re-
quired 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 con-
ditions posing serious jeopardy to a woman’s physical
health, the Government’s reading of EMTALA does not gut
Idaho’s Act.* Second, the United States clarified that fed-
eral conscience protections, for both hospitals and individ-
ual physicians, apply in the EMTALA context. Tr. of Oral
Arg. 87–89. That is another critical point: It alleviates
Idaho’s concern that the Government’s interpretation of
EMTALA would strip healthcare providers of conscience
protections.
Narrowing happened from the other direction too. The
United States identified PPROM, placental abruption, pre-
eclampsia, and eclampsia as conditions for which EMTALA
requires an emergency abortion to be available. (The same
conditions that the Government’s witnesses identified—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;
——————
*The United States also clarified that if pregnancy seriously jeopard-
izes the woman’s health postviability, EMTALA requires delivery, not
abortion. Brief for United States 10; Tr. of Oral Arg. 75. And it empha-
sized that EMTALA requires abortion only in an “emergency acute med-
ical situation,” where a woman’s health is in jeopardy if she does not re-
ceive an abortion “then and there.” Tr. of Oral Arg. 79–80. These two
temporal points also narrow the scope of EMTALA’s potential conflict
with Idaho’s Act.
Tr. of Oral Arg. 23. The same is true for the conditions iden-
tified 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 res-
olution of the question presented. That was a miscalcula-
tion in these cases, because the parties’ positions are still
evolving. The United States has clarified that EMTALA’s
reach is far more modest than it appeared when we granted
certiorari 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 sufficient op-
portunity to catch up. Cf. The Monrosa v. Carbon Black
Export, Inc., 359 U. S. 180, 184 (1959) (“Examination of a
case on the merits, on oral argument, may bring into ‘proper
focus’ a consideration 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 difficult and con-
sequential 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 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 first view”); New York v. Uplinger,
467 U. S. 246, 251 (1984) (Stevens, J., concurring) (dismiss-
ing as improvidently granted where “constitutional ques-
tions” would otherwise be considered “premature[ly]”). The
lower courts should address the Spending Clause issue in
the first instance.
Cite as: 603 U. S. ____ (2024) 7
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 pro-
ceedings 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 injunction re-
mained in effect. Nken, 556 U. S., at 434. The Court’s grant
of a stay reflected, among other things, its determination
that Idaho had satisfied that burden. Now, based on the
parties’ representations, it appears that the injunction 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 “serious
jeopardy” to the woman’s health, 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 irrep-
arable 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 prelim-
inary injunction. Contrary to Idaho’s concerns at the stay
stage, the Government’s interpretation of EMTALA does
not purport to transform emergency rooms into “federal
abortion enclaves governed not by state law, but by physi-
cian 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 de-
prive 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.
Cite as: 603 U. S. ____ (2024) 1
Opinion of JACKSON, J.

_________________
Nos. 23–726 and 23–727

_________________

23–726 v.
UNITED STATES
IDAHO, PETITIONER
23–727 v.
UNITED STATES
[June 27, 2024]
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 pa-
tient and, therefore, comply with EMTALA. But Idaho law
prohibits 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 conflict 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 pre-

