Automated-Refraction Prescription Bans Survive Rational Basis Review Under South Carolina’s Due Process and Equal Protection Clauses

I. Introduction

In Opternative, Inc. v. South Carolina Board of Medical Examiners and the South Carolina Department of Labor, Licensing and Regulation, the Supreme Court of South Carolina upheld the state’s Eye Care Consumer Protection Law, S.C. Code Ann. §§ 40-24-10 and 40-24-20 (Supp. 2025), against facial challenges under article I, section 3 of the South Carolina Constitution (due process and equal protection).

Opternative, Inc., a telehealth company offering an automated, remote refractive-error test (FDA approved), argued the Act irrationally prohibited eye doctors from issuing prescriptions for “spectacles” or “contact lenses” when based solely on refractive data generated by an automated “kiosk” (including phone/computer/Internet-based applications). Opternative contended the law amounted to unconstitutional economic protectionism.

The respondents—the South Carolina Board of Medical Examiners and the South Carolina Department of Labor, Licensing and Regulation—along with respondent-intervenor South Carolina Optometric Physicians Association (SCOPA), defended the Act as a public-health measure designed to ensure that prescriptions for corrective lenses are not issued without an examination adequate to detect conditions beyond refractive error.

The central issues were (1) what level of scrutiny applies (Opternative conceded rational basis), and (2) whether the Act rationally furthers a legitimate governmental interest and avoids irrational classifications, particularly in light of South Carolina’s broader acceptance of telemedicine under the South Carolina Telemedicine Act.

II. Summary of the Opinion

The Court affirmed summary judgment for the defendants, holding that the Eye Care Consumer Protection Law survives rational basis review and therefore does not violate substantive due process or equal protection under the state constitution.

Rational basis framework: The challenger must negate every conceivable basis supporting the statute.
Legitimate interest: Protecting public health is a legitimate governmental interest, and the record contained evidence supporting the view that in-person exams can detect ocular and systemic disease risks not addressed by kiosk-only refraction.
Reasonable relationship: Even if in-person exams are not always medically necessary in every case, the legislature could reasonably conclude that requiring more than kiosk-only refraction helps prevent missed diagnoses and contact lens complications.
Equal protection: The statute’s classification (eye doctors issuing prescriptions based solely on automated applications) is treated uniformly and rests on a reasonable basis given the distinct risks associated with corrective lenses and the limited nature of kiosk-only refraction.

The Court also noted that technology (including artificial intelligence) is rapidly developing and expressed confidence that the General Assembly will continue monitoring the policy rationale, but held the Act is not irrational on the present record.

III. Analysis

A. Precedents Cited

The Opinion relies heavily on established South Carolina rational-basis doctrine and on equal-protection principles recognizing legislative discretion to address problems incrementally.

1. Rational basis “conceivable basis” rule

Boiter v. S.C. Dep't of Transp., 393 S.C. 123, 712 S.E.2d 401 (2011): Cited for the rule that challengers bear the burden to “negate every conceivable basis which might support” a statute under rational basis review. The Court used Boiter to reject Opternative’s argument that the circuit court employed the wrong standard.
Lee v. S.C. Dep't of Nat. Res., 339 S.C. 463, 530 S.E.2d 112 (2000): Quoted via Boiter for the same “conceivable basis” formulation, reinforcing that South Carolina’s rational-basis test is exceptionally deferential.
Ani Creation, Inc. v. City of Myrtle Beach Bd. of Zoning Appeals, 440 S.C. 266, 890 S.E.2d 748 (2023): Cited to emphasize the challenger’s “steep hill to climb” under rational basis review and to confirm the contemporary vitality of the “negate every conceivable basis” test.
McLeod v. Starnes, 396 S.C. 647, 723 S.E.2d 198 (2012): Cited for describing the “conceivable basis standard” as South Carolina’s “long-held rational basis rule,” situating the Court’s approach as doctrinally settled rather than case-specific.

