Case reversed and remanded by
Supreme Court opinion filed 3/21/01
PUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

CRYSTAL M. FERGUSON; PAULA S.
HALE; ELLEN L. KNIGHT; PATRICIA R.
WILLIAMS; LORI GRIFFIN; PAMELA
PEAR; SANDRA POWELL; LAVERNE
SINGLETON; THERESA JOSEPH;
DARLENE M. NICHOLSON,
Plaintiffs-Appellants,

and

STATE-RECORD COMPANY,
INCORPORATED; THE EVENING POST
PUBLISHING COMPANY,
Intervenors-Plaintiffs,

v.

CITY OF CHARLESTON, South
Carolina; HARRISON L. PEOPLES, Dr.;
                                      No. 97-2512
THOMAS C. ROWLAND, JR., Dr.;
STANLEY C. BAKER, JR., Dr.;
CHARLES B. HANNA, Dr.;
COTESWORTH P. FISHBURNE, Dr.; E.
CONYERS O'BRYAN, Dr.; MELVYN
BERLINSKY; PATRICIA T. SMITH; M. J.
COOPER; HERBERT C. GRANGER;
ROBERT C. LAKE, JR.; PHILLIP D.
SASSER; CLAUDIA W. PEOPLES;
CARROLL V. BING, JR., Dr., as
Trustees of the Medical University
of South Carolina in their official
capacities; REUBEN GREENBERG;
CHARLES MOLONY CONDON; DAVID
SCHWACKE; SHIRLEY BROWN, R.N.;
EDGAR O. HORGER, III, M.D.;
VICTOR DEL BENE; JOHN SANDERS;
WILLIAM B. PITTARD, M.D.; ROGER
NEWMAN, M.D.; HAROLD BIVENS,
M.D.; MELESIA HENRY, R.N.,
personally and in their official
capacities,
Defendants-Appellees.

CENTER FOR CONSTITUTIONAL RIGHTS,
Amicus Curiae.

Appeal from the United States District Court
for the District of South Carolina, at Charleston.
C. Weston Houck, Chief District Judge.
(CA-93-2624-2-12)

Argued: October 26, 1998

Decided: July 13, 1999

Before WILKINS and NIEMEYER, Circuit Judges,
and BLAKE, United States District Judge
for the District of Maryland, sitting by designation.

_________________________________________________________________

Affirmed by published opinion. Judge Wilkins wrote the majority
opinion, in which Judge Niemeyer joined. Judge Blake wrote an opin-
ion dissenting in part.

_________________________________________________________________

COUNSEL

ARGUED: Priscilla Joyce Smith, CENTER FOR REPRODUCTIVE
LAW & POLICY, New York, New York, for Appellants. Barbara
Wynne Showers, Joseph Camden Wilson, IV, HOOD LAW FIRM,
L.L.C., Charleston, South Carolina, for Appellees. ON BRIEF:

                  2
Susan K. Dunn, Charleston, South Carolina, for Appellants. Robert H.
Hood, HOOD LAW FIRM, L.L.C., Charleston, South Carolina, for
Appellees. Kimani Paul-Emile, Barbara Olshansky, CENTER FOR
CONSTITUTIONAL RIGHTS, New York, New York, for Amicus
Curiae.

_________________________________________________________________

OPINION

WILKINS, Circuit Judge:

This litigation involves constitutional, statutory, and common-law
challenges to a policy instituted by the Medical University of South
Carolina (MUSC) in consultation with the Solicitor of the Ninth Judi-
cial Circuit of South Carolina; the City of Charleston, South Carolina
Police Department (CCPD); and various social services agencies. The
policy was intended to encourage pregnant women whose urine tested
positive for cocaine use to obtain substance abuse counseling. Appel-
lants, ten women who were tested pursuant to the policy, brought this
action claiming, inter alia, that the testing of their urine for evidence
of cocaine use constituted a warrantless search in violation of the
Fourth Amendment; that the policy had a racially disparate impact in
violation of regulations implementing Title VI of the Civil Rights Act
of 1964, as amended, 42 U.S.C.A. §§ 2000d to 2000d-6 (West 1994
& Supp. 1998); that the disclosure of medical information to law
enforcement personnel violated their constitutional right to privacy;
and that MUSC personnel committed the state-law tort of abuse of
process in administering the policy. The district court entered judg-
ment for Appellees1 1 on each of these claims at various stages of the
litigation. For the reasons set forth below, we affirm.
_________________________________________________________________
1 The complaint filed by Appellants named as defendants the City of
Charleston, South Carolina; the trustees of MUSC; CCPD Chief Reuben
Greenberg; former Ninth Circuit Solicitor Charles Condon; current Ninth
Circuit Solicitor David Schwacke; Nurse Shirley Brown; Nurse Melesia
Henry; and several physicians and MUSC officials involved in obstetri-
cal and neonatal care at MUSC. For ease of reference, we refer to these
parties collectively as "Appellees." The parties evidently agree that only
injunctive relief is being sought against those individual Appellees who
are state officers sued in their official capacities. See Edelman v. Jordan,
415 U.S. 651, 677 (1974).

                   3
I.

In the fall of 1989, MUSC instituted a policy providing for the test-
ing of the urine of pregnant women suspected of cocaine use and for
the reporting, under certain circumstances, of test results to law
enforcement officials. The impetus behind the policy came from
Nurse Shirley Brown, a case manager in the obstetrics department at
MUSC. Brown was concerned about a perceived rise in cocaine use
among pregnant women and the consequences for the health of the
users' children. Brown spoke with the General Counsel for MUSC
who in turn contacted the Ninth Circuit Solicitor (chief prosecuting
attorney) concerning the development of a policy to address the prob-
lem. Eventually, a task force was formed that included Nurse Brown,
the Solicitor, the Chief of CCPD, and doctors from various depart-
ments involved in perinatal care at MUSC. During the course of task
force meetings, the Solicitor informed the participants that because a
viable fetus was a "person" under South Carolina law, a woman who
ingested cocaine after the 24th week of pregnancy was guilty of the
crime of distributing a controlled substance to a person under the age
of eighteen, see S.C. Code Ann. § 44-53-440 (Law. Co-op. Supp. 1997).2
                                                                     2

Pursuant to the policy formulated by the task force and imple-
mented in late October or early November 1989, urine drug screens
to detect evidence of cocaine use were given to all MUSC maternity
patients when certain indicia of cocaine use were present: (1) separa-
tion of the placenta from the uterine wall; (2) intrauterine fetal death;
(3) no prenatal care; (4) late prenatal care (beginning after 24 weeks);
(5) incomplete prenatal care (fewer than five visits); (6) preterm labor
without an obvious cause; (7) a history of cocaine use; (8) unex-
plained birth defects; or (9) intrauterine growth retardation without an
obvious cause. When a patient tested positive, the test result was
reported to CCPD or a representative of the Solicitor's Office and the
_________________________________________________________________
2 The South Carolina Supreme Court previously had held that a viable
fetus was a person within the meaning of South Carolina criminal law.
See State v. Horne, 319 S.E.2d 703, 704 (S.C. 1984). Subsequently, the
court upheld a conviction for criminal child neglect in a case involving
a woman who ingested cocaine while pregnant with a viable fetus. See
Whitner v. State, 492 S.E.2d 777, 778-84 (S.C. 1997), cert. denied, 118
S. Ct. 1857 (1998).

