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Compassion in Dying v. Washington
Citations: 79 F.3d 790; 1996 WL 94848Docket: No. 94-35534
Court: Court of Appeals for the Ninth Circuit; March 5, 1996; Federal Appellate Court
The case at hand addresses the critical issue of whether terminally ill individuals possess a constitutionally-protected liberty interest in choosing the time and manner of their death, particularly in the context of seeking medical assistance to hasten death. Judge Reinhardt emphasizes the complexity of this matter, which touches on profound human concerns related to mortality and dignity. The court must evaluate the balance between this liberty interest and the state’s legitimate interests, primarily the preservation of human life. Ultimately, the court concludes that the Washington statute, which criminalizes physician-assisted suicide, infringes upon the Due Process Clause of the Fourteenth Amendment when it prohibits physicians from prescribing life-ending medication to terminally ill, competent adults wishing to hasten their deaths. This ruling marks a significant legal development, as it is the first federal appellate decision on the right-to-die issue. The plaintiffs include four physicians and three terminally ill patients, alongside the non-profit organization Compassion In Dying, all arguing against the restrictive statute that classifies aiding in suicide as a felony, thereby deterring physicians from providing assistance to their patients in need. The Washington statute criminalizes promoting a suicide attempt, making it a felony punishable by up to five years in prison and a fine of $10,000 (RCW 9A.36.060). Four plaintiff-doctors appealed on behalf of terminally ill, competent adult patients seeking assistance from their physicians to hasten their deaths. This group included three patient-plaintiffs: 1. Jane Roe, a 69-year-old retired pediatrician with metastatic cancer, suffers from severe pain, is bedridden, and has been referred to hospice care, indicating a life expectancy of less than six months. She is mentally competent and wishes to hasten her death with prescribed drugs, having requested support from Compassion in Dying. 2. John Doe, a 44-year-old artist with AIDS, experiences severe health decline, including loss of vision and chronic infections. He is aware of his terminal condition and desires physician-assisted death, understanding there is no cure. 3. James Poe, a 69-year-old retired sales representative suffering from emphysema and heart failure, experiences constant suffocation and severe pain. He is mentally competent and wishes to commit suicide with prescribed drugs. The identities of the patients are protected by pseudonyms, and all three died after the case commenced, with two having died before the District Court’s decision. The District Court correctly granted physicians standing to represent the rights of their terminally ill patients, establishing that the case remained relevant despite the patients' deaths. The physicians satisfy both Article III and jurisprudential standing requirements, drawing on precedents such as Singleton v. Wulff, which affirmed doctors' standing to challenge laws affecting their patients, and Doe v. Bolton, which allowed physicians to contest abortion statutes even without direct prosecution threats. The ambiguity in Bolton regarding whether physicians asserted their own rights or those of their patients was clarified by Singleton, which recognized the standing of doctors to defend their patients' rights. The current physicians face a tangible risk of prosecution under Washington law for their intended conduct, and the state has not indicated an intention to refrain from prosecution. Citing Babbitt v. United Farm Workers National Union, the excerpt emphasizes that the risk of arrest is not a prerequisite for standing in constitutional challenges. The precedent further reinforces that physicians are directly impacted by criminal statutes and should not be compelled to face prosecution to seek relief. The issue of whether the deaths of the patient-plaintiffs would affect their attorneys' ability to continue the case remains open, but the capable-of-repetition-yet-evading-review doctrine suggests the controversy could recur, similar to the rationale in Roe v. Wade. The Court noted that when pregnancy is a significant factor in litigation, the typical 266-day gestation period often concludes before the appellate process is completed, potentially rendering the case moot. This circumstance could hinder the progression of pregnancy-related cases beyond the trial stage. The District Court addressed claims from two of the three categories of plaintiffs: terminally ill patients asserting their right to medical assistance and physicians advocating on their behalf. However, claims by Compassion In Dying were not considered, nor were claims from terminally ill patients seeking assistance from such organizations. The appellate jurisdiction arises from a partial summary judgment certified by the District Court under Federal Rule of Civil Procedure 54(b). The plaintiffs contested only the "or aids" provision of Washington statute RCW 9A.36.060, which prohibits assisting in suicide, arguing it infringes upon the constitutional liberty interest of terminally ill, mentally competent adults wishing to hasten their deaths through physician-prescribed medication. They claimed this provision violates both the Due Process Clause of the Fourteenth Amendment and the Equal Protection Clause by unjustly distinguishing between similar terminally ill patients. Chief District Judge Barbara Rothstein ruled that a competent, terminally ill adult has the constitutional right under the Fourteenth Amendment to pursue physician-assisted suicide, finding the statute an undue burden on this right and discriminatory against similarly situated patients. On appeal, a three-judge panel reversed the District Court's decision by a 2-1 vote, asserting that there is no due process liberty interest in physician-assisted suicide and that the statute does not breach the Equal Protection Clause. Thus, the statute was upheld both facially and as applied. Judge Wright dissented, arguing the statute should be deemed invalid for terminally ill, mentally competent adults due to violations of their privacy and equal protection rights. The case is reheard en banc due to its significant importance, affirming the District Court’s decision and clarifying the relief scope. The court finds that the "or aids" provision of Washington statute RCW 9A.36.060, which restricts the prescription of life-ending medication to terminally ill, competent adults wishing to hasten death, violates the Due Process Clause of the Fourteenth Amendment. The court does not address whether this provision also violates the Equal Protection Clause. In analyzing the potential Due Process violation, the court first establishes that there exists a liberty interest in determining the time and manner of one’s death. This leads to the inquiry of whether prohibiting physicians from prescribing life-ending medication constitutes a violation of due process rights for terminally ill patients. Recognizing a liberty interest does not prevent the state from imposing restrictions, but necessitates a balancing test between individual liberty interests and state interests. Citing prior cases, including *Cruzan v. Director, Missouri Dept. of Health*, *Youngberg*, and *Mills*, the court emphasizes that a balancing approach is integral to evaluating substantive due process