vent a patient’s death, that doctor could no longer provide
abortion care that she viewed as reasonably necessary to
keep a patient from losing her uterus, going into organ fail-
ure, or avoiding any number of other serious health risks.
Compare §18–622(a)(i) with 42 U. S. C. §1395dd(e)(1)(A).
As a practical matter, this Court’s intervention meant that
Idaho physicians were forced to step back and watch as
their patients suffered, or arrange for their patients to be
airlifted out of Idaho.
This months-long catastrophe was completely unneces-
sary. 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 re-
quires doctors to provide medically necessary stabilizing
abortions in limited situations. See ante, at 4–6 (concurring
opinion). To the extent that Idaho law conflicts 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 first place. I dissent in part be-
cause, in my view, the Court is wrong to dismiss these cases
as improvidently 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 mech-
anism 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 justified 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
Cite as: 603 U. S. ____ (2024) 3
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 trans-
ferred out of State to receive the care they need. Brief for
St. Luke’s Health System as Amicus Curiae 14–15.
If anything, the need for a clear answer to the Supremacy
Clause question has only increased in the intervening
months. Other States across the country have enacted leg-
islation that gives rise to the same sort of legal conflict 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, affirming a permanent injunction that prevents the
United States from enforcing EMTALA’s requirements
with respect to stabilizing emergency abortions prohibited
by Texas law. See Texas v. Becerra, 89 F. 4th 529, 533
(2024). The United States has already petitioned for certi-
orari 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 re-
view. The Government continues to maintain (correctly, in
my view) that EMTALA’s plain text requires hospitals to
provide 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 Government 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-
flict between the state and federal law—as they are actually
being interpreted and applied on the ground—is both sub-
stantial and significant. Ante, at 4–6. It is a clash that
clearly exists despite the attempt by Idaho’s counsel to
muddy the waters concerning the scope of the State’s law.
The textual conflict 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 de-
terioration 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 abor-
tion is “necessary to prevent the [patient’s] death,” Idaho
Code Ann. §18–622(2)(a)(i)—conflicts 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 the membranes
Cite as: 603 U. S. ____ (2024) 5
(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
rhetorical maneuver as a material change that (also con-
veniently) reduces the conflict between state and federal
law to the point that a ruling from this Court is no longer
warranted. See ante, at 6–7 (BARRETT, J., concurring). But
it is both legally and factually implausible to say that
Idaho’s current litigating position actually mitigates the
conflict between that State’s law and EMTALA.
The conflict between state and federal law still exists—in
real life. Idaho cannot credibly maintain that its law al-
ways permits abortions in cases of PPROM or pre-eclamp-
sia such that its mandate never conflicts with federal law.
The same medical condition can present with different risks
in different patients. See, e.g., Brief for Physicians for Re-
productive Health as Amicus Curiae 10–11; Brief for Physi-
cians for Human Rights as Amicus Curiae 11–19. And, of-
ten, a doctor 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 dif-
ferent legal thresholds for action under state and federal
law—not to mention the severe criminal penalties for a mis-
calculation—would surely be cowed into not providing abor-
tion care that medical standards warrant and federal law
requires. Do not take my word for this; it is already hap-
pening.* So it is strange, to say the least, that this Court
——————
*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
would shirk its duty to resolve a pressing legal issue on the

basis of representations that defy medical realities.
In any event, the representations Idaho’s counsel made
during oral argument and in the State’s briefs filed in this
Court are not a definitive 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 Northwest v. State, 171 Idaho 374, 445–
446, 522 P. 3d 1132, 1203–1204 (2023). And that is to say
nothing of local prosecutors, who may not be aware of (or
care about) Idaho’s newfound 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) (with-
holding funding from local governments if their officials de-
cline to enforce Idaho felony laws, which include these fel-
ony 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 officials in Idaho have
targeted physicians). Still, some of my colleagues latch onto
the bald representations of Idaho’s counsel, using them as
an escape hatch that justifies 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 distorted this litigation process. We
permitted Idaho’s law to go into effect by staying the Dis-
trict Court’s injunction in the first place, then allowed this
matter to sit on our merits docket for five 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
——————
for Amanda Zurawski et al. as Amici Curiae 29–30 (same); Brief for Phy-
sicians for Human Rights as Amicus Curiae 12–17 (same).
Cite as: 603 U. S. ____ (2024) 7
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 this case presents.
We have granted certiorari and heard argument. We
have had ample opportunity to consider the issues. The
parties were well represented on both sides, and dozens of
amici have weighed in. What is more, the necessary legal
reasoning is straightforward, and the answer to the ques-
tion presented is—or at least should be—quite clear: Idaho
law prohibits 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) (“[I]t has long been settled that state laws
that conflict with federal laws are ‘without effect’ ” (quoting
Maryland v. Louisiana, 451 U. S. 725, 746 (1981))). There
is simply no good reason not to resolve this conflict now.
* * *
Despite the clarity of the legal issue and the dire need for
an answer from this Court, today six Justices refuse to rec-
ognize the rights that EMTALA protects. See ante, at 4–7
(BARRETT, J., concurring); post, at 4–11 (ALITO, J., dissent-
ing). The majority opts, instead, to dismiss 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 11–14 (ALITO, J., dissenting). And three
more decline to disagree with those dissenters on the mer-
its. See ante, at 4–7 (BARRETT, J., concurring). The latter
group offers only murmurs that “petitioners have raised a
difficult and consequential argument” about Congress’s au-
thority under the Spending Clause. Ante, at 6 (BARRETT, J.,
concurring). So, as of today, the Court has not adopted
Idaho’s farfetched theories—but it has not rejected them ei-
ther.
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 filed with
us after the Fifth Circuit enabled Texas’s flouting 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 comparatively more convenient point in time? Or
maybe we will keep punting on this issue altogether, allow-
ing chaos to reign wherever lower courts enable States to
flagrantly undercut federal law, facilitating the suffering of
people in need of urgent medical treatment.
After today, there will be a few months—maybe a few
years—during which doctors may no longer need to airlift
pregnant patients out of Idaho. As JUSTICE KAGAN empha-
sizes, portions of Idaho’s law will be preliminarily enjoined
(at least for now). Ante, at 2, 4. But having not heard from
this Court on the ultimate pre-emption issue, Idaho’s doc-
tors will still have to decide whether to provide emergency
medical care in the midst of highly charged legal circum-
stances with no guarantee that this fragile detente over the
State’s categorical prohibitions will be maintained. Cf.
ante, at 8 (BARRETT, J., concurring) (“Even with the prelim-
inary 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
requires, pregnant patients in Idaho, Texas, and elsewhere
will be paying the price. Because we owe them—and the
Nation—an answer to the straightforward pre-emption
question presented in these cases, I respectfully dissent.
Cite as: 603 U. S. ____ (2024) 1
ALITO, J., dissenting

