A recent US Supreme Court decision, which grabbed headlines because it involved an abortion-related drug, with potential repercussions in litigation far-removed from health care due to the decision hinging on “standing,” i.e., when parties have been injured in a manner permitting them to sue.

In FDA v. Alliance for Hippocratic Medicine, the Supreme Court held that plaintiffs lacked Article III standing to challenge the US Food and Drug Administration’s (FDA) actions regarding the regulation of mifepristone, a drug that can be used in combination with another drug to end a pregnancy. 

In 2016 and 2021, the FDA had approved certain regulatory requirements for the drug, making it easier for doctors to prescribe and patients to access mifepristone. The plaintiffs, including pro-life doctors and medical associations, sued the FDA alleging that these changes violated the Administrative Procedure Act (APA). The Supreme Court’s recent decision barred this challenge, holding that “a plaintiff’s desire to make a drug less available for other doctors does not establish standing to sue” under Article III of the US Constitution.

What’s in the Ruling?

Federal law charges the FDA with ensuring that drugs on the market are safe and effective when used as directed. As part of the FDA’s approval process, the drug’s sponsor (usually a drug manufacturer or marketer) must submit an application demonstrating these facts. 

Mifepristone was initially approved in 2000 for use in terminating pregnancies up to seven weeks under specified — and particular — conditions, including multiple in-person office visits, but the conditions for its use were loosened by the FDA in 2016 (one office visit) and in 2021 (no office visits). 

Relevant here, two pro-life medical associations petitioned to have the FDA withdraw its 2016 modifications in 2019. The FDA denied this petition, and the plaintiffs sued under the APA challenging the lawfulness of the initial 2000 approval as well as the 2016 and 2021 actions modifying mifepristone’s conditions of use. After finding that the groups had standing, a Texas district court enjoined the FDA’s approval of mifepristone and in essence, ordered the drug off the market. While the district court’s injunction was stayed during the appeal, the Supreme Court granted certiorari to review a Fifth Circuit decision upholding the district court’s decision that plaintiffs had standing. 

What Does it Mean to Have Standing?

Whether plaintiffs have standing to sue under Article III of the US Constitution is a “bedrock constitutional requirement” applied in all cases to protect constitutional separation of powers. While the executive branch has the broad ability to enforce laws passed by Congress, courts’ abilities are more limited. To establish standing, a plaintiff must demonstrate that he or she will “suffer an injury in fact,” said injury was likely caused by the defendant, and that the injury likely would be addressed by the requested relief. The “injury in fact” requirement is designed to screen out plaintiffs who might have only general legal or policy objections to a particular action. Causation, in turn, is difficult for plaintiffs to establish when they challenge government action or inaction that affects others.

The plaintiffs in Alliance for Hippocratic Medicine sought to challenge the FDA’s regulation of mifepristone even though none of them used or proscribed the drug. Accordingly, the plaintiffs presented various theories of how they could establish standing, all of which the Court rejected. These theories were as follows:

• The FDA’s relaxed regulation of mifepristone could result in more emergency abortions and that women could seek treatment from some of the plaintiff doctors. The Court rejected this argument because plaintiffs failed to provide any instances where this hypothetical situation actually happened or demonstrate that federal conscience laws which continue in effect — and that protect doctors with objections to the morality of abortion from providing them — were insufficient to protect them from liability. 
• The regulations caused downstream economic injuries, such as time spent treating patients who had used mifepristone. The Court rejected this argument, noting that the law does not permit doctors to challenge loosening of public safety requirements simply because more patients might be injured. In essence, the doctors here were merely “concerned bystanders” who had no right to pursue claims in court. 
• The medical organizations who were plaintiffs were “impaired” in their ability to provide services and incurred costs to oppose the FDA’s actions. Costs included drafting citizen petitions to the FDA and engaging in public advocacy and education, resulting in the diversion of resources from other priorities. The Court rejected this theory, noting that “an organization that has not suffered a concrete injury cannot spend its way into standing” by expending money to argue against a policy.
• Finally, the Court rejected that the plaintiffs here must have standing because otherwise “no one” would have standing to challenge the FDA’s loosening of mifepristone regulations. In the Court’s view, the remedy in such situations is through the political branches. 

The Court’s rejection of the plaintiffs’ theories of standing protects the FDA’s mifepristone-related decisions from this round of attacks in court, and leaves regulation of mifepristone to the legislative and executive branches. 

What’s Next?

The Court focused in part on the district court’s standing decision as being an outlier that was incorrectly upheld by the Fifth Circuit. If that was most significant to the holding, the effects of this decision may be limited to standing jurisprudence in the Fifth Circuit.

That being said, standing plays a major role in many environmental cases and the organizational standing principles here may have broader repercussions. As we have discussed, the Fifth Circuit itself has upheld organizational standing when a “categorical injury” is alleged. Two years ago in Environment Texas Citizen Lobby Inc. v. ExxonMobil Corp., the Fifth Circuit held that nongovernmental entity plaintiffs that allege broad injuries — e.g., that the facility’s illegal emissions made plaintiffs less likely to recreate in an area — do not need to demonstrate that any particular facility violation caused the broad, alleged injuries.

Whether this holding is consistent with the Fifth Circuit’s holding in Alliance for Hippocratic Medicine is unclear, but with the Supreme’ Court’s decision, organizations that challenge regulations may face a heightened burden to demonstrate that their “core business activities,” not their issue advocacy, was harmed. This is not a new consideration. In 1982, the Supreme Court decided Havens Realty Corp. v. Coleman in which it stated that “diversion of resources,” particularly monetary resources, may establish standing when the resources are related to a plaintiff’s core business activities. Alliance for Hippocratic Medicine simply clarifies that advocacy activities are not “core business activities.”