cases. The legal tradition of balancing individual rights against state interests dates back to at least 1905, as established in *Jacobson v. Massachusetts*. The court concludes that if the balance favors the state, the statute is constitutional; if it favors the individual, the statute is unconstitutional, either on its face or as applied. The analysis concludes that individual liberty interests are paramount, particularly in the context of determining the existence of a liberty interest surrounding the right to die. It emphasizes the complex and emotionally charged nature of this issue, acknowledging the diverse perspectives that influence people's views, including personal philosophies, life experiences, and moral standards. The document references the Supreme Court's guidance from Roe v. Wade, stressing the importance of conducting an objective analysis in sensitive matters. It also cites Justice Harlan's dissent in Poe v. Ullman, highlighting that the liberty guaranteed by the Due Process Clause extends beyond specific constitutional guarantees and encompasses a broad spectrum of freedoms that resist arbitrary state restrictions. Furthermore, it recalls Justice Brandeis's dissent in Olmstead v. United States, which underscores the constitutional aim to secure conditions that favor the pursuit of happiness and respect for individual beliefs and feelings. The examination of liberty interests in end-of-life decisions draws parallels to abortion cases, noting that the weight of competing interests may shift based on individual circumstances, thereby affecting judicial outcomes at different life stages. Both abortion and assisted suicide involve critical life-and-death issues, invoking significant moral and religious concerns while raising fundamental questions about individual choice. Historical patterns show that despite condemnation, both practices persist, often leading individuals to seek unsafe alternatives when denied medical assistance, resulting in tragic outcomes. The legal debates surrounding these issues are deeply emotional and divisive, with similar arguments and constitutional principles on both sides. The Court's approach to abortion cases, particularly in *Planned Parenthood v. Casey*, serves as a precedent for right-to-die cases, emphasizing the importance of personal dignity and autonomy as protected by the Fourteenth Amendment. The initial panel defined the liberty interest narrowly as a "constitutional right to aid in killing oneself," but this view is too restrictive. The broader inquiry should focus on the liberty interest in determining the time and manner of one’s death, rather than just the means of assistance. This approach mirrors the Supreme Court's reasoning in abortion cases, which assessed the existence of a general liberty interest (the right to an abortion) before considering specific means of implementing that interest. For instance, in *Roe v. Wade*, the Court recognized a woman's right to an abortion independent of the method of assistance, highlighting that the Texas statute at issue only prohibited assistance, not the act itself. A woman has a constitutional right to choose an abortion, as established by the Court, which first affirmed this right before analyzing whether state prohibitions on assistance unconstitutionally restrict that liberty interest. In Planned Parenthood v. Casey, the Court reaffirmed this liberty interest without addressing spousal notification initially, and subsequently examined if requiring married women to notify their spouses before obtaining an abortion constituted an undue burden. A similar analytical approach is applied to the question of whether there is a liberty interest in determining the time and manner of one’s death, specifically in relation to Washington’s ban on assisted suicide. The terms "right to die," "determining the time and manner of one’s death," and "hastening one’s death" are preferred over "suicide," as they encompass a broader range of actions, including the refusal or termination of unwanted medical treatment. The law does not classify the resulting death from such refusals as "suicide," nor does it label the actions of those assisting in these refusals as "assisted suicide." The Court raises doubts about the appropriateness of the terms "suicide" and "assisted suicide" for the conduct in question. The term "physician-assisted suicide" is employed for this case, referring specifically to the prescription of medication by a physician to enable a patient to end their life, which is the conduct the plaintiffs seek constitutional protection for. There is no definitive test for establishing a liberty interest under the Due Process Clause; courts must exercise judgment based on conscience, traditions, and evolving societal values, considering both historical context and contemporary circumstances. The Court has defined "fundamental rights" as those that are "implicit in the concept of ordered liberty," a standard reaffirmed in Bowers v. Hardwick. In Palko v. Connecticut, these rights are characterized as essential to liberty and justice, while Moore v. East Cleveland describes them as "deeply rooted" in American history and tradition. Recently, the Court has focused more on substantive due process interests, reflecting a continuum approach that includes a range of liberty interests, with varying degrees of judicial protection. Fundamental rights can only be limited by compelling state interests, whereas other interests, like the right to refuse unwanted medical treatment, face a less stringent balancing test. The Court's evolving approach may signal a shift away from a rigid classification system to a more flexible balancing framework where the significance of a right dictates the level of justification required for its infringement. Nonetheless, in the current case, a balancing test is applicable based on traditional jurisprudence. The dissent's interpretation of Reno v. Flores is challenged, emphasizing that the Court did not reject the use of a balancing test for important liberty interests, nor did it establish a new classification system. Liberty interests can either be classified as fundamental rights or important liberties subject to a balancing test, but rational basis review is not applicable in this context, as indicated by previous case law, particularly Flores. The Court has reiterated that the boundaries of the substantive Due Process Clause evolve over time and are not constrained by historical precedents at the time of the Fourteenth Amendment’s adoption. The Casey decision emphasized that prior failure to recognize a liberty interest does not preclude its acknowledgment. It highlighted that personal experiences, such as those related to pregnancy, are too intimate for the state to dictate. In contrast, a recent panel erroneously asserted that historical analysis alone suffices to dismiss a substantive liberty interest claim. This perspective is flawed; historical context alone cannot justify denying a claimed liberty, as exemplified by the invalidation of anti-miscegenation laws in Loving v. Virginia, which were once commonplace. The Casey ruling reinforced that substantive due process does not depend solely on historical validation. The Due Process Clause is understood to protect a broad range of personal liberties beyond narrowly defined practices that were recognized at the time of the Fourteenth Amendment's ratification. This principle affirms that there are aspects of personal freedom from government intrusion, which has been upheld in various Supreme