_________________
Nos. 23–726 and 23–727

_________________

23–726 v.
UNITED STATES
IDAHO, PETITIONER
23–727 v.
UNITED STATES
[June 27, 2024]
JUSTICE ALITO, with whom JUSTICE THOMAS joins, and

with whom JUSTICE GORSUCH joins as to Parts I and II, dis-
senting.
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 partici-
pating in Medicare to “scree[n]” and “stabilize” “any indi-
vidual” who comes to an emergency room with an “emer-
gency medical condition” that jeopardizes the patient’s
“health.” §§1395dd(a), (b)(1)(A), (e)(1)(A). And if the pa-
tient 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

abortions. 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 permits 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 find ways to
limit Dobbs’s reach. Protecting Access to Reproductive
Healthcare 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 hospitals—that is, the vast majority of hospitals1—
must perform abortions on request when the “health” of a
pregnant woman is in serious jeopardy. §1395dd(e)(1)(A)(i).
In the Government’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 Specific to
Patients Who Are Pregnant or Are Experiencing Pregnancy
Loss 1 (QSO–22–22–Hospitals, July 11, 2022). The Govern-
ment sued Idaho on this preemption theory and obtained a
preliminary injunction against enforcement of the state law
“to the extent it conflicts with EMTALA.” 623 F. Supp. 3d
1097, 1117 (Idaho 2022).
The Government’s preemption theory is plainly unsound.
Far from requiring hospitals to perform abortions,
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
——————
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 Pay-
ments Dependent on Medicare or Medicaid (Mar. 2024).
Cite as: 603 U. S. ____ (2024) 3
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 at-
tached to the receipt of federal funds must be unambiguous.
Arlington Central School Dist. Bd. of Ed. v. Murphy, 548
U. S. 291, 296 (2006); Pennhurst State School and Hospital
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 flaws in the Government’s theory and
Idaho’s “strong” likelihood of success, this Court stayed the
preliminary 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 dismisses
the writ and, what is worse, vacates the stay.
This about-face is baffling. 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
question of statutory interpretation. It is squarely pre-
sented 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 promi-
nent medical organizations. Altogether, we have more than
1,300 pages of briefing to assist us, and we heard nearly two
hours of argument. Everything there is to say about the
statutory interpretation question has probably been said
many times over. That question is as ripe for decision as it
ever will be. Apparently, the Court has simply lost the will
to decide the easy but emotional and highly politicized ques-
tion 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
hospitals 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
without regard to the individual’s ability to pay.
§§1395dd(a), (h). The purpose of this screening is to deter-
mine whether the individual has an “emergency medical
condition,” which EMTALA defines as follows:
“a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain)
such that the absence of immediate medical attention
could reasonably be expected to result in—
“(i) placing the health of the individual (or, with re-
spect to a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy,
“(ii) serious impairment to bodily functions, or
“(iii) serious dysfunction of any bodily organ or
Cite as: 603 U. S. ____ (2024) 5
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 qualified
personnel for the treatment” as long as the transfer would
effect 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,” subsec-
tion (e)(1) defines an emergency medical condition as one
that is sufficiently 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 hospital
identifies an emergency medical condition threatening the
child, it must “stabilize” that condition to ensure that the
child’s health does not remain in “jeopardy.”
§§1395dd(b)(1)(A), (e)(1)(A)(i). It goes without saying that
aborting an “unborn child” does not protect it from jeopardy.
Similarly, if a hospital wants to transfer a pregnant
woman to another facility, it may not do so unless, among
other things, a physician certifies directly or through an in-
termediary that the medical benefits of transfer outweigh
——————
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.
any “increased risks” to the woman “and, in the case of la-

