Full opinion text
DECISION AND AMENDED ORDER MARRERO, District Judge. Plaintiff Monroe S. Harris (“Harris”) brought this action challenging the revocation by defendant New York State Department of Health (“DOH” or the “State”) of his medical license by reason of various charges of professional misconduct, including instances of incompetent and grossly negligent patient care, fraudulent reporting and failure to maintain proper records. Harris claims that DOH’s action failed to make accommodations for his alleged learning and attention deficit disabilities, thereby discriminating against him in violation of Title II of the Americans with Disabilities Act (the “ADA”), 42 U.S.C. § 12101, et seq., and § 504 of the Rehabilitation Act of 1973 (the “Rehabilitation Act” or “ § 504”), 29 U.S.C. § 794, et seq. Harris also asserts violations of his federal constitutional due process and statutory rights protected by 42 U.S.C. § 1983. The State moved pursuant to Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6) to dismiss Harris’s First Amended Complaint on the grounds that the claims there asserted are barred by doctrines precluding federal district court appellate review or relitigation of matters already adjudicated in state courts, as well as by the Eleventh Amendment to the United States Constitution. For the reasons set forth below the motion to dismiss is granted. I. STANDARD OF REVIEW Different legal standards govern a court’s review of motions to dismiss made pursuant to Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6). On a motion to dismiss pursuant to Fed.R.Civ.P. 12(b)(1), it is a court’s duty to resolve disputed jurisdictional facts. See Cargill International S.A. v. M/T Pavel Dybenko, 991 F.2d 1012, 1019 (2d Cir.1993); see also Ruhrgas A.G. v. Marathon Oil Co., 526 U.S. 574, 583, 119 S.Ct. 1563, 143 L.Ed.2d 760 (1999); Lyndonville Savings Bank & Trust Co. v. Lussier, 211 F.3d 697, 700 (2d Cir.2000) (“[F]ailure of subject matter jurisdiction is not waivable and may be raised at any time by a party or the court sua sponte.”). A court may fulfill its duty by reference to evidence outside the pleadings. See Zappia Middle East Construction Co. v. Emirate of Abu Dhabi, 215 F.3d 247, 253 (2d Cir.2000). Furthermore, in resolving a challenge to subject matter jurisdiction, a court does not draw inferences in favor of the plaintiff. See Newsom-Lang v. Warren International, 129 F.Supp.2d 662, 663-64 (S.D.N.Y.2001). A district court may grant a motion to dismiss pursuant to Fed.R.Civ.P. 12(b)(6) only if it appears beyond doubt that the non-moving party could prove no set of facts that would entitle it to relief. See Hishon v. King & Spalding, 467 U.S. 69, 73, 104 S.Ct. 2229, 81 L.Ed.2d 59 (1984); Valmonte v. Bane, 18 F.3d 992, 998 (2d Cir.1994). In reviewing the pleadings, a court must accept the non-moving party’s well-pleaded factual allegations as true. See Hishon, 467 U.S. at 73, 104 S.Ct. 2229; Dove v. Fordham, 56 F.Supp.2d 330, 335 (S.D.N.Y.1999). Furthermore, a court may consider documents attached to the complaint as exhibits, or incorporated by reference, as well as any documents that are integral to, or explicitly referenced in, the pleading. See Stuto v. Fleishman, 164 F.3d 820, 826 n. 1 (2d Cir.1991); Ciambriello v. County of Nassau, 137 F.Supp.2d 216, 222 (E.D.N.Y.2001). II. FACTS Harris alleges that from childhood on and continuing throughout his life he has suffered from learning disabilities, of which he was not fully aware until recently, that caused him substantial difficulties at all schools he attended. Despite these impediments, Harris asserts, he graduated from medical school in 1963 and one year later was issued a license to practice medicine and surgery in New York State, where he was board certified in the areas of family practice, geriatric and bariatric medicine. For over thirty years he maintained a practice in Queens County, New York, and held staff privileges at five separate hospitals. Beginning 1989 Harris experienced difficulties with various New York State regulatory agencies and was the subject of several administrative proceedings detailed below. A. THE BCS AND OPMC INVESTIGATIONS In 1992, following an audit commenced in 1989 by the DOH’s Bureau of Controlled Substances (“BCS”), Harris entered into a stipulation with the BCS (the “BCS Stipulation”) in which he acknowledged that he had made errors in storing and dispensing controlled substances at his medical office in Queens, New York, in violation of Article 38 (“Article 33”) of the State’s Public Health Law (“PHL”). Two years later, allegedly prompted by the BCS audit of Harris, BPMC commenced a formal investigation of Harris for professional misconduct. In this connection, in September 1994 Harris and the DOH’s Office of Professional Medical Conduct (“OPMC”) stipulated to a Consent Order (the “Consent Order”) in which Harris admitted to violations of Article 33. By terms of the Consent Order, Harris was fined, put on probation, his license placed on stayed suspension for two years and he was required to file quarterly audits. Harris’s license was reinstated in October 1994. B. HOSPITAL REAPPOINTMENT APPLICATIONS On three separate occasions between September 1990 and September 1992 Harris filed applications for reappointment to various hospitals where he held privileges to practice medicine. In each case, while the BCS investigation remained pending, he responded “No” to a question on the application inquiring whether he was the subject of any disciplinary action. Again in May 1994, in a similar application for medical practice privileges at another hospital, Harris faked to disclose that he had signed the BCS Stipulation in 1992. In a reappointment application he filed at the Catholic Medical Center in September, 1994 he omitted to disclose that he had been disciplined by BCS and that just days before he had executed the Consent Order with OPMC agreeing to the stayed suspension and other sanctions. In March 1996, as a consequence of an inquiry by the Catholic Medical Center which revealed the 1994 Consent Order, Harris’s appointment renewal to practice at the hospital was denied. Subsequently, in his application in November, 1996, to the State Department of Education for renewal of his medical license he failed to acknowledge that his practice privileges at a hospital had been terminated in March, 1996. C.THE BPMC PROCEEDING In October, 1998, BPMC filed a Statement of Charges (the “Statement of Charges”) against Harris. It alleged several counts of misconduct arising from Harris’s reappointment applications, including fraudulent practice, moral unfitness, and making or filing false reports, as well as negligence, incompetence and failing to maintain records in connection with his medical practice. (See Statements of Charges at ¶¶ A-F.) The counts regarding negligence and incompetence on more than one occasion allege Harris’s failure to perform adequate medical examinations, to provide proper treatment and prescribe appropriate drugs, and to maintain accurate records related to the care he rendered to three specific patients, referred to as Patients A, B and C. (See id. at ¶ G-I.) A hearing by a BPMC committee was conducted in November and December, 1998. In this connection, Harris introduced the testimony of Dr. Steven Migden (“Migden”), a clinical psychologist Harris retained to examine him in preparation for the BPMC hearing. Migden testified at the December hearing