                  4
patient was arrested for distributing cocaine to a minor. In early 1990,
the policy was amended so that a patient who tested positive for
cocaine use was given a choice between being arrested and receiving
drug treatment. Positive test results of a patient who elected drug
treatment were not forwarded to CCPD, and the patient was not
arrested, unless she tested positive for cocaine use a second time or
failed to comply with treatment obligations. A patient who was
arrested could avoid prosecution by completing a drug treatment pro-
gram. Upon successful completion of such a program, the charges
would be dismissed.3   3
_________________________________________________________________
3 The dissent repeatedly characterizes Appellees' actions in implement-
ing the policy as animated by a vindictive purpose to prosecute women
who used cocaine during pregnancy. The record simply does not support
this. Although the very real possibility of arrest was employed as an
incentive for women to comply with treatment obligations, the record is
abundantly clear that Appellees were motivated by a desire to protect the
health of children born at MUSC, and that the policy was formulated and
implemented with this goal in mind. Indeed, the district court so found.
See J.A. 2739 (finding that the "goal [of the policy] was not to arrest
patients but to facilitate their treatment and protect both the mother and
unborn child"). And, the evidence in the record more than amply sup-
ports this finding. See, e.g., J.A. 583 (testimony of Nurse Shirley Brown)
(confirming that the reason for the policy was "concern ... for the health
and safety and care of these fetuses and soon to be children"); id. at 602
(testimony of Nurse Shirley Brown) (agreeing that"it was always the
intention of you and the people at the Medical University of South Caro-
lina, and in fact from what you learned at these meetings, [the] Charles-
ton Police Department, ... [and] the Solicitor, to help the women get
treatment, not to arrest them, not to prosecute them, not to cause them
to go to jail"); id. at 779-80 (testimony of Solicitor Charles Condon)
(stating that "the problem presented to us at that time [was], how to help
these babies and how to stop the totally preventable damage being done
to these innocent little children" and explaining that "[t]he policy from
its inception was amnesty-based.... [I]f you lived up to some very basic
requirements, number one being drug free, ... and, number two, if you
would go to free drug treatment, not a thing would happen to you"); id.
at 785-86 (testimony of Solicitor Charles Condon) ("The idea that we
were involved in a prosecution program is almost laughable .... The idea
was not to prosecute people and put them in jail, the idea was to use legal
intervention that was working to change human behavior to protect chil-
dren, to protect babies."); id. at 863 (testimony of MUSC's General
Counsel) ("[T]his was not supposed to be a punitive policy where we

                  5
Implementation of the policy by MUSC involved substantial record
keeping and educational efforts. A maternity patient whose urine
tested positive for cocaine use was shown an educational video con-
cerning the harmful effects of cocaine use during pregnancy and was
given letters from the Solicitor's Office and the hospital staff relating
to the policy. In addition, MUSC personnel advised the patient of the
need to obtain substance abuse counseling and scheduled an initial
appointment for such counseling. The patient then was given a docu-
ment noting the date and time of the appointment. Additionally,
MUSC maintained records on patients whose urine tested positive for
cocaine use as a means of tracking them to ensure that they complied
with the requirements of the policy.

Appellants, all of whom were subjected to the policy,4  4 brought this
action asserting, as pertinent here, infringement of their constitutional
right to privacy; violation of their Fourth Amendment right to be free
of unreasonable searches and seizures; disparate impact discrimina-
tion on the basis of race; and commission of the state-law tort of
abuse of process. After presentation of the evidence, the district court
granted judgment as a matter of law to Appellees on the claims of
commission of abuse of process and violation of the right to privacy
to the extent Appellants sought damages. The jury returned a verdict
in favor of Appellees on the Fourth Amendment claim. At a post-trial
hearing, the court denied injunctive relief on Appellants' claims of the
denial of their constitutional right to privacy. Finally, the district court
rendered findings of fact based on the evidence presented at trial and
ruled in favor of Appellees on the Title VI claim of disparate impact
discrimination.
_________________________________________________________________

went out and punished people for doing something, even though we
knew the activity was illegal. What we were trying to do is give those
babies a chance to be born normal."). Indeed, while some of the Appel-
lants were arrested, not one of them was prosecuted; this fact belies the
dissent's assertion that a purpose of the policy was to convict and punish
women who used cocaine during pregnancy.
4 At least two Appellants were subjected to urine drug screens shortly
before formal adoption of the policy. Testimony in the record indicates,
however, that MUSC personnel began to apply the policy informally in
October 1989.

                  6
On appeal, Appellants challenge the submission of the Fourth
Amendment claim to the jury and the sufficiency of the evidence sup-
porting the verdict; the decision of the district court granting judg-
ment to Appellees on the Title VI claim; and the orders of the court
granting Appellees judgment as a matter of law on the claims for vio-
lation of the constitutional right to privacy and commission of the tort
of abuse of process. We review these issues seriatim.

II.

At trial, Appellants contended that the urine drug screens consti-
tuted searches within the meaning of the Fourth Amendment. They
further claimed that because they did not consent to the screens, the
tests violated the Fourth Amendment.5 5 The district court ruled that the
urine screens fell within the ambit of the Fourth Amendment and sub-
mitted the question of whether Appellants had consented to the
searches to the jury, which found in favor of Appellees. Appellants
now maintain that the district court erred in submitting the issue of
consent to the jury and, alternatively, that the verdict is not supported
by the evidence. We find it unnecessary to address these contentions
because we affirm on the basis that the searches were reasonable as
special needs searches.

The Fourth Amendment, made applicable to the states through the
Fourteenth Amendment, provides in pertinent part that "[t]he right of
the people to be secure in their persons ... against unreasonable
searches and seizures[ ] shall not be violated." U.S. Const. amend. IV;
see Mapp v. Ohio, 367 U.S. 643, 655 (1961). Simply put, this amend-
ment guarantees that governmental intrusions into privacy by means
of searches or seizures must be reasonable. Typically, this reasonable-
ness requirement acts as a constraint on governmental authority to
undertake a search or seizure in the absence of individualized suspi-
cion. See Chandler v. Miller, 520 U.S. 305, 308 (1997). Generally, a
search performed without a warrant is unreasonable per se unless it
fits within a narrowly defined exception to the warrant requirement.
See, e.g., Schneckloth v. Bustamonte, 412 U.S. 218, 219 (1973);
United States v. Lattimore, 87 F.3d 647, 650 (4th Cir. 1996) (en
_________________________________________________________________
5 MUSC personnel did not obtain warrants before conducting the urine
drug screens.

                  7
banc). Nevertheless, "neither a warrant nor probable cause, nor,
indeed, any measure of individualized suspicion, is an indispensable
component of reasonableness in every circumstance." National Trea-
sury Employees Union v. Von Raab, 489 U.S. 656, 665 (1989).
Rather, there are situations in which "a Fourth Amendment intrusion
serves special governmental needs, beyond the normal need for law
enforcement." Id. In such cases, "it is necessary to balance the indi-
vidual's privacy expectations against the Government's interests to
determine whether it is impractical to require a warrant or some level
of individualized suspicion in the particular context." Id. at 665-66;
see Chandler, 520 U.S. at 314 (explaining that"[w]hen ... `special
needs'--concerns other than crime detection--are alleged in justifica-
tion of a Fourth Amendment intrusion, courts must undertake a
context-specific inquiry, examining closely the competing private and
public interests advanced by the parties"). This balancing requires
consideration of the governmental interest prompting the invasion; the
effectiveness of the intrusion, i.e., the degree to which the intrusion
reasonably is thought to advance the governmental interest; and the
magnitude of the intrusion upon the individuals affected, from both
a subjective and objective standpoint. See Michigan Dep't of State
Police v. Sitz, 496 U.S. 444, 455 (1990); id. at 451-55 (applying test);
DesRoches v. Caprio, 156 F.3d 571, 574 (4th Cir. 1998).

