Klavan v. Crozer-Chester Medical Center

Citations: 60 F. Supp. 2d 436; 1999 U.S. Dist. LEXIS 12461; 1999 WL 619336Docket: CIV. A. 99-2016

Court: District Court, E.D. Pennsylvania; August 16, 1999; Federal District Court

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Marshall Klavan, M.D., represented by guardian ad litem Jerome J. Shestack, filed a lawsuit against Crozer-Chester Medical Center and several medical professionals for "wrongful life" and violation of his liberty interest in refusing unwanted medical treatment. Klavan, once a respected physician, had created an Advance Medical Directive (AMD) in 1993, explicitly stating his wish to avoid extraordinary medical measures due to a fear of debilitating conditions similar to his father's. In April 1997, following a suicide attempt, he was found unconscious and resuscitated despite his AMD and explicit wishes. After deteriorating into a persistent vegetative state, his family communicated his AMD to the medical staff. However, after a directive from Joan K. Richards, the president of CCMC, extraordinary measures were again employed when his condition worsened. Klavan’s claims include a Fourteenth Amendment violation based on his right to refuse medical treatment, as recognized in the Supreme Court case Cruzan v. Director, Missouri Dept. of Health. The court determined that Klavan failed to demonstrate that the defendants were "state actors," which is essential for his constitutional claim, leading to the dismissal of the motions by the defendants.

Several defendants have moved to dismiss the complaint, citing both a lack of subject matter jurisdiction under Fed. R.Civ. P. 12(b)(1) and failure to state a claim under 12(b)(6). Referencing Boyle v. Governor's Veterans Outreach, Assistance Ctr., the court determines that motions regarding state action should be considered solely under Rule 12(b)(6). In evaluating such motions, the court accepts all facts alleged in the complaint as true, only dismissing if it is clear that no relief could be granted under any conceivable set of facts. Legal conclusions presented by the plaintiff, however, are not accepted as true.

Dr. Klavan's claims under the Fourteenth Amendment assert a protected liberty interest in refusing unwanted medical treatment. However, the Fourteenth Amendment does not apply to private conduct, necessitating state action for liability. The Supreme Court has identified multiple tests for determining state action, including the "traditional exclusive governmental function," "symbiotic relationship," and "close nexus" tests, with the applicable test depending on the specific case facts.

Dr. Klavan acknowledges that the defendants do not qualify as state actors under the "traditional exclusive governmental function" test but contends they do qualify under the "symbiotic relationship" and "close nexus" tests. Thus, the court will analyze both tests, starting with the "symbiotic relationship" test, which assesses the degree of interdependence between the state and the private party in question. Under this test, a private entity may be deemed a state actor if the state has significantly integrated itself into the private party's activities, making it a joint participant in those actions.

State regulation alone does not constitute state action for institutions, even if the regulation is comprehensive. Similarly, extensive financial aid does not equate to state action. The "close nexus" test examines the relationship between state actions and the specific conduct in question, contrasting with the "symbiotic relationship" test, which assesses the overall connection between the state and the entity involved. A sufficiently close nexus exists only if the state exerts coercive power or significant encouragement that effectively makes the private actions those of the state. Mere state approval or acquiescence does not meet this threshold. The objective of this test is to ensure constitutional standards apply only when the state is directly responsible for the alleged conduct.

Dr. Klavan contends that the defendants qualify as state actors under both the "symbiotic relationship" and "close nexus" tests based on five arguments: 1) their receipt of Hill-Burton funds, 2) Medicare and Medicaid payments, 3) compliance with licensing regulations, 4) obligations under laws to inform patients of treatment rights, and 5) responsibilities under the Pennsylvania Advance Directive for Health Care Act. However, case law—including Hodge and Blum—indicates that receipt of such funds and compliance with regulations do not establish state action under 42 U.S.C. § 1983. Courts have consistently ruled that government funding and regulation alone do not render entities state actors. Thus, the defendants' receipt of government funds does not qualify them as state actors, irrespective of the tests applied.

Dr. Klavan contends that the defendants qualify as state actors due to their compliance with state and federal licensing requirements, their obligations to inform patients of their treatment rights, and their alleged violations of Pennsylvania's Advance Directive for Health Care Act. However, the court disagrees, referencing the Supreme Court's ruling in Sullivan, which determined that extensive state regulation of private entities does not inherently transform their actions into state actions for Fourteenth Amendment purposes. The court cites other cases like Blum and Moose Lodge to support its position that mere regulation does not establish a "symbiotic relationship" between the state and the defendants. Furthermore, the court highlights that Dr. Klavan has not demonstrated a significant interdependence or "close nexus" between the defendants’ regulatory compliance and their treatment decisions. Regarding Dr. Klavan's argument about the defendants' obligations under the Pennsylvania Advance Directive for Health Care Act, the court concludes that a private entity's violation of state law cannot, by itself, create state action. Accepting Dr. Klavan's view would imply that any noncompliance by independent contractors with state laws could lead to liability under 42 U.S.C. 1983, which the court rejects.

The Pennsylvania statute does not indicate that the General Assembly intended to grant state agency powers to health care providers, regardless of their adherence to the statute. There is insufficient "interdependence" between the Commonwealth and the defendants to classify them as "joint participants" in the alleged violations. The defendants' decisions, which allegedly breached the statute, negate any "close nexus" to the Commonwealth, meaning they cannot be considered state actors. Previous cases, including Cardio-Medical Assocs. and Holton, reached similar conclusions regarding state action. Therefore, Dr. Klavan's Fourteenth Amendment claim is dismissed. 

Regarding supplemental jurisdiction under 28 U.S.C. § 1367(c)(3), the court may decline to exercise this jurisdiction if all original jurisdiction claims are dismissed. Despite the serious nature of Dr. Klavan's case, the court opts not to intervene in state public policy issues based solely on limited jurisdiction. Consequently, the court dismisses the remaining state law claims without prejudice, allowing for their reassertion in state court.

The order issued on August 16, 1999, includes that the defendants' motions to dismiss are granted, Count I is dismissed for failure to state a claim, the court declines jurisdiction over remaining counts, and several petitions to join in dismissals are granted as unopposed. The motion to extend time for co-defendants is denied as moot, and the case is closed statistically.

Dr. Klavan, referred to as the plaintiff, is pursuing claims against several defendants, including Crozer-Chester Medical Center, its staff, and a nurse. The court collectively identifies these parties as "defendants." The defendants argue for the dismissal of Dr. Klavan's state law claims. However, the court declines to consider these arguments due to its determination that the defendants are not deemed state actors and its decision to avoid exercising supplemental jurisdiction over these claims.

The court references the Supreme Court's 1982 "Lugar trilogy" to guide its analysis of "state action." In this context, it notes that joint participation with the state may transform a private entity into a state actor for certain claims, but not for others, as established in key cases. The inquiry focuses not just on whether a private group serves a public function but on whether that function is traditionally an exclusive state prerogative. Examples of such exclusive functions include conducting elections and exercising eminent domain, which the Supreme Court has seldom found to be met.

Specifically, the court highlights that providing hospital services is not considered a traditional public function reserved solely for the state, citing various case law that supports this position. Additionally, the analysis of "state action" is consistent under both the Fourteenth Amendment and Section 1983 claims.