that Harris suffered from certain learning disabilities, including disorders of written expression and dyslexia and possibly attention deficit hyperactivity disorder (“ADHD”) and that further testing was necessary to rule out dementia. He asserted that these disabilities “might” have caused Harris to misunderstand or be confused by the hospital reappointment application forms he had filed. (See BPMC Order at 7.) At the conclusion of the hearing in February 1999 the BPMC issued its ruling and Order. It sustained the six charges of fraudulent practice and six charges of making or filing false statements. The BPMC /ejected as “implausible” Harris’s contention, as suggested by Migden, that his learning disabilities might have caused him to misunderstand and be confused by the questions on the hospital reappointment applications. (See id.) The BPMC hearing committee, noting that at the 1996 Catholic Medical Center reappointment hearings Harris offered several reasons to explain the manner in which he answered the applications as he did, stressed that “[a]t no time did he claim that he was confused due to a learning disability.” (Id. at 8.) The BPMC also upheld the specifications charging negligence on more than one occasion and incompetence on more than one occasion arising from Harris’s medical care of Patients A and C. The findings as to Patient A indicate that Harris failed to make an adequate physical examination, to make a proper diagnosis of the patient’s condition and to maintain proper records of treatment. Moreover, Harris inappropriately prescribed an appetite suppressant drug to Patient A for nine years even though the patient was not overweight. (Id. at 11-12.) As regards Patient C, the BPMC found that Harris’s treatment constituted gross negligence, specifically in prescribing to a patient with a history of heart disease a drug contraindicated for persons suffering from such condition. With respect to the counts alleging failure to maintain adequate records, the BPMC noted that Harris had submitted two sets of records. One was hand written and the other was a much more detailed typed version, from which the BPMC inferred that the latter was not prepared contemporaneously but later in anticipation of review. (Id. at 22-23.) Having concluded that the number and nature of the charges sustained were sufficiently serious, the BPMC revoked Harris’s medical license. (Id. at 23.) D. THE ADMINISTRATIVE REVIEW BOARD Harris appealed the BPMC’s ruling to the State Administrative Review Board (“ARB”) pursuant to PHL § 230-c(4)(a). In June 1999 the ARB issued a decision and order (the “ARB Order”) which sustained the BPMC’s determination as to both its findings of professional misconduct by Harris and its revocation of his medical license. Harris alleges in the Complaint that the ARB accepted that Harris was disabled and treated him as such, but refused to accept that his disability could have manifested itself as asserted by Migden and also refuséd to offer him reasonable accommodations. In fact, the ARB found sufficient evidence on the record to support the BPMC’s conclusion that Harris had answered the hospital reappointment and license renewal applications falsely and with the requisite intent to mislead. (See ARB Order, at 9-10.) The ARB considered and rejected Harris’s defense attributing his false answers to confusion and lack of understanding of the forms brought about by his claimed learning disabilities. It held that the BPMC had acted properly within its authority as fact finder in rejecting the explanations that the testimony of Harris and Migden offered for Harris’s misleading applications. (Id.) The ARB also upheld the BPMC’s findings of fact and judgments concerning the sufficiency of the evidence and credibility of the witnesses in concluding that Harris’s treatment of Patients A and C fell below the level of accepted medical standards. (Id. at 8.) Finally, the ARB sustained the revocation of Harris’s license as an appropriate penalty under the circumstances, finding no mitigating considerations sufficient to outweigh Harris’s misconduct and rejecting his contention that the penalty was excessive and grounded on various errors. (Id. at 12-13.) In the ARB proceeding, Harris raised six grounds contesting the BPMC Order, none of which argued that his learning disabilities explained or excused the negligent or incompetent medical care he rendered to Patients A and C, as determined by the BPMC. (See ARB Order at 5-6.) E. THE ARTICLE 78 PROCEEDING Harris sought judicial review of the ARB’s ruling pursuant to PHL § 230-c(5) by commencing an action in the State Supreme Court, Appellate Division, under Article 78 of the New York Civil Practice Law and Rules (“Article 78”). There he renewed his argument that his false answers on the hospital and State licensing applications could be explained and excused by his learning disabilities. The Appellate Division heard oral argument on September 12, 2000 and issued a ruling on October 19, 2000.' It unanimously rejected Harris’s argument, upheld the ARB’s ruling and dismissed the petition. See Harris v. Novello, 276 A.D.2d 848, 714 N.Y.S.2d 365 (N.Y.A.D. 3rd Dep’t 2000). The court found “unavailing here” Harris’s arguments that the hospital reappointment and medical license renewal application forms were too difficult for him to understand, responding that “[t]he administrative finder of fact is ‘free to reject [a] plaintiffs explanations’ or excuses for false answers on applications, and so long as its determination is not arbitrary or capricious, it will be confirmed.” Id. at 368. The court rejected Harris’s argument that the revocation penalty was excessive. See id. at 368. The Appellate Division also found in the record a substantial basis to sustain the BPMC’s charges of negligence and incompetence as regards Harris’s care of Patients A and C. See id. Harris did not seek leave to file an appeal with the New York Court of Appeals. F. THE NOVEMBER 2, 2000 LETTER Harris underwent further evaluation by Migden in January and March 2000. Although not specified in the Complaint, Harris contends that Migden issued a report (the “2000 Report”) which allegedly was sent to counsel on July 10, 2000, two days prior to the deadline for the submission of Harris’s reply in the Article 78 proceeding. The Complaint asserts that in the results of this subsequent testing, Mig-den ruled out the possibility of dementia and confirms that Harris has “a static, lifelong learning disability involving written language (i.e., dyslexia and written expression disorder) and a related, chronic problem with attention and concentration that is probably best described as ADHD.” (Compl. at ¶48). On the basis of the alleged new evidence and findings Harris maintains were contained in Migden’s 2000 Report, Harris wrote to DOH on November 2, 2000 (the “November 2000 Letter”) requesting administrative reconsideration of the revocation of his license. Harris states that although he requested a response within thirty days, DOH ignored the November 2000 Letter. This litigation followed. Harris here asserts four causes of action arising out of the State’s failure to acknowledge and accommodate his learning disabilities prior to revoking his medical license: violations of the ADA and the Rehabilitation Act; deprivation of property and liberty rights without due process in violation of the Fourteenth Amendment of the federal Constitution; and denial of federal