The parties evidently have agreed throughout this litigation that
MUSC is a state hospital and that MUSC employees therefore are
government actors.6 6 And, the district court found as a fact that MUSC
personnel conducted the urine drug screens for medical purposes
wholly independent of an intent to aid law enforcement efforts.7   7
_________________________________________________________________
6 Our analysis is premised on the assumption that when a state hospital
develops a general policy to test the urine of certain patients suspected
of drug use, the testing constitutes a search within the meaning of the
Fourth Amendment. But cf. United States v. Attson, 900 F.2d 1427,
1432-33 (9th Cir. 1990) (holding that government-employed doctor who,
for medical purposes, tests a patient's urine for evidence of alcohol use
does not conduct a search within the meaning of the Fourth Amendment
unless he "act[s] with the intent to assist the government in its investiga-
tory or administrative purposes and not for an independent purpose").
7 The district court declined to hold the searches at issue here reason-
able under a special needs analysis because law enforcement officers

                   8
Accordingly, the question presented is whether a balancing of
MUSC's interest in protecting the health of children whose mothers
use cocaine during pregnancy, the effectiveness of the policy to iden-
tify and treat women who use cocaine during pregnancy, and the
degree of intrusion experienced by women whose urine was tested for
evidence of cocaine use results in a conclusion that the searches vio-
lated the Fourth Amendment.

A.

The first factor to be considered is the governmental need. The
Fourth Amendment does not require a governmental need that is com-
pelling in an absolute sense. See Vernonia Sch. Dist. 47J v. Acton,
_________________________________________________________________
were involved in the formulation of the policy. However, the involve-
ment of law enforcement officers does not make a special needs analysis
inappropriate. See Sitz, 496 U.S. at 451-55 (upholding, under a special
needs balancing test, a sobriety checkpoint operated by uniformed police
officers); Norwood v. Bain, 166 F.3d 243, 245 (4th Cir. 1999) (en banc)
(per curiam), cert. denied, ___ U.S.L.W. ___, 1999 WL 296948 (U.S.
June 14, 1999) (No. 98-1777).

The dissent makes the related argument that the use of evidence
obtained during the searches to support the arrest of some patients pre-
cludes application of the special needs balancing test. We disagree with
this proposition, as does the Supreme Court. See Griffin v. Wisconsin,
483 U.S. 868, 870, 875-77 (1987) (determining that warrantless search
based on reasonable grounds was justified by the special needs of the
Wisconsin probation system even though evidence gathered during the
search was employed to support a criminal conviction); see also Sitz, 496
U.S. at 448 (noting that suspicionless stop at sobriety checkpoint resulted
in arrest for driving under the influence). The dissent's attempt to distin-
guish Sitz is unpersuasive. It is true that the decision of the Court "ad-
dress[ed] only the initial stop of each motorist passing through a
checkpoint and the associated preliminary questioning and observation
by checkpoint officers." Sitz, 496 U.S. at 450-51. However, the fact that
the initial suspicionless seizures led ultimately to an arrest cannot have
escaped the attention of the Court. If, as the dissent contends, the intent
to use information obtained during a suspicionless seizure to further
investigate and ultimately arrest an individual rendered the special needs
analysis inappropriate, Sitz would have been decided differently.

                  9
515 U.S. 646, 661 (1995). Instead, the interest must be "important
enough to justify the particular search at hand, in light of other factors
that show the search to be relatively intrusive upon a genuine expecta-
tion of privacy." Id.; see Chandler , 520 U.S. at 318. The hazard giv-
ing rise to the alleged special need must be a concrete danger, not
merely a hypothetical one. See Chandler, 520 U.S. at 318-19;
Vernonia, 515 U.S. at 662-63 (explaining that a sharp rise in drug use
by student athletes supported school officials' assertion that random
drug testing without individualized suspicion was warranted).

The policy at issue here was developed after medical personnel at
MUSC noticed an alarming increase in the number of pregnancies
affected by cocaine use. Maternal cocaine use is associated with a
number of pregnancy complications, including low birth weight, pre-
mature labor, birth defects, and neurobehavioral problems. Even a
single use of cocaine during pregnancy may result in separation of the
placenta from the uterine wall--a condition that may threaten the life
of the mother and the fetus--or a stroke in the fetus. Moreover, costs
related to caring for infants exposed to cocaine in utero are substan-
tial, as evidenced by the testimony of an expert for Appellants who
testified that he had estimated in the late 1980s that such expenses
nationwide might exceed three billion dollars annually over the next
ten years. In light of the documented health hazards of maternal
cocaine use and the resulting drain on public resources, MUSC offi-
cials unquestionably possessed a substantial interest in taking steps to
reduce cocaine use by pregnant women. Cf. Vernonia, 515 U.S. at
661-62 (concluding that interest in deterring drug use by schoolchil-
dren was important in light of severe effects of drug use on adoles-
cents).

B.

The second factor, the effectiveness of the search, focuses on "the
degree to which [it] advances the public interest." Sitz, 496 U.S. at
453 (internal quotation marks omitted). In analyzing this factor, how-
ever, our review must leave "the decision as to which among reason-
able alternative ... techniques should be employed to deal with a
serious public danger" to "the governmental officials who have a
unique understanding of, and a responsibility for, limited public
resources." Id. at 453-54.

                  10
Here, there can be little doubt that testing the urine of maternity
patients when certain indicia of possible cocaine use were present was
an effective way to identify and treat maternal cocaine use while con-
serving the limited resources of a public hospital. Indeed, prenatal
testing was the only effective means available to accomplish the pri-
mary policy goal of persuading women to stop using cocaine during
their pregnancies in order to reduce health effects on children exposed
to cocaine in utero.

Appellants argue, however, that the policy was ineffective because
it was both underinclusive and overinclusive. The policy was underin-
clusive, Appellants claim, because it did not address use of other
drugs--such as alcohol and nicotine--that may pose risks to a devel-
oping fetus. And, Appellants maintain that the policy was overinclu-
sive because women were tested on the basis of having received
inadequate prenatal care, a factor that Appellants contend is more
accurately associated with poverty than with cocaine use.

Neither of these assertions, even if true, has any bearing on the
effectiveness of the means adopted to achieve the goal of identifying
and treating maternal cocaine use among MUSC patients. The first
fails because it addresses only the wisdom of the policy itself. And,
the second fails because the fact that the criteria for testing under the
policy did not necessarily correlate with cocaine use in all patients did
not render those criteria ineffective. Accordingly, we conclude that
the method chosen by MUSC officials was an effective one.8 8
_________________________________________________________________

8 The dissent maintains that the urine screens were not an effective
means of identifying cocaine use by pregnant women because some
patients were arrested after giving birth, when"any adverse effect of
maternal cocaine use on the developing fetus had already occurred."
Infra at 27. In applying the special needs balancing test, however, the
proper focus is not on whether any arrests under the policy were an
effective means of advancing the identified government interest, but
rather on the effectiveness of the urine screens. Urine screens conducted
up to the time of birth unquestionably were effective to determine
whether a woman had used cocaine during her pregnancy and thus
whether her child required treatment for prenatal exposure to cocaine.

                  11
C.

Finally, the degree of intrusion, both objective and subjective, suf-
fered by Appellants was minimal. The objective intrusion suffered by
an individual is "measured by the duration of the seizure and the
intensity of the investigation." Id. at 452. The subjective level of
intrusion is measured by the extent to which the method chosen mini-
mizes or enhances fear and surprise on the part of those searched or
detained. See id.

