                               RECOMMENDED FOR PUBLICATION
                               Pursuant to Sixth Circuit I.O.P. 32.1(b)
                                      File Name: 20a0226p.06

                   UNITED STATES COURT OF APPEALS
                                  FOR THE SIXTH CIRCUIT



                                                                 ┐
CHRISTINE BEARDEN; DAVID BEARDEN; TERRI COOK;
                                                                 │
CAROLYN GIBBONS; ELMER DARRELL GREER; LADONNA F.
                                                                 │
GREER; MARK HUTCHINS; KEVIN MITCHELL; JAMIE
                                                                 │
STRANGE PIERSON; CRYSTAL GAIL REGAN,
                                                                 │
                                Plaintiffs-Appellants,            >       No. 20-5047
                                                                 │
       v.                                                        │
                                                                 │
BALLAD HEALTH; MEDICAL EDUCATION ASSISTANCE                      │
CORPORATION, dba East Tennessee Physicians and                   │
Associates, dba University Physicians Practice Group;            │
BARBARA ALLEN, JULIE BENNETT, DAVID LESTER, ALAN                 │
LEVINE, DAVID MAY, GARY PEACOCK, DOUG SPRINGER,                  │
and KEITH WILSON, in their capacities as members of the          │
Board of Ballad Health and/or Medical Education                  │
Assistance Corporation; DAVID GOLDEN and SCOTT M.                │
NISWONGER, in their capacities as members of the Board           │
of Ballad Health and/or Medical Education Assistance             │
Corporation and in their official capacities as members of       │
the Board of Trustees of East Tennessee State University;        │
BRIAN NOLAND, in his capacity as a member of the Board           │
of Ballad Health and/or Medical Education Assistance             │
Corporation, in his official capacity as a member of the         │
Board of Trustees of East Tennessee State University and         │
as President of East Tennessee State University and ex-          │
officio member of the Board of Directors of Medical              │
Education Assistance Corporation,                                │
                                     Defendants-Appellees.       │
                                                                 ┘

                          Appeal from the United States District Court
                      for the Eastern District of Tennessee at Greeneville.
                     No. 2:19-cv-00055—Curtis L. Collier, District Judge.

                               Decided and Filed: July 23, 2020

                Before: GIBBONS, GRIFFIN, and THAPAR, Circuit Judges.
 No. 20-5047                    Bearden, et al. v. Ballad Health, et al.                    Page 2


                                        _________________

                                             COUNSEL

ON BRIEF: Francis X. Santore, Jr., SANTORE & SANTORE, Greeneville, Tennessee, for
Appellants. Jimmie C. Miller, HUNTER, SMITH & DAVIS, LLP, Kingsport, Tennessee,
Jeffrey W. Brennan, MCDERMOTT WILL & EMERY LLP, Washington, D.C., Michelle
Lowery, MCDERMOTT WILL & EMERY LLP, Los Angeles, California, for Ballad Health
Appellees. Lynda M. Hill, Joshua T. Lewis, FROST BROWN TODD LLC, Nashville,
Tennessee, Matthew C. Blickensderfer, FROST BROWN TODD LLC, Cincinnati, Ohio, for
Appellee Medical Education Assistance Corporation. Janet M. Kleinfelter, OFFICE OF THE
TENNESSEE ATTORNEY GENERAL, Nashville, Tennessee, for Appellees David Golden,
Scott Niswonger, and Brian Noland.
                                        _________________

                                             OPINION
                                        _________________

       THAPAR, Circuit Judge. As our court has previously explained, there are good reasons
not to disparage your opponent, especially in court filings. “The reasons include civility; the
near-certainty that overstatement will only push the reader away . . . ; and that, even where the
record supports an extreme modifier, the better practice is usually to lay out the facts and let the
court reach its own conclusions.” Bennett v. State Farm Mut. Auto. Ins. Co., 731 F.3d 584, 585
(6th Cir. 2013) (cleaned up). The most important reason here is that counsel’s colorful insults do
nothing to show that his clients have standing to bring this lawsuit. We affirm the district court’s
dismissal for lack of jurisdiction.

       Two years ago, the Tennessee Department of Health allowed two healthcare companies
to merge into a single entity known as Ballad Health. Some of the board members of the
resulting entity also had ties to another healthcare organization in the area called the Medical
Education Assistance Corporation (MEAC). Over a year later, a group of plaintiffs filed a
seven-page complaint, alleging that Ballad, MEAC, and various individual defendants had
created an interlocking directorate in violation of the Clayton Antitrust Act. See 15 U.S.C. § 19.