rights protected under 42 U.S.C. § 1988. III. DISCUSSION A. BACKGROUND This case presents a convergence of several powerful imperatives embodied in our legal system, all of them fundamental to the effective administration of justice and to the proper functioning of the system’s separate federal and state components. The parties collide over which of several basic legal principles implicated in their dispute should govern its resolution: whether this Court should exercise its jurisdiction and serve as a forum to vindicate federal rights asserted under 42 U.S.C. § 1983, or whether it is precluded from doing so by reason of a judgment previously rendered in a related proceeding in state court involving the same parties; whether the Court, responding to the invocation of federal law protecting federal rights,.should conduct its own inquiry into the merits of the violations asserted, or be bound by the state court’s prior decision on the underlying matter; whether the Court should consider federal law questions that allegedly were not actually decided by the state court, or give full effect to the state adjudication as to claims that could have been raised in that proceeding but were not. At such junctures, in the ensuing confluence and clash of premises, doctrines, policies and objectives, substantial confusion and directional tension often abounds. So here, the parties’ conflict over the decisive issues mirrors doctrinal splits that have driven the courts and engendered ambiguity and divided guidance over .the same questions. Thus, an overview of the various precepts and policies underlying this action may inform the Court’s approach in resolving them. To this end, the Court notes several principles that flow into the mix, and are classified for the purposes of this discussion as concerning matters of structure, comity, access and efficiencies pertaining to the legal system. 1. Structure The structural principles reflect that, from the beginning, the constitutional blueprint of this country’s justice system actually comprised “two essentially separate legal systems, each of which “proceeds” independently of the other with ultimate review in [the Supreme Court] of the federal questions raised in either system.” Atlantic Coast Line R.R. Co. v. Brotherhood of Locom. Engrs., 398 U.S. 281, 286, 90 S.Ct. 1739, 26 L.Ed.2d 234 (1970). At the time the federal courts structure was established following the ratification of the national Constitution, each state already had in place its own distinct judicial system. The superimposition of the federal scheme thus required special sensitivity as to how the parallel justice network would function with regards to matters entailing overlapping jurisdiction. 2. Comity The reality of the dual plan raised a potential for inevitable conflicts and frictions that made it difficult for the overall justice system to “function if state and federal courts were free to fight each other for control of a particular case.” Id. Accordingly, to enable the distinct parts to operate harmoniously and effectively within their separate spheres and avoid unnecessary tension, several Congressional statutes and judicial doctrines have endeavored to draw lines providing demarcation and guidance in certain areas where federal-state jurisdictional overlap exists. See id. (citing Oklahoma Packing Co. v. Oklahoma Gas & Elec. Co., 309 U.S. 4, 9, 60 S.Ct. 215, 84 L.Ed. 537 (1940)). Among these prescriptions, some of them central to the resolution of the matter at bar and further discussed below, the following are the most prominent. a. Full Faith and Credit. As an integral part of its measures to implement the Constitution’s Full Faith and Credit Clause, Congress in 1790 enacted the Full Faith and Credit Statute, codified in 28 U.S.C. § 1738. That legislation, intended to ensure that federal courts extend to state court decisions the same, effect accorded to those judgments under the law of the particular state where the judgments are rendered, provides in pertinent part: [J]udicial proceedings [of any State court] ... shall have the same full faith and credit in every court within the United States and its Territories and Possessions as they have by law or usage in the courts of such State.... See Allen v. McCurry, 449 U.S. 90, 96, 101 S.Ct. 411, 66 L.Ed.2d 308 (1980); Migra v. Warren City Sch. Dist. Bd. of Ed., 465 U.S. 75, 80-81, 104 S.Ct. 892, 79 L.Ed.2d 56 (1984); Kremer v. Chemical Const. Corp., 456 U.S. 461, 466, 102 S.Ct. 1883, 72 L.Ed.2d 262 (1982). b. Anti-Injunction. Congress also legislated early in our history to enable state courts to adjudicate disputes without undue interference from federal courts. To this end, it enacted the anti-injunction statute, 28 U.S.C. § 2283, which derives from an Act of 1793 and provides that: A court of the United States may not grant an injunction to stay proceedings in a State court except as expressly authorized by Act of Congress, or where necessary in aid of its jurisdiction, or to protect or effectuate its judgments. See also Younger v. Harris, 401 U.S. 37, 43, 91 S.Ct. 746, 27 L.Ed.2d 669 (1971); Atlantic Coast Line, 398 U.S. at 286-87, 90 S.Ct. 1739; but cf. Mitchum v. Foster, 407 U.S. 225, 242-43, 92 S.Ct. 2151, 32 L.Ed.2d 705 (1972). c. Preclusion Rules. To further ensure that federal courts accord state court judgments the same preclusive effect given to such decisions by the rendering state courts, the Supreme Court, in construing 28 U.S.C. § 1738, has held that the doctrines of res judicata and collateral estoppel apply to bar relitigation in federal court of certain issues and claims actually settled or that could have been raised in prior state proceedings. See Allen, 449 U.S. at 105, 101 S.Ct. 411; Migra, 465 U.S. at 85, 104 S.Ct. 892. d. Review by Certiorari In defining the appellate jurisdiction of federal courts, Congress prescribed an avenue for direct review by the Supreme Court of final state court judgments grounded on federal law. See 28 U.S.C. § 1257. Based on this statute and general principles of federal-state comity, the Supreme Court has held, as enunciated in the doctrine denominated Rooker-Feldman, that the exclusive forum for appellate review of state court decisions construing federal law is the Supreme Court. See Rooker v. Fidelity Trust Co., 263 U.S. 413, 416, 44 S.Ct. 149, 68 L.Ed. 362 (1923); District of Columbia v. Feldman, 460 U.S. 462, 482-83, 103 S.Ct. 1303, 75 L.Ed.2d 206 (1983); Atlantic Coast Line, 398 U.S. at 296, 90 S.Ct. 1739; see also ASARCO Inc. v. Kadish, 490 U.S. 605, 622, 109 S.Ct. 2037, 104 L.Ed.2d 696 (1989) (“The Rooker-Feldman doctrine interprets 28 U.S.C. § 1257 as ordinarily barring direct review in the lower federal courts of a decision reached by the highest state court, for such authority is vested solely in this Court.”). Lower federal courts, therefore, lack subject matter jurisdiction to serve as appellate tribunals for the purpose of reversing or modifying such state court judgments, even if grounded on erroneous reading or application of federal law. See Feldman, 460 U.S. at 476, 103 S.Ct. 1303; ASARCO, 490 U.S. at 622, 109 S.Ct. 2037; Texaco Inc. v. Pennzoil Co., 784 F.2d 1133, 1142 (2d Cir.1986), rev’d on other grounds, 481 U.S. 1, 107 S.Ct. 1519, 95 L.Ed.2d 1 (1987) (“[A]n inferior federal court established by Congress pursuant to Art. Ill, § 1, of the Constitution may not act as an appellate tribunal for the purpose of overruling a state court