U.S. Supreme Court Rust v. Sullivan, 500
U.S. 173 (1990) Rust v. Sullivan Nos. 89-1391, 89-1392 Argued Oct. 30, 1990 Decided May 23, 1991 500
U.S. 173 CERTIORARI TO THE UNITED STATES
COURT OF APPEALS FOR THE SECOND
CIRCUIT Syllabus Section 1008 of the Public Health Service Act specifies that
none of the federal funds appropriated under the Act's Title X for
family-planning services "shall be used in programs where abortion
is a method of family planning." In 1988, respondent Secretary of
Health and Human Services issued new regulations that, inter
alia, prohibit Title X projects from engaging in counseling
concerning, referrals for, and activities advocating abortion as a
method of family planning, and require such projects to maintain an
objective integrity and independence from the prohibited abortion
activities by the use of separate facilities, personnel, and
accounting records. Before the regulations could be applied,
petitioners -- Title X grantees and doctors who supervise Title X
funds -- filed suits, which were consolidated, challenging the
regulations' facial validity and seeking declaratory and injunctive
relief to prevent their implementation. In affirming the District
Court's grant of summary judgment to the Secretary, the Court of
Appeals held that the regulations were a permissible construction
of the statute and consistent with the First and Fifth
Amendments. Held: 1. The regulations are a permissible construction of Title X.
Pp. 500 U. S.
183 -191.

															(a) Because § 1008 is ambiguous, in that it does not speak
directly to the issues of abortion counseling, referral, and
advocacy, or to "program integrity," the Secretary's construction
must be accorded substantial deference as the interpretation of the
agency charged with administering the statute, and may not be
disturbed as an abuse of discretion if it reflects a plausible
construction of the statute's plain language and does not otherwise
conflict with Congress' expressed intent. Chevron
U.S.A. Inc. v. Natural Resource Defense Council,
Inc. , 467 U. S. 837 , 467 U. S.
842 -844. P. 500 U. S.
184 .

															(b) Title X's broad language plainly allows the abortion
counseling, referral, and advocacy regulations. Since the Title
neither defines Page 500 U. S. 174 § 1008's "method of family planning" phrase nor enumerates what
types of medical and counseling services are entitled to funding,
it cannot be said that the Secretary's construction of the § 1008
prohibition to require a ban on such activities within Title X
projects is impermissible. Moreover, since the legislative history
is ambiguous as to Congress' intent on these issues, this Court
will defer to the Secretary's expertise. Petitioners' contention,
that the regulations are entitled to little or no deference because
they reverse the Secretary's longstanding policy permitting
nondirective counseling and referral for abortion, is rejected.
Because an agency must be given ample latitude to adapt its rules
to changing circumstances, a revised interpretation may deserve
deference. The Secretary's change of interpretation is amply
supported by a "reasoned analysis" indicating that the new
regulations are more in keeping with the statute's original intent,
are justified by client experience under the prior policy, and
accord with a shift in attitude against the "elimination of unborn
children by abortion." Pp. 500 U. S. 184 -187.

															(c) The regulations' "program integrity" requirements are not
inconsistent with Title X's plain language. The Secretary's view,
that the requirements are necessary to ensure that Title X grantees
apply federal funds only to authorized purposes and avoid creating
the appearance of governmental support for abortion-related
activities, is not unreasonable in light of § 1008's express
prohibitory language and is entltled to deference. Petitioners'
contention is unpersuasive that the requirements frustrate
Congress' intent, clearly expressed in the Act and the legislative
history, that Title X programs be an integral part of a broader,
comprehensive, health care system that envisions the efficient use
of non-Title X funds. The statements relied on are highly
generalized and do not directly address the scope of § 1008 and,
therefore, cannot form the basis for enjoining the regulations.
Indeed, the legislative history demonstrates that Congress intended
that Title X funds be kept separate and distinct from
abortion-related activities. Moreover, there is no need to
invalidate the regulations in order to save the statute from
unconstitutionality, since petitioners' constitutional arguments do
not carry the day. Pp. 500 U.S.
187 -191.

															2. The regulations do not violate the First Amendment free
speech rights of private Title X fund recipients, their staffs, or
their patients by impermissibly imposing viewpoint-discriminatory
conditions on Government subsidies. There is no question but that §
1008's prohibition is constitutional, since the Government may make
a value judgment favoring childbirth over abortion, and implement
that judgment by the allocation of public funds. Maher v.
Roe, 432 U. S. 464 , 432 U. S. 474 .
In so doing, the Government has not discriminated on the basis of
viewpoint; it has merely chosen to fund one activity to the
exclusion of another. Similarly, Page 500 U. S. 175 in implementing the statutory prohibition by forbidding
counseling, referral, and the provision of information regarding
abortion as a method of family planning, the regulations simply
ensure that appropriated funds are not used for activities,
including speech, that are outside the federal program's scope. Arkansas Writers' Project, Inc. v. Ragland, 481 U.
S. 221 , distinguished. Petitioners' view that, if the
Government chooses to subsidize one protected right, it must
subsidize analogous counterpart rights, has been soundly rejected. See, e.g., Regan v. Taxation With Representation of Wash., 461 U. S. 540 . On
their face, the regulations cannot be read, as petitioners contend,
to bar abortion referral or counseling where a woman's life is
placed in imminent peril by her pregnancy, since it does not seem
that such counseling could be considered a "method of family
planning" under § 1008, and since provisions of the regulations
themselves contemplate that a Title X project could engage in
otherwise prohibited abortion-related activities in such
circumstances. Nor can the regulations' restrictions on the
subsidization of abortion-related speech be held to
unconstitutionally condition the receipt of a benefit, Title X
funding, on the relinquishment of a constitutional right, the right
to engage in abortion advocacy and counseling. The regulations do
not force the Title X grantee, or its employees, to give up
abortion-related speech; they merely require that such activities
be kept separate and distinct from the activities of the Title X
project. FCC v. League of Women Voters of Cal., 468 U. S. 364 , 468 U. S. 400 ; Regan, supra, 461 U.S. at 461 U. S. 546 ,
distinguished. Although it could be argued that the traditional
doctor-patient relationship should enjoy First Amendment protection
from Government regulation, even when subsidized by the Government, cf., e.g., United States v. Kokinda, 497 U.
S. 720 , 497 U. S. 726 ,
that question need not be resolved here, since the Title X program
regulations do not significantly impinge on the doctor-patient
relationship. Pp. 500 U. S.
192 -200.

															3. The regulations do not violate a woman's Fifth Amendment
right to choose whether to terminate her pregnancy. The Government
has no constitutional duty to subsidize an activity merely because
it is constitutionally protected, and may validly choose to
allocate public funds for medical services relating to childbirth
but not to abortion. Webster v. Reproductive Health
Services, 492 U. S. 490 , 492 U. S. 510 .
That allocation places no governmental obstacle in the path of a
woman wishing to terminate her pregnancy, and leaves her with the
same choices as if the Government had chosen not to fund family
planning services at all. See, e.g., Harris v. McRae, 448 U. S. 297 , 448 U. S. 315 , 448 U. S. 317 ; Webster, supra, 492 U. S. 509 .
Nor do the regulations place restrictions on the patient/doctor
dialogue which violate a woman's right to make an informed and
voluntary choice under Akron v. Akron Center for
Reproductive Health, Inc. , 462 U.S. Page 500 U. S. 176 416, and Thornburg v. American College of Obstetricians and
Gynecologists, 476 U. S. 747 .
Unlike the laws invalidated in those cases, which required all
doctors to provide all pregnant patients contemplating abortion
with specific antiabortion information, here, a doctor's ability to
provide, and a woman's right to receive, abortion-related
information remains unfettered outside the context of the Title X
project. The fact that most Title X clients may be effectively
precluded by indigency from seeing a health care provider for
abortion-related services does not affect the outcome here, since
the financial constraints on such a woman's ability to enjoy the
full range of constitutionally protected freedom of choice are the
product not of governmental restrictions, but of her indigency. McRae, supra, 448 U.S. at 448 U. S. 316 .
Pp. 500 U. S.
201 -203.

															889 F.2d 401 (C.A.2 1989), affirmed.

															REHNQUIST, C.J., delivered the opinion of the Court, in which
WHITE, KENNEDY, SCALIA, and SOUTER, JJ., joined. BLACKMUN, J.,
filed a dissenting opinion, in which MARSHALL, J., joined; in Part
I of which O'CONNOR, J., joined; and in Parts II and III of which
STEVENS, J., joined, post, p. 500 U. S. 203 .
STEVENS, J., post, p. 500 U. S. 220 ,
and O'CONNOR, J., filed dissenting opinions, post, p. 500 U. S.
223 . Page 500 U. S. 177 CHIEF JUSTICE REHNQUIST delivered the opinion of the Court.

															These cases concern a facial challenge to Department of Health
and Human Services (HHS) regulations which limit Page 500 U. S. 178 the ability of Title X fund recipients to engage in
abortion-related activities. The United States Court of Appeals for
the Second Circuit upheld the regulations, finding them to be a
permissible construction of the statute, as well as consistent with
the First and Fifth Amendments of the Constitution. We granted
certiorari to resolve a split among the Courts of Appeals.
[ Footnote 1 ] We affirm. I A In 1970, Congress enacted Title X of the Public Health Service
Act (Act), 84 stat. 1506, as amended, 42 U.S.C. §§ 300-300a6, which
provides federal funding for family planning services. The Act
authorizes the Secretary to

															"make grants to and enter into contracts with public or
nonprofit private entities to assist in the establishment and
operation of voluntary family planning projects which shall offer a
broad range of acceptable and effective family Page 500 U. S. 179 planning methods and services."

															42 U.S.C. § 300(a). Grants and contracts under Title X must "be
made in accordance with such regulations as the Secretary may
promulgate." 42 U.S.C. § 300a-4. Section 1008 of the Act, however,
provides that "[n]one of the funds appropriated under this
subchapter shall be used in programs where abortion is a method of
family planning." 42 U.S.C. § 300a-6. That restriction was intended
to ensure that Title X funds would

															"be used only to support preventive family planning services,
population research, infertility services, and other related
medical, informational, and educational activities."

															H.R. Conf.Rep. No. 91-1667, p. 8 (1970), U.S.Code Cong. &
Admin.News 1970, pp. 5068, 5081-82.

															In 1988, the Secretary promulgated new regulations designed to
provide

															"'clear and operational guidance' to grantees about how to
preserve the distinction between Title X programs and abortion as a
method of family planning."

															53 Fed.Reg. 29232924 (1988). The regulations clarify, through
the definition of the term "family planning," that Congress
intended Title X funds "to be used only to support preventive family planning services." H.R.Conf. Rep. No.
91-1667, p. 8, U.S.Code Cong. & Admin.News 1970, p. 5081
(emphasis added). Accordingly, Title X services are limited to
"preconceptual counseling, education, and general reproductive
health care," and expressly exclude "pregnancy care (including
obstetric or prenatal care)." 42 CFR § 59.2 (1989). [ Footnote 2 ] The regulations

															"focus the emphasis of the Title X program on its traditional
mission: the provision of preventive family planning services
specifically designed to enable individuals to determine the number
and spacing of their children, while clarifying that pregnant women
must be referred to appropriate prenatal care services."

															53 Fed.Reg. 2925 (1988).

															The regulations attach three principal conditions on the grant
of federal funds for Title X projects. First, the regulations
specify that a

															"Title X project may not provide counseling concerning the use
of abortion as a method of family planning or provide referral for
abortion as a method of family planning."

															42 CFR 59.8(a)(1) (1989). Because Title X is limited to
preconceptional services, the program does not furnish services
related to childbirth. Only in the context of a referral out of the
Title X program is a pregnant woman given transitional information.
§ 59.8(a)(2). Title X Page 500 U. S. 180 projects must refer every pregnant client

															"for appropriate prenatal and/or social services by furnishing a
list of available providers that promote the welfare of the mother
and the unborn child." Ibid. The list may not be used indirectly to encourage
or promote abortion,

															"such as by weighing the list of referrals in favor of health
care providers which perform abortions, by including on the list of
referral providers health care providers whose principal business
is the provision of abortions, by excluding available providers who
do not provide abortions, or by 'steering' clients to providers who
offer abortion as a method of family planning."