bor, to the unborn child.” §§1395dd(c)(1)(A)(ii), (e)(1)(B).
Thus, regardless 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 unsuccess-
fully—to get around this language. First, the Government
argues that EMTALA’s repeated use of the term “individ-
ual,” coupled with the Dictionary Act’s definition 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 flat 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 ref-
erences 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 filing suit.7 Many references concern transfer to another
facility,8 and when a pregnant woman is transferred, her
“unborn child” obviously goes with her. Another reference
concerns a woman’s “emergency medical condition,” which,
as noted, includes conditions that jeopardize her “unborn
——————
3 The Dictionary Act defines 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 defi-
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 support
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).
Cite as: 603 U. S. ____ (2024) 7
child.”9 And some references expressly mention both the

“individual” and “the unborn child.”10 No use of the term
“individual” supports the Government’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 fol-
low that this person may demand to be sworn in as Presi-
dent.
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 le-
gally be used in this country. Cf. 21 U. S. C. §360bbb–0a
(granting terminal patients the right to try experimental
drugs). Likewise here, a woman’s right to withhold consent
to treatment 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 abor-
tions.
——————
9 §1395dd(e)(1)(A)(i).
10 §§1395dd(c)(1)(A)(ii) and (2)(A), (e)(1)(A)(i).
B
For those who find it appropriate to look beyond the stat-
utory 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(I), pt. 1, p. 27
(1985); K. Treiger, Preventing Patient Dumping: Sharpen-
ing the COBRA’s Fangs, 61 N. Y. U. L. Rev. 1186, 1188
(1986). And none of many briefs submitted in this suit has
found any suggestion in the proceedings leading up to
EMTALA’s passage 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 Congress, including the support of Members such
as Representative 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 enacted and amended—the Hyde
Amendment contained only one exception: for abortions
necessary 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
——————
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.
Cite as: 603 U. S. ____ (2024) 9
abortions that the Government says EMTALA mandates.

It would have been strange indeed if a Congress that re-
peatedly sought to prevent federal funding of abortions sim-
ultaneously enacted a law that, as interpreted by the Gov-
ernment, 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 an-
other 1987 speech, he promised that his administration
would “oppose any legislation that would require individu-
als or institutions, public or private, to finance or perform
abortions.” Id., Remarks at a White House Briefing 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 Future (Feb. 6, 1986).
Around the same time, President Reagan’s HHS Secre-
tary testified before Congress that “the Administration
steadfastly opposes [the] creation of [a] program which
would encourage, promote or finance the performance of
abortions.” Statement of the Hon. Margaret M. Heckler, in
Budget Reconciliation: Hearings before the Senate Commit-
tee on Finance, 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 op-