       The defendants soon moved to dismiss the case for lack of standing (among other
grounds). In response, the plaintiffs sought leave to amend their complaint. Their proposed
twenty-nine-page complaint included the following “allegations”:
 No. 20-5047                  Bearden, et al. v. Ballad Health, et al.                     Page 3


       •   That MEAC “surrendered to [Ballad] much in the manner Marshal Petain
           surrendered France to Adolph Hitler.” R. 48-1, Pg. ID 942.
       •   That the Ballad merger was an “Octopus which was birthed by [two
           individuals] on one of the local golf courses while [they] were walking down
           the ‘green fairways of indifference,’ to the health, safety and welfare of
           millions of people.” Id.; see also id. at 949 (referring to the merged entity as
           “the Levine-Greene Octopus”).
       •   That Ballad and MEAC are “intertwined in an incestuous relationship, the
           likes of which have not been seen since the days of Sodom and Gomorrah.”
           Id. at 950; see also id. at 943 (describing the defendants as in “an incestuous,
           antitrust relationship”).
       •   That the Tennessee Department of Health’s failure to supervise the defendants
           “is akin to the Tennessee Bureau of Investigation allowing criminals to rape,
           murder, pillage, loot and plunder on its watch, while its agents stand by.” Id.
           at 951.
       •   That “a virus has been effectively introduced into the Ballad Board which has
           sickened all 11 directors, and which requires their permanent quarantine.” Id.
           at 954.

       Some of these references weren’t new. In an earlier brief—which was struck for failure
to comply with the local court rules—the plaintiffs described the merged entity as “[t]he Ballad
Octopus . . . created from the petri dish of a few so-called economic and business ‘leaders’ in its
market area.” R. 38, Pg. ID 828–29. This creature, the plaintiffs continued, “now attempts to
slink back into its hidey hole by firing its putrid pool of purple ink into the faces of these
plaintiffs, who dare challenge its hegemony over the health care of the persons in this market
area, to wit: its Motion to Dismiss.” Id. at 829. The plaintiffs elaborated on their argument with
further animal metaphors. They “wonder[ed]” whether Ballad was “affixing its buzzard-like
grin” upon the region, “ready to ravenously pounce upon the medical facilities in these areas like
the buzzard swoops down upon the carcass of a dead cow.” Id. at 835. They described a related
entity as a “duck trying to pretend he is a swan.” Id. at 842. And at one point, they explained:
“This Octopus walks like a duck and quacks like a duck, and, therefore, it is a duck.” Id. at 859.

       Nor did matters end there. When the defendants criticized this language as disrespectful,
the plaintiffs doubled down and explained why they thought these comparisons were appropriate.
For instance, the plaintiffs described the history surrounding Marshal Pétain’s surrender of
France and offered to let the district court “draw its own conclusions” on whether this was “an
 No. 20-5047                   Bearden, et al. v. Ballad Health, et al.                    Page 4


apt comparison.” R. 57, Pg. ID 2003. They also compared one of the individual defendants,
who had stuttered during a prior television interview, to “Porky Pig, a famous Warner Brothers
cartoon character, [who] also stuttered.” Id. at 2007. And the plaintiffs concluded their brief by
noting, “[m]ost respectfully,” that “Ballad ha[d] been acting like an octopus, by squirting its ink
into the ocean of jurisprudence to cloud the issues in this case.” Id. at 2008.

        After these filings, the district court found that the plaintiffs had failed to adequately
allege standing and thus dismissed the case for lack of jurisdiction. We review that decision de
novo. See Phillips v. DeWine, 841 F.3d 405, 413 (6th Cir. 2016).

        The “irreducible constitutional minimum of standing” has three well-known
requirements: (1) the plaintiff must have suffered an “injury in fact”; (2) that injury must have
been “caus[ed]” by the defendant’s conduct; and (3) the injury must be “redress[able] by a
favorable decision.” Lujan v. Defs. of Wildlife, 504 U.S. 555, 560–61 (1992) (cleaned up); see
also Duncan v. Muzyn, 885 F.3d 422, 427 (6th Cir. 2018). At the pleading stage, plaintiffs must
allege sufficient facts to establish these elements as they would any other element of their suit.
See Lujan, 504 U.S. at 561. This case begins—and ends—with the first requirement: injury in
fact.