															§ 59.8(a)(3). The Title X project is expressly prohibited from
referring a pregnant woman to an abortion provider, even upon
specific request. One permissible response to such an inquiry is
that

															"the project does not consider abortion an appropriate method of
family planning, and therefore does not counsel or refer for
abortion."

															§ 59.8(b)(5).

															Second, the regulations broadly prohibit a Title X project from
engaging in activities that "encourage, promote or advocate
abortion as a method of family planning." § 59.10(a). Forbidden
activities include lobbying for legislation that would increase the
availability of abortion as a method of family planning, developing
or disseminating materials advocating abortion as a method of
family planning, providing speakers to promote abortion as a method
of family planning, using legal action to make abortion available
in any way as a method of family planning, and paying dues to any
group that advocates abortion as a method of family planning as a
substantial part of its activities. Ibid. B Third, the regulations require that Title X projects be
organized so that they are "physically and financially separate"
from prohibited abortion activities. § 59.9. To be deemed
physically and financially separate,

															"a Title X project must have an objective integrity and
independence from prohibited activities. Mere bookkeeping
separation of Title X funds from other monies is not
sufficient." Ibid. The regulations Page 500 U. S. 181 provide a list of nonexclusive factors for the Secretary to
consider in conducting a case-by-case determination of objective
integrity and independence, such as the existence of separate
accounting records and separate personnel, and the degree of
physical separation of the project from facilities for prohibited
activities. Ibid. Petitioners are Title X grantees and doctors who supervise Title
X funds suing on behalf of themselves and their patients.
Respondent is the Secretary of the Department of Health and Human
Services. After the regulations had been promulgated, but before
they had been applied, petitioners filed two separate actions,
later consolidated, challenging the facial validity of the
regulations and seeking declaratory and injunctive relief to
prevent implementation of the regulations. Petitioners challenged
the regulations on the grounds that they were not authorized by
Title X and that they violate the First and Fifth Amendment rights
of Title X clients and the First Amendment rights of Title X health
providers. After initially granting the petitioners a preliminary
injunction, the District Court rejected petitioners' statutory and
constitutional challenges to the regulations and granted summary
judgment in favor of the Secretary. New York v.
Bowen, 690 F.
Supp. 1261 (SDNY 1988).

															A panel of the Court of Appeals for the Second Circuit affirmed.
889 F.2d 401 (1989). Applying this Court's decision in Chevron U.S.A. Inc. v.
Natural Resources Defense Council, Inc. , 467 U. S. 837 , 467 U. S.
842 -843 (1984), the Court of Appeals determined that the
regulations were a permissible construction of the statute that
legitimately effectuated Congressional intent. The court rejected
as "highly strained," petitioners' contention that the plain
language of § 1008 forbids Title X projects only from performing
abortions. The court reasoned that

															"it would be wholly anomalous to read Section 1008 to mean that
a program that merely counsels, but does not perform, abortions
does not include abortion as a 'method of family planning.'"

															889 F.2d at 407. "[T]he natural Page 500 U. S. 182 construction of . . . the term method of family planning'
includes counseling concerning abortion." Ibid. The court
found this construction consistent with the legislative history,
and observed that "[a]ppellants' contrary view of the legislative history is based
entirely on highly generalized statements about the expansive scope
of the family planning services"

															that "do not specifically mention counseling concerning abortion
as an intended service of Title X projects" and that "surely cannot
be read to trump a section of the statute that specifically
excludes it." Id. at 407-408.

															Turning to petitioners' constitutional challenges to the
regulations, the Court of Appeals rejected petitioners' Fifth
Amendment challenge. It held that the regulations do not
impermissibly burden a woman's right to an abortion, because
the

															"government may validly choose to favor childbirth over abortion
and to implement that choice by funding medical services relating
to childbirth but not those relating to abortion." Id. at 410. Finding that the prohibition on the
performance of abortions upheld by the Court in Webster v.
Reproductive Health Services, 492 U.
S. 490 (1989), was "substantially greater in impact than
the regulations challenged in the instant matter," 889 F.2d at 411,
the court concluded that the regulations "create[d] no affirmative
legal barriers to access to abortion." Ibid., citing Webster v. Reproductive Health Services. The court likewise found that the

															"Secretary's implementation of Congress's decision not to fund
abortion counseling, referral or advocacy also does not, under
applicable Supreme Court precedent, constitute a facial violation
of the First Amendment rights of health care providers or of
women."

															889 F.2d at 412. The court explained that, under Regan v.
Taxation With Representation of Wash., 461 U.
S. 540 (1983), the government has no obligation to
subsidize even the exercise of fundamental rights, including
"speech rights." The court also held that the regulations do not
violate the First Amendment by "condition[ing] receipt of a benefit
on the Page 500 U. S. 183 relinquishment of constitutional rights," because Title X
grantees and their employees "remain free to say whatever they wish
about abortion outside the Title X project." 889 F.2d at 412.
Finally, the court rejected petitioners' contention that the
regulations "facially discriminate on the basis of the viewpoint of
the speech involved." Id. at 414. II We begin by pointing out the posture of the cases before us.
Petitioners are challenging the facial validity of the regulations.
Thus, we are concerned only with the question whether, on their
face, the regulations are both authorized by the Act, and can be
construed in such a manner that they can be applied to a set of
individuals without infringing upon constitutionally protected
rights. Petitioners face a heavy burden in seeking to have the
regulations invalidated as facially unconstitutional.

															"A facial challenge to a legislative Act is, of course, the most
difficult challenge to mount successfully, since the challenger
must establish that no set of circumstances exists under which the
Act would be valid. The fact that [the regulations] might operate
unconstitutionally under some conceivable set of circumstances is
insufficient to render [them] wholly invalid." United States v. Salerno, 481 U.
S. 739 , 481 U. S. 745 (1987).

															We turn first to petitioners' contention that the regulations
exceed the Secretary's authority under Title X, and are arbitrary
and capricious. We begin with an examination of the regulations
concerning abortion counseling, referral, and advocacy, which every
Court of Appeals has found to be authorized by the statute, and
then turn to the "program integrity requirement," with respect to
which the courts below have adopted conflicting positions. We then
address petitioner's claim that the regulations must be struck down
because they raise a substantial constitutional question. Page 500 U. S. 184 A We need not dwell on the plain language of the statute, because
we agree with every court to have addressed the issue that the
language is ambiguous. The language of § 1008 -- that "[n]one of
the funds appropriated under this subchapter shall be used in
programs where abortion is a method of family planning" -- does not
speak directly to the issues of counseling, referral, advocacy, or
program integrity. If a statute is

															"silent or ambiguous with respect to the specific issue, the
question for the court is whether the agency's answer is based on a
permissible construction of the statute." Chevron, 467 U.S. at 467 U. S.
842 -843.

															The Secretary's construction of Title X may not be disturbed as
an abuse of discretion if it reflects a plausible construction of
the plain language of the statute and does not otherwise conflict
with Congress' expressed intent. Ibid. In determining
whether a construction is permissible,

															"[t]he court need not conclude that the agency construction was
the only one it could permissibly have adopted . . . or even the
reading the court would have reached if the question initially had
arisen in a judicial proceeding." Id. at 467 U. S. 843 ,
n. 11. Rather, substantial deference is accorded to the
interpretation of the authorizing statute by the agency authorized
with administering it. Id. at 467 U. S.
844 .

															The broad language of Title X plainly allows the Secretary's
construction of the statute. By its own terms, § 1008 prohibits the
use of Title X funds "in programs where abortion is a method of
family planning." Title X does not define the term "method of
family planning," nor does it enumerate what types of medical and
counseling services are entitled to Title X funding. Based on the
broad directives provided by Congress in Title X in general and §
1008 in particular, we are unable to say that the Secretary's
construction of the prohibition in § 1008 to require a ban on
counseling, referral, and advocacy within the Title X project is
impermissible. Page 500 U. S. 185 The District Courts and Courts of Appeals that have examined the
legislative history have all found, at least with regard to the
Act's counseling, referral, and advocacy provisions, that the
legislative history is ambiguous with respect to Congress' intent
in enacting Title X and the prohibition of § 1008. Massachusetts v. Sullivan, 899 F.2d 53, 62 (CA1 1990)
("Congress has not addressed specifically the question of the scope
of the abortion prohibition. The language of the statute and the
legislative history can support either of the litigants'
positions"); Planned Parenthood Federation of America v.
Sullivan, 913 F.2d 1492, 1497 (CA10 1990) ("[T]he
contemporaneous legislative history does not address whether
clinics receiving Title X funds can engage in nondirective
counseling including the abortion option and referrals"); New
York v. Sullivan, 889 F.2d 401, 407 (CA2 1989) (case below)
("Nothing in the legislative history of Title X detracts" from the
Secretary's construction of § 1008). We join these courts in
holding that the legislative history is ambiguous, and fails to
shed light on relevant congressional intent. At no time did
Congress directly address the issues of abortion counseling,
referral, or advocacy. The parties' attempts to characterize highly
generalized, conflicting statements in the legislative history into
accurate revelations of congressional intent are unavailing.
[ Footnote 3 ] Page 500 U. S. 186 When we find, as we do here, that the legislative history is
ambiguous and unenlightening on the matters with respect to which
the regulations deal, we customarily defer to the expertise of the
agency. Petitioners argue, however, that the regulations are
entitled to little or no deference, because they "reverse a
longstanding agency policy that permitted nondirective counseling
and referral for abortion," Brief for Petitioners in No. 89-1392,
p. 20, and thus represent a sharp beak from the Secretary's prior
construction of the statute. Petitioners argue that the agency's
prior consistent interpretation of Section 1008 to permit
nondirective counseling and to encourage coordination with local
and state family planning services is entitled to substantial
weight.

															This Court has rejected the argument that an agency's
interpretation "is not entitled to deference because it represents
a sharp break with prior interpretations" of the statute in
question. Chevron, 467 U.S. at 467 U. S. 862 .
In Chevron, we held that a revised interpretation deserves
deference because "[a]n initial agency interpretation is not
instantly carved in stone," and "the agency, to engage in informed
rulemaking, must consider varying interpretations and the wisdom of
its policy on a continuing basis." Id. at 467 U. S.
863 -864. An agency is not required to " establish
rules of conduct to last forever,'" Motor
Vehicle Mfrs. Assn. of United States v.
State Page 500 U. S. 187 Farm Mutual Automobile Ins. Co., 463 U. S.
29 , 463 U. S. 42 (1983), quoting American Trucking Assns., Inc. v. Atchinson, T.
& S.F.R. Co., 387 U. S. 397 , 387 U. S. 416 (1967); NLRB v. Curtin Matheson Scientific, Inc., 494 U. S. 775 (1990), but rather "must be given ample latitude to `adapt [its]
rules and policies to the demands of changing circumstances.'" Motor Vehicle Mfrs., supra, 463 U.S. at 463 U. S. 42 ,
quoting Permian Basin Area Rate Cases, 390 U.
S. 747 , 390 U. S. 784 (1968).