judgment, even though the judgment may rest on an erroneous resolution of constitutional or federal law issues. The exclusive procedure for federal review is that specified in 28 U.S.C. 1257.”); Moccio v. New York State Office of Court Adm’n, 95 F.3d 195, 197 (2d Cir.1996). e.Abstention. In some cases the constraints on federal court intrusion into state judicial proceedings may apply even when the federal courts presumptively are vested with jurisdiction. The Supreme Court has instructed federal courts to abstain, under general principles of comity and federalism, from granting injunctive relief to restrain state judicial proceedings, not only in criminal cases but in certain civil actions in which the exercise of federal jurisdiction would disturb federal-state comity, whether the matter is still pending or fully decided without exhaustion of state appellate remedies. See Younger, 401 U.S. at 44, 91 S.Ct. 746; Huffman v. Pursue, Ltd., 420 U.S. 592, 608-09, 95 S.Ct. 1200, 43 L.Ed.2d 482 (1975); Pennzoil v. Texaco, 481 U.S. 1, 10-11, 107 S.Ct. 1519, 95 L.Ed.2d 1 (1987). Taken together, these principles manifest an unequivocal purpose integral to this country’s longstanding governmental arrangement. They convey the value of mutual federal-state court recognition and respect embodied in the concepts of comity and federalism frequently invoked and repeatedly reaffirmed by the Supreme Court as vital to the proper functioning of the justice system. As articulated by the Supreme Court, that notion reflects that: [A] proper respect for state functions, a recognition of the fact that the entire country is made up of a Union of separate State governments, and a continuance of the belief that the National Government will fare best if the States and their institutions are left free to perform their separate functions in separate ways .... What the concept does represent is a system in which there is sensitivity to the legitimate interests of both State and National Governments, and in which the National Government, anxious though it may be to vindicate and protect federal rights and federal interests, always endeavors to do so in ways that will not unduly interfere with the legitimate activities of the States. Younger, 401 U.S. at 44, 91 S.Ct. 746; see also Pennzoil, 481 U.S. at 10-11, 107 S.Ct. 1519. Implicit in the justice system’s structural arrangement, as reflected in the division of labor arranged over the years, is that each component is equally competent, as and where appropriate, to apply federal law consistent with constitutional principles, as well as similarly bound by the judgments rendered by the other. See U.S. Constitution, Art. VI (declaring that “the Judges in every State shall be bound” by the federal Constitution, laws and treaties); see also Stone v. Powell, 428 U.S. 465, 493-94, 96 S.Ct. 3037, 49 L.Ed.2d 1067 (1976) (reaffirming the constitutional obligation of state courts to uphold and apply federal law, and expressing confidence in their ability to do so); see also Pennzoil, 481 U.S. at 15, 107 S.Ct. 1519 (“We cannot assume that state judges will interpret ambiguities in state procedural law to bar presentation of federal claims. Accordingly, when a litigant has not attempted to present his federal claims in related state-court proceedings, a federal court should assume that state procedures will afford an adequate remedy....”) (citations omitted); Huffman, 420 U.S. at 611, 95 S.Ct. 1200 (“Appellee is in truth urging us to base a rule on the assumption that state judges will not be faithful to their constitutional responsibilities. This we refuse to do.”). A corollary to the principles of comity and competence, from the states’ perspective, is that if state courts are to fulfill their obligations to abide by and carry out federal constitutional strictures, they must be free to do so with maximum decisional latitude and minimal intrusion from the federal system. See generally Rooker 263 U.S. at 416, 44 S.Ct. 149; Feldman 460 U.S. at 482-83, 103 S.Ct. 1303; Pennzoil, 481 U.S. at 10-11, 107 S.Ct. 1519. 3. Access A third major imperative that enters here concerns access to the federal justice system. Encompassed within this principle is a basic purpose for which Congress created federal tribunals and conferred specific jurisdiction upon them: to afford persons who have legitimate claims subject to federal jurisdiction maximal opportunity to avail themselves of a federal forum to adjudicate their disputes. See Willcox v. Consolidated Gas Co., 212 U.S. 19, 40, 29 S.Ct. 192, 53 L.Ed. 382 (1909) (“When a Federal Court is properly appealed to in a case over which it has by law jurisdiction, it is its duty to take such jurisdiction.... The right of a party plaintiff to choose a Federal court where there is a choice cannot be properly denied.”) (citations omitted); see also England v. Louisiana State Bd. of Med. Examrs., 375 U.S. 411, 415-16, 84 S.Ct. 461, 11 L.Ed.2d 440 (1964) (noting that the abstention doctrine’s “recognition of the role of state courts as the final expositors of state law implies no disregard for the primacy of the federal judiciary in deciding questions of federal law.”) By the same token, federal courts have a strong interest in administering the procedures and construing the substance of the national justice system, particularly as to aspects designed to enforce federal constitutional norms and prevent deprivation of federal rights. See Zwickler v. Koota, 389 U.S. 241, 247, 88 S.Ct. 391, 19 L.Ed.2d 444 (1967) (noting that under various statutes Congress enacted after the Civil War, federal courts “ ‘became the primary and powerful reliances for vindicating every right given by the Constitution, the laws, and treaties of the United State.’ ”) (quoting Frankfurter & Landis, The Business of the Supreme Court: A Study in the Federal Judicial System, at 65). In this regard, the Supreme Court has observed that: In thus expanding federal judicial power, Congress imposed the duty upon all levels of the federal judiciary to give due respect to a suitor’s choice of a federal forum for the hearing and decision of his federal constitutional claims. Plainly, escape from that duty is not permissible merely because state courts also have the solemn responsibility, equally with the federal courts “... to guard, enforce, and protect every right granted or secured by the constitution of the United States....” Id. at 248, 88 S.Ct. 391 (quoting Robb v. Connolly), 111 U.S. 624, 637, 4 S.Ct. 544, 28 L.Ed. 542 (1884); Monroe v. Pape, 365 U.S. 167, 183, 81 S.Ct. 473, 5 L.Ed.2d 492 (1961); but cf. Huffman, 420 U.S. at 606, n. 18, 95 S.Ct. 1200. To no lesser degree, at times adding a contrapuntal strain to federal-state judicial relations, the states also “have important interests in administering certain aspects of their judicial systems,” in particular in enforcing the orders and judgments of their courts. Pennzoil, 481 U.S. at 12-13, 107 S.Ct. 1519 (citing Trainor v. Hernandez, 431 U.S. 434, 441, 97 S.Ct. 1911, 52 L.Ed.2d 486 (1977); Middlesex County Ethics Comm. v. Garden State Bar Ass’n, 457 U.S. 423, 432, 102 S.Ct. 2515, 73 L.Ed.2d 116 (1982); Juidice v. Vail, 430 U.S. 327, 335-36, 97 S.Ct. 1211, 51 L.Ed.2d 376 (1977)). Nevertheless, as is common wisdom, even the best laid plans are bound to contain inherent flaws, and — in the course of their evolution from idea to reality, from rudiments to perfected model — to encounter operational and developmental