Court cases. Notably, in Loving v. Virginia, the Court recognized interracial marriage as a protected liberty despite its absence from the Bill of Rights and its illegality in many states in the 19th century. Similarly, the right to marry—whether between prisoners or civilians—was affirmed in Turner v. Safley, and the prohibition of contraceptives to minors was struck down in Carey v. Population Services International and Griswold v. Connecticut, highlighting protection against state interference in marital privacy. The excerpt also critiques the historical perspective on constitutional rights, particularly the dissenting view in Roe v. Wade, which argued that abortion rights were not supported by historical practices, noting that a significant number of states had restrictive abortion laws in 1868. The document further discusses the historical context of suicide, countering a panel's claim that a constitutional right to assisted suicide was unknown in the past. It references ancient Greek and Roman views, where suicide was sometimes seen as honorable and not universally condemned, with instances of societal acceptance and even state-sanctioned assistance in such acts, illustrating a complex historical attitude toward the issue. Grief and despair are discussed in context with suicide, highlighting varying philosophical perspectives from ancient Greece and Rome. Socrates, while opposing suicide, is noted for his own death by hemlock, influencing others. Plato viewed suicide as justifiable under extreme circumstances, such as severe illness or unbearable conditions. Most Greeks accepted suicide, with only the Pythagorean school opposing it, a minority view. Stoics celebrated suicide as a rational choice, exemplified by Cato, who took his life to avoid dishonor. Roman law reflected similar attitudes, where suicide was not punishable if driven by pain, sickness, or weariness of life. However, irrational suicides were penalized due to their perceived lack of rationality. Convicted criminals faced property forfeiture upon suicide to protect the emperor's interests. Early Christians viewed death as an escape from earthly suffering, fostering a temptation towards suicide, with martyrdom ideals reaching extremes in groups like the Donatists, who sought death for religious affirmation. Travellers were coerced into committing acts of martyrdom through promises of rewards or threats of death, as noted by St. Augustine regarding the Donatists. He condemned suicide as a "detestable and damnable wickedness," concerned that the trend could diminish the Christian population. The distinction between martyrdom and suicide was often blurred until St. Augustine's influence. By 562 A.D., the Council of Braga denied burial rights to suicides, and the Council of Toledo in 693 A.D. proclaimed excommunication for suicide attempts. The Christian belief that suicide was inherently sinful persisted for a millennium, challenged later by thinkers like Montesquieu, Voltaire, and Sir Thomas More, who supported the terminally ill's right to choose death. England treated suicide as a crime from at least the thirteenth century, with Bracton integrating Roman law and allowing for exceptions based on mental state and suffering. Sir Edward Coke reinforced this view in the 17th century, stating those who committed suicide forfeited their movable property but recognized exceptions for those not of sound mind. In practice, juries in 18th century England often showed leniency towards suicides, reflecting a compassionate response to the circumstances surrounding the act. Traditional English views on suicide were influenced by taboos and fears, as reflected in common law, which regarded suicide as a potential haunting of the living. Consequently, it was customary to bury the body at a crossroads to prevent the spirit from returning, often with a stake through the body as an additional measure. These attitudes migrated to America, where by 1798, six of the 13 original colonies had abolished penalties for suicide. Post-revolutionary America saw no recorded punishments for suicide or attempted suicide under common law. By the adoption of the Fourteenth Amendment in 1868, suicide was largely unpunishable; only nine of the 37 states had statutes against assisting suicide, with most states not criminalizing these actions since the early 1900s. A notable 1901 ruling by the New Jersey Supreme Court declared suicide non-criminal, acknowledging ethical justifications in some cases, such as to escape rape or incurable suffering. Currently, no state has laws against suicide or attempted suicide, and no such laws have existed for at least a decade, although many states maintain laws against assisting suicide. Societal attitudes toward suicide remain complex; the lack of criminal sanction does not equate to societal approval. Recent trends show growing support for allowing terminally ill individuals to hasten their deaths, with polls indicating that a significant majority of Americans support options for terminally ill patients to refuse or terminate treatment. Support for physician-assisted suicide has also increased, with various polls in the 1990s showing strong public backing for legalizing such practices for the terminally ill. Mixed results have emerged from referenda held in three states regarding the role of physicians in assisting terminally ill patients in ending their lives. Voters in Oregon approved a referendum on physician-assisted suicide by a narrow margin of 51 to 49 percent in November 1994, indicating a growing public support for allowing doctors to assist terminally ill patients in hastening death. In contrast, similar measures in Washington and California received only 46 percent support and included fewer safeguards. The presence of laws criminalizing assisted suicide does not reflect societal disapproval, especially when such laws are rarely enforced; there have been no reported cases of doctors facing criminal punishment for assisting terminally ill patients in ending their lives. This lack of enforcement suggests widespread discontent with existing laws. The historical context shows a longstanding, albeit hidden, practice of physicians aiding terminally ill patients in ending their suffering. A survey indicated that one in five doctors had assisted in a patient's suicide, with accounts published in both professional and mainstream media. The modern debate surrounding the right to refuse treatment or seek assistance in dying has gained urgency due to changes in the nature of illnesses and advancements in medical technology. Today, Americans often experience prolonged and painful deaths from manageable diseases, contrary to historical experiences where illness typically led to quicker deaths. This shift has prompted a movement advocating for dignity in dying, reinforcing the emerging rights to refuse treatment and to receive assistance in ending one’s life. The evolving understanding of death and medical capabilities suggests a strong liberty interest in determining the circumstances of one’s death, warranting recognition in legal frameworks. The substantive component of the Due Process Clause limits state intrusion into significant personal matters without substantial justification. The Court has recognized constitutional protection under the Fourteenth Amendment for personal decisions regarding marriage (Loving v. Virginia), procreation (Skinner v. Oklahoma), family relationships (Prince v. Massachusetts), child rearing and education (Pierce v. Society of Sisters), and non-procreative