															We find that the Secretary amply justified his change of
interpretation with a "reasoned analysis." Motor Vehicle Mfrs.,
supra, 463 U.S. at 463 U. S. 42 .
The Secretary explained that the regulations are a result of his
determination, in the wake of the critical reports of the General
Accounting Office (GAO) and the Office of the Inspector General
(OIG), that prior policy failed to implement properly the statute
and that it was necessary to provide "clear and operational
guidance to grantees to preserve the distinction between Title X
programs and abortion as a method of family planning." 53 Fed.Reg.
2923-2924 (1988). He also determined that the new regulations are
more in keeping with the original intent of the statute, are
justified by client experience under the prior policy, and are
supported by a shift in attitude against the "elimination of unborn
children by abortion." We believe that these justifications are
sufficient to support the Secretary's revised approach. Having
concluded that the plain language and legislative history are
ambiguous as to Congress' intent in enacting Title X, we must defer
to the Secretary's permissible construction of the statute. B We turn next to the "program integrity" requirements embodied at
§ 59.9 of the regulations, mandating separate facilities,
personnel, and records. These requirements are not inconsistent
with the plain language of Title X. Petitioners contend, however,
that they are based on an impermissible construction of the statute
because they frustrate the clearly Page 500 U. S. 188 expressed intent of Congress that Title X programs be an
integral part of a broader, comprehensive, health care system. They
argue that this integration is impermissibly burdened because the
efficient use of nonTitle X funds by Title X grantees will be
adversely affected by the regulations.

															The Secretary defends the separation requirements of § 59.9 on
the grounds that they are necessary to assure that Title X grantees
apply federal funds only to federally authorized purposes and that
grantees avoid creating the appearance that the government is
supporting abortion-related activities. The program integrity
regulations were promulgated in direct response to the observations
in the GAO and OIG reports that,

															"[b]ecause the distinction between the recipient's title X and
other activities may not be easily recognized, the public can get
the impression that Federal funds are being improperly used for
abortion activities."

															App. 85. The Secretary concluded that:

															"[M]eeting the requirement of section 1008 mandates that Title X
programs be organized so that they are physically and financially
separate from other activities which are prohibited from inclusion
in a Title X program. Having a program that is separate from such
activities is a necessary predicate to any determination that
abortion is not being included as a method of family planning in
the Title X program."

															53 Fed.Reg. 2940 (1988). The Secretary further argues that the
separation requirements do not represent a deviation from past
policy because the agency has consistently taken the position that
§ 1008 requires some degree of physical and financial separation
between Title X projects and abortion-related activities.

															We agree that the program integrity requirements are based on a
permissible construction of the statute, and are not inconsistent
with Congressional intent. As noted, the legislative history is
clear about very little, and program integrity is no exception. The
statements relied upon by the petitioners Page 500 U. S. 189 to infer such an intent are highly generalized, and do not
directly address the scope of § 1008.

															For example, the cornerstone of the conclusion that, in Title X,
Congress intended a comprehensive, integrated system of family
planning services is the statement in the statute requiring state
health authorities applying for Title X funds to submit "a state
plan for a coordinated and comprehensive program of family planning
services." § 1002. This statement is, on its face, ambiguous as to
Congress' intent in enacting Title X and the prohibition of § 1008.
Placed in context, the statement merely requires that a State
health authority submit a plan for a "coordinated and comprehensive
program of family planning services" in order to be eligible for
Title X funds. By its own terms, the language evinces Congress'
intent to place a duty on state entities seeking federal funds; it
does not speak either to an overall view of family planning
services or to the Secretary's responsibility for implementing the
statute. Likewise, the statement in the original House Report on
Title X that the Act was "not intended to interfere with or limit
programs conducted in accordance with State or local laws" and
supported through non-Title X funds is equally unclear. H.R.
Conf.Rep. No. 91-1667, pp. 8-9 (1970), U.S.Code Cong. &
Admin.News 1970, p. 5082. This language directly follows the
statement that it is the

															"intent of both Houses that the funds authorized under this
legislation be used only to support preventive family planning
services. . . . The conferees have adopted the language contained
in section 1008, which prohibits the use of such funds for
abortion, in order to make this intent clear." Id. at 8, U.S.Code Cong. & Admin.News 1970, pp.
5081-82. When placed in context and read in light of the express
prohibition of § 1008, the statements fall short of evidencing a
congressional intent that would render the Secretary's
interpretation of the statute impermissible.

															While the petitioners' interpretation of the legislative history
may be a permissible one, it is by no means the only one, and it is
certainly not the one found by the Secretary. It is well Page 500 U. S. 190 established that legislative history which does not demonstrate
a clear and certain congressional intent cannot form the basis for
enjoining the regulations. See Motor Vehicle Mfrs., 463
U.S. at 463 U. S. 42 .
The Secretary based the need for the separation requirements
"squarely on the congressional intent that abortion not be a part
of a Title X funded program." 52 Fed.Reg. 33212 (1987). Indeed, if
one thing is clear from the legislative history, it is that
Congress intended that Title X funds be kept separate and distinct
from abortion-related activities. It is undisputed that Title X was
intended to provide primarily prepregnancy preventive services.
Certainly the Secretary's interpretation of the statute that
separate facilities are necessary, especially in light of the
express prohibition of § 1008, cannot be judged unreasonable.
Accordingly, we defer to the Secretary's reasoned determination
that the program integrity requirements are necessary to implement
the prohibition.

															Petitioners also contend that the regulations must be
invalidated because they raise serious questions of constitutional
law. They rely on Edward J. Debartolo Corp. v. Florida Gulf
Coast Building and Construction Trades Council, 485 U.
S. 568 (1988), and NLRB v. Catholic Bishop of
Chicago, 440 U. S. 490 (1979), which hold that "an Act of Congress ought not to be
construed to violate the Constitution if any other possible
construction remains available." Id. at 440 U. S. 500 .
Under this canon of statutory construction, "[t]he elementary rule
is that every reasonable construction must be resorted to in order
to save a statute from unconstitutionality." Debartolo Corp., supra, 485 U.S. at 485 U. S. 575 (emphasis added) quoting Hooper v. California, 155 U. S. 648 , 155 U. S. 657 (1895).

															The principle enunciated in Hooper v. California,
supra, and subsequent cases is a categorical one:

															"as between two possible interpretations of a statute, by one of
which it would be unconstitutional and by the other valid, our
plain duty is to adopt that which will save the Act." Blodgett v. Holden, 275 U. S. 142 , 275 U. S. 148 (1927) (opinion of Holmes, J.). This principle Page 500 U. S. 191 is based at least in part on the fact that a decision to declare
an act of Congress unconstitutional "is the gravest and most
delicate duty that this Court is called on to perform." Id. Following Hooper, supra, cases such as United States v. Delaware and Hudson Co., 213 U.
S. 366 , 213 U. S. 408 ,
and United States v. Jin Fuey Moy, 241 U.
S. 394 , 241 U. S. 401 ,
developed the corollary doctrine that

															"[a] statute must be construed, if fairly possible, so as to
avoid not only the conclusion that it is unconstitutional but also
grave doubts upon that score." Jin Fuey Moy, supra, at 9241 U.S. 401401. This canon is
followed out of respect for Congress, which we assume legislates in
the light of constitutional limitations. FTC v. American
Tobacco Co., 264 U. S. 298 , 264 U. S.
305 -307 (1924). It is qualified by the proposition that
"avoidance of a difficulty will not be pressed to the point of
disingenuous evasion." Moore Ice Cream Co. v. Rose, 289 U. S. 373 , 289 U. S. 379 (1933).

															Here Congress forbade the use of appropriated funds in programs
where abortion is a method of family planning. It authorized the
Secretary to promulgate regulations implementing this provision.
The extensive litigation regarding governmental restrictions on
abortion since our decision in Roe v. Wade, 410 U.
S. 113 (1973), suggests that it was likely that any set
of regulations promulgated by the Secretary -- other than the ones
in force prior to 1988 and found by him to be relatively toothless
and ineffectual -- would be challenged on constitutional grounds.
While we do not think that the constitutional arguments made by
petitioners in this case are without some force, in 500 U.
S. infra, we hold that they do not carry the
day. Applying the canon of construction under discussion as best we
can, we hold that the regulations promulgated by the Secretary do
not raise the sort of "grave and doubtful constitutional
questions," Delaware and Hudson Co., supra, 213 U.S. at 213 U. S. 408 ,
that would lead us to assume Congress did not intend to authorize
their issuance. Therefore, we need not invalidate the regulations
in order to save the statute from unconstitutionality. Page 500 U. S. 192 III Petitioners contend that the regulations violate the First
Amendment by impermissibly discriminating based on viewpoint
because they prohibit

															"all discussion about abortion as a lawful option -- including
counseling, referral, and the provision of neutral and accurate
information about ending a pregnancy -- while compelling the clinic
or counselor to provide information that promotes continuing a
pregnancy to term."

															Brief for Petitioners in No. 891391, p. 11. They assert that the
regulations violate the "free speech rights of private health care
organizations that receive Title X funds, of their staff, and of
their patients" by impermissibly imposing "viewpoint-discriminatory
conditions on government subsidies," and thus penaliz[e] speech
funded with non-Title X monies. Id. at 13, 14, 24.
Because

															"Title X continues to fund speech ancillary to pregnancy testing
in a manner that is not evenhanded with respect to views and
information about abortion, it invidiously discriminates on the
basis of viewpoint." Id. at 18. Relying on Regan v. Taxation With
Representation of Wash. and Arkansas Writers Project, Inc.
v. Ragland, 481 U. S. 221 , 481 U. S. 234 (1987), petitioners also assert that, while the Government may
place certain conditions on the receipt of federal subsidies, it
may not "discriminate invidiously in its subsidies in such a way as
to ai[m] at the suppression of dangerous ideas.'" Regan,
supra, 461 U.S. at 461 U. S. 548 (quoting Cammarano v. United States, 358 U.
S. 498 , 358 U. S. 513 (1959)). There is no question but that the statutory prohibition
contained in § 1008 is constitutional. In Maher v. Roe,
supra, we upheld a state welfare regulation under which
Medicaid recipients received payments for services related to
childbirth, but not for nontherapeutic abortions. The Court
rejected the claim that this unequal subsidization worked a
violation of the Constitution. We held that the government may
"make a value judgment favoring childbirth over abortion, and . . .
implement that judgment by the allocation Page 500 U. S. 193 of public funds." Id. 432 U.S. at 432 U. S. 474 .
Here the Government is exercising the authority it possesses under Maher and McRae to subsidize family planning
services which will lead to conception and childbirth, and
declining to "promote or encourage abortion." The Government can,
without violating the Constitution, selectively fund a program to
encourage certain activities it believes to be in the public
interest, without at the same time funding an alternate program
which seeks to deal with the problem in another way. In so doing,
the Government has not discriminated on the basis of viewpoint; it
has merely chosen to fund one activity to the exclusion of the
other. "[A] legislature's decision not to subsidize the exercise of
a fundamental right does not infringe the right." Regan,
supra, 461 U.S. at 461 U. S. 549 . See also Buckley v. Valeo, 424 U. S.
1 (1976); Cammarano v. United States, supra. "A
refusal to fund protected activity, without more, cannot be equated
with the imposition of a penalty' on that activity." McRae, 448 U.S. at 448 U. S. 317 ,
n.19. "There is a basic difference between direct state interference
with a protected activity and state encouragement of an alternative
activity consonant with legislative policy." Maher, 432 U.S. at 432 U. S.
475 .

															The challenged regulations implement the statutory prohibition
by prohibiting counseling, referral, and the provision of
information regarding abortion as a method of family planning. They
are designed to ensure that the limits of the federal program are
observed. The Title X program is designed not for prenatal care,
but to encourage family planning. A doctor who wished to offer
prenatal care to a project patient who became pregnant could
properly be prohibited from doing so because such service is
outside the scope of the federally funded program. The regulations
prohibiting abortion counseling and referral are of the same ilk;
"no funds appropriated for the project may be used in programs
where abortion is a method of family planning," and a doctor
employed by the project may be prohibited in Page 500 U. S. 194 the course of his project duties from counseling abortion or
referring for abortion. This is not a case of the Government
"suppressing a dangerous idea," but of a prohibition on a project
grantee or its employees from engaging in activities outside of its
scope.