Generally, the privacy interests implicated by the collection and
testing of urine are not minimal. See Skinner v. Railway Labor Execu-
tives' Ass'n, 489 U.S. 602, 626 (1989). The context in which the
searches at issue here occurred, however, indicates that they were
only minimally intrusive. In the first place, the collection and testing
of urine was conducted in the course of medical treatment to which
Appellants had consented. The giving of a urine sample is a normal,
routine, and expected part of a medical examination. See Yin v.
California, 95 F.3d 864, 870 (9th Cir. 1996) (observing that "[i]n
today's world, a medical examination that does not include either a
blood test or urinalysis would be unusual"). Therefore, on an objec-
tive level, the duration and intensity of the search indicate that the
Fourth Amendment intrusion was minimal at best. Cf. Dimeo v.
Griffin, 943 F.2d 679, 682 (7th Cir. 1991) (en banc) (indicating that
a urine drug screen conducted in the course of a medical examination
presents reduced privacy concerns). With respect to the subjective
level of intrusion, we note that urine drug screens were conducted
whenever one of the criteria for testing was met; a treating physician
had no discretion to decline to order a urine test under the policy. See
Turner v. Dammon, 848 F.2d 440, 446-47 (4th Cir. 1988) (explaining
that "[t]he cases upholding warrantless administrative searches clearly
establish that these rules require certainty, regularity, and neutrality
in the conduct of the searches"). This fact, combined with the routine
nature of urine testing in medical examinations, indicates that the
searches were minimally intrusive on a subjective level.

D.

In sum, the rising use of cocaine by pregnant women among
MUSC's patient base and the public health problems associated with

                  12
maternal cocaine use created a special need beyond normal law
enforcement goals; the method chosen to address that need--testing
the urine of pregnant women when indicia of possible cocaine use
were present--effectively advanced the public interest; and the intru-
sion suffered by Appellants was minimal. Therefore, a balancing of
these factors clearly demonstrates that the searches conducted were
reasonable and thus not violative of the Fourth Amendment.

III.

Title VI provides in pertinent part that "[n]o person in the United
States shall, on the ground of race, ... be subjected to discrimination
under any program or activity receiving Federal financial assistance."
42 U.S.C.A. § 2000d. Pursuant to Title VI, Appellants9
                                                     9 challenged
MUSC's policy of testing for and reporting cocaine use by pregnant
women, maintaining that it disparately impacted African-American
women.10
       10

In order to succeed on a Title VI disparate impact claim, a plaintiff
first must establish a prima facie case of discrimination by showing
"that a facially neutral practice has a disproportionate adverse effect
on a group protected by Title VI." Elston v. Talladega County Bd. of
Educ., 997 F.2d 1394, 1407 (11th Cir. 1993). The burden then "shifts
to the defendant to demonstrate the existence of a substantial legiti-
_________________________________________________________________
9 Of the ten Appellants, eight are African-American, one is of mixed
race, and one is Caucasian.
10 Although the statutory language of Title VI addresses only inten-
tional discrimination, federal agencies that provide funds may prohibit
disparate impact discrimination through regulations implementing Title
VI. See Alexander v. Choate, 469 U.S. 287, 293 (1985) (discussing hold-
ings of Guardians Ass'n v. Civil Serv. Comm'n , 463 U.S. 582 (1983));
New York Urban League, Inc. v. New York, 71 F.3d 1031, 1036 (2d Cir.
1995) (per curiam). The parties agree that at least one federal agency that
provides funds to MUSC has promulgated regulations prohibiting dispa-
rate impact discrimination in the operations of programs or activities.
See, e.g., 45 C.F.R. § 80.3(b)(2) (1997) (providing that recipients of
funds from the Department of Health and Human Services may not, in
furnishing services or benefits, "utilize criteria or methods of administra-
tion which have the effect of subjecting individuals to discrimination
because of their race").

                  13
mate justification for the allegedly discriminatory practice." New York
Urban League, Inc. v. New York, 71 F.3d 1031, 1036 (2d Cir. 1995)
(per curiam) (internal quotation marks omitted). If the defendant suc-
ceeds in doing so, the plaintiff nevertheless will prevail by showing
"that other less discriminatory means would serve the same objec-
tive." Id.

Here, Appellants maintained that the policy disproportionately
affected African-Americans in several ways. Specifically, Appellants
argued that African-Americans were disproportionately affected by
application of the policy (1) only at MUSC; (2) only to certain depart-
ments at MUSC; and (3) only to cocaine. Appellants further asserted
that the application of the factors utilized to determine which patients
would be tested for cocaine use disproportionately affected African-
Americans. The district court concluded that Appellants had failed to
establish a prima facie case of discrimination with respect to any of
the challenged practices. Additionally, the district court determined
that even if a prima facie case of discrimination had been established,
MUSC11
     11 had offered a legitimate justification for the policy--that it
identified pregnant women who abused cocaine so that they could be
referred for treatment. Further, the court held that Appellants had
failed to carry their burden of establishing the existence of an equally
_________________________________________________________________
11 Appellants' counsel represented to the district court that Appellants
were pursuing the Title VI claim only against MUSC. Appellants now
contend, however, that this representation was "mistaken" and should be
ignored by this court. Reply Br. of Appellants at 11. Even if we could
do so, the evidence presented was inadequate to establish liability under
Title VI against the Solicitor or the City of Charleston--the defendants
to whom Appellants now point.

Our review of the record reveals nothing to support a conclusion that
the Solicitor or the City of Charleston possessed authority to require
other hospitals to implement the policy. Accordingly, Appellants failed
to prove that either of these parties implemented a policy that resulted in
a disparate impact on African-Americans. Indeed, the testimony of Solic-
itors Condon and Schwacke indicates that they unsuccessfully attempted
to persuade other area hospitals to adopt policies similar to MUSC's; this
testimony leaves the unmistakable impression that if either Solicitor
could have forced health care providers to implement such a policy, he
would have done so.

                  14
effective practice that would have a less disparate impact because the
alternative practices offered by Appellants would have been prohibi-
tively expensive.

Appellants now contend that the district court erred in concluding
that they failed to establish a prima facie case of discrimination and
to provide a viable, less discriminatory alternative. With respect to the
establishment of a prima facie case, Appellants assert that the policy
resulted in a disproportionate impact on African-Americans in two
respects.

First, Appellants point to the fact that the policy was implemented
only at MUSC and maintain that failure to apply the policy at all area
hospitals resulted in a disproportionate effect on African-Americans.
However, we need not consider whether the failure to apply the policy
to all area hospitals would suffice to establish a prima facie case of
discrimination. Because there is no evidence in the record to support
a conclusion that MUSC could have forced other hospitals to adopt
the policy, requiring MUSC to implement the policy at other area hos-
pitals could not constitute a viable, less discriminatory alternative.
Appellants consequently cannot prevail on this claim.

Second, Appellants maintain that MUSC's decision to target
cocaine rather than all substances that are potentially harmful to
fetuses--including nicotine and alcohol--disproportionately affected
African-American women. In support of this contention, Appellants
note that only 68 percent of maternity patients who tested positive for
any drug were African-American, while 90 percent of maternity
patients who tested positive for cocaine were African-American.12  12 We
_________________________________________________________________
12 The district court rejected this argument, concluding without expla-
nation that the relevant comparison was between the racial composition
of the group of women who tested positive for cocaine use and the racial
composition of the group of women who were arrested based on positive
urine drug screens. The difference in the racial composition of these two
groups, the court noted, was not statistically significant. We reject this
reasoning. As the Supreme Court has noted, it is not sufficient for a
defendant to show a racial balance at the end of a selection process;
rather, the pertinent question for purposes of a disparate impact analysis
is whether a given step in the process disproportionately affects members
of one race. See Connecticut v. Teal, 457 U.S. 440, 450-51 (1982).