intercourse (Griswold v. Connecticut). Additionally, individuals have the right to make intimate decisions such as whether to bear a child (Eisenstadt v. Baird) or continue an unwanted pregnancy (Roe v. Wade). A key theme in these cases is the protection of highly personal and intimate choices. The decision to end one’s life, particularly to avoid excessive pain, is presented as one of the most personal choices. The cases from Pierce to Roe support the conclusion that a liberty interest in controlling the time and manner of one's death falls under the protection of the Due Process Clause. Two more recent cases, Planned Parenthood v. Casey and Cruzan v. Director, Missouri Dept. of Health, are highlighted as particularly persuasive in affirming this principle. Casey emphasizes that intimate choices central to personal dignity and autonomy are protected by the Fourteenth Amendment. The district judge found Casey's reasoning relevant for assessing a terminally ill person's choice to commit suicide, equating this decision's intimacy and significance to that of abortion. A competent terminally ill adult has a significant liberty interest in choosing a dignified death, avoiding a state of helplessness and suffering. The ability to determine how one dies influences not only the individual's final days but also the lasting memories of loved ones. Prohibiting such individuals from hastening their deaths can have a more profound impact than forcing a woman to carry a pregnancy to term. A case involving an AIDS patient, referred to as "Smith," illustrates this point. Smith suffered immensely, unable to walk and requiring a catheter, leading to the loss of friends and unbearable pain that medication could not alleviate. Despite being mentally competent and requesting assistance to end his suffering, the treating physician was legally barred from helping, resulting in prolonged agony until death. This situation emphasizes the deeply personal nature of end-of-life choices, which are central to personal dignity and autonomy. The legal precedent set in *Cruzan* supports the notion of a constitutionally protected liberty interest in terminating unwanted medical treatments. The Court affirmed that patients have the right to refuse specific medical procedures, referencing cases like *Jacobson v. Massachusetts*, which weighed individual liberty against state interests, and *Washington v. Harper*, which highlighted the substantial interference with liberty caused by forced medical treatment. Additionally, *Parham v. J.R.* acknowledged a child's liberty interest in avoiding unnecessary confinement for medical care. A competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment, inferred from prior Supreme Court decisions. This includes the refusal of all types of medical treatment, such as dialysis, artificial respiration, and the artificial delivery of food and water. Justice O’Connor noted that forcing a competent adult to undergo medical procedures against their will infringes on their liberty, dignity, and autonomy over their treatment choices. Chief Justice Rehnquist emphasized that the choice between life and death is deeply personal, and while the state may impose heightened evidentiary requirements, it cannot deny the due process interests involved in both life and the refusal of life-sustaining treatment. The majority recognized that granting a request to discontinue artificial nutrition and hydration would lead to death, thereby affirming a liberty interest in hastening one’s own death. The cases of Casey and Cruzan support the conclusion that the Constitution acknowledges a due process liberty interest in controlling the time and manner of one’s death, particularly relevant for mentally competent, terminally ill individuals and those in irreversible unconscious states. However, this recognition does not equate to an unrestricted right to act on that interest, as state regulation and prohibitory actions may still be constitutionally permissible. The next step is to determine the constitutionality of the state's attempts to limit this liberty interest. To assess whether a state action that impairs a liberty interest violates an individual’s substantive due process rights, several relevant factors must be analyzed: 1. The significance of the state's interests, both generally and in the specific case context. 2. How those interests are advanced by the state law or regulation. 3. The importance of the liberty interest, both intrinsically and within its exercise context. 4. The extent of the burden imposed on this liberty interest by the state action. 5. The implications of either upholding or overturning the statute or regulation. The state’s interests identified in this case include: 1. Preserving life. 2. Preventing suicide. 3. Avoiding third-party involvement and preventing arbitrary or undue influence. 4. Protecting family members and loved ones. 5. Maintaining the integrity of the medical profession. 6. Preventing negative consequences from a potential declaration of unconstitutionality. The state asserts a fundamental interest in preserving life, consistent with precedents such as *Cruzan*, which affirms the state’s right to prioritize life preservation without making qualitative judgments about life. However, this interest is not absolute and varies based on circumstances, including the medical condition and preferences of the individual involved. Notably, Washington's Natural Death Act reflects a legislative determination that the state's interest in preserving life may yield to the informed wishes of terminally ill, competent adults regarding life-sustaining treatment, indicating an acknowledgment of a due process liberty interest in making such medical decisions. The legislature emphasizes the importance of individual autonomy in end-of-life decisions, noting that prolonging life for terminally ill patients can lead to a loss of dignity, unnecessary suffering, and no medical benefit. The Washington statute allows competent adults to preemptively refuse life-sustaining treatment through living wills and durable powers of attorney. The Washington Supreme Court has recognized that legal guardians may discontinue life-sustaining treatment even when surrogate decision-making is not explicitly authorized by the Washington Natural Death Act. Washington's approach is consistent with over 40 other states that have similar living will statutes, allowing adults to declare their wishes regarding medical treatment in terminal illness or permanent unconsciousness. Many states also enable patients to appoint surrogates for medical decisions. Additionally, federal law supports patients' rights to refuse life-sustaining treatment and mandates that hospitals inform patients of these rights upon admission. Although the preservation of life is a primary state interest, it diminishes significantly when individuals are terminally ill or permanently comatose and have expressed a desire to forgo further treatment. The state's interest in compelling these individuals to remain alive is less compelling when they cannot pursue liberty or happiness. Regarding suicide, the state possesses a strong interest in its prevention, despite not criminalizing the act. The state's justification for its legislation has focused on suicide prevention, citing statistics about varying suicide rates among age groups, particularly among the youth. In 1991, suicide was the second leading cause of death for individuals aged 15-34 and among the top five causes for those aged 35-54. This highlights the state's vested