															To hold that the Government unconstitutionally discriminates on
the basis of viewpoint when it chooses to fund a program dedicated
to advance certain permissible goals because the program, in
advancing those goals, necessarily discourages alternate goals
would render numerous government programs constitutionally suspect.
When Congress established a National Endowment for Democracy to
encourage other countries to adopt democratic principles, 22 U.S.C.
§ 4411(b), it was not constitutionally required to fund a program
to encourage competing lines of political philosophy such as
Communism and Fascism. Petitioners' assertions ultimately boil down
to the position that, if the government chooses to subsidize one
protected right, it must subsidize analogous counterpart rights.
But the Court has soundly rejected that proposition. Regan v.
Taxation With Representation of Wash., supra; Maher v. Roe, supra;
Harris v. McRae, supra. Within far broader limits than
petitioners are willing to concede, when the government
appropriates public funds to establish a program, it is entitled to
define the limits of that program.

															We believe that petitioners' reliance upon our decision in Arkansas Writers Project, supra, is misplaced. That case
involved a state sales tax which discriminated between magazines on
the basis of their content. Relying on this fact, and on the fact
that the tax "targets a small group within the press," contrary to
our decision in Minneapolis Star & Tribune Co. v. Minnesota
Comm'r of Revenue, 460 U. S. 575 (1983), the Court held the tax invalid. But we have here not the
case of a general law singling out a disfavored group on the basis
of speech content, but a case of the Government refusing Page 500 U. S. 195 to fund activities, including speech, which are specifically
excluded from the scope of the project funded.

															Petitioners rely heavily on their claim that the regulations
would not, in the circumstance of a medical emergency, permit a
Title X project to refer a woman whose pregnancy places her life in
imminent peril to a provider of abortions or abortion-related
services. This case, of course, involves only a facial challenge to
the regulations, and we do not have before us any application by
the Secretary to a specific fact situation. On their face, we do
not read the regulations to bar abortion referral or counseling in
such circumstances. Abortion counseling as a "method of family
planning" is prohibited, and it does not seem that a medically
necessitated abortion in such circumstances would be the equivalent
of its use as a "method of family planning." Neither § 1008 nor the
specific restrictions of the regulations would apply. Moreover, the
regulations themselves contemplate that a Title X project would be
permitted to engage in otherwise prohibited abortion-related
activity in such circumstances. Section 59.8(a)(2) provides a
specific exemption for emergency care, and requires Title X
recipients "to refer the client immediately to an appropriate
provider of emergency medical services." 42 CFR 59.8(a)(2) (1989).
Section 59.5(b)(1) also requires Title X projects to provide
"necessary referral to other medical facilities when medically
indicated." [ Footnote 4 ] Page 500 U. S. 196 Petitioners also contend that the restrictions on the
subsidization of abortion-related speech contained in the
regulations are impermissible because they condition the receipt of
a benefit, in this case Title X funding, on the relinquishment of a
constitutional right, the right to engage in abortion advocacy and
counseling. Relying on Perry v. Sindermann, 408 U.
S. 593 , 408 U. S. 597 (1972), and FCC v. League of Women Voters of Cal., 468 U. S. 364 (1984), petitioners argue that,

															"even though the government may deny [a] . . . benefit for any
number of reasons, there are some reasons upon which the government
may not rely. It may not deny a benefit to a person on a basis that
infringes his constitutionally protected interests -- especially,
his interest in freedom of speech." Perry, supra, 408 U.S. at 408 U. S.
597 .

															Petitioners' reliance on these cases is unavailing, however,
because here the government is not denying a benefit to anyone, but
is instead simply insisting that public funds be spent for the
purposes for which they were authorized. The Secretary's
regulations do not force the Title X grantee to give up
abortion-related speech; they merely require that the grantee keep
such activities separate and distinct from Title X activities.
Title X expressly distinguishes between a Title X grantee and a Title X project. The grantee, which normally is a
health care organization, may receive funds from a variety of
sources for a variety of purposes. Brief for Petitioners in No.
89-1391, pp. 3, n. 5, 13. The grantee receives Title X funds,
however, for the specific and limited purpose of establishing and
operating a Title X project. 42 U.S.C. § 300(a). The regulations
govern the scope of the Title X project's activities, and
leave the grantee unfettered in its other activities. The Title X grantee can continue to perform abortions, provide
abortion-related services, and engage in abortion advocacy; it
simply is required to conduct those activities through programs
that are separate and independent from the project that receives
Title X funds. 42 CFR 59.9 (1989). Page 500 U. S. 197 In contrast, our "unconstitutional conditions" cases involve
situations in which the government has placed a condition on the recipient of the subsidy, rather that on a particular
program or service, thus effectively prohibiting the recipient from
engaging in the protected conduct outside the scope of the
federally funded program. In FCC v. League of Women Voters of
Cal., we invalidated a federal law providing that
noncommercial television and radio stations that receive federal
grants may not "engage in editorializing." Under that law, a
recipient of federal funds was "barred absolutely from all
editorializing," because it "is not able to segregate its
activities according to the source of its funding," and thus "has
no way of limiting the use of its federal funds to all
noneditorializing activities." The effect of the law was that

															"a noncommercial educational station that receives only 1% of
its overall income from [federal] grants is barred absolutely from
all editorializing"

															and "barred from using even wholly private funds to finance its
editorial activity." 468 U.S. at 468 U. S. 400 .
We expressly recognized, however, that were Congress to permit the
recipient stations to

															"establish affiliate' organizations which could then use the
station's facilities to editorialize with nonfederal funds, such a
statutory mechanism would plainly be valid." Ibid. Such a scheme would permit the station

															"to make known its views on matters of public importance through
its nonfederally funded, editorializing affiliate without losing
federal grants for its noneditorializing broadcast activities." Ibid. Similarly, in Regan, we held that Congress could, in
the exercise of its spending power, reasonably refuse to subsidize
the lobbying activities of tax-exempt charitable organizations by
prohibiting such organizations from using tax-deductible
contributions to support their lobbying efforts. In so holding, we
explained that such organizations remained free "to receive
deductible contributions to support . . . nonlobbying
activit[ies]." 461 U.S. at 461 U. S. 545 . Thus, a charitable organization could
create, under § 501(c)(3) of the Internal Page 500 U. S. 198 Revenue Code of 1954, 26 U.S.C. § 501(c)(3), an affiliate to
conduct its nonlobbying activities using tax-deductible
contributions, and at the same time establish, under § 501(c)(4), a
separate affiliate to pursue its lobbying efforts without such
contributions. Regan, supra, at 461 U. S. 544 .
Given that alternative, the Court concluded that

															"Congress has not infringed any First Amendment rights or
regulated any First Amendment activity[; it] has simply chosen not
to pay for [appellee's] lobbying." Id. at 461 U. S. 546 .
We also noted that appellee

															"would, of course, have to ensure that th § 501(c)(3)
organization did not subsidize the § 501(c)(4) organization;
otherwise, public funds might be spent on an activity Congress
chose not to subsidize." Ibid. The condition that federal funds will be used
only to further the purposes of a grant does not violate
constitutional rights.

															"Congress could, for example, grant funds to an organization
dedicated to combating teenage drug abuse, but condition the grant
by providing that none of the money received from Congress should
be used to lobby state legislatures." See id. at 461 U. S.
548 .

															By requiring that the Title X grantee engage in abortion-related
activity separately from activity receiving federal funding,
Congress has, consistent with our teachings in League of Women
Voters and Regan, not denied it the right to engage
in abortion-related activities. Congress has merely refused to fund
such activities out of the public fisc, and the Secretary has
simply required a certain degree of separation from the Title X
project in order to ensure the integrity of the federally funded
program.

															The same principles apply to petitioners' claim that the
regulations abridge the free speech rights of the grantee's staff.
Individuals who are voluntarily employed for a Title X project must
perform their duties in accordance with the regulation's
restrictions on abortion counseling and referral. The employees
remain free, however, to pursue abortion-related activities when
they are not acting under the auspices of the Title X project. The
regulations, which govern solely Page 500 U. S. 199 the scope of the Title X project's activities, do not in any way
restrict the activities of those persons acting as private
individuals. The employees' freedom of expression is limited during
the time that they actually work for the project, but this
limitation is a consequence of their decision to accept employment
in a project, the scope of which is permissibly restricted by the
funding authority. [ Footnote
5 ]

															This is not to suggest that funding by the Government, even when
coupled with the freedom of the fund recipients to speak outside
the scope of the Government-funded project, is invariably
sufficient to justify government control over the content of
expression. For example, this Court has recognized Page 500 U. S. 200 that the existence of a Government "subsidy," in the form of
Government-owned property, does not justify the restriction of
speech in areas that have "been traditionally open to the public
for expressive activity," United States v. Kokinda, 497 U. S. 720 , 497 U. S. 726 (1990); Hague v. CIO, 307 U. S. 496 , 307 U. S. 515 (1939) (opinion of Roberts, J.), or have been "expressly dedicated
to speech activity." Kokinda, supra, at 497 U. S. 726 ; Perry Education Assn. v. Perry Local Educators' Assn., 460 U. S. 37 , 460 U. S. 45 (1983). Similarly, we have recognized that the university is a
traditional sphere of free expression so fundamental to the
functioning of our society that the Government's ability to control
speech within that sphere by means of conditions attached to the
expenditure of Government funds is restricted by the vagueness and
overbreadth doctrines of the First Amendment, Keyishian v.
Board of Regents, 385 U. S. 589 , 385 U. S. 603 , 385 U. S.
605 -606 (1967). It could be argued by analogy that
traditional relationships such as that between doctor and patient
should enjoy protection under the First Amendment from government
regulation, even when subsidized by the Government. We need not
resolve that question here, however, because the Title X program
regulations do not significantly impinge upon the doctorpatient
relationship. Nothing in them requires a doctor to represent as his
own any opinion that he does not in fact hold. Nor is the
doctor-patient relationship established by the Title X program
sufficiently all-encompassing so as to justify an expectation on
the part of the patient of comprehensive medical advice. The
program does not provide post-conception medical care, and
therefore a doctor's silence with regard to abortion cannot
reasonably be thought to mislead a client into thinking that the
doctor does not consider abortion an appropriate option for her.
The doctor is always free to make clear that advice regarding
abortion is simply beyond the scope of the program. In these
circumstances, the general rule that the Government may choose not
to subsidize speech applies with full force. Page 500 U. S. 201 IV We turn now to petitioners' argument that the regulations
violate a woman's Fifth Amendment right to choose whether to
terminate her pregnancy. We recently reaffirmed the long-recognized
principle that

															"'the Due Process Clauses generally confer no affirmative right
to governmental aid, even where such aid may be necessary to secure
life, liberty, or property interests of which the government itself
may not deprive the individual.'" Webster, 492 U.S. at 492 U. S. 507 ,
quoting DeShaney v. Winnebago County Dept. of Social
Services, 489 U. S. 189 , 489 U. S. 196 (1989). The Government has no constitutional duty to subsidize an
activity merely because the activity is constitutionally protected,
and may validly choose to fund childbirth over abortion and
" implement that judgment by the allocation of public funds'"
for medical services relating to childbirth, but not to those
relating to abortion. Webster, supra, 492 U.S. at 492 U. S. 510 (citation omitted). The Government has no affirmative duty to
"commit any resources to facilitating abortions," Webster, 492 U.S. at 492 U. S. 511 ,
and its decision to fund childbirth but not abortion "places no governmental obstacle in the path of a woman who
chooses to terminate her pregnancy, but rather, by means of unequal
subsidization of abortion and other medical services, encourages
alternative activity deemed in the public interest." McRae, 448 U.S. at 448 U. S.
315 .