pose[d].” Ibid.
C
Desperate to find some crumb of support for its interpre-
tation, the Government scrapes together a handful of
sources that it says evidence a general understanding that
EMTALA requires hospitals to perform health-related
abortions prohibited 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 finds 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) (exclud-
ing ectopic pregnancies from the definition of “abortion”).
In the remaining case, the hospital was faulted, not for fail-
ing to perform an abortion, but for discharging a sick preg-
nant 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 Fed-
——————
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 Deficiencies—2024Q1 (2010–2016 file) Row
16,961. But Idaho law does not apply to “non-viable pregnancies . . .
where the unborn child is no longer developing.” Planned Parenthood
Great Northwest v. State, 171 Idaho 374, 445, 522 P. 3d 1132, 1203
(2023); see also Idaho Code Ann. §§18–604(1), (11).
Cite as: 603 U. S. ____ (2024) 11
eral law, including . . . EMTALA.” 42 U. S. C. §18023(d) (in-

ternal quotation marks omitted). Because this provision
was placed in a section of the Act concerning abortion, the
Government infers that it reflects a congressional under-
standing that EMTALA sometimes requires abortions.
Brief for United States 19–20. That inference is totally un-
warranted. The provision in question refers to the entire
massive Affordable Care Act, not just the relatively few pro-
visions concerning abortion. Compare §18023(d), with
§18023(c) (referring more narrowly to “this subsection”). It
reaffirms 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 Govern-
ment’s interpretation of EMTALA either.
II
As the previous Part shows, EMTALA’s text and context
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.”
Pennhurst, 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 nullify-
ing whatever 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
——————
13 Section 18023(d) also demands compliance with state emergency
care requirements, and laws like Idaho’s impose requirements regarding

permissible emergency care for pregnant women.
Clause] provisions . . . is in no way mandatory”). “[T]he ‘le-

gitimacy of Congress’ power’ ” to enforce conditions tied to
federal funds depends on whether the parties who accepted
federal funds also “ ‘voluntarily and knowingly’ ” accepted
the conditions. Cummings 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 condi-
tions.” 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
dispute that such a requirement is not unambiguously
clear. The statute does not mention abortion, let alone ex-
pressly bind hospitals to perform abortions contrary to state
law.
The need for clear statutory language is especially im-
portant in this suit because the Government’s interpreta-
tion would intrude on an area traditionally left to state con-
trol, namely, the practice of medicine. We typically expect
Congress 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
Cite as: 603 U. S. ____ (2024) 13
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
“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
preemption even further. It contends that EMTALA cannot
preempt the State’s abortion regulations because Idaho is
not a party to the agreement between the Federal Govern-
ment 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 conception 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 hos-
pitals’ 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
——————
14 Only one state psychiatric hospital accepts Medicare funds, and it
does not have an emergency room. 2 App. 531.

even if he or she does not meet the State’s licensing require-

ments.
While the Government is not troubled by the potential
consequences of its preemption argument, Congress was
sensitive to state prerogatives. The Medicare Act, in which
EMTALA is situated, disclaims any construction that
would “authorize any Federal officer or employee to exercise
any supervision or control over the practice of medicine or
the manner in which medical services are provided” in a
particular State. 42 U. S. C. §1395. This disclaimer evi-
dences 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 directly conflicts with a re-
quirement of this section.” §1395dd(f ). This phrasing sig-
nals 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
Spending Clause statutes can preempt the laws of non-con-
senting 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 prevent the use of federal money for purposes
——————
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 Benefits Act with regard to contracts for
health benefits negotiated between the Federal Government and insur-
ance carriers. It did not present the question whether Spending Clause
conditions placed on private parties could preempt States from enforcing
their criminal 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.
Cite as: 603 U. S. ____ (2024) 15
other than those intended by Congress.16 The Government

has not identified any decision holding that a federal law
enacted under the Spending Clause preempts a state crim-
inal 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, it provides yet another reason to be wary about
interpreting EMTALA 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 Government’s interpretation and put that matter
to rest.17
——————
16 See Philpott v. Essex County Welfare Bd., 409 U. S. 413, 415 (1973)
(attachment of Social Security benefits); 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, 271 (1985) (use of federal payments
in lieu of taxes made to municipalities with federal facilities).
17 JUSTICE SOTOMAYOR, JUSTICE KAGAN, and JUSTICE JACKSON endorse
the Government’s interpretation of EMTALA but barely bother to ex-