interest in preventing suicides, especially among those facing mental health issues, as many suicides involve individuals with treatable conditions. Most states allow for involuntary commitment of individuals at risk of self-harm and permit the use of nondeadly force to prevent suicide attempts. However, the state's interest in preventing suicides is notably reduced concerning terminally ill, competent adults who choose to end their lives to alleviate unbearable suffering from incurable diseases. Unlike other individuals whose suicides may be preventable, terminally ill patients cannot be cured, and their desire to die is seen as a rational response to their condition, not a senseless act. The state has recognized that its interests often do not outweigh the wishes of these patients, gradually allowing them to hasten their deaths with physician assistance in various contexts. Over time, societal and medical perspectives have shifted toward a more compassionate and understanding approach to the rights of terminally ill patients, culminating in significant legal and ethical discussions on the matter. The first major concession was allowing terminally ill individuals to refuse medical treatment. The initial legal distinction between extraordinary and ordinary medical treatment aimed to provide a standard for patients to refuse treatment while avoiding the recognition of a right to suicide or euthanasia. However, this distinction became unworkable, leading to terminally ill patients being allowed to refuse both types of treatment. Practices such as "do not resuscitate" orders were initially accepted, but outright termination of treatment became permissible as well. Currently, many states permit terminally ill patients to request the cessation of life-sustaining food and water, allowing for death by self-starvation. Physicians can also administer pain-relieving medication that may hasten death, blurring the lines of acceptable medical practice. Opponents of physician-assisted suicide must clarify how it differs from these accepted practices. The state argues that physician-assisted suicide is fundamentally different because it involves an active role by the physician, results in deaths not caused by the patient's illness, and requires the doctor to provide the means of death. However, these distinctions fail to hold up against current medical ethics and practices. The distinction between commission and omission is meaningless, as both involve active participation from doctors in patient deaths. The argument regarding underlying disease lacks legitimacy since patients can die due to artificially induced starvation, as exemplified by Nancy Cruzan's case. Furthermore, the provision of medication to facilitate a patient’s self-starvation similarly does not stem from an underlying ailment but rather from active medical assistance. Ultimately, the state's distinctions do not effectively differentiate between permissible and prohibited medical conduct within the context of contemporary practices. Doctors have long provided medications to terminally ill patients with the dual purpose of alleviating pain and hastening death, a practice accepted within medical ethics. This often involves administering treatments like intravenous morphine, fully aware that such actions can accelerate the patient's demise. The argument regarding causation in these cases is seen as a minor hurdle in advocating for the rights of terminally ill patients, as the actual cause of death is the medication administered. While recognizing that acknowledging physician-assisted suicide may represent a departure from past judicial decisions and may distress individuals with strong moral or religious beliefs, the document argues that the state's interest in preventing this practice is not significantly greater than its interest in other life-ending medical interventions currently accepted. There is no meaningful ethical or constitutional distinction between providing medication that hastens death and withdrawing life support, as both result in the intended outcome of the patient's death. Furthermore, the classification of deaths from prescribed medication as "suicide" is questioned, especially when similar deaths from the refusal of life support are not labeled as such. The argument posits that a terminally ill patient's decision to hasten their death through medical means should not be equated with suicide, suggesting that the state’s interest in preventing suicide does not apply in these circumstances. The state has a dual interest in preventing both suicides and deaths resulting from medical or legal errors, acknowledging the challenges in predicting the duration of terminal illness and assessing mental competence. Despite these uncertainties, it is believed that effective safeguards can be established to minimize errors. The document emphasizes that while life-and-death decisions are critical, an error could potentially allow individuals suffering from severe pain to end their lives peacefully and with dignity. Concerns about third-party involvement in assisting suicide are noted, particularly the argument that such assistance may increase suicide rates and undermine the sanctity of life. These concerns are deemed less significant when assistance is provided under medical supervision, especially for terminally ill patients. The majority opinion upholding Washington’s statute emphasizes the need to prevent undue influence over individuals’ decisions regarding their end-of-life choices. Criticism is directed at the rationale that the statute protects poor and minority individuals from exploitation, likening it to discredited arguments against abortion. The text argues that the real concern is that disadvantaged individuals may not receive equitable access to medical assistance for a dignified death. The notion that these groups would disproportionately seek assisted suicide due to inadequate healthcare is dismissed as absurd. Additionally, similar arguments regarding the disabled are countered, asserting that there is no evidence of pressure to seek assisted suicide, and that advocacy groups would act to protect their interests against any potential misuse of the practice. Concerns persist, however, that disabilities might be wrongly interpreted as rendering life “valueless.” Seriously impaired individuals, alongside non-impaired individuals, share the liberty interest in controlling their own fate. Denying them this option risks forcing them to endure prolonged suffering. The ideal resolution involves ensuring that assisted suicide is fairly practiced with adequate safeguards to prevent abuses. A significant concern arises regarding the potential for undue pressure on infirm or elderly individuals from self-interested relatives or others, which could lead them to end their lives against their own wishes. This risk is already present, as terminally ill individuals may face pressure to decline life-saving treatment. However, the imminent nature of their death can reduce the likelihood of this undue influence. The introduction of physician-assisted suicide could actually provide a safeguard against such abuses through the involvement of impartial third parties. Additionally, terminally ill patients might feel compelled to hasten their deaths out of concern for their families’ financial well-being due to escalating medical costs. While regulations can help prevent hasty decisions, it is not inherently wrong for terminally ill adults to consider their families' economic welfare in their decision-making. The