                  15
agree that this disparity--5.44 standard deviations--is sufficient to
establish a prima facie case of disparate impact discrimination. See
Hazelwood Sch. Dist. v. United States, 433 U.S. 299, 311 n.17 (1977)
(observing that a variance "of more than two or three standard devia-
tions" permits an inference of discrimination); Lewis v. Bloomsburg
Mills, Inc., 773 F.2d 561, 568-69 & n.13 (4th Cir. 1985) (noting that
variance of five to eight standard deviations permits an inference of
discrimination).13
                 13

MUSC justified its decision to target cocaine on the basis of a per-
ceived rise in the number of pregnant women abusing cocaine and the
resistance of these women to obtaining treatment for their addictions.
Appellants do not dispute that these are legitimate, nondiscriminatory
reasons for MUSC's actions, but rather assert that at least two alterna-
tive practices exist which, if adopted, would have lessened the dis-
criminatory impact of the policy: (1) reporting use of all illegal drugs
and alcohol, and (2) testing all maternity patients. 14 The district court
found that both of these practices would have been prohibitively
expensive. See Wards Cove Packing Co. v. Atonio , 490 U.S. 642, 661
(1989) (explaining that determination whether alternative measures
_________________________________________________________________
13 In its memorandum opinion, the district court stated that the compari-
son was "between the MUSC maternity population and those who tested
positive for cocaine." J.A. 2743. We need not resolve this ambiguity,
however, because either comparison results in a statistical difference of
greater than three standard deviations.
14 Appellants also argue that other substances, including nicotine and
alcohol, pose dangers to a fetus that are as great, or greater than, the dan-
gers posed by cocaine. Appellants therefore assert that MUSC's decision
to target cocaine--a drug predominantly used by African-Americans--is
merely a pretext for discrimination. First, we note that this argument is
relevant only to Appellants' claim of intentional racial discrimination, a
claim that was rejected by the jury and that Appellants have not raised
on appeal. Second, we find no evidence of pretext in MUSC's decision
to target cocaine use--a problem that MUSC perceived as being particu-
larly urgent--rather than testing for all potentially harmful substances.
Cf. Bowen v. Owens, 476 U.S. 340, 347 (1986) (noting that "[t]his Court
consistently has recognized that in addressing complex problems a legis-
lature `may take one step at a time, addressing itself to the phase of the
problem which seems most acute'" (quoting Williamson v. Lee Optical
of Okla., Inc., 348 U.S. 483, 489 (1955))).

                  16
exist that would serve the same purpose as a challenged practice with
a less disparate impact should take into account whether the proposed
alternatives impose undue costs or other burdens). With respect to the
first alternative, Appellants point out that the urine drug screens con-
ducted by MUSC indicated the past use of any drug, not just cocaine.
Appellants do not challenge, however, the factual finding of the dis-
trict court that application of the policy--including its tracking and
reporting requirements--to all drugs would have been prohibitively
expensive. Further, they do not assert that the district court committed
clear error in finding that testing the urine of all maternity patients at
MUSC would have been prohibitively expensive. Accordingly, we
cannot conclude that Appellants have demonstrated the existence of
a means of accomplishing the goals of the policy that would have
been equally effective while imposing a less disparate impact on
African-Americans. We therefore conclude that the district court cor-
rectly granted judgment to Appellees on the Title VI claim.

IV.

Next, Appellants maintain that the district court erred in rejecting
their claim that the disclosure of information contained in their medi-
cal records to a representative of the Solicitor's Office and officers of
the CCPD violated their constitutional right to privacy.15
                                                         15 We conclude
that any privacy interest Appellants possessed in their medical records
was outweighed by a compelling governmental interest, particularly
in light of the nonpublic nature of the disclosure.

The Constitution does not include a general right to privacy. See
Condon v. Reno, 155 F.3d 453, 464 (4th Cir. 1998). Nevertheless, the
_________________________________________________________________
15 Appellants also contend that the actions of Nurse Laura Hildebrand,
who disclosed medical information concerning Appellants at meetings of
the Suspected Child Abuse and Neglect (SCAN) committee, violated
their right to privacy. The district court concluded that even if these alle-
gations of disclosure were correct, Appellants were not entitled to any
damages based on the actions of Nurse Hildebrand because she was not
a party defendant. Further, the court concluded that Appellants were not
entitled to injunctive relief because the SCAN committee had been dis-
banded and there was no indication that it would be reconstituted at any
point in the future. We affirm these rulings.

                  17
Supreme Court has recognized that individuals possess a constitu-
tional "interest in avoiding disclosure of personal matters." Whalen v.
Roe, 429 U.S. 589, 599 (1977). This interest, however, is limited to
disclosures of information that touch on rights that"are fundamental
or implicit in the concept of ordered liberty." Paul v. Davis, 424 U.S.
693, 713 (1976) (internal quotation marks omitted); see Bloch v.
Ribar, 156 F.3d 673, 684 (6th Cir. 1998); United States v. McFillin,
713 F.2d 57, 60 (4th Cir. 1981) (holding that a constitutional right to
privacy is implicated when the information disclosed"affects an
essential component of a person's dignity"); cf. Condon, 155 F.3d at
464 (noting that the Supreme Court has recognized a constitutional
right to privacy only with respect to certain limited areas, such as
"matters of reproduction, contraception, abortion, and marriage" (cita-
tions omitted)). Moreover, even in those instances in which a consti-
tutional right of privacy attaches to personal information, disclosure
of that information will not violate the Constitution if "the govern-
ment's interest in disseminating the information" outweighs "the indi-
vidual's interest in keeping the information private." Bloch, 156 F.3d
at 684.

Although the Supreme Court addressed a claim to a right of pri-
vacy in medical records in Whalen, it declined to decide whether such
information merits constitutional privacy protection. See Whalen, 429
U.S. at 605-06. And, the circuit courts of appeals are divided on this
issue. Compare Doe v. Southeastern Pa. Transp. Auth., 72 F.3d 1133,
1137 (3d Cir. 1995) (recognizing that an individual possesses a con-
stitutional privacy right in medical records), with Jarvis v. Wellman,
52 F.3d 125, 126 (6th Cir. 1995) (holding that no constitutionally pro-
tected privacy interest exists in medical records). We need not decide
the question, however, because we conclude that even if Appellants
possess a constitutional interest in the nondisclosure of their medical
records, that interest is outweighed by the interest of the government
in disclosure.

It is well settled that a state has a compelling interest in the identifi-
cation of law breakers and in deterring future misconduct. See Bloch,
156 F.3d at 686; Sanitation & Recycling Indus., Inc. v. New York, 107
F.3d 985, 998 (2d Cir. 1997). Here, any medical records disclosed
were disseminated only to a limited number of law enforcement
personnel--the prosecuting attorney and arresting officers--in the

                   18
course of their official duties. There is no indication that Appellants'
medical records were disclosed to others within the Solicitor's Office,
the CCPD, or the public in general. See American Fed'n of Gov't
Employees, AFL-CIO v. Department of Housing & Urban Dev., 118
F.3d 786, 793 (D.C. Cir. 1997) (holding "that the individual interest
in protecting ... privacy ... is significantly less important where the
information is collected by the government but not disseminated pub-
licly"); Watson v. Lowcountry Red Cross, 974 F.2d 482, 487-88 (4th
Cir. 1992) (indicating that disclosure of information to a district court
did not abridge constitutional privacy interest because the disclosure
was not public). Accordingly, we hold that no privacy right of Appel-
lants was violated.