															That the regulations do not impermissibly burden a woman's Fifth
Amendment rights is evident from the line of cases beginning with Maher and McRae and culminating in our most
recent decision in Webster. Just as Congress' refusal to
fund abortions in McRae left "an indigent woman with at
least the same range of choice in deciding whether to obtain a
medically necessary abortion as she would have had if Congress had
chosen to subsidize no health care costs at all," 448 U.S. at 448 U. S. 317 ,
and

															"Missouri's refusal to allow public employees to perform
abortions in public hospitals leaves a pregnant woman with the same
choices as if the State had chosen not Page 500 U. S. 202 to operate any public hospitals," Webster, supra, at 492 U. S. 509 ,
Congress' refusal to fund abortion counseling and advocacy leaves a
pregnant woman with the same choices as if the government had
chosen not to fund family planning services at all. The difficulty
that a woman encounters when a Title X project does not provide
abortion counseling or referral leaves her in no different position
than she would have been if the government had not enacted Title
X.

															In Webster, we stated that,

															"[h]aving held that the State's refusal [in Maher ] to
fund abortions does not violate Roe v. Wade, it strains
logic to reach a contrary result for the use of public facilities
and employees."

															492 U.S. at 492 U. S.
509 -510. It similarly would strain logic, in light of
the more extreme restrictions in those cases, to find that the mere
decision to exclude abortion-related services from a federally
funded pre-conceptual family planning program, is
unconstitutional.

															Petitioners also argue that by impermissibly infringing on the
doctor/patient relationship and depriving a Title X client of
information concerning abortion as a method of family planning, the
regulations violate a woman's Fifth Amendment right to medical
self-determination and to make informed medical decisions free of
government-imposed harm. They argue that, under our decisions in Akron v. Akron Center for Reproductive Health, Inc., 462 U. S. 416 (1983), and Thornburg v. American College of Obstetricians and
Gynecologists, 476 U. S. 747 (1986), the government cannot interfere with a woman's right to
make an informed and voluntary choice by placing restrictions on
the patient/doctor dialogue.

															In Akron, we invalidated a city ordinance requiring all physicians to make specified statements to the patient
prior to performing an abortion in order to ensure that the woman's
consent was "truly informed." 462 U.S. at 462 U. S. 423 .
Similarly, in Thornburg, we struck down a state statute
mandating that a list of agencies offering alternatives to abortion
and a description of fetal development be provided to every woman considering terminating her pregnancy through
an Page 500 U. S. 203 abortion. Critical to our decisions in Akron and Thornburg to invalidate a governmental intrusion into the
patient/doctor dialogue was the fact that the laws in both cases
required all doctors within their respective jurisdictions
to provide all pregnant patients contemplating an abortion
a litany of information, regardless of whether the patient sought
the information or whether the doctor thought the information
necessary to the patient's decision. Under the Secretary's
regulations, however, a doctor's ability to provide, and a woman's
right to receive, information concerning abortion and
abortion-related services outside the context of the Title X
project remains unfettered. It would undoubtedly be easier for a
woman seeking an abortion if she could receive information about
abortion from a Title X project, but the Constitution does not
require that the Government distort the scope of its mandated
program in order to provide that information.

															Petitioners contend, however, that most Title X clients are
effectively precluded by indigency and poverty from seeing a health
care provider who will provide abortion-related services. But once
again, even these Title X clients are in no worse position than if
Congress had never enacted Title X.

															"The financial constraints that restrict an indigent woman's
ability to enjoy the full range of constitutionally protected
freedom of choice are the product not of governmental restrictions
on access to abortion, but rather of her indigency." McRae, supra, 448 U.S. at 448 U. S.
316 .

															The Secretary's regulations are a permissible construction of
Title X, and do not violate either the First or Fifth Amendments to
the Constitution. Accordingly, the judgment of the Court of Appeals
is Affirmed. [ Footnote 1 ]

															Both the First Circuit and the Tenth Circuit have invalidated
the regulations, primarily on constitutional grounds. See
Massachusetts v. Secretary of Health and Human Services, 899
F.2d 53 (CA1 1990); Planned Parenthood Federation of America v.
Sullivan, 913 F.2d 1492 (CA10 1990).

															[ Footnote 2 ]

															"Most clients of title X-sponsored clinics are not pregnant, and
generally receive only physical examinations, education on
contraceptive methods, and services related to birth control."

															General Accounting Office Report, App. at 95.

															[ Footnote 3 ]

															For instance, the Secretary relies on the following passage of
the House Report as evidence that the regulations are consistent
with legislative intent:

															"It is, and has been, the intent of both Houses that the funds
authorized under this legislation be used only to support
preventive family planning services, population research,
infertility services, and other related medical, informational, and
educational activities. The conferees have adopted the language
contained in section 1008, which prohibits the use of such funds
for abortion, in order to make this intent clear."

															H.R.Conf.Rep. No. 91-1667, p. 8 (1970), U.S.Code Cong.Admin.News
1970, pp. 5081-82. Petitioners, however, point to language in the
statement of purpose in the House Report preceding the passage of
Title X stressing the importance of supplying both family planning
information and a full range of family planning information, and of
developing a comprehensive and coordinated program. Petitioners
also rely on the Senate Report which states:

															"The committee does not view family planning as merely a
euphemism for birth control. It is properly a part of comprehensive
health care, and should consist of much more than the dispensation
of contraceptive devices. . . . [A] successful family planning
program must contain . . . [m]edical services, including
consultation examination, prescription, and continuing supervision,
supplies, instruction, and referral to other medical services as
needed."

															S.Rep. No. 91-1004, p. 10 (1970).

															These directly conflicting statements of legislative intent
demonstrate amply the inadequacies of the "traditional tools of
statutory construction," Immigration and
Naturalization Service v. Cardoza-Fonseca , 480 U.S.
[421] at 480 U. S.
446 -447, in resolving the issue before us.

															[ Footnote 4 ]

															We also find that, on their face, the regulations are narrowly
tailored to fit Congress' intent in Title X that federal funds not
be used to "promote or advocate" abortion as a "method of family
planning." The regulations are designed to ensure compliance with
the prohibition of § 1008 that none of the funds appropriated under
Title X be used in a program where abortion is a method of family
planning. We have recognized that Congress' power to allocate funds
for public purposes includes an ancillary power to ensure that
those funds are properly applied to the prescribed use. See
South Dakota v. Dole, 483 U. S. 203 , 483 U. S.
207 -209 (1987) (upholding against Tenth Amendment
challenge requirement that States raise drinking age as condition
to receipt of federal highway funds); Buckley v. Valeo, 424 U. S. 1 , 424 U. S. 99 (1976).

															[ Footnote 5 ]

															Petitioners also contend that the regulations violate the First
Amendment by penalizing speech funded with non-Title X monies. They
argue that, since Title X requires that grant recipients contribute
to the financing of Title X projects through the use of matching
funds and grant-related income, the regulation's restrictions on
abortion counseling and advocacy penalize privately funded
speech.

															We find this argument flawed for several reasons. First, Title X
subsidies are just that, subsidies. The recipient is in no way
compelled to operate a Title X project; to avoid the force of the
regulations, it can simply decline the subsidy. See Grove City
College v. Bell, 465 U. S. 555 , 465 U. S. 575 (1984) (petitioner's First Amendment rights not violated, because
it "may terminate its participation in the [federal] program, and
thus avoid the requirements of [the federal program]"). By
accepting Title X funds, a recipient voluntarily consents to any
restrictions placed on any matching funds or grant-related income.
Potential grant recipients can choose between accepting Title X
funds -- subject to the Government's conditions that they provide
matching funds and forgo abortion counseling and referral in the
Title X project -- or declining the subsidy and financing their own
unsubsidized program. We have never held that the Government
violates the First Amendment simply by offering that choice.
Second, the Secretary's regulations apply only to Title X programs.
A recipient is therefore able to "limi[t] the use of its federal
funds to [Title X] activities." FCC v. League of Women Voters
of Cal., 468 U. S. 364 , at 468 U. S. 400 (1984). It is in no way "barred from using even wholly private
funds to finance" its pro-abortion activities outside the Title X
program. Ibid. The regulations are limited to Title X
funds; the recipient remains free to use private, non-Title X funds
to finance abortion-related activities.

															JUSTICE BLACKMUN, with whom JUSTICE MARSHALL joins, with whom
JUSTICE STEVENS joins as to Parts II and Page 500 U. S. 204 III, and with whom JUSTICE O'CONNOR joins as to Part I,
dissenting.

															Casting aside established principles of statutory construction
and administrative jurisprudence, the majority in these cases today
unnecessarily passes upon important questions of constitutional
law. In so doing, the Court, for the first time, upholds
viewpoint-based suppression of speech solely because it is imposed
on those dependent upon the Government for economic support. Under
essentially the same rationale, the majority upholds direct
regulation of dialogue between a pregnant woman and her physician
when that regulation has both the purpose and the effect of
manipulating her decision as to the continuance of her pregnancy. I
conclude that the Secretary's regulation of referral, advocacy, and
counseling activities exceeds his statutory authority, and also
that the Regulations violate the First and Fifth Amendments of our
Constitution. Accordingly, I dissent, and would reverse the
divided-vote judgment of the Court of Appeals. I The majority does not dispute that "[f]ederal statutes are to be
so construed as to avoid serious doubt of their constitutionality." Machinists v. Street, 367 U. S. 740 , 367 U. S. 749 (1961). See also Hooper v. California, 155 U.
S. 648 , 155 U. S. 657 (1895); Crowell v. Benson, 285 U. S.
22 , 285 U. S. 62 (1932); United States v. Security Industrial Bank, 459 U. S. 70 , 459 U. S. 78 (1982). Nor does the majority deny that this principle is fully
applicable to cases such as the instant one, in which a plausible
but constitutionally suspect statutory interpretation is embodied
in an administrative regulation. See Edward J. DeBartolo Corp.
v. Florida Gulf Coast Building & Construction Trades
Council, 485 U. S. 568 , 485 U. S. 575 (1988); NLRB v. Catholic Bishop of Chicago, 440 U.
S. 490 (1979); Kent v. Dulles, 357 U.
S. 116 , 357 U. S.
129 -130 (1958). Rather, in its zeal to address the
constitutional issues, the majority sidesteps this established
canon of construction with the feeble excuse that the
challenged Page 500 U. S. 205 Regulations

															"do not raise the sort of 'grave and doubtful constitutional
questions,' . . . that would lead us to assume Congress did not
intend to authorize their issuance." Ante at 500 U. S. 191 ,
quoting United States v. Delaware and Hudson Co., 213 U. S. 366 , 213 U. S. 408 (1909).

															This facile response to the intractable problem the Court
addresses today is disingenuous, at best. Whether or not one
believes that these Regulations are valid, it avoids reality to
contend that they do not give rise to serious constitutional
questions. The canon is applicable to this case not because "it was
likely that [the Regulations] . . . would be challenged on
constitutional grounds," ante at 500 U. S. 191 ,
but because the question squarely presented by the Regulations --
the extent to which the Government may attach an otherwise
unconstitutional condition to the receipt of a public benefit --
implicates a troubled area of our jurisprudence in which a court
ought not entangle itself unnecessarily. See, e.g., Epstein, Unconstitutional Conditions, State Power, and the Limits
of Consent, 102 Harv.L.Rev. 4, 6 (1988) (describing this problem as
"the basic structural issue that for over a hundred years has
bedeviled courts and commentators alike. . . ."); Sullivan,
Unconstitutional Conditions, 102 Harv.L.Rev. 1413, 1415-1416 (1989)
(observing that this Court's unconstitutional conditions cases
"seem a minefield to be traversed gingerly").

															As is discussed in Parts II and III, infra, the
Regulations impose viewpoint-based restrictions upon protected
speech, and are aimed at a woman's decision whether to continue or
terminate her pregnancy. In both respects, they implicate core
constitutional values. This verity is evidenced by the fact that
two of the three Courts of Appeals that have entertained challenges
to the Regulations have invalidated them on constitutional grounds. See Massachusetts v. Secretary of Health and Human
Services, 899 F.2d 53 (CA1 1990); Planned Parenthood
Federation of America v. Sullivan, 913 F.2d 1492 (CA10
1990). Page 500 U. S. 206 A divided panel of the Tenth Circuit found the Regulations

															"fal[l] squarely within the prohibition in Thornburgh v.
American College of Obstetricians and Gynecologists, 476 U. S.
747 (1986), and City of Akron v. Akron Center for
Reproductive Health, Inc., 462 U. S. 416 (1983), against
intrusion into the advice a woman requests from or is given by her
doctor."