plain why they think the interpretation is correct. JUSTICE KAGAN’s opin-
ion, 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 4 (con-
curring opinion). JUSTICE KAGAN conveniently fails to note that
EMTALA defines the term “emergency medical condition” and that this
definition includes any condition that is sufficiently serious to “plac[e]
. . . the health of [a pregnant] woman or her unborn child . . . in serious
jeopardy.” §1395dd(e)(1)(A)(i). Therefore, as I have already explained,
EMTALA demands that a covered hospital stabilize any sufficiently se-
rious 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
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
showing that it was likely to prevail on the merits. See
Munaf v. Geren, 553 U. S. 674, 690 (2008). And as I have
explained, its argument was almost certain to lose. That in
itself is sufficient 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 15, 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 there-
fore 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 7 (BARRETT, J., joined by
ROBERTS, C. J., and KAVANAUGH, J., concurring). That jus-
tification is patently unsound. “ ‘[A]ny time a State is en-
joined by a court from effectuating statutes enacted by rep-
resentatives of its people, it suffers a form of irreparable
injury.’ ” Maryland v. King, 567 U. S. 1301, 1303 (2012)
(ROBERTS, C. J., in chambers). And in this case, Idaho’s in-
jury is not abstract. As I will explain, it is very likely that
——————
apply to Spending Clause measures or how Idaho can be bound by con-
ditions 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 7 (opinion concurring in part and dissenting
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.
Cite as: 603 U. S. ____ (2024) 17
the preliminary injunction will lead to more abortions, in-

cluding in at least some cases where the fetus is viable. The
State of Idaho wants to prevent that; the preliminary in-
junction 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
interpreted by the Government, conflicts with the Idaho
law, ante, at 7–8, 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: “In Idaho, doctors have to shut their eyes to
everything except death,” whereas under EMTALA, a phy-
sician is supposed to think about serious threats to a preg-
nant woman’s health. Tr. of Oral Arg. 102. In light of this
perceived conflict, the Solicitor General said it was “gravely
mistaken” to suggest that “there really isn’t in operation a
difference between” EMTALA and Idaho law. Id., at 101–
102.
Idaho agreed that the Government’s interpretation of
EMTALA conflicts 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
briefing 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 fighting
about nothing?
Three of the six Justices in the majority also agree that

there is a conflict—and judging from their fiery rhetoric, a
big one. See ante, at 1 (KAGAN, J., joined by SOTOMAYOR,
J., and by JACKSON, J., as to Part II, concurring); ante, at 7
(JACKSON, J., concurring in part and dissenting in part).
And they are correct to this extent: there is a real conflict.
A
I begin with the Government’s argument that “there are
numerous conditions” that may afflict 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-
quires hospitals to perform an abortion on demand in these
circumstances.
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] nec-
essary to prevent the death of the pregnant woman.” Idaho
Code Ann. §18–622(2)(a)(i). And even then, the doctor must
“attemp[t] to perform the abortion in the manner that . . .
provide[s] the best opportunity for the unborn child to sur-
vive,” 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 ‘neces-
sary.’ ” Ibid.; accord, id., at 446, 522 P. 3d, at 1203 (noting
that the Act “imposes a subjective standard based on the
individual physician’s good faith medical judgment”). And
Cite as: 603 U. S. ____ (2024) 19
any latitude, it said, “ ‘operates for the benefit, not the dis-
advantage, 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 situ-
ation of a woman who experiences a condition that was dis-
cussed in the briefs and at argument: preterm prelabor rup-
ture of membranes (PPROM), which occurs when a
woman’s amniotic sac breaks before the 37th week of preg-
nancy. 1 App. 295. The Members of this Court are not phy-
sicians and should therefore be wary about expressing con-
clusions about medical issues. But guidance provided by
prominent medical institutions is sufficient to show how
Idaho law and EMTALA, as interpreted by the Govern-
ment, may conflict 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 conflict is
high.
On the other hand, when PPROM occurs earlier than
that, the chances of conflict are greatly increased. If
PPROM occurs before the 34th week and the woman’s preg-
nancy continues, she may experience conditions such as an
infection of the amniotic fluid, inflammation of the uterine
lining, hemorrhage, or sepsis.19 However, life-threatening
——————
18 See, e.g., 1 App. 306; Mount Sinai, Premature Rupture of Membranes,
https://www.mountsinai.org/health-library/special-topic/premature-
rupture-of-membranes#:~:text=Sometimes%20the%20membranes%
20break%20before,rupture%20of%20membranes%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 approxi-

mately 1% to 5% developed life-threatening sepsis. 1 App. 298. A review
complications are not inevitable, and according to the