difficulties, and even to be tested by purposeful hindering or corruption of their effective functioning. To repair the imperfections, such deficiencies ordinarily engender demands for remedial work. In this country’s historical development, the legal system endured the “corrupting influence of the Ku Klux Klan and its sympathizers on the governments and law enforcement agencies... ”, which prompted Congressional concern that “the state courts had been deficient in protecting federal rights.” Allen, 449 U.S. at 98-99, 101 S.Ct. 411 (1980) (citing Monroe, 365 U.S. at 174, 81 S.Ct. 473, and Mitchum, 407 U.S. at 241-42, 92 S.Ct. 2151). Congress responded by enacting 42 U.S.C. § 1983, described by the Supreme Court as representing the product of a “vast transformation from the concepts of federalism that had prevailed.” Mitchum, 407 U.S. at 242, 92 S.Ct. 2151. In doing so, Congress conceived that it was altering the relationship between the States and the Nation with respect to the protection of federally created rights; it was concerned that state in-strumentalities could not protect those rights; it realized that state officers might, in fact, be antipathetic to the vindication of those rights; and it believed that these failings extended to the state courts. Id.; see also Allen, 449 U.S. at 99, 101 S.Ct. 411. In this regard, the purpose of § 1983, as expressed by the Supreme Court, was to interpose the federal courts between the States and the people, as guardians of the people’s federal rights — to protect the people from unconstitutional action under color of state law, “whether that action be executive, legislative, or judicial.” Mitchum, 407 U.S. at 242, 92 S.Ct. 2151 (quoting Ex parte Virginia, 100 U.S. 339, 346, 10 Otto 339, 25 L.Ed. 676 (1879)); see also Monroe, 365 U.S. at 180, 81 S.Ct. 473. In brief, § 1983 empowered federal courts to “step in where state courts were unable or unwilling, to protect federal rights.” Allen, 449 U.S. at 101, 101 S.Ct. 411 (citing Monroe, 365 U.S. at 173-74, 81 S.Ct. 473). Even so, however, Congress’ purpose was that of “adding to the jurisdiction of the federal courts, not subtracting from that of the state courts.” Allen, 449 U.S. at 99, 101 S.Ct. 411 (citing Monroe, 365 U.S. at 183, 81 S.Ct. 473) (“The federal remedy is supplementary to the state remedy....”); but cf., Texaco, 784 F.2d at 1144 (“To relegate the § 1983 claimant in such cases to the state court would ignore Congress’ purpose in adopting that statute. Section 1983 was intended ‘to provide dual or concurrent forums in the State and federal system, enabling the plaintiff to choose the forum in which to seek relief.”) (internal citation omitted); Miofsky v. Superior Court, 703 F.2d 332, 335 (9th Cir.1983) (“[D]istrict courts have subject matter jurisdiction over suits brought under Section 1983 even when the state action that allegedly violated plaintiffs federally protected rights takes the form of state court proceedings.”) 4. Efficiencies The fourth set of principles that issues at the juncture here is designed to promote judicial efficiencies and operational practicalities within the state and federal courts as well as between the two legal systems. To this end, in the interest of consistency, avoidance of relitigation of settled matters and finality of judgments, both systems incorporate the firmly-rooted doctrines of res judicata and collateral es-toppel. But these concepts and the interests they serve are also essential to fostering federal-state comity. See Allen, 449 U.S. at 95-96, 101 S.Ct. 411 (acknowledging the value of res judicata and collateral estoppel not only in reducing unnecessary litigation and fostering reliance on adjudication, but also in “promoting] the comity between state and federal courts that has been recognized as a bulwark of the federal system.”) (citing Younger, 401 U.S. at 43-45, 91 S.Ct. 746). Recognizing the value of these doctrines to the justice system and to our notion of federalism, the Supreme Court has held that, despite the adjustments of judicial power effectuated by § 1983, in enacting that statute Congress did not intend to contravene the common law preclusion rules of res judicata and collateral estoppel or to repeal the full faith and credit federal courts must accord state court judgments pursuant to 28 U.S.C. § 1738. See Allen, 449 U.S. at 97-98, 101 S.Ct. 411 (“Section 1983 creates a new federal cause of action. It says nothing about the preclusive effect of state-court judgments.”) For these reasons, federal district courts are obliged to accord due recognition to the preclusive effect of state court judgments that adjudicate federal rights after full and fair consideration, even if the state court’s decision may have been erroneous. See id. at 101, 104, 101 S.Ct. 411. The prescription embodied in the rules of preclusion derives not only from the policies of judicial economy and practicalities promoted by common law precedents, but from Congressional mandate enacted in 28 U.S.C. § 1738 requiring federal courts to give full faith and credit to state court judgments. See Allen, 449 U.S. at 96, 101 S.Ct. 411; Migra, 465 U.S. at 80-81, 104 S.Ct. 892. Accordingly, the Supreme Court held in Allen that judgments resolving issues that were actually litigated in state court proceedings are entitled to the same preclusive effect in a subsequent federal § 1983 action as such determinations would enjoy in the State courts that rendered them. See Allen, 449 U.S. at 105, 101 S.Ct. 411. Further advancing the interests and policies reflected by the common law rules of preclusion, the Supreme Court later extended Allen in holding that state court decisions grounded on federal issues must be accorded preclusive effect not only as to matters actually adjudicated in the prior state judicial proceedings, but also to those that could have been litigated in the state court. See Migra, 465 U.S. at 84-85, 104 S.Ct. 892. 5. Reconciliation In abstract juxtaposition, the basic principles sketched out above seem at odds. On the one hand, they posit the existence of primary jurisdiction conferred upon federal tribunals charged to recognize the litigant’s interest in access to a national forum to protect rights and remedies grounded on federal law. On the other, the principles compel restraints on the exercise of federal jurisdiction. In the interest of promoting judicial economy, consistency, finality of judgments and most particularly our notions of comity and federalism, they mandate federal court deference to the prior adjudications of state tribunals on the same matters, even those grounded on federal law. Yet the several principles may be harmonized. From the intersection of principles and purposes, issues a clear message that, read as a whole, resonates consistently through the whole body of legislation and judicial doctrine on point enunciated over the course of more than two centuries of this country’s history and jurisprudence. In measuring the values it reckons, and giving due weight to all that is at stake, Congress has struck a constitutional and policy balance resolving the tension between the various competing jurisdictional values. As construed and reaffirmed by the Supreme Court, the equilibrium holds that, subject from time to time to special adjustment to account for exceptional circumstances, “it is more important to give full faith and credit to state-court judgments than to ensure separate forums for federal and state claims.” Migra, 465 U.S. at 84, 104 S.Ct. 892; see also Huffman, 420 U.S. at 606, 95 S.Ct. 1200; Allen, 449 U.S. at 105, 101 S.Ct. 411. Essentially the same reasoning supports a conclusion that a single avenue for federal appellate review of state court rulings based on federal law represents a more appropriate arrangement of our dual legal system than a structure which would encourage truncation of state judicial proceedings and superimposition of additional federal layers to the appellate process governing state court judgments. 