															913 F.2d at 1501. The First Circuit, en banc with one judge
dissenting, found the Regulations to violate both the privacy
rights of Title X patients and the First Amendment rights of Title
X grantees. See also New York v. Sullivan, 889 F.2d 401,
415 (CA2 1989) (Kearse, J., dissenting in part). That a bare
majority of this Court today reaches a different result does not
change the fact that the constitutional questions raised by the
Regulations are both grave and doubtful.

															Nor is this a case in which the statutory language itself
requires us to address a constitutional question. Section 1008 of
the Public Health Service Act, 84 Stat. 1508, 42 U.S.C. § 300a-6,
provides simply: "None of the funds appropriated under this title
shall be used in programs where abortion is a method of family
planning." The majority concedes that this language "does not speak
directly to the issues of counseling, referral, advocacy, or
program integrity," ante at 500 U. S. 184 ,
and that "the legislative history is ambiguous" in this respect. Ante at 500 U. S. 186 .
Consequently, the language of § 1008 easily sustains a
constitutionally trouble-free interpretation. [ Footnote 2/1 ] Page 500 U. S. 207 Thus, this is not a situation in which "the intention of
Congress is revealed too distinctly to permit us to ignore it
because of mere misgivings as to power." Moore Ice Cream Co. v.
Rose, 289 U. S. 373 , 289 U. S. 379 (1933). Indeed, it would appear that our duty to avoid passing
unnecessarily upon important constitutional questions is strongest
where, as here, the language of the statute is decidedly ambiguous.
It is both logical and eminently prudent to assume that, when
Congress intends to press the limits of constitutionality in its
enactments, it will express that intent in explicit and unambiguous
terms. See Sunstein, Law and Administration After Chevron, 90 Colum.L.Rev. 2071, 2113 (1990) ("It is thus
implausible that, after Chevron, agency interpretations of
ambiguous statutes will prevail even if the consequence of those
interpretations is to produce invalidity or to raise serious
constitutional doubts").

															Because I conclude that a plainly constitutional construction of
§ 1008 "is not only fairly possible' but entirely reasonable," Machinists, 367 U.S. at 367 U. S. 750 ,
I would reverse the judgment of the Court of Appeals on this ground
without deciding the constitutionality of the Secretary's
Regulations. II I also strongly disagree with the majority's disposition of
petitioners' constitutional claims, and because I feel that a
response thereto is indicated, I move on to that issue. A Until today, the Court never has upheld viewpoint-based
suppression of speech simply because that suppression was a
condition upon the acceptance of public funds. Whatever may be the
Government's power to condition the receipt of its largess upon the
relinquishment of constitutional rights, it surely does not extend
to a condition that suppresses the recipient's cherished freedom of
speech based solely upon the content or viewpoint of that speech. Speiser v. Randall, 357 U. S. 513 , 357 U. S.
518 -519 (1958) ("To deny an exemption to claimants Page 500 U. S. 208 who engage in certain forms of speech is in effect to penalize
them for such speech. . . . The denial is frankly aimed at the
suppression of dangerous ideas,'" quoting American
Communications Assn. v. Douds, 339 U.
S. 382 , 339 U. S. 402 (1950)). See Cammarano v. United States, 358 U.
S. 498 , 358 U. S. 513 (1959). See also League of Women Voters, 468 U.S. at 468 U. S. 407 (REHNQUIST, J., dissenting). Cf. Arkansas Writers' Project,
Inc. v. Ragland, 481 U. S. 221 , 481 U. S. 237 (1987) (SCALIA, J., dissenting). This rule is a sound one, for, as
the Court often has noted: ""A regulation of speech that is motivated by nothing more than
a desire to curtail expression of a particular point of view on
controversial issues of general interest is the purest example of a law . . . abridging the freedom of speech, or of the
press.'"" League of Women Voters, 468 U.S. at 468 U. S.
383 -384, quoting Consolidated Edison Co. v. Public
Service Comm'n of New York, 447 U. S. 530 , 447 U. S. 546 (1980) (STEVENS, J., concurring in judgment).

															"[A]bove all else, the First Amendment means that government has
no power to restrict expression because of its message, its ideas,
its subject matter, or its content." Police Department of Chicago v. Mosley, 408 U. S.
92 , 408 U. S. 95 (1972).

															Nothing in the Court's opinion in Regan v. Taxation With
Representation of Washington, 461 U.
S. 540 (1983), can be said to challenge this
long-settled understanding. In Regan, the Court upheld a
content-neutral provision of the Internal Revenue Code, 26 U.S.C. §
501(c)(3), that disallowed a particular tax-exempt status to
organizations that "attempt[ed] to influence legislation," while
affording such status to veterans' organizations irrespective of
their lobbying activities. Finding the case controlled by Cammarano, supra, the Court explained:

															"The case would be different if Congress were to discriminate
invidiously in its subsidies in such a way as to " ai[m] at the
suppression of dangerous ideas.'" . . . We find no indication that
the statute was intended to suppress any ideas or any demonstration
that it has had that effect." 461 U.S. at 461 U. S. 548 ,
quoting Cammarano, 358 U.S. at Page 500 U. S. 209 358 U. S. 513 ,
in turn quoting Speiser, 357 U.S. at 357 U. S. 519 .
The separate concurrence in Regan joined the Court's
opinion precisely

															"[b]ecause 26 U.S.C. § 501's discrimination between veterans'
organizations and charitable organizations is not based on the
content of their speech." Id. 461 U.S. at 461 U. S.
551 .

															It cannot seriously be disputed that the counseling and referral
provisions at issue in the present cases constitute content-based
regulation of speech. Title X grantees may provide counseling and
referral regarding any of a wide range of family planning and other
topics, save abortion. Cf. Consolidated Edison Co., 447
U.S. at 447 U. S. 537 ("The First Amendment's hostility to content-based regulation
extends not only to restrictions on particular viewpoints, but also
to prohibition of public discussion of an entire topic"); Boos
v. Barry, 485 U. S. 312 , 485 U. S. 319 (1988) (opinion of O'CONNOR, J.) (same).

															The Regulations are also clearly viewpoint-based. While
suppressing speech favorable to abortion with one hand, the
Secretary compels anti-abortion speech with the other. For example,
the Department of Health and Human Services' own description of the
Regulations makes plain that

															"Title X projects are required to facilitate access to
prenatal care and social services, including adoption services,
that might be needed by the pregnant client to promote her
wellbeing and that of her child, while making it abundantly clear
that the project is not permitted to promote abortion by
facilitating access to abortion through the referral process."

															53 Fed.Reg. 2927 (1988) (emphasis added).

															Moreover, the Regulations command that a project refer for
prenatal care each woman diagnosed as pregnant, irrespective of the
woman's expressed desire to continue or terminate her pregnancy. 42
CFR § 59.8(a)(2) (1990). If a client asks directly about abortion,
a Title X physician or counselor is required to say, in essence,
that the project does not consider abortion to be an appropriate
method of family planning. § 59.8(b)(4). Both requirements are
antithetical to Page 500 U. S. 210 the First Amendment. See Wooley v. Maynard, 430 U. S. 705 , 430 U. S. 714 (1977).

															The Regulations pertaining to "advocacy" are even more
explicitly viewpoint-based. These provide: "A Title X project may
not encourage, promote or advocate abortion as a method of
family planning." § 59.10 (emphasis added). They explain:

															"This requirement prohibits actions to assist women to
obtain abortions or increase the availability or
accessibility of abortion for family planning purposes."

															§ 59.10(a) (emphasis added). The Regulations do not, however,
proscribe or even regulate antiabortion advocacy. These are clearly
restrictions aimed at the suppression of "dangerous ideas."

															Remarkably, the majority concludes that "the Government has not
discriminated on the basis of viewpoint; it has merely chosen to
fund one activity to the exclusion of another." Ante at 500 U. S. 193 .
But the majority's claim that the Regulations merely limit a Title
X project's speech to preventive or preconceptional services, ibid., rings hollow in light of the broad range of
non-preventive services that the Regulations authorize Title X
projects to provide. [ Footnote 2/2 ]
By refusing to fund those family planning projects that advocate
abortion because they advocate abortion, the Government plainly has
targeted a particular viewpoint. Cf. Ward v. Rock Against
Racism, 491 U. S. 781 (1989). The majority's reliance on the fact that the Regulations
pertain solely to funding decisions simply begs the question.
Clearly, there are some bases upon which government may not rest
its decision to fund or not to fund. For example, the Members of
the majority surely would agree that government may not base
its Page 500 U. S. 211 decision to support an activity upon considerations of race. See, e.g., Yick Wo v. Hopkins, 118 U.
S. 356 (1886). As demonstrated above, our cases make
clear that ideological viewpoint is a similarly repugnant ground
upon which to base funding decisions.

															The majority's reliance upon Regan in this connection
is also misplaced. That case stands for the proposition that
government has no obligation to subsidize a private party's efforts
to petition the legislature regarding its views. Thus, if the
challenged Regulations were confined to nonideological limitations
upon the use of Title X funds for lobbying activities, there would
exist no violation of the First Amendment. The advocacy Regulations
at issue here, however, are not limited to lobbying, but extend to
all speech having the effect of encouraging, promoting, or
advocating abortion as a method of family planning. § 59.10(a).
Thus, in addition to their impermissible focus upon the viewpoint
of regulated speech, the provisions intrude upon a wide range of
communicative conduct, including the very words spoken to a woman
by her physician. By manipulating the content of the doctor/patient
dialogue, the Regulations upheld today force each of the
petitioners "to be an instrument for fostering public adherence to
an ideological point of view [he or she] finds unacceptable." Wooley v. Maynard, 430 U.S. at 430 U. S. 715 .
This type of intrusive, ideologically based regulation of speech
goes far beyond the narrow lobbying limitations approved in Regan, and cannot be justified simply because it is a
condition upon the receipt of a governmental benefit. [ Footnote 2/3 ] Page 500 U. S. 212 B The Court concludes that the challenged Regulations do not
violate the First Amendment rights of Title X staff members,
because any limitation of the employees' freedom of expression is
simply a consequence of their decision to accept employment at a
federally funded project. Ante at 500 U. S.
198 -199. But it has never been sufficient to justify an
otherwise unconstitutional condition upon public employment that
the employee may escape the condition by relinquishing his or her
job. It is beyond question

															"that a government may not require an individual to relinquish
rights guaranteed him by the First Amendment as a condition of
public employment." Abood v. Detroit Board of Education, 431 U.
S. 209 , 431 U. S. 234 (1977), citing Elrod v. Burns, 427 U.
S. 347 , 427 U. S.
357 -360 (1976), and cases cited therein; Perry v.
Sindermann, 408 U. S. 593 (1972); Keyishian v. Board of Regents, 385 U.
S. 589 (1967). Nearly two decades ago, it was said:

															"For at least a quarter-century, this Court has made clear that,
even though a person has no 'right' to a valuable governmental
benefit, and even though the government may deny him the benefit
for any number of reasons, there are some reasons upon which the
government may not rely. It may not deny a benefit to a Page 500 U. S. 213 person on a basis that infringes his constitutionally protected
interests -- especially, his interest in freedom of speech. For if
the government could deny a benefit to a person because of his
constitutionally protected speech or associations, his exercise of
those freedoms would, in effect, be penalized and inhibited. This
would allow the government to 'produce a result which [it] could
not command directly.'" Perry v. Sindermann, 408 U.S. at 408 U. S. 597 ,
quoting Speiser v. Randall, 357 U.
S. 513 , 357 U. S. 526 (1958).

