Bragdon v. Abbott

After disclosing she was HIV-positive on a patient registration form, Respondent Abbott was informed by her dentist, Petitioner, of his policy against filling cavities of HIV-infected patients. Petitioner offered to perform the work at a hospital with no added service fee, but with the cost of the use of the hospital’s facilities borne by Respondent. Respondent declined. Abbott’s had not manifested the “most serious symptoms” of her illness when the incidents were reported.

Respondent brought an action against Petitioner § 302 of the Americans with Disabilities Act (ADA), alleging discrimination on the basis of her disability. Abbott asserted that her HIV infection substantially limited her ability to bear children, and that this qualified her as a person with a disability under the ADA.

§ 302 of the ADA provides: “No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations of any place of public accommodation by any person who . . . operates a place of public accommodation,” § 12182(a). “Disability” is defined as “(A) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (B) a record of such an impairment; or (C) being regarded as having such an impairment,” § 12102(2). “Public accommodation” is defined to include the “professional office of a health care provider,” § 12181(7)(F).

The mandate not to discriminate is qualified by a later subsection, which provides: “Nothing in this subchapter shall require an entity to permit an individual to participate in or benefit from the goods, services, facilities, privileges, advantages and accommodations of such entity where such individual poses a direct threat to the health or safety of others.” § 12182(b)(3). “Direct threat” is defined in the ADA as “a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures or by the provision of auxiliary aids or services.”

The lower courts held that held Respondent’s HIV infection was a disability under the ADA, even though her infection had not yet progressed to the symptomatic stage, and that treating Respondent in Petitioner’s office would not have posed a direct threat to the health and safety of others.

The Court first set out to determine whether HIV was a disability under the ADA when the disease had not yet progressed to the symptomatic phase. The Court held that Respondent’s HIV infection was a disability under subsection (A) of the definitional section of ADA § 12102(2), i.e., “a physical or mental impairment that substantially limits one or more of the major life activities of such individual.”

The Court held that the ADA must be construed to grant “at least as much protection” as provided by the Rehabilitation Act regulations, as the ADA’s definition of disability was drawn “almost verbatim” from the definition of “handicapped individual” included in the Rehabilitation Act.

The Court considered subsection (A) of the ADA definition in three steps:

• Firstly, it considered whether Respondent’s HIV infection amounted to a “physical impairment.”

The Court held that HIV infection, whether symptomatic or asymptomatic, qualifies as an impairment:

In light of the immediacy with which the virus begins to damage the infected person's white blood cells and the severity of the disease, we hold it is an impairment from the moment of infection . . . HIV infection must be regarded as a physiological disorder with a constant and detrimental effect on the infected person's hemic and lymphatic systems from the moment of infection. HIV infection satisfies the statutory and regulatory definition of a physical impairment during every stage of the disease.

• Secondly, the Court examined whether the “life activity” upon which Respondent relied (reproduction and childbearing) constituted a “major life activity.”

Respondent had claimed from the outset that her HIV infection placed a substantial limitation on her ability to reproduce and to bear children. The Court therefore restricted its discussion to this life activity only. The Court affirmed Court of Appeals finding that reproduction falls well within the phrase “major life activity,” stating that “[r]eproduction and the sexual dynamics surrounding it are central to the life process itself.” The Court further held that this interpretation was consistent with the representative list of functions contained within the Rehabilitation Act regulations.

• Finally, the Court considered whether the impairment substantially limited Respondent's “life activity.”

The Court held that, based on the medical evidence, Respondent’s HIV infection substantially limited her ability to reproduce in two independent ways:

1)    A woman infected with HIV who tries to conceive a child imposes on the man a significant risk of becoming infected

2)    An infected woman risks infecting her child during gestation and childbirth via perinatal transmission.

The Court rejected the contention that the lower risk of transmission of the disease to one’s child does not represent a substantial limitation on reproduction. It declared: "The Act addresses substantial limitations on major life activities, not utter inabilities. Conception and childbirth are not impossible for an HIV victim but, without doubt, are dangerous to the public health. This meets the definition of a substantial limitation."

The Court further held that “when significant limitations result from the impairment, the definition is met even if the difficulties are not insurmountable.” The Court noted that “every agency to consider the issue under the Rehabilitation Act found statutory coverage for persons with asymptomatic HIV.”

Lastly, the Court looked into whether there was sufficient evidence indicating Respondent’s HIV infection posed a “direct threat to the health and safety” of her treating dentist (§ 12182(b)(3)). The Court held that Petitioner did not present any “objective, medical evidence” indicating that it would be safer to treat Abbott in a hospital as opposed to his office.

“In light of the immediacy with which the virus begins to damage the infected person's white blood cells and the severity of the disease, we hold it is an impairment from the moment of infection. As noted earlier, infection with HIV causes immediate abnormalities in a person's blood, and the infected person's white cell count continues to drop throughout the course of the disease, even when the attack is concentrated in the lymph nodes. In light of these facts, HIV infection must be regarded as a physiological disorder with a constant and detrimental effect on the infected person's hemic and lymphatic systems from the moment of infection. HIV infection satisfies the statutory and regulatory definition of a physical impairment during every stage of the disease.” 524 U.S., p. 637.

“As the Court of Appeals held, ‘[t]he plain meaning of the word `major' denotes comparative importance’ and ‘suggest[s] that the touchstone for determining an activity's inclusion under the statutory rubric is its significance.’ 107 F. 3d, at 939, 940. Reproduction falls well within the phrase ‘major life activity.’ Reproduction and the sexual dynamics surrounding it are central to the life process itself.” 524 U.S., p. 638.

“In the end, the disability definition does not turn on personal choice. When significant limitations result from the impairment, the definition is met even if the difficulties are not insurmountable. For the statistical and other reasons we have cited, of course, the limitations on reproduction may be insurmountable here. Testimony from the respondent that her HIV infection controlled her decision not to have a child is unchallenged. App. 14; 912 F. Supp., at 587; 107 F. 3d, at 942. In the context of reviewing summary judgment, we must take it to be true. Fed. Rule Civ. Proc. 56(e). We agree with the District Court and the Court of Appeals that no triable issue of fact impedes a ruling on the question of statutory coverage. Respondent's HIV infection is a physical impairment which substantially limits a major life activity, as the ADA defines it. In view of our holding, we need not address the second question presented, i. e., whether HIV infection is a per se disability under the ADA.” 524 U.S., pp. 641 - 642.

“[t]he Rehabilitation Act regulations support the inclusion of reproduction as a major life activity, since reproduction could not be regarded as any less important than working and learning. Petitioner advances no credible basis for confining major life activities to those with a public, economic, or daily aspect. In the absence of any reason to reach a contrary conclusion, we agree with the Court of Appeals' determination that reproduction is a major life activity for the purposes of the ADA.” 524 U.S., p. 641.