        To establish an injury in fact, plaintiffs must show that they suffered “an invasion of a
legally protected interest” that is both “concrete and particularized” and “actual or imminent, not
conjectural or hypothetical.” Id. at 560 (cleaned up). As for the former two components,
plaintiffs must show that they are affected “in a personal and individual way” and must allege
something more than a “bare procedural violation” of a statute. Spokeo, Inc. v. Robins, 136 S.
Ct. 1540, 1548, 1550 (2016) (cleaned up); Hagy v. Demers & Adams, 882 F.3d 616, 621 (6th
Cir. 2018). As for the latter component, plaintiffs must show that they have already suffered an
injury or that a threatened injury is “certainly impending.” Clapper v. Amnesty Int’l USA, 568
U.S. 398, 409 (2013) (cleaned up); Buchholz v. Meyer Njus Tanick, PA, 946 F.3d 855, 865 (6th
Cir. 2020). Simply put, the injury-in-fact requirement ensures that courts stay within their proper
role of resolving cases or controversies—and nothing more.
 No. 20-5047                      Bearden, et al. v. Ballad Health, et al.                     Page 5


        Now consider the plaintiffs’ complaint. Liberally construed, the complaint addresses
injury in fact in three places:

        •   “All plaintiffs aver that they have standing to bring this litigation, in that []
            each has or will sustain injury as a direct and proximate result of the acts to be
            hereinafter set forth . . . . [I]t may certainly be said that each of the plaintiffs
            are directly affected by the illegal, improper acts to be alleged, and, therefore,
            are seeking their own remedies, and not any remedies for any third parties.”
            R. 1, Pg. ID 2.
        •   “In the extreme, [certain individual defendants] have the authority, in
            conjunction with [others], to dissolve [MEAC], and thus completely stifle its
            status as a market competitor with Ballad.” Id. at 5.
        •   “Plaintiffs . . . aver that not only they, but the general public in the multi-state
            service area of both of the corporate defendants, have an interest in seeing that
            an improper, illegal, interlocking Board of Directors does not govern the
            regions’ dominant health care entity.” Id.

        The first allegation does nothing to help the plaintiffs because it’s a “legal conclusion,”
which need not be accepted as true even at the pleading stage. Ashcroft v. Iqbal, 556 U.S. 662,
678 (2009).

        The second allegation fares little better.        The plaintiffs themselves characterize the
dissolution of MEAC as an “extreme” scenario and have alleged nothing that would move this
event beyond the realm of speculation—let alone show that it is “certainly impending.” Clapper,
568 U.S. at 409 (cleaned up). What’s more, the plaintiffs have not alleged anything to show that
this speculative risk will affect them “in a personal and individual way.” Spokeo, 136 S. Ct. at
1548 (cleaned up). Based on the complaint, the only thing we know about the plaintiffs is that
they live in the local area. We know nothing about what medical services they have sought in
the past, what services they will seek in the future, or how the dissolution of MEAC would affect
their access to these services.

        The third allegation suffers from similar problems. Again, the plaintiffs allege nothing
that shows that any injury is “particularized” to them. To the contrary, they frame the case as
about an “interest” that the “general public” holds in preventing violations of antitrust law. R. 1,
Pg. ID 5. For similar reasons, the plaintiffs have not shown that any injury is “concrete.”
Instead, their allegation seems much like the “bare procedural violation[s]” that both the
 No. 20-5047                    Bearden, et al. v. Ballad Health, et al.                    Page 6


Supreme Court and our court have found to be insufficient to establish standing. See Spokeo,
136 S. Ct. at 1549–50; Hagy, 882 F.3d at 621–22. All told, the complaint fails to allege an injury
in fact.

           Nor would it have changed matters if the plaintiffs had been given leave to amend their
complaint. It’s true that the proposed amended complaint was four times as long as the original.
But the additional pages added only insults, not an injury. At least as to standing, the amended
complaint consists entirely of unsupported legal conclusions, see, e.g., R. 48-1, Pg. ID 929
(“[A]ll plaintiffs aver that they have a plausible, colorable claim of injury due to the defendants’
joint and several violations of the Clayton Antitrust Act’s provisions regarding prohibition of
interlocking directorates.” (emphasis removed)); id. at 939 (“Plaintiffs . . . aver that they,
individually and jointly are either in danger of being harmed by this interlocking directorate, or,
at the very least, are potentially in danger of being harmed by this interlocking directorate.”); id.
at 945 (“In short, plaintiffs aver that they have Article III standing.” (emphasis removed)), and
events that are never linked to concrete and particularized harms to the plaintiffs, see, e.g., id.
940–43 (describing actions taken by the defendants). It is a “long-settled principle that standing
cannot be inferred argumentatively from averments in the pleadings, but rather must
affirmatively appear in the record.” Fednav, Ltd. v. Chester, 547 F.3d 607, 617 (6th Cir. 2008)
(cleaned up). This case is no different.

           Indeed, the plaintiffs all but admit that they can’t satisfy the normal standing
requirements. In their proposed amended complaint, they candidly confess that their theory of
“injury in fact” might be “an aberration” of the requirement as articulated in prior decisions. R.
48-1, Pg. ID 944. And on appeal, they describe it as “paradoxical[]” that they would be expected
to allege a “specific, concrete, imminent or actualized injury”—despite that being the well-
established standard. Reply Br. at 5. Instead, the plaintiffs offer a few alternative theories for
why they have standing to sue.