6. The Reconciliation in Practice a. Rooker-Feldman and the Rules of Preclusion But, as is often the case, even an explicitly declared principle may be easier in distillation and articulation than it is in practice. Application of the balance propounded by the Supreme Court for adjusting the federal-state court jurisdiction, deference and comity values has yielded conflicting results, recurring uncertainties and unanswered questions. In particular, the precise demarcations of the Rooker-Feldman doctrine on the one hand, and the preclusive effect of common law res judicata and collateral estoppel on the other, remain obscure. Some courts hold them effectively synonymous, interchangeable or at least co-extensive. See, e.g., Moccio, 95 F.3d at 199-200 (noting that under Rooker-Feldman a claim would be barred if it would be foreclosed “under the principles of preclusion.”); Robinson v. Ariyoshi, 753 F.2d 1468, 1472 (9th Cir.1985) (“[W]e view the res judicata requirement of full and fair opportunity to litigate, and the Feldman ‘inextricably intertwined’ barrier to federal jurisdiction as two sides of the same coin.”), remanded on other grounds, 477 U.S. 902, 106 S.Ct. 3269, 91 L.Ed.2d 560 (1986); Gauthier v. Continental Diving Servs., Inc., 831 F.2d 559, 561 (5th Cir.1987) (noting that “Rooker-Feldman casts in jurisdictional terms a rule that is very close if not identical to the more familiar principle that a federal court must give full faith and credit to a state court judgment.”); but see GASH Assocs. v. Village of Rosemont, Ill., 995 F.2d 726, 728 (7th Cir.1993) (noting that “both sets of principles define the respect one court owes to an earlier judgment. But the two are not coextensive.”); Hachamovitch v. DeBuono, 159 F.3d 687, 696 (2d Cir.1998) (noting that “[w]hether the Rooker-Feldman doctrine is coextensive with preclusion or extends beyond preclu-sionary rules is a question that has perplexed courts and commentators.”). Other courts have conflated the doctrines altogether, citing Rooker-Feldman as support for application of what they held to be dismissal based on res judicata. See, e.g., Robinson, 753 F.2d at 1472 (“[W]e have read Rooker not as a jurisdictional barrier but as an application of res judicata.”); see also Turco v. Monroe Bar Ass’n, 554 F.2d 515, 520-21 (2d Cir.), cert. denied, 434 U.S. 834, 98 S.Ct. 122, 54 L.Ed.2d 95 (1977); Friarton Estates Corp. v. City of New York, 681 F.2d 150, 158 (2d Cir.1982); see generally 18 Charles Alan Wright, Arthur R. Miller and Edward H. Cooper, Federal Practice and Procedure § 4469.1 (2001 Supp.) (herein “Wright, Miller & Cooper”); Gary Thompson, The Rooker-Feldman Doctrine and the Subject Matter Jurisdiction of Federal District Courts, 42 Rutgers L.Rev. 859, 866, 904 (1990). But cf. Worldwide Church of God v. McNair, 805 F.2d 888, 893 (9th Cir.1986). A leading treatise characterizes Rooker-Feldman as a “transmutation of res judicata doctrine into jurisdictional dogma.” Wright, Miller & Cooper, § 4469.1 at 665. And one circuit court has described the principle as “a combination of the abstention and res judicata doctrines-” U.S. v. Owens, 54 F.3d 271, 274 (6th Cir.) cert. dismissed, 516 U.S. 983, 116 S.Ct. 492, 133 L.Ed.2d 418 (1995); see also E.B. v. Verniero, 119 F.3d 1077, 1091 (3d Cir.1997) (referring to “Rooker-Feldman abstention”), cert denied, 522 U.S. 1109, 118 S.Ct. 1039, 140 L.Ed.2d 105 (1998). And yet the doctrines differ in fundamental ways that may materially affect how a case may be decided. See generally Wright, Miller & Cooper, § 4469.1, at 664 (noting that “[t]he Rooker-Feldman doctrine has been deliberately taken beyond some aspects of res judicata doctrine. It has independent force.”). The Supreme Court has instructed that the Rooker-Feldman principle addresses the subject matter jurisdiction of federal district courts. In fact, as discussed above, the doctrine has a statutory predicate in 28 U.S.C. § 1257. That provision grants appellate review over state court decisions solely to the Supreme Court and thus, by negative inference, not to district courts established in the same legislation as courts of original jurisdiction. See Rooker, 263 U.S. at 416, 44 S.Ct. 149. In Feldman itself the Supreme Court expressly declared as ground for its holding that to the extent plaintiffs had sought appellate review in federal district court of a determination by a state court, “the District Court lacked subject matter jurisdiction over the complaints.” Feldman, 460 U.S. at 482, 103 S.Ct. 1303. See also Atlantic Coast Line, 398 U.S. at 296, 90 S.Ct. 1739 (without citing to Rooker, noting that “lower federal courts possess no power whatever to sit in direct review of state court decisions.”); ASARCO, 490 U.S. at 622, 109 S.Ct. 2037; see also Texaco, 784 F.2d at 1137 (dismissing certain claims “for lack of subject matter jurisdiction since they sought appellate review on the merits of the Texas judgment in violation of 28 U.S.C. Section 1257 as interpreted by the United States Supreme Court.”); Moccio, 95 F.3d at 198 (“A challenge under the Rooker-Feldman doctrine is for lack of subject matter jurisdiction”) (citing Gentner v. Shulman, 55 F.3d 87, 89 (2d Cir.1995)). Reinforcing the jurisdictional underpinnings of Rooker-Feldman, the Seventh Circuit has ruled that the doctrine compels that its applicability must be determined before a district court considers res judi-cata. See GASH Assocs., 995 F.2d at 728-29 (holding that the district court erred by dismissing the case on the basis of res judicata because Rooker-Feldman applied and thus deprived the court of jurisdiction); Centres, Inc. v. Town of Brookfield, 148 F.3d 699, 703 (7th Cir.1998) (“If Rooker-Feldman applies, a res judicata claim must not be reached.”); Garry v. Geils, 82 F.3d 1362, 1365 (7th Cir.1996). By casting the doctrine as one barring federal court jurisdiction, the Supreme Court necessarily underscored the substantive and procedural distinctions between Rooker-Feldman and the preclusion effects of res judicata and collateral estop-pel. Absence of subject matter jurisdiction operates as a bar to the exercise of the court’s power to consider the merits of a case, and may be raised at any point, even sua sponte by the court. See Moccio, 95 F.3d at 198 (“A challenge to a federal court’s subject matter jurisdiction under the Rooker-Feldman doctrine may be raised at any time by either party or sua sponte by the court.”). A dismissal so grounded is not a judgment on the merits of the underlying case and does not of itself preclude a subsequent suit on the same matter. See Fed. R. Civ. p. 41(b); St. Pierre v. Dyer, 208 F.3d 394, 399-401 (2d Cir.2000); 18 James Wm. Moore et al, Moore’s Federal Practice (3d ed. 1997) (“Moore’s Federal Practice”) § 131.30[3][b]. Moreover, the doctrine may apply to bar exercise of federal jurisdiction over actions involving both final and interlocutory judgments of state courts. See