PPROM Foundation, death is “extremely rare.”20 A physi-
cian 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 prevent infection.21
When PPROM occurs before the 24th week of pregnancy,
the potential for conflict appears to be even higher. But in
that situation, it may still be possible to manage the situa-
tion 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
——————
of studies after 1993 indicated that the most common maternal morbidity
is infection of the amniotic fluid, “with approximately 37% of women de-
veloping this complication.” T. Waters & B. Mercer, The Management of
Preterm Premature Rupture of Membranes Near the Limit of Fetal Via-
bility, Am. J. Obstetrics & Gynecology (AJOG), p. 231 (Sept. 2009); see
also Brief for Physicians for Reproductive Health as Amicus Curiae 18.
20 PPROM Foundation, PPROM Facts, https://www.aapprom.
org/community/ppromfacts (June 21, 2024) (PPROM Facts).
21 Ibid.; see also Children’s Hospital of Philadelphia, Premature Rup-
ture of Membranes (PROM)/Preterm Premature Rupture of Membranes

(PPROM), https://www.chop.edu/conditions-diseases/premature-rupture-
membranes-prompreterm-premature-rupture-membranes-pprom (June
21, 2024).
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. Ozel et al., Outcomes of Pregnancies Complicated by Preterm
Premature Rupture of Membranes Before and After 24 Gestational
Weeks: A Retrospective Analysis, J. Clinical Obstetrics & Gynecology, p.
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, AJOG, p. 5 (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);
Cite as: 603 U. S. ____ (2024) 21
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 neces-
sary to prevent the woman’s death. Because this is a “sub-
jective” standard, Planned Parenthood, 171 Idaho, at 446,
522 P. 3d, at 1204, different doctors may reach different
conclusions 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 infection, let alone life-threatening sepsis or any
other potentially 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
sufficiently “severe” to cause “infection and serious risk of
sepsis.” See, e.g., 2 id., at 547. 24
According to the Government’s experts, 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
——————
P. Wagner et al., Outcome of Pregnancies With Spontaneous PPROM Be-
fore 24+0 Weeks’ Gestation (2016) (reporting that “[a]bout half ” of fe-
tuses in PPROM pregnancies that make it to viability “will be discharged
alive without major complications”).
24 It has been estimated that PPROM occurs in about 2% of all preg-
nancies 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.
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
dysfunction” to her reproductive organs.
§§1395dd(c)(1)(A)(ii), (e)(1)(A)(i) and (iii); see, e.g., 2 App.
594 (“Providing stabilizing treatment in the form of termi-
nation 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 conflict between what Idaho law permits and
what EMTALA, as interpreted by the Government, de-
mands. 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
interpretation of EMTALA matters. Idaho has always per-
mitted abortions that are necessary to preserve the life of a
pregnant woman, but it has not allowed abortions for other
non-life-threatening medical conditions. Planned
Parenthood, 171 Idaho, at 391–394, 522 P. 3d, at 1149–1152
(summarizing Idaho’s historical restrictions); see also
Dobbs, 597 U. S., at 302–330 (compiling other state statutes
with identical exceptions). This balance reflects Idaho’s
judgment about a difficult 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 dif-
ferent 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 read-
ing of EMTALA would authorize abortions for mental-
health reasons. My colleagues dismiss this concern because
at argument, the Solicitor General “emphatically disa-
vowed the notion that an abortion is ever required as stabi-
lizing treatment for mental health conditions.” Ante, at 5
Cite as: 603 U. S. ____ (2024) 23
(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 includes mental health, Tr. of Oral Arg. 77–78,
and if that is so, it is not difficult to imagine a situation in
which the Government’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 decision” about the treatment she received.
Brief for United States 41. If the woman preferred to abort
rather than manage her depression alongside her preg-
nancy, it is not apparent why the Government’s reading of
EMTALA would not require that abortion.
We have seen where a rule permitting abortions to pro-
tect 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 ap-
propriate 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,
psychological, 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
——————
25 See, e.g., J. Ely, The Wages of Crying Wolf: A Comment on Roe v.
Law School Professor Mary Ann Glendon put it: “[W]hen