2. Substantive due process—legitimate interest and reasonable relationship

R.L. Jordan Co. v. Boardman Petroleum, Inc., 338 S.C. 475, 527 S.E.2d 763 (2000): Provided the substantive due process formulation: whether the statute “bears a reasonable relationship to any legitimate interest of government.” The Court applied this test to validate public-health protection as a legitimate interest and to uphold the means chosen.
Dantzler v. Callison, 230 S.C. 75, 94 S.E.2d 177 (1956): Quoted for the principle that public health is of “vital importance” such that “any rational means to that end must be upheld.” This citation framed the Eye Care Consumer Protection Law as classic police-power legislation.
Commonwealth v. Zimmerman, 108 N.E. 893 (Mass. 1915): Quoted through Dantzler, supporting the longstanding judicial view that health regulations merit substantial deference even when contested on liberty-based theories.

3. Equal protection—classification and incrementalism

Denene, Inc. v. City of Charleston, 359 S.C. 85, 596 S.E.2d 917 (2004): Supplied the three-part state equal protection rational-basis test: (1) classification reasonably relates to legislative purpose; (2) members are treated alike; and (3) classification rests on a reasonable basis. The Court used this structure to evaluate Opternative’s telemedicine-based comparison argument.
SPUR at Williams Brice Owners Ass'n, Inc. v. Lalla, 415 S.C. 72, 781 S.E.2d 115 (Ct. App. 2015): Cited for the proposition that equal protection does not require the legislature to eradicate all “evils of the same genus” at once. This directly supported the Court’s conclusion that regulating corrective-lens prescriptions more strictly than other telemedicine contexts is not inherently irrational.
Ry. Express Agency v. People of State of N.Y., 336 U.S. 106, 69 S. Ct. 463, 93 L. Ed. 533 (1949): Quoted via SPUR to anchor the incrementalism principle in widely recognized equal protection doctrine: legislatures may address problems step-by-step.

4. Prior proceedings in this litigation (standing clarification)

Opternative, Inc. v. S.C. Bd. of Med. Exam'rs, 433 S.C. 405, 859 S.E.2d 263 (Ct. App. 2021): Described as reversing the circuit court on standing and remanding for merits. The Supreme Court’s present decision is procedurally downstream from that remand.
Opternative, Inc. v. S.C. Bd. of Med. Exam'rs, 437 S.C. 258, 878 S.E.2d 861 (2022): Noted for affirming the court of appeals on standing while expressly clarifying that standing should not be read as a merits signal—an important judicial housekeeping move that preserves neutrality.

B. Legal Reasoning

1. The Court’s rational-basis posture: extreme deference and “conceivable bases”

A pivotal feature of the decision is methodological: the Court reiterated that South Carolina rational basis review places a heavy burden on challengers. The circuit court’s use of a “conceivable basis” approach was not a misstep but a faithful application of controlling precedent.

This framing matters because Opternative’s core theme—“this is just economic protectionism”—attempts to narrow the range of acceptable governmental purposes. Under “conceivable basis” review, however, the Court does not require the legislature to have chosen the best policy, relied on definitive medical consensus, or adopted the least restrictive alternative. The statute survives if any legitimate interest and rational connection can be conceived and is not negated by the challenger.

2. Substantive due process: public health as a legitimate interest; in-person exams as a rational means

The Court accepted that protecting public health is a legitimate governmental interest and found the record supported the premise that kiosk-only refraction risks missed detection of eye diseases and systemic conditions and can fail to address contact-lens fitting and corneal health.

The Opinion relied particularly on affidavits from Dr. Melvin Shipp and Dr. Mark Robinson describing:

potential detection during in-person comprehensive exams of glaucoma, cataracts, macular degeneration, binocular vision disorders, and corneal dystrophy;
potential identification of systemic conditions (e.g., diabetes, hypertension, hypercholesterolemia, autoimmune disorders) through in-person examination;
risks of poorly fit contact lenses, including corneal irritation, scarring, infection, and potential vision loss, and the role of corneal evaluation and counseling on hygiene/over-wear.

Although the Court acknowledged the affidavits contained information that could “support the opposite conclusion,” rational basis review tolerates mixed evidence. The question was not whether remote refraction can be safe in some circumstances, but whether the legislature could rationally choose to forbid prescriptions based solely on kiosk-generated refractive data.