Campbell v. Greisberger, 80 F.3d 703, 706-07 (2d Cir.1996) (noting that “[i]t cannot be the meaning of Rooker-Feldman that, while the inferior federal courts are barred from reviewing final decisions of state courts, they are free to review interlocutory orders.”). By contrast, res judicata and collateral estoppel, resting on common law principles, are affirmative defenses which, if not pleaded, may be waived. See Fed. R.Civ.P. 8(c); Rivet v. Regions Bank, 522 U.S. 470, 474, 118 S.Ct. 921, 139 L.Ed.2d 912 (1998); Pangburn v. Culbertson, 200 F.3d 65, 68 n. 1 (2d Cir.1999). To this degree, whether the preclusion doctrines are invoked thus may depend primarily on the alertness or competence of counsel. An application of either principle presupposes that the substance of the issues or claims deemed precluded was addressed in the prior litigation and embodied in a corresponding final judgment that constitutes a ruling on the merits. See G. & C. Merriam Co. v. Saalfield, 241 U.S. 22, 28, 36 S.Ct. 477, 60 L.Ed. 868 (1916); Shamley v. ITT Corp., 869 F.2d 167, 170 (2d Cir.1989); Baris v. Sulpicio Lines, Inc., 74 F.3d 567, 570 (5th Cir. rehearing en banc, 101 F.3d 367 (5th Cir.1996)); 18 Moore’s Federal Practice § 131.30[3][a]. Moreover, because they generate from common law, the precise scope of the preclusion doctrines is not uniform, but may vary from state to state. And insofar as res judicata and collateral estoppel apply in federal actions to require the courts to accord preclusive effect to prior state adjudications, the mandate derives not from a jurisdictional statute, but from 28 U.S.C. § 1738 and general comity principles. See Allen, 449 U.S. at 96, 101 S.Ct. 411; Krem er, 456 U.S. at 466, 102 S.Ct. 1883. Unlike the purview of § 1257, these principles do not uniformly address the federal courts’ subject matter jurisdiction. Rather, they mandate the federal tribunal giving full faith and credit to state court judgments only to the degree demanded by res judi-cata and collateral estoppel doctrines as recognized under the law of the particular state from which the judgment emerged. See Allen, 449 U.S. at 95-96, 101 S.Ct. 411; Migra, 465 U.S. at 85, 104 S.Ct. 892. Because it stems from § 1257, on the other hand, Rooker-Feldman applies to bar district court review only of state judicial decisions, and not to unre-viewed determinations of state bodies acting in administrative, legislative or ministerial roles. See Feldman, 460 U.S. at 477-85, 103 S.Ct. 1303; Van Harken v. City of Chicago, 103 F.3d 1346, 1348-49 (7th Cir.), cert. denied, 520 U.S. 1241, 117 S.Ct. 1846, 137 L.Ed.2d 1049 (1997); 18 Moore’s Federal Practice § 133.30[3][c](i). The common law preclusion rules, however, may extend to both judicial and administrative determinations. See United States v. Utah Constr. & Mining Co., 384 U.S. 394, 422, 86 S.Ct. 1545, 16 L.Ed.2d 642 (1966); Kirkland v. City of Peekskill, 828 F.2d 104, 107-109 (2d Cir.1987); Hachamovitch, 159 F.3d at 694. On the same basis, Rooker-Feldman does not serve to bar federal jurisdiction brought by a party not involved in the prior state proceeding, see Johnson v. De Grandy, 512 U.S. 997, 1004-06, 114 S.Ct. 2647, 129 L.Ed.2d 775 (1994), while the rules of preclusion extend their binding effects to non-parties in privity with a litigant in the earlier action. Consistent with these rules, the application of res judicata and collateral estoppel presumes the exercise of the court’s subject matter jurisdiction to review so much of the merits of a particular action as would allow a substantive determination of what issues or claims may have been resolved in some prior proceeding, thereafter barring collateral relit-igation of those matters in another forum. See Stoll v. Gottlieb, 305 U.S. 165, 171-72, 59 S.Ct. 134, 83 L.Ed. 104 (1938); Nemaizer v. Baker, 793 F.2d 58, 65 (2d Cir.1986); see generally 18 Moore’s Federal Practice § 131.30[l][d][ii]-[iii]. In the final analysis, the doctrinal distinctions discussed above have significance. The differences may be especially consequential in particular instances in which state law may not preclude collateral attacks on certain judgments, and thus the federal full faith and credit statute would not proscribe a later federal suit, but in which it nonetheless would serve important interests of the justice system to bar the subsequent relitigation in federal court. See, e.g., GASH Assocs., 995 F.2d at 728; Ritter v. Ross, 992 F.2d 750, 755 (7th Cir.1993); Garry, 82 F.3d at 1369. One of the primary objectives served by the rules of preclusion is to bring finality to litigation. In some cases, how and where that finality is attained may be essential. Whatever the dictates of the rules of preclusion, it may at times better advance the overall interests of the parties and the legal system for finality to be achieved in state courts. As in the case at bar, such occasions may arise where, for example, by virtue of the posture of the state proceeding at the time the federal action is commenced, opportunity for additional state review of the matter may be indicated or may still be timely. Such further consideration may be especially critical in matters like those at issue in Feldman and here — the licensing and disciplining of professionals — in which the states have an acute and unique stake because the underlying dispute involves a challenge to the state’s regulatory scheme and the state itself is the party accused of constitutional violations. Under these circumstances, insofar as renewed consideration, where feasible, may-serve to conclude adjudication of incomplete state proceedings, ambiguous matters or new issue's raised by later discovered evidence, the additional review and finality of the litigation may more appropriately occur by reopening of the state proceeding, rather than by foreclosing it in a federal court judgment applying the state rules of preclusion — a result which would not obtain in the case of a federal ruling rendered on the basis of absence of subject matter jurisdiction. These circumstances underscore the observation of one treatise that “[o][ften there are good reasons to defer to state proceedings, and to refuse to set aside state-court orders, even though preclusion does not apply. The full faith and credit statute does not exhaust the principles of comity and abstention.” Wright, Miller & Cooper, at 664. Moreover, the jurisdictional grounding of Rooker-Feldman, as another commentator has observed, “thus provides for a limited, uniform federal law of preclusion in cases that varying state laws may not foreclose.” David P. Currie, Res Judicata: The Neglected Defense, 45 U. Chi. L.Rev. 317, 324 (1978). b. The Common Thread: “Inextricably Intertwined” Implicitly recognizing that some overlap does exist in the practical effects of both the Rooker-Feldman principle and the preclusion of res judicata and collateral estoppel, the Supreme Court enunciated the “inextricably intertwined” test to bar exercise of jurisdiction if the matters presented in the federal forum cannot be disentangled from the merits of the state court’s prior judgment on the same issue or claim. In Feldman, it noted that [i]f the constitutional claims presented to a United States District Court are inextricably intertwined with the state court’s denial in a judicial proceeding of a particular plaintiffs application for admission [to practice law], then the District Court is in essence being called upon to review the