dissenting opinion heavily references Professor Kamisar, criticizing the focus on assisted suicide rather than addressing the lack of universal healthcare, which reflects deeper flaws in national values. Concerns regarding inadequate medical coverage should be directed to Congress, which must enact necessary health care legislation. As the judiciary, the role is to refrain from exacerbating the suffering of citizens due to Congressional inaction or moral beliefs of others. There is recognition of the risk that doctors may become desensitized to terminal illness, potentially treating requests for assistance in dying in a routine manner rather than with the necessary individualized care. While some physicians may lack the personal touch due to societal pressures, many remain compassionate, especially in geriatric care. Most doctors are expected not to assist in hastening death unless there is no reasonable chance to alleviate suffering or if there is clarity regarding the patient’s wishes. The medical profession's ethical standards and training discourage such actions, and regulatory frameworks can mitigate risks of negligent recommendations by physicians. Concerns about undue influence in end-of-life decisions are acknowledged as significant, warranting serious consideration despite efforts to minimize them. The state has a legitimate interest in protecting dependent family members, but this interest is diminished when dealing with terminally ill patients facing inevitable death. Compelling such patients to endure prolonged suffering does not serve the interests of innocent parties and may instead cause them greater harm. The state seeks to uphold the integrity of the medical profession by prohibiting conduct inconsistent with a physician's role as a healer. However, criminalizing medical assistance for patients in need is argued to pose a greater threat to this integrity by potentially forcing compassionate doctors into unlawful behaviors. The belief that legalizing physician-assisted suicide would undermine doctors' commitment to patient care is challenged by evidence of longstanding practices where physicians have discreetly aided terminally ill patients in hastening death, often with public and professional tacit approval. The document highlights that current medical practices, such as withdrawing life support or administering lethal doses with a "double effect," are similar to the proposed physician-assisted suicide, suggesting no inherent risk to the profession's integrity. Growing support for physician-assisted suicide among doctors is noted, with a study indicating that 60% of Oregon physicians favor legalization, while a Michigan study shows over 70% of responding doctors believe professional ethics do not prohibit assisted suicide. Opposition to the practice among some physicians is primarily linked to strong religious beliefs rather than ethical concerns. Ultimately, the document asserts that a physician's duty is to alleviate suffering, focusing on comfort when curing is not possible. The doctor fulfills a legitimate medical role even when aware that his actions will result in the patient’s death. The American Medical Association (AMA) supports the dual effect of administering medicine but opposes the legalization of physician-assisted suicide at this time. Historically, the AMA has shifted its stance on the Hippocratic Oath; it previously argued that performing abortions violated the Oath but now claims that assisting terminally ill patients in hastening their death does as well. The Hippocratic Oath's rigid interpretation is not a definitive guide for contemporary medical or legal issues, as evidenced by the Supreme Court's decisions in cases like Roe v. Wade, which highlighted the Oath’s limited acceptance and rigidity. If strictly interpreted, the Oath would prohibit various medical practices, including surgeries, which is now seen as unreasonable. Most physicians adapt to evolving legal contexts, as shown by the routine performance of abortions following the recognition of the constitutional right to do so. Similarly, recognizing a constitutional right to assisted suicide would not compromise the ethical integrity of the medical profession. Physicians would not be mandated to act against their personal beliefs; those opposed to assisting in hastening death could opt out, while others could provide support to terminally ill patients seeking to control their end-of-life decisions. Finally, concerns about the potential adverse consequences of permitting physician-assisted suicide, often framed as fear of a "slippery slope," suggest that recognizing this right could lead to the erosion of life-preserving restrictions. The text argues against the slippery slope argument raised by opponents of assisted suicide, which posits that legalizing assisted death will lead to the state sanctioning death for those deemed burdensome to society, rather than for those who are terminally ill and wish to die. This argument has been likened to fears surrounding the legalization of abortion, where critics claimed it would lead to widespread misuse, yet these fears did not materialize. The Supreme Court has consistently recognized substantive due process rights despite concerns about potential abuses. The text also addresses a second form of the slippery slope argument, which suggests that defining "terminally ill" will become increasingly difficult, ultimately expanding the criteria for assisted death beyond reasonable limits. It counters this by asserting that the terms "terminal illness" and "terminal condition" have been effectively defined in various statutes, including the Uniform Rights of the Terminally Ill Act and numerous state laws. While acknowledging some definitional challenges, it concludes that these do not justify denying a liberty interest in hastening one’s death, as the category of the terminally ill can be adequately defined. The dissent acknowledges that the prescription of lethal medication by physicians for terminally ill patients seeking to end their lives does not create a clear distinction between acceptable and unacceptable medical practices. It is recognized that differentiating physician-assisted suicide from other forms of medical assistance in dying can be complex, especially when patients are unable to self-administer the drugs. The excerpt emphasizes that the pivotal issue in right-to-die cases is whether the death is voluntary, where a patient chooses to end their life, or involuntary, where someone else decides on their behalf. The ruling specifically addresses the constitutionality of prohibiting doctors from prescribing medication to terminally ill patients wishing to hasten their death. The Washington statute banning assisted suicide significantly impacts terminally ill individuals, as it effectively prevents them from accessing what may be their only viable option for a dignified death. Many patients, due to their physical conditions, lack the ability to end their lives independently and often depend on physician assistance, whether explicitly or implicitly. While some may attempt to stockpile medications, they typically lack the knowledge and resources to do so safely, risking a painful or prolonged death due to potential miscalculations in drug dosages. Thus, the statute functions as a prohibition rather than a safeguard for terminally ill patients. The excerpt emphasizes that while a prohibition on physician-assisted suicide limits the exercise of a liberty interest, it effectively restricts this interest similarly to