V.

Finally, Appellants maintain that the district court erred in granting
Appellees judgment as a matter of law on the claim that the manner
in which the policy was applied constituted the state-law tort of abuse
of process. More specifically, Appellants assert that MUSC personnel
improperly threatened Appellants with arrest in order to coerce them
into obtaining substance abuse counseling.

Under South Carolina law, "[t]he essential elements of abuse of
process are: (1) an ulterior purpose; and (2) a wilful act in the use of
the process not proper in the regular conduct of the proceeding."
Johnson v. Painter, 307 S.E.2d 860, 860 (S.C. 1983). "The improper
purpose usually takes the form of coercion to obtain a collateral
advantage[ ] not properly involved in the proceeding itself." Hainer
v. American Med. Int'l, Inc., 492 S.E.2d 103, 107 (S.C. 1997). In
order to satisfy the requirement of an improper act, the plaintiff must
show that the defendant made "[s]ome definite act or threat not autho-
rized by the process or aimed at an object not legitimate in the use
of the process .... There is no liability where the defendant has done
nothing more than carry out the process to its authorized conclusion,
even though with bad intentions." Id.

Here, the district court determined that MUSC personnel did not
have an improper ulterior purpose in advising women who tested pos-
itive for cocaine use that they would be subject to arrest if they did
not obtain substance abuse counseling. Since Appellees did not seek

                  19
to obtain any collateral advantage for themselves, the court reasoned,
there could be no abuse of process. We need not decide whether
Appellees had an ulterior purpose, however, because we conclude that
they performed no act not authorized by the process. At most, Appel-
lees accurately informed Appellants that ingestion of cocaine after the
24th week of pregnancy constituted a criminal offense for which they
could be prosecuted. That maternity patients who tested positive for
cocaine use could avoid criminal prosecution by obtaining treatment
does not render the implementation of the policy abusive. Cf.
Johnson, 307 S.E.2d at 861 (holding that offer to abandon criminal
prosecution in exchange for restitution did not amount to abuse of
process).

VI.

In sum, we reject Appellants' challenges to the judgments in favor
of Appellees. Accordingly, we affirm.

AFFIRMED

BLAKE, District Judge, dissenting in part:

The majority has concluded that the warrantless testing of urine for
evidence of cocaine use which resulted in the arrest of nine of the 10
plaintiffs in this case constituted a reasonable search under the "spe-
cial needs" exception to the warrant requirement of the Fourth
Amendment. On this point, respectfully, I dissent. Furthermore, I dis-
agree with the majority's conclusion that as to the Title VI claim the
appellants failed to demonstrate the existence of a less discriminatory
alternative policy. Accordingly, I would reverse the district court's
decisions concerning the appellants' Fourth Amendment and Title VI
claims and remand for consideration of appropriate relief.

I.

Some additional factual background is necessary to explain my
position on the Fourth Amendment issue. Preliminarily, assuming that
concern for the health of fetuses being carried by pregnant women
using crack cocaine was a motivating force in the development of the

                   20
MUSC policy, it nevertheless is clear from the record that an initial
and continuing focus of the policy was on the arrest and prosecution
of drug-abusing mothers, either before or after they had given birth
to the children presumably affected by the cocaine use.11 The prosecu-
torial purpose of the policy and the substantial involvement of law
enforcement officials from the very beginning of its implementation
are both illustrated by a letter sent by MUSC General Counsel Joseph
C. Good to Charles Condon, Charleston City Solicitor, on August 23,
1989. In the letter, Mr. Good wrote:

       I read with great interest in Saturday's newspaper accounts
       of our good friend, the Solicitor for the Thirteenth Judicial
       Circuit, prosecuting mothers who gave birth to children who
       tested positive for drugs. . . .

        Please advise us if your office is anticipating future crimi-
       nal action and what if anything our Medical Center needs to
       do to assist you in this matter.

(J.A. Vol. III at 2052.) In addition, operational guidelines issued by
Captain Roberts of the Charleston police force on October 12, 1989,
with copies to Solicitor Condon and to MUSC nurse Shirley Brown
(one of the instigators of the MUSC program), refer to the positive
drug tests as "probable cause" for arrest of the mother, on charges of
possession only if the pregnancy is 27 weeks or less, and on charges
of both possession and distribution to persons under 18 if the preg-
nancy is 28 weeks or more. (J.A. Vol. III at 1412-1414.)2   2 Further, a
letter from Mr. Good to a Senior Assistant Attorney General on
December 19, 1989, explaining the MUSC program, states that it was
developed by MUSC "[a]t the suggestion of law enforcement and the
solicitor's office. . . ." (J.A. Vol. III at 1457.) These are merely a few
_________________________________________________________________
1 As set forth in greater detail below, seven of the plaintiffs were
arrested after the birth of their children.
2 In regard to the Title VI issue, it should be noted that the police
department guidelines are not limited to cocaine only but refer to "illegal
drugs" generally, which the guidelines define as"heroin, crack/cocaine,
amphetamines, and any other drug illegally ingested by the patient that
medical authorities deem a threat to the life and safety of the unborn
child." (J.A. Vol. III at 1412.)

                  21
examples of the evidence in the record that supports a finding of both
prosecutorial intent on the part of MUSC and substantial involvement
of law enforcement officials in developing the program.

Following is a short summary of the circumstances under which the
plaintiffs in this case were tested and arrested:

Sandra Powell, African-American, received prenatal care at MUSC
from the end of her first trimester. (J.A. Vol. I at 322.) In October
1989, she delivered her child at MUSC and tested positive for
cocaine. (J.A. Vol. III at 1842-44, 1853.) She was arrested at the hos-
pital the following day. (J.A. Vol. III at 1844, 1852.)

Lori Griffin, African-American, received prenatal care at MUSC
beginning in July 1989. (J.A. Vol. III at 1563.) She was admitted to
the hospital on October 7, 1989, with contractions. (J.A. Vol. III at
1560.) She tested positive for cocaine. (J.A. Vol. III at 1559.) She was
arrested and taken to the county jail. (J.A. Vol. III at 1560, 1563.) She
was returned to MUSC from jail on October 25, 1989, to deliver her
child.

Ellen Knight, African-American, received prenatal care at MUSC
prior to the fall of 1989. (J.A. Vol. I at 293.) She arrived at the hospi-
tal on November 6, 1989, in labor. (J.A. Vol. III at 1698.) Although
her cocaine test was negative, her child tested positive at birth. (J.A.
Vol. III at 1705, 1707.) She was arrested at the hospital on November
8, 1989.

Laverne Singleton, African-American, delivered her child on
November 9, 1989, in the ambulance on the way to MUSC. (J.A. at
I 225; Vol. III at 1859, 1865.) She tested positive for cocaine at the
time of admission. (J.A. Vol. III at 1859-60.) She was arrested at the
hospital the next morning. (Id.)

Paula Hale, African-American, first arrived at MUSC in December
1990 in labor. (J.A. Vol. III at 1581-83.) She tested positive for
cocaine at delivery and was referred to substance abuse counseling.
(Id.) She was arrested in March 1991 after failing to complete the
drug treatment program. (J.A. Vol. III at 1585-86.)

                   22
Pamela Pear, African-American, arrived at MUSC in July 1990
with pre-term labor symptoms. (J.A. Vol. III at 1817.) She tested pos-
itive for cocaine during that visit. (Id.) She was referred to substance
abuse counseling. (J.A. Vol. III at 1736.) In August 1990, she was
again admitted to MUSC for pre-term labor and tested positive for
cocaine. (J.A. Vol. III at 1757.) She was arrested at the hospital and
was released on bond the same day. She delivered her child at MUSC
in September 1990. (J.A. Vol. III at 1765.)