state court decision. This the District Court may not do. Feldman, 460 U.S. at 483 n. 16, 103 S.Ct. 1303. However, the “inextricably intertwined” standard, as several courts have acknowledged, is ambiguous and “by itself does not provide district courts with a bright line rule.” Razatos v. Colorado Supreme Court, 746 F.2d 1429, 1433 (10th Cir.1984), cert. denied, 471 U.S. 1016, 105 S.Ct. 2019, 85 L.Ed.2d 301 (1985). Absent a more definitive statement delineating the scope of Rooker-Feldman’s “inexorably intertwined” standard, the courts have propounded several defining concepts and relied upon various inquiries to guide application of the doctrine. Some of the factors focus on the nature and purpose of the federal action, as manifested by a close reading of the federal complaint. These considerations include: (1) whether the case brought in federal court by the party unsuccessful in state court amounts merely to a recasting of losing claims under a semblance of federal law causes of action not decided or interposed in the prior state proceeding, so that “in essence” the district court is being called upon to undertake appellate review of the state court decision, see Feldman, 460 U.S. at 483 n. 16, 103 S.Ct. 1303; (2) whether the invocation of the federal court’s jurisdiction effectively seeks a “direct review” of a state court judgment, see Atlantic Coast Line, 398 U.S. at 296, 90 S.Ct. 1739 and Allah v. Superior Court, 871 F.2d 887, 891 (9th Cir.1989); (3) whether the federal proceeding represents a “general challenges” to specified state laws or rules, or rather a more “particularized challenge” to a given state court adjudication as it applies to or affects the federal complainant, Feldman, 460 U.S. at 485-86 n. 18, 103 S.Ct. 1303; Razatos, 746 F.2d at 1433; Stern v. Nix, 840 F.2d 208, 212 (3d Cir.), cert. denied, 488 U.S. 826, 109 S.Ct. 77, 102 L.Ed.2d 53 (1988); (4) whether the federal remedy requested represents a “prospective” challenge directed at application of state rules or procedures in the future, or a “retrospective challenge” seeking injunc-tive relief to nullify or bar enforcement of a state court judgment, Centifanti v. Nix, 865 F.2d 1422, 1429-30 (3d Cir.1989); (5) whether the federal action contesting a state rule that was the subject of an earlier state proceeding may stand on its own, so that its purpose is “‘separable from and collateral to’ ” the related adjudication, Pennzoil, 481 U.S. at 21, 107 S.Ct. 1519 (Brennan, J., concurring) (citing National Socialist Party v. Skokie, 432 U.S. 43, 44, 97 S.Ct. 2205, 53 L.Ed.2d 96 (1977)). In a variation of these standards, an inquiry enunciated by other courts turns on the source of the injury and its relationship to the relief the federal claimant seeks. Specifically, this tests asks (1) whether the alleged injury arises from the rendering of the state court judgment itself, or is distinct from plaintiffs loss in the state proceeding, see Garry, 82 F.3d at 1365-66; GASH Assocs., 995 F.2d at 729; and (2) whether the federal plaintiff “is seeking to undo a [state court] remedial order of some sort,” Nesses v. Shepard, 68 F.3d 1003, 1004 (7th Cir.1995). Another definition proposed centers on the effect of the federal litigation, in particular whether the “federal claim succeeds only to the extent that the state court wrongly decided the issues before it,” Pennzoil, 481 U.S. at 25, 107 S.Ct. 1519 (Marshall, J., concurring); Hachamovitch, 159 F.3d at 695-96; Sheehan v. Marr, 207 F.3d 35, 40 (1st Cir.2000). Yet other tests look to what transpired in the state proceedings, including: (1) whether the party seeking federal relief has had a reasonable or full and fair opportunity to litigate his federal claim in state tribunals, including the party’s ability to raise a claim on state appellate review, see Wood v. Orange County, 715 F.2d 1543, 1547 (11th Cir.1983), cert. denied, 467 U.S. 1210, 104 S.Ct. 2398, 81 L.Ed.2d 355 (1984); Blue Cross & Blue Shield v. Weiner, 868 F.2d 1550 (11th Cir.), cert. denied, 493 U.S. 892, 110 S.Ct. 239, 107 L.Ed.2d 190 (1989); and (2) whether in the state proceeding the court has undertaken “consideration” and “decision” on the merits of the issue or claim in contention, Robinson, 753 F.2d at 1472. c. Rooker-Feldman vs. Abstention No greater clarity or precision exists in the gray zones where the jurisdictional strictures of Rooker-Feldman converge with the principles of comity and federalism that compel application of the doctrine of abstention in circumstances in which the Rooker-Feldman bar arguably appeared appropriate. See Owens, 54 F.3d at 274 (noting the relationship between Rooker-Feldman and abstention doctrines). In Pennzoil, for example, a plurality of the Supreme Court held, without addressing Rooker-Feldman, that the Younger abstention doctrine mandated reversal of the federal district court’s decision. The lower court ruling had been predicated on a finding that Rooker-Feldman did not bar the court’s assertion of subject matter jurisdiction. The district court thus enjoined a civil action still pending in state court to enforce a judgment under circumstances where, as' characterized by the Supreme Court, “the State’s interest in the proceeding are so important that exercise of the federal judicial power would disregard the comity between the States and the National Government.” 481 U.S. at 10, 107 S.Ct. 1519. Conversely, in Huffman the Supreme Court reversed the district court’s issuance of an injunction barring, on First Amendment grounds, enforcement of a state trial court order directing the closing of plaintiffs theater. The state court judgment was not appealed to the state’s highest court. Accordingly, the federal district court’s exercise of jurisdiction theoretically could have been barred by application of Rooker-Feldman principles. Instead, the Supreme Court, employing terms that resonate of Rooker-Feldman, held, as in Pennzoil, that the district court should have abstained in accordance with the Younger doctrine: In short, we do not believe that a State’s judicial system would be fairly accorded the opportunity to resolve federal issues arising in its courts if a federal district court were permitted to substitute itself for the State’s appellate courts. We therefore hold that Younger standards must be met to justify federal intervention in a state judicial proceeding as to which a losing litigant has not exhausted his appellate remedies. Huffman, 420 U.S. at 609, 95 S.Ct. 1200; cf. Thomas v. Kadish, 748 F.2d 276 (5th Cir.1984), cert. denied, 473 U.S. 907, 105 S.Ct. 3531, 87 L.Ed.2d 655 (1985) (applying Rooker-Feldman, without reference to abstention, to sustain dismissal for lack of subject matter jurisdiction where the plaintiff challenged in federal court, without appealing to the state Supreme Court, a trial court’s denial of his application for admission to the state bar). This review of the principles implicated in the instant case, given their relationships and inherent tension and the confusion surrounding their application, serves as the backdrop to the Court’s consideration of the relevant facts at issue here. B. APPLICATION OF PRINCIPLES Harris’s federal claims under the ADA and the Rehabilitation Act allege that DOH refused to acknowledge evidence of his learning disabilities and revoked his medical license without considering or offering him reasonable means to accommodate those disabilities. His Fourteenth Amendment claims assert defic