past abortion prohibitions. State laws and regulations are deemed necessary to prevent errors and abuse while protecting legitimate state interests. Model statutes could be implemented to ensure safeguards for patients seeking lethal medication, such as requiring witnesses for voluntariness, short waiting periods, second medical opinions, psychological assessments, and reporting procedures to prevent abuse. These safeguards could also be developed by medical associations, provided they address state concerns. The text highlights that error is an inherent risk in any human process, but sufficient protections can be established through collaboration among states, the medical profession, and the healthcare industry. It references the Supreme Court's decision in Cruzan, which acknowledged the states' legitimate role in regulating the refusal of life-sustaining treatment without prohibiting the exercise of such decisions. The Court upheld Missouri's requirement for clear evidence of a patient's wishes as a valid regulation with less impact on due process compared to outright prohibitions. In conclusion, the excerpt argues against total prohibitions on essential liberty interests like physician-assisted suicide, advocating for regulatory frameworks that provide necessary safeguards instead. It draws parallels with abortion rights and the withdrawal of life-sustaining treatment, suggesting that states should enact regulations that balance their legitimate interests with the protection of individual rights. Liberty interests regarding the right to hasten death are primarily the responsibility of individual states. The strength of this liberty interest varies based on factors like the individual's physical condition. For young and healthy individuals, the interest is minimal, as compelling them to live does not typically lead to significant suffering. In contrast, for mentally competent adults who are terminally ill and wish to end their lives without coercion, the liberty interest is significantly heightened due to the unbearable pain and suffering they face. The Washington statute imposes considerable burdens on this liberty interest. Plaintiffs presented compelling evidence that the statute creates formidable obstacles for terminally ill patients seeking to die with dignity. Testimonies revealed instances where patients were forced into gruesome actions due to the lack of physician assistance, driven by fears of legal repercussions. One case involved a 34-year-old man suffering from AIDS and lymphoma, who, after enduring severe pain, sought medical help to hasten his death but was denied due to the statute. He ultimately chose to end his life by jumping off a bridge. Another patient resorted to withholding insulin, leading to a painful death, while an elderly man took his life in isolation to avoid burdening his family with potential criminal charges. Testimony presented by the plaintiffs indicates that many terminally ill patients attempting suicide often fail, resulting in severe injury or prolonged suffering. A notable case involved an 80-year-old woman with metastatic breast cancer who sought assistance from her doctor, Dr. Abigail Halperin, to end her life. Although Dr. Halperin believed in fulfilling her patient’s wishes, she refrained due to fear of legal repercussions under Washington statute RCW 9A.36.060. Consequently, the patient resorted to a painful method of suffocation instead of receiving the requested prescriptions. Further testimony revealed that numerous terminally ill patients lack the physical or psychological ability to utilize violent methods of suicide, their only options without medical assistance. One witness described how his terminally ill wife desired to die but was uncertain how to do so, fearing the outcomes of various methods. Another recounted the anguish of watching a loved one suffer and plead for death. The plaintiffs argue that the prohibition on physician-assisted suicide imposes significant burdens on competent, terminally ill adults wishing to hasten their deaths. This argument is supported by a substantial body of legal, medical, and sociological literature, as well as anecdotal evidence from media sources. Although the statute does not entirely negate the liberty interest in dying, it severely restricts its exercise for most terminally ill individuals, often forcing them to seek illicit help. Additionally, the emotional toll on family members who assist or refuse to assist terminally ill loved ones is highlighted, as they endure guilt and pain over these decisions. The plaintiffs contend that authorizing physician assistance could alleviate these burdens. The document concludes by indicating that regardless of the decision made regarding the statute, complex issues surrounding the right to die will persist, affecting an increasing number of elderly Americans and their families, thus warranting careful societal consideration. The excerpt delineates the judicial application of a balancing test, weighing the constitutionally-protected liberty interest of individuals against the state's competing interests. It emphasizes that this balancing is inherently a matter of judicial judgment rather than a mechanical process. The liberty interest concerning the timing and manner of death is particularly strong for terminally ill patients, especially when the state's interest in protecting life and preventing suicide is comparatively weak. While the state has legitimate concerns about undue influence and abuse in life-and-death decisions, these concerns are mitigated by the mandatory involvement of physicians, who are generally inclined to preserve life, and through the implementation of regulatory safeguards. The excerpt argues that the state's total prohibition on assisted suicide for terminally ill patients is excessively burdensome, as the state's interests could be sufficiently protected through less restrictive measures. The potential adverse consequences for terminally ill patients from rejecting an as-applied challenge are significant, whereas the state's adverse consequences would be minimal. The text posits that the state's interests in preventing assisted suicide do not differ fundamentally from its interests in other medical practices that may lead to a patient's death. Ultimately, even if the state's interest were to be deemed significantly greater, it would still not outweigh the individual's compelling interest in making decisions regarding the end of their life, a decision that is profoundly personal and significant. Broad state policies that undermine the rights of terminally ill individuals to make personal choices raise concerns about state overreach. The legal examination concludes that the "or aids" provision of Washington statute RCW 9A.36.06 is unconstitutional as it restricts competent terminally ill adults from using prescribed medication to hasten their deaths. This ruling contrasts with the Oregon District Court's decision in Lee v. State of Oregon, where a similar statute was deemed to violate the Equal Protection Clause for denying terminally ill patients benefits available to non-terminally ill individuals. The current ruling asserts that prohibiting physicians from assisting terminally ill patients in ending their lives violates their liberty interests, directly contradicting the conclusions in Lee. Chief Judge Rothstein's decision to invalidate the "or aids" provision is primarily based on due process grounds, eliminating the need to address potential Equal Protection issues. The ruling affirms the existence