Roe is read with Doe, third-trimester restrictions are effec-
tively ruled out as well—for Roe’s dictum that such re-
strictions might be permissible if they did not interfere with
the mother’s health was negated by Doe’s definition 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 men-
tal-health emergencies “could never lead to pregnancy ter-
mination” because abortion “is not the accepted standard of
practice 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 posi-
tion taken by prominent medical associations that endorse
abortion 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 impera-
tive”); American Psychological Association, Resolution Af-
firming and Building on APA’s History of Support for Re-
productive Rights (Feb. 2022).
For these reasons, there is a real potential for conflict 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.
——————
Wade, 82 Yale L. J. 920, 921, and n. 19 (1973); J. Dellapenna, Dispelling
the Myths of Abortion History 695 (2006) (“Blackmun’s definition of a
woman’s ‘health’ in Doe as encompassing anything affecting her ‘well-
being’ virtually 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 defined that excep-
tion so broadly that it swallowed up any possibility of a ban”).
Cite as: 603 U. S. ____ (2024) 25
* * *
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 ap-
peal to the Ninth Circuit, which will have to decide the is-
sue 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 re-
spectfully dissent.

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(Slip Opinion) Cite as: 603 U. S.

NOTICE: This opinion is subject to formal revision before publication in the

SUPREME COURT OF THE UNITED STATES

Nos. 23–726 and 23–727

MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF

KAGAN, J., concurring

SUPREME COURT OF THE UNITED STATES

Nos. 23–726 and 23–727

MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF

JUSTICE KAGAN, with whom JUSTICE SOTOMAYOR joins,

KAGAN, J., concurring

to prevail in its suit, entered a preliminary injunction. Dur-

KAGAN, J., concurring

EMTALA requires a Medicare-funded hospital to offer an

KAGAN, J., concurring

KAGAN, J., concurring

occur. §1395dd(e)(3)(A). The statute does not list particu-

KAGAN, J., concurring

in an amendment to EMTALA, ensures that a woman with

BARRETT, J., concurring

SUPREME COURT OF THE UNITED STATES

Nos. 23–726 and 23–727

MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF

JUSTICE BARRETT, with whom THE CHIEF JUSTICE and

BARRETT, J., concurring

they believe that “abortion is the stabilizing treatment nec-

BARRETT, J., concurring

After the District Court ruled, the Idaho Supreme Court

BARRETT, J., concurring

have “shed more light on this case than in the nature of

BARRETT, J., concurring

need for “immediate determination in this Court,” Supreme

BARRETT, J., concurring

BARRETT, J., concurring

For these reasons, a “deviation from normal appellate

BARRETT, J., concurring

id., at 15. Thus, even with the preliminary injunction in

SUPREME COURT OF THE UNITED STATES

Nos. 23–726 and 23–727

MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF

JUSTICE JACKSON, concurring in part and dissenting in

could actually say that the abortion was necessary to pre-

EMTALA remains as imperative as ever. The United

have changed their tune about the exact types of medical

(PPROM), sepsis, and placental abruption, to name just a

would shirk its duty to resolve a pressing legal issue on the

courts to carry on as if none of this has happened. As the

must pregnant patients wait for an answer? Until we con-

ALITO, J., dissenting

SUPREME COURT OF THE UNITED STATES

Nos. 23–726 and 23–727

MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF

JUSTICE ALITO, with whom JUSTICE THOMAS joins, and

ALITO, J., dissenting

States enacted new laws restricting the performance of

ALITO, J., dissenting

even if there were some ambiguity in the statutory text, we

ALITO, J., dissenting

ALITO, J., dissenting

part.” §1395dd(e)(1)(A) (emphasis added).2

ment’s view, an “impairment” or “dysfunction” under §1395dd (e)(1)(A)(i)

ALITO, J., dissenting

any “increased risks” to the woman “and, in the case of la-