Theresa Joseph, who was multi-racial,3     3 was first seen at MUSC on
June 5, 1991, for a non-pregnancy related matter. (J.A. Vol. III at
1599.) She tested positive for cocaine at that time and was referred
to the obstetrical clinic. (J.A. Vol. III at 1601-02.) She was admitted
to the hospital again, for the same non-pregnancy complaint, on June
13, 1991. She again tested positive for cocaine and was referred to
substance abuse counseling. (J.A. Vol. III at 1612, 1626.) She failed
to complete the substance abuse program in July 1991. (J.A. Vol. III
at 1656, 1682.) She was seen again in September 1991 and once more
tested positive for cocaine. (J.A. Vol. I at 515; Vol. III at 1628-29.)
Finally, she arrived at MUSC in October 1991 in labor and tested pos-
itive for cocaine. (J.A. Vol. III at 1632, 1634.) Her child was born on
October 18, 1991, and Ms. Joseph was arrested at the hospital. (Id.)

Crystal Ferguson, African-American, tested positive for cocaine
during a prenatal visit to MUSC in June 1991. (J.A. Vol. III at 1530.)
She agreed to attend substance abuse counseling. (J.A. Vol. III at
1537.) On August 4, 1991, she delivered her child at MUSC. She
tested positive for cocaine at that time. (J.A. Vol. III at 1533.) She
was arrested on August 7, 1991, for failing to comply with the drug
treatment program. (J.A. Vol. III at 1541.)

Patricia Williams, African-American, received prenatal care at
MUSC beginning in January 1992. (J.A. Vol. III at 1910.) She tested
positive for cocaine at the time of her first visit and was referred to
substance abuse counseling. (J.A. Vol. III at 1903, 1939-40.) She did
not complete the counseling program and returned for additional pre-
natal care three times, testing positive for cocaine each time. (J.A.
_________________________________________________________________
3 Ms. Joseph is now deceased. She was described as "black" on her
Charleston Police Department Incident Report. (J.A. Vol. III at 1655.)

                   23
Vol. III at 1901-02, 1907.) In March 1992, she arrived at the hospital
in labor. (J.A. Vol. III at 1910-11.) She again tested positive for
cocaine. (Id.) Her baby was born on March 10, 1992, and on March
12, 1992, she was arrested at the hospital. (Id. )

Darlene Nicholson, Caucasian, received regular prenatal care at
MUSC. (J.A. Vol. I at 447-48, 450; Vol. III at 1717, 1724.) At her
December 17, 1993 prenatal visit she tested positive for cocaine. (J.A.
Vol. I at 452-53.) At that time, she was told that she must voluntarily
admit herself to the MUSC psychiatric unit for substance abuse treat-
ment or she would be arrested. (Id.) She entered the psychiatric unit
and remained there until she was released after 30 days. (J.A. Vol. III
at 1717.) She delivered her child at MUSC on February 21, 1994.
(J.A. Vol. I at 458.)

In none of these cases was a warrant obtained before the urine test-
ing was done or before the results were turned over to the police and
the plaintiffs were arrested. Furthermore, the consent forms signed by
the plaintiffs did not advise them that their drug test results would be
disclosed to the police. The majority excuses the lack of a warrant,
or indeed any determination of probable cause, by relying on the
"special needs" exception to the ordinary Fourth Amendment require-
ment that a warrant be obtained.

II.

The Supreme Court has held that

        where a Fourth Amendment intrusion serves special govern-
        mental needs, beyond the normal need for law enforcement,
        it is necessary to balance the individual's privacy expecta-
        tions against the Government's interests to determine
        whether it is impractical to require a warrant or some level
        of individualized suspicion in the particular context.

National Treasury Employees Union v. Von Raab , 489 U.S. 656, 665-
66 (1989) (emphasis added). Similarly, the Court has instructed that

        When such "special needs" -- concerns other than crime
        detection -- are alleged in justification of a Fourth Amend-

                   24
       ment intrusion, courts must undertake a context-specific
       inquiry, examining closely the competing private and public
       interests advanced by the parties.

Chandler v. Miller, 520 U.S. 305, 314 (1997) (emphasis added). Sev-
eral aspects of the "special needs" exception require careful analysis
in the context of this case.

First, as the emphasized portions of the above quotations make
clear, the "special needs" exception does not apply where the govern-
mental intrusion is intended to be used for law enforcement purposes.
In Von Raab, the issue was whether "it violates the Fourth Amend-
ment for the United States Customs Service to require a urinalysis test
from employees who seek transfer or promotion to certain positions."
489 U.S. at 659. The Supreme Court in that case held that the Fourth
Amendment permitted the suspicionless testing of employees who
applied for positions directly involving the use of firearms or the
interdiction of illegal drugs. Id. at 679. In reaching this conclusion,
the Court applied a "special needs" analysis, balancing the individu-
als' privacy interests against the non-law enforcement governmental
interests served by the urinalysis policy. Significantly, in deciding to
apply the "special needs" balancing test to the facts before it, the
Court emphasized that "[i]t is clear that the Customs Service's drug-
testing program is not designed to serve the ordinary needs of law
enforcement. Test results may not be used in a criminal prosecution
of the employee without the employee's consent." Id. at 666 (empha-
sis added). In fact, in none of the cases relied on by the majority,
other than the sobriety checkpoint and probation supervision cases
which will be addressed below, were the results of the drug tests or
other searches intended for use in a criminal prosecution. See
Vernonia Sch. Dist. v. Acton, 515 U.S. 646, 651 (1995) (authorizing
only certain school officials to have access to test results); Skinner v.
Railway Labor Executives' Ass'n, 489 U.S. 602, 621 & n. 5 (1989)
("While [the provision permitting drug testing of railroad personnel]
might be read broadly to authorize the release of biological samples
to law enforcement authorities, the record does not disclose that it was
intended to be, or actually has been, so used."); Yin v. State of
California, 95 F.3d 864, 869, 873 (9th Cir. 1996) (state employee
required to submit to medical examination solely to determine her
ability to perform normal work duties); Dimeo v. Griffin, 943 F.2d

                  25
679, 685 (7th Cir. 1990) (en banc) (jockeys and other participants in
horse racing required to undergo random drug tests as condition of
occupational licensure). In sharp contrast, nine out of ten of the plain-
tiffs in this case were arrested based on the test results, and one
avoided arrest only by committing herself to a psychiatric unit. Under
these circumstances, I believe the "special needs" exception does not
apply.

The majority cites Michigan Department of State Police v. Sitz, 496
U.S. 444 (1990), and Griffin v. Wisconsin, 483 U.S. 868 (1987), for
the proposition that the defendants' intention to use the results of the
drug tests as probable cause to arrest the plaintiffs in this case does
not preclude application of the special needs balancing test. In Sitz,
however, the Supreme Court was careful to explain that the special
needs exception applied only to the suspicionless"seizure," that is,
the initial stop of each motorist and the associated preliminary ques-
tioning and observation, 496 U.S. at 450-51, which the Court charac-
terized as only a "slight" intrusion. Id. at 451. The Court specifically
noted that the "[d]etention of particular motorists for more extensive
field sobriety testing may require satisfaction of an individualized
suspicion standard." Id. at 451 (citing United States v. Martinez-
Fuerte, 428 U.S. 543, 559 (1976)). The Sitz balancing test, which jus-
tifies the relatively slight intrusion of a checkpoint seizure, does not
serve also to justify searches of the motorists' persons or effects with-
out consent or probable cause. See United States v. Ortiz, 422 U.S.
891, 896-97 (1975). Griffin also is readily distinguishable. In that
case, the Supreme Court upheld the validity of a warrantless search
conducted by a state probation officer at the home of a criminal
defendant on probation under a regulation which permitted such
searches as long as the probation officer had "reasonable grounds" to
believe the probationer possessed contraband forbidden under the
conditions of his probation. The Court noted that probation was a
form of criminal sanction imposed after a finding of guilt, 483 U.S.
at 874, and supervision of probationers was a "`special need' of the
State permitting a degree of impingement upon privacy that would not
be constitutional if applied to the public at large." Id. at 875.