Opternative pointed to the American Academy of Ophthalmology policy statement suggesting in-person exams are not always medically necessary before prescribing corrective lenses. The Court answered by emphasizing the rationality of the legislature adopting a more protective rule, especially where record evidence suggested most providers rarely perform refraction without an eye exam unless an exam occurred within the prior year. This converted a contested medical-policy debate into a deferential legislative-policy choice.

3. Equal protection: defining the classification narrowly and rejecting telemedicine “apples-to-oranges” comparisons

The Court defined the regulated class as “eye doctors who prescribe lenses based solely on an automated application.” It then found:

Reasonable relation to purpose: the class and restriction align with the public-health purpose for the same reasons supporting the due process analysis.
Uniform treatment: the statute imposes a uniform rule within the class—no intra-class favoritism.
Reasonable basis for differential treatment vis-à-vis other telemedicine: even if other prescriptions can be issued via telemedicine, corrective-lens prescriptions present unique risks because kiosk-only refraction can be divorced from any visual inspection of the eyes and from broader health assessment.

Opternative’s strongest equal-protection argument was comparative: the South Carolina Telemedicine Act allows treatment via electronic information technology so long as doctors adhere to the standard of care, and it bars prescriptions only where an in-person physical exam is necessary for diagnosis. The Court’s response was twofold:

Incremental regulation is allowed: relying on SPUR at Williams Brice Owners Ass'n, Inc. v. Lalla and Ry. Express Agency v. People of State of N.Y., the Court reiterated that equal protection does not force the legislature to regulate all telemedicine risks in one comprehensive sweep.
This context is different: many telemedicine encounters involve photographs, videos, or live consultations permitting physicians to visually assess symptoms, whereas kiosk-only refraction involves prescriptions based on responses to an automated eye chart without any visual examination of the eyes—supporting a rational legislative distinction.

C. Impact

Reinforcement of South Carolina’s deferential rational-basis review: By foregrounding “negate every conceivable basis,” the Opinion strengthens a litigation reality: facial constitutional challenges to economic/health regulations will be difficult unless challengers can foreclose not only the legislature’s stated rationale but also plausible alternative justifications.
Legislative space to regulate telehealth by specialty and risk: The Court signaled that telemedicine’s general permissibility does not immunize any particular telehealth practice from tighter regulation where the legislature can plausibly identify unique patient-safety concerns.
Practical blueprint for defending health-and-safety statutes: The Opinion illustrates how targeted expert evidence (affidavits explaining missed-diagnosis risks and standard practices) can supply the “rational link” needed—even when countervailing evidence exists.
Technology-forward caution: The Court’s closing remarks invite future legislative reassessment as AI and remote diagnostic tools improve, implicitly acknowledging that what is “rational” may evolve with technology and medical practice—even if today’s statute survives.

IV. Complex Concepts Simplified

Rational basis review: The most deferential constitutional test. A law is upheld if it is rationally related to any legitimate government purpose. Courts generally do not weigh policy wisdom; they look for plausibility.
“Negate every conceivable basis”: The challenger must show there is no plausible legitimate justification for the law—not merely that the legislature’s chosen justification is debatable.
Substantive due process: A limit on what the government may do, even with proper procedures. Under rational basis, the question becomes whether the law reasonably relates to a legitimate purpose.
Equal protection (rational basis): The government may draw distinctions among groups if the classification is reasonable and tied to a legitimate purpose, and similarly situated members are treated the same.
Economic protectionism claim: An argument that a law’s true aim is to protect an industry from competition. Under deferential review, that argument fails if a plausible public-interest rationale exists.
“Kiosk” in the Act: Defined broadly to include automated equipment or automated applications used on phones/computers/Internet devices, in person or remotely, that provide refractive data.

V. Conclusion

The Supreme Court of South Carolina’s decision affirms that, under article I, section 3, a public-health justification will sustain a health-professions regulation so long as the legislature could rationally believe the law reduces patient risk—even amid conflicting evidence and even when the regulation constrains telehealth innovation.

Two doctrinal takeaways dominate: (1) South Carolina rational basis review requires challengers to negate every conceivable basis, and (2) equal protection allows targeted, incremental regulation where the legislature can plausibly distinguish a particular practice—here, prescribing corrective lenses based solely on automated refraction—from other forms of telemedicine.