															The majority attempts to circumvent this principle by
emphasizing that Title X physicians and counselors "remain free . .
. to pursue abortion-related activities when they are not acting
under the auspices of the Title X project." Ante at 500 U. S. 198 .
"The regulations," the majority explains, "do not in any way
restrict the activities of those persons acting as private
individuals." Ibid. Under the majority's reasoning, the
First Amendment could be read to tolerate any governmental
restriction upon an employee's speech so long as that restriction
is limited to the funded workplace. This is a dangerous
proposition, and one the Court has rightly rejected in the
past.

															In Abood, it was no answer to the petitioners' claim of
compelled speech as a condition upon public employment that their
speech outside the workplace remained unregulated by the State. Nor
was the public employee's First Amendment claim in Rankin v.
McPherson, 483 U. S. 378 (1987), derogated because the communication that her employer
sought to punish occurred during business hours. At the least, such
conditions require courts to balance the speaker's interest in the
message against those of government in preventing its
dissemination. Id. at 483 U. S. 384 ; Pickering v. Board of Education, 391 U.
S. 563 , 391 U. S. 568 (1968).

															In the cases at bar, the speaker's interest in the communication
is both clear and vital. In addressing the family planning needs of
their clients, the physicians and counselors who staff Title X
projects seek to provide them with the full range of information
and options regarding their health and reproductive freedom.
Indeed, the legitimate expectations Page 500 U. S. 214 of the patient and the ethical responsibilities of the medical
profession demand no less.

															"The patient's right of self-decision can be effectively
exercised only if the patient possesses enough information to
enable an intelligent choice. . . . The physician has an ethical
obligation to help the patient make choices from among the
therapeutic alternatives consistent with good medical
practice."

															Current Opinions, the Council on Ethical and Judicial Affairs of
the American Medical Association � 8.08 (1989). See also President's Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research, Making Health Care
Decisions 70 (1982); American College of Obstetricians &
Gynecologists, Standards for Obstetric-Gynecologic Services 62 (7th
ed.1989). When a client becomes pregnant, the full range of
therapeutic alternatives includes the abortion option, and Title X
counselors' interest in providing this information is
compelling.

															The Government's articulated interest in distorting the
doctor/patient dialogue -- ensuring that federal funds are not
spent for a purpose outside the scope of the program -- falls far
short of that necessary to justify the suppression of truthful
information and professional medical opinion regarding
constitutionally protected conduct. [ Footnote 2/4 ] Moreover, the offending Regulation is not
narrowly tailored to serve this interest. For example, the
governmental interest at stake could be served by imposing rigorous
bookkeeping standards to ensure financial separation or adopting
content-neutral rules for the balanced dissemination of family
planning and health information. See Massachusetts v. Secretary
of Health & Human Services, 899 F.2d 53, 74 (CA1 1990), cert. pending, No. 89-1929. By failing to balance or even
to consider the free speech interests claimed by Title X physicians
against the Government's asserted interest in suppressing the
speech, the Court falters in its duty to implement the
protection Page 500 U. S. 215 that the First Amendment clearly provides for this important
message. C Finally, it is of no small significance that the speech the
Secretary would suppress is truthful information regarding
constitutionally protected conduct of vital importance to the
listener. One can imagine no legitimate governmental interest that
might be served by suppressing such information. Concededly, the
abortion debate is among the most divisive and contentious issues
that our Nation has faced in recent years.

															"But freedom to differ is not limited to things that do not
matter much. That would be a mere shadow of freedom. The test of
its substance is the right to differ as to things that touch the
heart of the existing order." West Virginia Board of Education v. Barnette, 319 U. S. 624 , 319 U. S. 642 (1943). III By far the most disturbing aspect of today's ruling is the
effect it will have on the Fifth Amendment rights of the women who,
supposedly, are beneficiaries of Title X programs. The majority
rejects petitioners' Fifth Amendment claims summarily. It relies
primarily upon the decisions in Harris v. McRae, 448 U. S. 297 (1980), and Webster v. Reproductive Health Services, 492 U. S. 490 (1989). There were dissents in those cases, and we continue to
believe that they were wrongly and unfortunately decided. Be that
as it may, even if one accepts as valid the Court's theorizing in
those cases, the majority's reasoning in the present cases is
flawed.

															Until today, the Court has allowed to stand only those
restrictions upon reproductive freedom that, while limiting the
availability of abortion, have left intact a woman's ability to
decide without coercion whether she will continue her pregnancy to
term. Maher v. Roe, 432 U. S. 464 (1977), McRae, and Webster are all to this
effect. Today's decision abandons that principle, and with
disastrous results. Page 500 U. S. 216 Contrary to the majority's characterization, this is not a case
in which individuals seek government aid in exercising their
fundamental rights. The Fifth Amendment right asserted by
petitioners is the right of a pregnant woman to be free from
affirmative governmental interference in her decision. Roe v. Wade, 410 U. S. 113 (1973), and its progeny are not so much about a medical procedure
as they are about a woman's fundamental right to
self-determination. Those cases serve to vindicate the idea that
"liberty," if it means anything, must entail freedom from
governmental domination in making the most intimate and personal of
decisions. See, e.g., Akron v. Akron Center for Reproductive
Health, Inc., 462 U. S. 416 , 462 U. S. 444 (1983) (governmental interest in ensuring that pregnant women
receive medically relevant information "will not justify abortion
regulations designed to influence the woman's informed choice
between abortion or childbirth"); Maher v. Roe, 432 U.S.
at 432 U. S. 473 (noting that the Court's abortion cases "recognize a
constitutionally protected interest in making certain kinds of
important decisions' free from governmental compulsion," quoting Whalen v. Roe, 429 U. S. 589 , 429 U. S. 599 (1977)); see also Harris v. McRae, 448 U.S. at 448 U. S. 312 ; Thornburgh, 476 U.S. at 476 U. S. 759 ; Roe v. Wade, 410 U.S. at 410 U. S.
169 -170 (Stewart, J., concurring). By suppressing
medically pertinent information and injecting a restrictive
ideological message unrelated to considerations of maternal health,
the Government places formidable obstacles in the path of Title X
clients' freedom of choice and thereby violates their Fifth
Amendment rights. It is crystal clear that the aim of the challenged provisions --
an aim the majority cannot escape noticing -- is not simply to
ensure that federal funds are not used to perform abortions, but to
"reduce the incidence of abortion." 42 CFR § 59.2 (1990) (in
definition of "family planning"). As recounted above, the
Regulations require Title X physicians and counselors to provide
information pertaining only to childbirth, Page 500 U. S. 217 to refer a pregnant woman for prenatal care irrespective of her
medical situation, and, upon direct inquiry, to respond that
abortion is not an "appropriate method" of family planning.

															The undeniable message conveyed by this forced speech, and the
one that the Title X client will draw from it, is that abortion
nearly always is an improper medical option. Although her
physician's words, in fact, are strictly controlled by the
Government, and wholly unrelated to her particular medical
situation, the Title X client will reasonably construe them as
professional advice to forgo her right to obtain an abortion. As
would most rational patients, many of these women will follow that
perceived advice and carry their pregnancy to term, despite their
needs to the contrary and despite the safety of the abortion
procedure for the vast majority of them. Others, delayed by the
Regulations' mandatory prenatal referral, will be prevented from
acquiring abortions during the period in which the process is
medically sound and constitutionally protected.

															In view of the inevitable effect of the Regulations, the
majority's conclusion that

															"[t]he difficulty that a woman encounters when a Title X project
does not provide abortion counseling or referral leaves her in no
different position than she would have been if the government had
not enacted Title X," ante at 500 U. S. 202 ,
is insensitive and contrary to common human experience. Both the
purpose and result of the challenged Regulations is to deny women
the ability voluntarily to decide their procreative destiny. For
these women, the Government will have obliterated the freedom to
choose as surely as if it had banned abortions outright. The denial
of this freedom is not a consequence of poverty, but of the
Government's ill-intentioned distortion of information it has
chosen to provide. [ Footnote
2/5 ] Page 500 U. S. 218 The substantial obstacles to bodily self-determination that the
Regulations impose are doubly offensive because they are effected
by manipulating the very words spoken by physicians and counselors
to their patients. In our society, the doctor/patient dialogue
embodies a unique relationship of trust. The specialized nature of
medical science and the emotional distress often attendant to
health-related decisions requires that patients place their
complete confidence, and often their very lives, in the hands of
medical professionals. One seeks a physician's aid not only for
medication or diagnosis, but also for guidance, professional
judgment, and vital emotional support. Accordingly, each of us
attaches profound importance and authority to the words of advice
spoken by the physician.

															It is for this reason that we have guarded so jealously the
doctor/patient dialogue from governmental intrusion.

															"[I]n Roe and subsequent cases, we have 'stressed
repeatedly the central role of the physician, both in consulting
with the woman about whether or not to have an abortion, and in
determining how any abortion was to be carried out.'" Akron, 462 U.S. at 462 U. S. 447 quoting Colautti v. Franklin, 439 U.
S. 379 , 439 U. S. 387 (1979). See also Thornburgh, 476 U.S. at 476 U. S. 763 .
The majority's approval of the Secretary's Regulations flies in the
face of our repeated warnings that regulations tending to "confine
the attending physician in an undesired and uncomfortable
straitjacket in the practice of his profession," cannot endure. Planned Parenthood of Central Mo. v. Danforth, 428 U. S. 52 , 428 U. S. 67 , n.
8 (1976).

															The majority attempts to distinguish our holdings in Akron and Thornburgh on the post hoc basis that the governmental Page 500 U. S. 219 intrusions into the doctor/patient dialogue invalidated in those
cases applied to all physicians within a jurisdiction
while the Regulations now before the Court pertain to the narrow
class of healthcare professionals employed at Title X projects. Ante at 500 U. S. 202 .
But the rights protected by the Constitution are personal rights. Loving v. Virginia, 388 U. S.
1 , 388 U. S. 12 (1967); Shelley v. Kraemer, 334 U. S.
1 , 334 U. S. 22 (1948). And for the individual woman, the deprivation of liberty by
the Government is no less substantial because it affects few,
rather than many. It cannot be that an otherwise unconstitutional
infringement of choice is made lawful because it touches only some
of the Nation's pregnant women, and not all of them.

															The manipulation of the doctor/patient dialogue achieved through
the Secretary's Regulations is clearly an effort "to deter a woman
from making a decision that, with her physician, is hers to make." Thornburgh, 476 U.S. at 476 U. S. 759 .
As such, it violates the Fifth Amendment. [ Footnote 2/6 ] IV In its haste further to restrict the right of every woman to
control her reproductive freedom and bodily integrity, the majority
disregards established principles of law and contorts this Court's
decided cases to arrive at its preordained result. The majority
professes to leave undisturbed the free speech protections upon
which our society has come to rely, but one must wonder what force
the First Amendment retains if it is read to countenance the
deliberate manipulation by the Government Page 500 U. S. 220 of the dialogue between a woman and her physician. While
technically leaving intact the fundamental right protected by Roe v. Wade, the Court, "through a relentlessly
formalistic catechism," McRae, 448 U.S. at 448 U. S. 341 (MARSHALL, J., dissenting), once again has rendered the right's
substance nugatory. See Webster v. Reproductive Health
Services, 492 U.S. at 492 U. S. 537 (opinions concurring in part and
dissenting in part). This is a course nearly as noxious as
overruling Roe directly, for if a right is found to be
unenforceable, even against flagrant attempts by government to
circumvent it, then it ceases to be a right at all. This, I fear,
may be the effect of today's decision.

															[ Footnote 2/1 ]

															The majority states: "There is no question but that the
statutory prohibition contained in § 1008 is constitutional." Ante at 500 U. S. 192 .
This statement simply begs the question. Were the Court to read §
1008 to prohibit only the actual performance of abortions with
Title X fund as, indeed, the Secretary did until February 2, 1988, see 53 Bed.Reg. 2923 (1988) -- the provision would fall
within the category of restrictions that the Court upheld in Harris v. McRae, 448 U. S. 297 (1980), and Maher v. Roe, 432 U.
S. 464 (1977). By interpreting the statute to authorize
the regulation of abortion-related speech between physician and
patient, however, the Secretary, and now the Court, have rejected a
constitutionally sound construction in favor of one that is by no
means clearly constitutional.