Accordingly, I believe the majority reads Sitz and Griffin too
broadly in suggesting that the special needs exception can justify a

                  26
suspicionless search of a member of the public intended to produce
evidence for use in a criminal arrest.

In this case, the MUSC policy was intended from its inception to
result in the arrest and possible prosecution of pregnant women who
were patients at the state hospital. In all the other special needs cases
cited by the majority, arrest was at most an incidental possibility and
not a direct result of the warrantless Fourth Amendment intrusion
sought to be justified. It is simply inconsistent with the record in this
case to identify the drug testing imposed by MUSC as not serving
normal law enforcement needs. I would find that the avowed and
actual purpose of arresting patients who tested positive for cocaine,
as well as the extensive involvement of law enforcement officials in
designing and implementing the policy, preclude application of the
special needs analysis in this case.

Even if I assume, however, that a special needs balancing test
should be applied, and further assume that the governmental interest
identified by the majority -- i.e., the adverse effect of maternal
cocaine use on the health of children exposed to cocaine in utero --
is substantial, I believe that the policy fails the test of "effectiveness,"
i.e., "[t]he degree to which the search advances the public interest."
See Sitz, 496 U.S. at 453. It is undisputed that seven of the plaintiffs
were arrested after giving birth (indeed, several were taken into cus-
tody at the hospital wearing only their hospital gowns), rather than
during the prenatal period.4   4 By that time, any adverse effect of mater-
nal cocaine use on the developing fetus had already occurred, and the
arrest could only have had a punitive rather than a preventive purpose.

Nor is it correct to say that the degree of intrusion on the mother's
privacy was "minimal" simply because the test occurred in the context
of a hospital examination. Unlike the policy in Von Raab, under the
MUSC policy the test results are reported not simply to a licensed
physician, but to law enforcement officials with no medical reason for
receiving the information. Cf. Von Raab, 489 U.S. at 672 n.2 (noting
_________________________________________________________________
4 Moreover, several of the plaintiffs who were not arrested until after
giving birth had tested positive for cocaine multiple times during the pre-
natal period when, according to the purported purpose of the policy,
intervention was crucial.

                   27
as one of the procedures that minimized the intrusiveness of the drug-
screening program that "an employee need not disclose personal med-
ical information to the Government unless his test result is positive,
and even then any such information is reported to a licensed physi-
cian").

For all the above reasons, I agree with the trial court that the drug
testing policy applied to the plaintiffs in this case violated the Fourth
Amendment, in the absence of valid consent.

The district court also properly found that the various consent
forms signed by the plaintiffs, which did not advise them that the drug
test results would be disclosed to the police, did not alone establish
valid consent. Accordingly, the court submitted this case to the jury
on the issue of consent, and the jury returned a verdict in favor of the
defendants. The plaintiffs moved for judgment under Fed. R. Civ. P.
50(b), and the court denied the motion.

I disagree that the evidence presented at trial was sufficient to sus-
tain the jury's verdict. When considering a Rule 50(b) motion for
judgment as a matter of law, the district court must view the evidence
in the light most favorable to the non-moving party and then deter-
mine whether a reasonable jury could draw only one conclusion from
the evidence. See Townley v. Norfolk & Western Ry. Co., 887 F.2d
498, 499 (4th Cir. 1989). We review the district court's ruling on a
Rule 50(b) motion by applying the same standards de novo. Id. In
addition to the consent forms, the defendants presented other evi-
dence, such as letters that either accompanied the forms or were dis-
tributed after a positive test result, and a public service announcement
issued by the Solicitor's Office in 1990. The public service announce-
ment indicated that pregnant women who tested positive for drug use
could be subject to prosecution; however, it was seen by only two of
the plaintiffs. (J.A. Vol. I at 374, 518-19.) The plaintiffs' presumed
familiarity with this information, even when combined with a general
knowledge that use of cocaine is illegal, is not sufficient to establish
the plaintiffs' voluntary and knowing consent to the possible use
against them in a criminal case of drug test results taken in the course
of their pregnancy and labor. Cf. Von Raab, 489 U.S. at 666 (positive
test results "may not be used in a criminal prosecution without the
employee's consent"). I also question whether consent can be volun-

                  28
tary, in a constitutional sense, when given by an indigent, uninsured
woman in labor, who is dependent on medical care provided by the
state's public hospital. If the special needs exception had been held
not to apply, a more thorough analysis of this issue would have been
necessary.

III.

I agree with the majority's analysis of the Title VI issue, except
with regard to the availability of an equally effective alternative pol-
icy with a less discriminatory impact.5  5 The plaintiffs point out, cor-
rectly, that the urine tests being performed under the MUSC policy
indicate a patient's past use, not just of cocaine, but of other illegal
drugs as well. (J.A. Vol. II at 1336-42.) Consequently, applying the
policy to the past use of all illegal drugs, not just cocaine, as the plain-
tiffs suggested, would not have increased the cost of the testing. The
district court's finding that testing for all illegal drugs "would be pro-
hibitively expensive," therefore, is not supported by the record. In
affirming the decision below, the majority states that the plaintiffs
have not challenged the district court's factual finding "that applica-
tion of the policy -- including its tracking and reporting requirements
-- to all drugs would have been prohibitively expensive." The district
court, however, made no such finding. In considering the alternative
of focusing on all illegal drugs, not just cocaine, the court relied only
on the cost of testing, not tracking or reporting, to reject that alternative.6
                                                                              6
(J.A. Vol. IV at 2746). Since the plaintiffs have shown that their pro-
posed alternative of applying the testing policy to past use of any ille-
gal drug would not have resulted in any additional cost, the district
court's fact-finding on the issue of the cost of testing is clearly errone-
ous, and the plaintiffs have carried their burden of demonstrating the
availability of an equally effective alternative with a less discrimina-
_________________________________________________________________
5 The appellants' brief challenges the factual findings of the district
court concerning the cost of the testing program and the overall effec-
tiveness of the policy. (Brief of Appellants at 49).
6 Nor is any evidence on this issue apparent in the record, except for
evidence suggesting that the Charleston Substance Abuse Clinic, not
MUSC, would notify police regarding missed substance abuse appoint-
ments, (J.A. Vol. III at 1430), and that the Solicitor's Office would be
responsible for tracking compliance, generally. (J.A. Vol. I at 610-11.)

                  29
tory impact.7
            7 Accordingly, I would reverse the judgment in favor of
the defendants on the Title VI claim and remand for consideration of
injunctive relief.

IV.

In summary, I would reverse the district court on the Fourth
Amendment and Title VI claims, and remand for consideration of
appropriate relief. On these two issues, respectfully, I dissent.
_________________________________________________________________
7 The plaintiffs have not shown that the district court erred in rejecting
their second alternative, i.e., testing all maternity patients at MUSC.

                  30
