The most interesting thing about today’s decision striking down California’s unconstitutional Proposition 8 isn’t the fact that supporters of marriage equality won — that result was easy to predict from the judges’ comments during oral arguments more than a year ago. Rather, the most interesting thing about today’s decision is how narrow it is. The court crafted a rationale that applies to Prop 8 and probably only applies to Prop 8. While the opinion is firmly rooted in precedent, it expressly declines to consider the sweeping rationale employed by District Judge Vaughn Walker that is also grounded in precedent and the Constitution.

In 1996, the Supreme Court struck down an anti-gay Colorado constitutional amendment that stripped many gay men and lesbians of their existing legal rights in a case called Romer v. Evans. Today’s opinion relies heavily on Romer, honing in on the fact that Prop 8 stripped gay couples of a right they already enjoyed prior to its enactment — the right to marry a person of their choosing. As the Ninth Circuit explains:

The is not the first time the voters of a state have enacted an initiative constitutional amendment that reduces the rights of gays and lesbians under state law. In 1992, Colorado adopted Amendment 2 to its state constitution, which prohibited the state and its political subdivisions from providing any protection against discrimination on the basis of sexual orientation. . . . The Supreme Court held that Amendment 2 violated the Equal Protection Clause because “[i]t is not within our constitutional tradition to enact laws of this sort” — laws that “single out a certain class of citizens for disfavored legal status,” which “raise the inevitable inference that the disadvantage imposed is born of animosity toward the class of persons affected.” . . .

Proposition 8 is remarkably similar to Amendment 2. Like Amendment 2, Proposition 8 “single[s] out a certain class of citizens for disfavored legal status . . . .” Like Amendment 2, Proposition 8 has the “peculiar property” of withdraw[ing] from homosexuals, but no others,” and existing legal right — here, access to the official designation of “marriage” — that had been broadly available, notwithstanding the fact that the Constitution did not compel the state to confer it in the first place.

In other words, the court finds a constitutional violation that is unique to the state of California — only California once extended equal marriage rights to gay couples, then yanked them away through a subsequent amendment.

There are two upshots to this California-specific reasoning. The first is that it reduces the likelihood that the Supreme Court will hear the case, although Supreme Court review remains very highly likely. Had the Ninth Circuit applied Judge Walker’s much broader reasoning, the implication would be that every single state has a constitutional obligation to marry gay couples. The justices typically hear cases that present an exceptionally important legal question of national importance, and such a broad decision would certainly qualify. Today’s decision, by contrast, is narrow enough that there is an off chance the justices could pass on it.

The other upshot is that today’s opinion gives an out to the justices in case a majority of them find Prop 8 constitutionally offensive but aren’t yet ready to kick off a political firestorm by ordering Alabama to marry same-sex couples. The opinion is, at its heart, a decision that discretion is the better part of valor, and that the Constitution is best served by banking an easier victory today and putting off the big fight until tomorrow. Gay couples in Alabama — and indeed the Constitution itself — may suffer longer for that decision, but today’s decision also maximizes the likelihood that Proposition 8 will stay dead.

Jesus Navarro, a dialysis patient who will die without a kidney transplant, has private insurance. He has a donor to provide the needed kidney. But because he is an undocumented immigrant, hospital administrators at UC San Francisco Medical Center are refusing to allow the procedure, saying that there is no guarantee Navarro will receive the necessary follow-up care because of his immigration status. Now, Navarro is stuck in an “ethical gray area” for the hospital. “It puts the doctors in a very awkward and torn position,” said Arthur Caplan, a bioethics professor at the University of Pennsylvania. “You come into this trying to do good and find yourself stuck in the middle of a fight about immigration.”

For eight years, Navarro has used a home dialysis machine to cleanse his blood after his kidneys began to fail. He reached the top of the waitlist for a kidney in the spring, but doctors called off his transplant when they discovered his immigration status. Even after his wife offered her kidney for the transplant, administrators still refused to allow the surgery. Reece Fawley, executive director of transplantation at UC San Francisco, said in a statement that the hospital considers socioeconomic stability for all patients, including immigration status.

Navarro’s situation highlights a dilemma for hospitals when it comes to organ transplants for immigrants, especially if their undocumented status threatens their continued access to insurance:

Though no data are available, anecdotal evidence suggests clinics sometimes perform organ transplants on illegal immigrants, especially when the patients are young. In one high-profile case, UCLA Medical Center gave an undocumented woman three liver transplants before she turned 21.

But health administrators also reject patients because of their immigration status, though that usually happens when the patients lack insurance. Bellevue Hospital in New York attracted attention last year when it refused to transplant a kidney between brothers because they could not pay for the operation. [...]

Some bioethicists say the hospital should have performed the surgery because Navarro would not be taking resources away from other patients or putting his wife at serious risk.

After all, many legal residents fail to follow their post-surgical plan.

Some lawmakers would even want hospitals to check the immigration status for all patients. The Arizona legislature considered a bill that would require that, and Rep. Steve King (R-IA) said in November that it would not be going “too far” to have hospitals ask patients about their immigration status.

But in the meantime, Navarro’s private insurance from his job would cover the transplant and follow-up care, but he lost job last month after an immigration audit and his insurance could run out. If he is unable to extend his insurance and ends up in California’s Medi-Cal program, his problem would worsen because Medi-Cal would not cover the immunosuppressive drugs that prevent organ rejection after a transplant. “We don’t know what to do,” his wife said. “It’s like we’re on a ledge — we can’t go here or there.”