															[ Footnote 2/2 ]

															In addition to requiring referral for prenatal care and adoption
services, the Regulations permit general health services such as
physical examinations, screening for breast cancer, treatment of
gynecological problems, and treatment for sexually transmitted
diseases. 53 Fed.Reg. 2927 (1988). None of the latter are strictly
preventive, preconceptional services.

															[ Footnote 2/3 ]

															The majority attempts to obscure the breadth of its decision
through its curious contention that "the Title X program
regulations do not significantly impinge upon the doctor-patient
relationship." Ante at 500 U. S. 200 .
That the doctor-patient relationship is substantially burdened by a
rule prohibiting the dissemination by the physician of pertinent
medical information is beyond serious dispute. This burden is
undiminished by the fact that the relationship at issue here is not
an "all-encompassing" one. A woman seeking the services of a Title
X clinic has every reason to expect, as do we all, that her
physician will not withhold relevant information regarding the very
purpose of her visit. To suggest otherwise is to engage in
uninformed fantasy. Further, to hold that the doctor-patient
relationship is somehow incomplete where a patient lacks the
resources to seek comprehensive health care from a single provider
is to ignore the situation of a vast number of Americans. As
JUSTICE MARSHALL has noted in a different context:

															"It is perfectly proper for judges to disagree about what the
Constitution requires. But it is disgraceful for an interpretation
of the Constitution to be premised upon unfounded assumptions about
how people live." United States v. Kras, 409 U.
S. 434 , 409 U. S. 460 (1973) (dissenting opinion).

															[ Footnote 2/4 ]

															It is to be noted that the Secretary has made no claim that the
Regulations at issue reflect any concern for the health or welfare
of Title X clients.

															[ Footnote 2/5 ]

															In the context of common law tort liability, commentators have
recognized:

															"If there is no duty to go to the assistance of a person in
difficulty or peril, there is at least a duty to avoid any
affirmative acts which make his situation worse. . . . The same is
true, of course, of a physician who accepts a charity patient. Such
a defendant will then be liable for a failure to use reasonable
care for the protection of the plaintiffs interests."

															P. Keeton et al., Prosser and Keeton on the Law of
Torts 378 (5th ed.1984) (footnotes omitted). This observation seems
equally appropriate to the cases at bar.

															[ Footnote 2/6 ]

															Significantly, the Court interprets the challenged regulations
to allow a Title X project to refer a woman whose health would be
seriously endangered by continued pregnancy to an abortion
provider. Ante at 500 U. S. 195 . To hold otherwise would be to adopt an
interpretation that would most certainly violate a patient's right
to substantive due process. See, e.g., Youngberg v. Romeo, 457 U. S. 307 (1982); Revere v. Massachusetts General Hospital, 463 U. S. 239 (1983). The Solicitor General at oral argument, however, afforded
the Regulations a far less charitable interpretation. See Tr. of Oral Arg. 44-47.

															JUSTICE STEVENS, dissenting.

															In my opinion, the Court has not paid sufficient attention to
the language of the controlling statute or to the consistent
interpretation accorded the statute by the responsible cabinet
officers during four different Presidencies and 18 years.

															The relevant text of the "Family Planning Services and
Population Research Act of 1970" has remained unchanged since its
enactment. 84 Stat. 1504. The preamble to the Act states that it
was passed:

															"To promote public health and welfare by expanding, improving,
and better coordinating the family planning services and population
research activities of the Federal Government, and for other
purposes." Ibid. The declaration of congressional purposes
emphasizes the importance of educating the public about family
planning services. Thus, § 2 of the Act states, in part, that the
purpose of the Act is:

															"(1) to assist in making comprehensive voluntary family planning
services readily available to all persons desiring such
services;" * * * * "(5) to develop and make readily available information
(including educational materials) on family planning and Page 500 U. S. 221 population growth to all persons desiring such information."

															42 U.S.C. § 300 (Congressional Declaration of Purpose).

															In contrast to the statutory emphasis on making relevant
information readily available to the public, the statute contains
no suggestion that Congress intended to authorize the suppression
or censorship of any information by any Government employee or by
any grant recipient.

															Section 6 of the Act authorizes the provision of federal funds
to support the establishment and operation of voluntary family
planning projects. The section also empowers the Secretary to
promulgate regulations imposing conditions on grant recipients to
ensure that "such grants will be effectively utilized for the
purposes for which made." § 300a-4(b). Not a word in the statute,
however, authorizes the Secretary to impose any restrictions on the
dissemination of truthful information or professional advice by
grant recipients.

															The word "prohibition" is used only once in the Act. Section 6,
which adds to the Public Health Service Act the new Title X,
covering the subject of population research and voluntary planning
programs, includes the following provision:

															"PROHIBITION OF ABORTION"

															"SEC. 1008. None of the funds appropriated under this title
shall be used in programs where abortion is a method of family
planning."

															84 Stat. 1508, 42 U.S.C. § 300a-6. Read in the context of the
entire statute, this prohibition is plainly directed at conduct,
rather than the dissemination of information or advice, by
potential grant recipients.

															The original regulations promulgated in 1971 by the Secretary of
Health, Education and Welfare so interpreted the statute. This
" contemporaneous construction of [the] statute by the men
charged with the responsibility of setting its machinery in
motion'" is entitled to particular respect. See Power
Reactor Development Co. v. Electrical Workers , 367 Page 500 U. S. 222 U.S. 396, 367 U. S. 408 (1961) (citation omitted); Udall v. Tallman, 380 U. S.
1 , 380 U. S. 16 (1965); Aluminum Co. of America v. Central Lincoln Peoples'
Utility District, 467 U. S. 380 , 467 U. S. 390 (1984). The regulations described the kind of services that grant
recipients had to provide in order to be eligible for federal
funding, but they did not purport to regulate or restrict the kinds
of advice or information that recipients might make available to
their clients. Conforming to the language of the governing statute,
the regulations provided that "[t]he project will not provide abortions as a method of family planning." 42 CFR
§ 59.5(a)(9) (1972) (emphasis added). Like the statute itself, the
regulations prohibited conduct, not speech.

															The same is true of the regulations promulgated in 1986 by the
Secretary of Health and Human Services. They also prohibited grant
recipients from performing abortions, but did not purport to censor
or mandate any kind of speech. See 42 CFR §§ 59.159.13
(1986).

															The entirely new approach adopted by the Secretary in 1988 was
not, in my view, authorized by the statute. The new regulations did
not merely reflect a change in a policy determination that the
Secretary had been authorized by Congress to make. Cf. 467 U. S. S.A.
Inc. v. Natural Resources Defense Counsel, Inc., 467 U.
S. 837 , 467 U. S. 865 (1984). Rather, they represented an assumption of policymaking
responsibility that Congress had not delegated to the Secretary. See id. at 467 U. S.
842 -843 ("If the intent of Congress is clear, that is
the end of the matter; for the court, as well as the agency, must
give effect to the unambiguously expressed intent of Congress"). In
a society that abhors censorship and in which policymakers have
traditionally placed the highest value on the freedom to
communicate, it is unrealistic to conclude that statutory authority
to regulate conduct implicitly authorized the Executive to regulate
speech.

															Because I am convinced that the 1970 Act did not authorize the
Secretary to censor the speech of grant recipients or their Page 500 U. S. 223 employees, I would hold the challenged regulations invalid and
reverse the judgment of the Court of Appeals.

															Even if I thought the statute were ambiguous, however, I would
reach the same result for the reasons stated in JUSTICE O'CONNOR's
dissenting opinion. As she also explains, if a majority of the
Court had reached this result, it would be improper to comment on
the constitutional issues that the parties have debated. Because
the majority has reached out to decide the constitutional
questions, however, I am persuaded that JUSTICE BLACKMUN is correct
in concluding that the majority's arguments merit a response. I am
also persuaded that JUSTICE BLACKMUN has correctly analyzed these
issues. I have therefore joined Parts II and III of his
opinion.

															JUSTICE O'CONNOR, dissenting.

															"[W]here an otherwise acceptable construction of a statute would
raise serious constitutional problems, the Court will construe the
statute to avoid such problems unless such construction is plainly
contrary to the intent of Congress." Edward J. DeBartolo Corp. v. Florida Gulf Coast Building
& Construction Trades Council, 485 U.
S. 568 , 485 U. S. 575 (1988). JUSTICE BLACKMUN has explained well why this longstanding
canon of statutory construction applies in this case, and I join 500 U. S. 500 U. S. which constitute the Secretary's interpretation of § 1008 of the
Public Health Service Act, 84 Stat. 1508, 42 U.S.C. § 300a-6,
"raise serious constitutional problems": the regulations place
content-based restrictions on the speech of Title X fund
recipients, restrictions directed precisely at speech concerning
one of "the most divisive and contentious issues that our Nation
has faced in recent years." Ante at 500 U. S.
215 .

															One may well conclude, as JUSTICE BLACKMUN does in 500 U.
S. that the regulations are unconstitutional for this
reason. I do not join Part II of the dissent, however, for the same
reason that I do not join 500 U. S. in
which JUSTICE Page 500 U. S. 224 BLACKMUN concludes that the regulations are unconstitutional
under the Fifth Amendment. The canon of construction that JUSTICE
BLACKMUN correctly applies here is grounded in large part upon our
time-honored practice of not reaching constitutional questions
unnecessarily. See DeBartolo, supra, at 485 U. S.
575 .

															"It is a fundamental rule of judicial restraint . . . that this
Court will not reach constitutional questions in advance of the
necessity of deciding them." Three Affiliated Tribes of Fort Berthold Reservation v. Wold
Engineering, P.C., 467 U. S. 138 , 467 U. S. 157 (1984). See also Alexander v. Louisiana, 405 U.
S. 625 , 405 U. S. 633 (1972); Burton v. United States, 196 U.
S. 283 , 196 U. S. 295 (1905); Liverpool, New York and Philadelphia S.S. Co. v.
Commissioners of Emigration, 113 U. S. 33 , 113 U. S. 39 (1885) (In the exercise of its jurisdiction to pronounce
unconstitutional laws of the United States, this Court "has rigidly
adhered" to the rule "never to anticipate a question of
constitutional law in advance of the necessity of deciding
it").

															This Court acts at the limits of its power when it invalidates a
law on constitutional grounds. In recognition of our place in the
constitutional scheme, we must act with "great gravity and
delicacy" when telling a coordinate branch that its actions are
absolutely prohibited absent constitutional amendment. Adkins
v. Children's Hospital of District of Columbia, 261 U.
S. 525 , 261 U. S. 544 (1923). See also Blodgett v. Holden, 275 U.
S. 142 , 275 U. S.
147 -148 (1927) (Holmes, J., concurring). In this case,
we need only tell the Secretary that his regulations are not a
reasonable interpretation of the statute; we need not tell Congress
that it cannot pass such legislation. If we rule solely on
statutory grounds, Congress retains the power to force the
constitutional question by legislating more explicitly. It may
instead choose to do nothing. That decision should be left to
Congress; we should not tell Congress what it cannot do before it
has chosen to do it. It is enough in this case to conclude that
neither the language nor the history of § 1008 compels the
Secretary's interpretation, Page 500 U. S. 225 and that the interpretation raises serious First Amendment
concerns. On this basis alone, I would reverse the judgment of the
Court of Appeals and invalidate the challenged regulations.

Summary: In *Rust v. Sullivan*, the U.S. Supreme Court upheld regulations prohibiting Title X family-planning projects from counseling, referring, or advocating for abortion as a method of family planning. The Court found that the regulations were a permissible interpretation of the Public Health Service Act, which states that federal funds under Title X cannot be used for programs where abortion is a method of family planning. The Court deferred to the Secretary of Health and Human Services' expertise and found that the regulations did not violate the First or Fifth Amendments.