           The plaintiffs first argue that they need not satisfy the normal standing requirements
because the relevant provision of the Clayton Antitrust Act has a unique prophylactic purpose.
Yet the plaintiffs point to no authority for this position—and for good reason. “Injury in fact is a
constitutional requirement, and it is settled that Congress cannot erase [the] requirement . . . .”
 No. 20-5047                   Bearden, et al. v. Ballad Health, et al.                     Page 7


Spokeo, 136 S. Ct. at 1547–48 (cleaned up). As far as we are aware, there’s no Clayton Antitrust
Act exception to this rule.

       It’s true that there are still some difficult and unresolved questions about Congress’s
power to define new injuries in fact. See Hagy, 882 F.3d at 622–23. But fortunately, we need
not wade into those murky waters here. Nothing in the relevant provisions of the Clayton
Antitrust Act purports to create a novel injury in fact. To the contrary, the Act provides for
injunctive relief only “under the same conditions and principles as injunctive relief against
threatened conduct that will cause loss or damage is granted by courts of equity.” 15 U.S.C.
§ 26. That language hardly suggests an effort to overhaul the case-or-controversy requirement.
And in fact, courts have typically understood antitrust law as imposing a “more onerous”
standard than traditional standing analysis (though this heightened showing goes to the merits,
not our subject-matter jurisdiction). Static Control Components, Inc. v. Lexmark Int’l, Inc.,
697 F.3d 387, 402 (6th Cir. 2012). When it comes to constitutional standing, there appears to be
nothing special about antitrust law. See, e.g., Funeral Consumers All., Inc. v. Serv. Corp. Int’l,
695 F.3d 330, 342–43 (5th Cir. 2012) (collecting antitrust cases applying ordinary standing
analysis to deny injunctive relief); William C. Holmes & Melissa H. Mangiaracina, Antitrust
Law Handbook §§ 9:5, 9:7 (2019–20 ed.).

       The plaintiffs also argue that we should relax the usual requirements for standing because
this case implicates access to an important resource: healthcare. Just as courts sometimes say
that “death is different,” e.g., Ring v. Arizona, 536 U.S. 584, 606 (2002) (cleaned up), the
plaintiffs say that healthcare is different. But if anything, this analogy to the death penalty shows
why we can’t relax our usual standing requirements here. For although the Supreme Court has
treated death-penalty cases differently in some ways, it has emphatically refused to “create an
exception to traditional standing doctrine” in such cases. Whitmore v. Arkansas, 495 U.S. 149,
161 (1990). And that makes sense given that the Court has elsewhere described the “core
component of standing [as] an essential and unchanging part” of Article III. Lujan, 504 U.S. at
560. We have no authority to take a different view when it comes to healthcare.
 No. 20-5047                    Bearden, et al. v. Ballad Health, et al.                    Page 8


        Finally, the plaintiffs argue that they have standing because Ballad previously
“stipulated” (in an agreement with the State regarding its merger) that a breach of the agreement
would constitute “‘irreparable harm.’” Appellant Br. at 22 (quoting R. 1-1, Pg. ID 58). The
premise of this argument is flawed because parties can no more stipulate to elements of standing
than they can to standing itself. See, e.g., Va. House of Delegates v. Bethune-Hill, 139 S. Ct.
1945, 1951 (2019); Alongi v. Ford Motor Co., 386 F.3d 716, 728 (6th Cir. 2004) (“Subject-
matter jurisdiction cannot be conferred by consent of the parties . . . .”). And even on its own
terms, the stipulation applies only to a “breach or threatened breach” of the agreement (which the
plaintiffs have not alleged) and extends only to relief under the agreement itself (to which the
plaintiffs are not parties). R. 1-1, Pg. ID 58. In short, this provision does nothing to show that
the plaintiffs have suffered an injury in fact.

        In sum, the district court correctly dismissed the case for lack of jurisdiction.

        One last note. Like the district court, we take a moment to remind plaintiffs’ counsel
that, as an officer of the court, he is expected to treat other parties in the case (as well as their
counsel) with courtesy and professionalism.            “Careful research and cogent reasoning,
not aspersions, are the proper tools of our trade.” U.S.I. Props. Corp. v. M.D. Constr. Co., 860
F.2d 1, 6 n.2 (1st Cir. 1988). That is of course not to say that legal documents must be written in
dry legalese. Nor is it to criticize passionate and forceful advocacy in aid of a client’s cause—a
lawyerly virtue that counsel has displayed at points in this litigation. But just as one cannot
“equate contempt with courage or insults with independence,” we cannot dismiss the disparaging
statements in this case as mere stylistic flourishes or vigorous advocacy. Sacher v. United States,
343 U.S. 1, 14 (1952). Counsel will best serve his clients if he remembers this going forward.

        We affirm.