of a liberty interest in choosing the manner and timing of one's death and recognizes the complexity and controversy surrounding such decisions. The judiciary is encouraged to approach future discussions on these topics with objectivity and respect for the Constitution, acknowledging that some may believe that life-and-death decisions should not be judicially determined. Permitting individuals to exercise their right to choose aligns with the constitutional directive to limit government intervention in personal decisions, thereby empowering people to make choices that significantly impact their lives. The Constitution and judicial system protect individual freedoms against governmental overreach, ensuring that neither the state nor the majority can impose their will on individuals in matters of personal dignity and autonomy. Individuals opposed to physician-assisted death are free to adhere to their beliefs but cannot impose these views on others, especially in ways that would compel suffering. The Second Circuit is reviewing a related case, Quill v. Vacco, which addresses whether terminally ill, competent adults possess a fundamental right to physician-assisted suicide and the implications of New York's statutes in relation to the Equal Protection Clause. The organization Compassion In Dying supports terminally ill patients considering hastened death and their families. The doctors involved in the case have the standing to sue both on their own behalf and on behalf of patients, raising the issue of patients' liberty interests. The central constitutional query relates to whether state law can prohibit medical assistance for competent, terminally ill patients wishing to die. The text also discusses the capable-of-repetition-yet-evading-review doctrine, noting a distinction for terminally ill individuals, who are expected to die before litigation concludes, suggesting that their cases remain relevant despite potential mootness. The doctors maintain standing to challenge the Washington statute in both capacities. In *City of Los Angeles v. Lyons*, the Supreme Court reversed an injunction that prevented LAPD from using chokeholds, determining that the plaintiff, Lyons, had not demonstrated a real and immediate threat of being subjected to a chokehold again, as any future danger was deemed speculative. This case contrasts with the situation involving terminally ill patients, who face an undeniable threat to their rights and well-being. The plaintiffs assert that the Fourteenth Amendment protects terminally ill adults' rights to make end-of-life decisions, including using physician-prescribed drugs to hasten death and alleviate suffering. The District Court's ruling on the Washington statute's constitutionality is ambiguous, as it is unclear whether the judge intended to invalidate the entire statute or merely the "or aids" provision, which is severable under state law. The plaintiffs only challenged the "or aids" provision in relation to terminally ill adults, providing evidence specifically for that group without addressing broader implications. The District Court did not resolve the claims raised by *Compassion In Dying* and indicated that further proceedings might be necessary, suggesting that the ruling did not aim to strike down the provision on its face. Declaring a statute unconstitutional as applied to specific groups is not uncommon, as illustrated in cases like Tennessee v. Garner, where the Supreme Court found a state law allowing deadly force against felony suspects unconstitutional for those not posing an immediate threat, and Wisconsin v. Yoder, which ruled the mandatory attendance law unconstitutional only for Amish children who graduated eighth grade. The document emphasizes that the facial validity of RCW 9A.36.060 is not being decided, thus making the rigorous Salerno test for facial challenges inapplicable. A facial challenge is notably difficult, requiring proof that no circumstances exist under which the statute could be valid. The text argues against using the Salerno test for the plaintiffs' constitutional challenge and references differing standards applied in abortion rights cases, particularly in Planned Parenthood of Southeastern Pennsylvania v. Casey, where liberty interests are dynamically analyzed compared to the relatively static nature of other rights. The Washington Natural Death Act affirms the fundamental right of adults to make healthcare decisions, including end-of-life choices. The summary also notes the dissenting opinion in Plessy v. Ferguson, which challenges the balancing test approach to rights analysis. The dynamic analysis required in abortion cases is highlighted, indicating that the state's interests and a woman's liberty interest evolve throughout pregnancy. State action regarding physician-assisted death is significantly influenced by judicial precedents, notably Planned Parenthood v. Casey, which has implications for how courts assess the constitutionality of such actions. The term "physician-assisted death" refers to both the prescribing and administration of lethal medication to patients, with distinctions made among the terms "assisted suicide," "physician-assisted suicide," and "physician aid-in-dying." The case in question does not address the constitutionality of prohibiting physicians from administering life-ending drugs. Justice Powell, who voted in favor of the decision, later expressed regret over his vote, indicating a reconsideration of the arguments against the ruling. The Bowers v. Hardwick decision has faced significant criticism, with commentators likening its implications to segregationist ideologies and calling it a reflection of homophobic attitudes. However, a passage from the joint opinion in Casey, which garnered support from five justices, is deemed uncontroversial. The Court's approach to assessing liberty interests has evolved, with minimal interests subjected to rational basis review, as seen in Kelley v. Johnson, while more significant interests are evaluated under strict scrutiny or a balancing test. The district judge's ruling on a constitutional challenge to a New York statute limiting physician assistance in hastening death was criticized for incorrectly requiring historical evidence from plaintiffs to substantiate their claim. Plaintiffs in Quill v. Koppell failed to establish that physician-assisted suicide has historical legal recognition, even for terminally ill patients. The document compares this issue to the historical context of anti-miscegenation laws, highlighting that an originalist interpretation of the Constitution would have perpetuated racial discrimination, as seen in Virginia's past prohibitions against interracial marriage. Such laws date back to colonial times, with Maryland's 1661 statute marking the beginning of anti-miscegenation legislation. Throughout the 19th century, forty-one states enacted such laws, and during the debates over the Fourteenth Amendment, most slave and non-slave states maintained these statutes. The judiciary upheld these laws until the Supreme Court's landmark decision in Loving v. Virginia, which declared anti-miscegenation statutes unconstitutional based on violations of the Equal Protection and Due Process Clauses, thus overturning centuries of legal precedent. The Court's historical inquiry extended beyond the founding era, referencing British common law and earlier practices, as exemplified in Roe v. Wade, which traced abortion's legal history back to ancient times. Historical perspectives on suicide reveal varying cultural attitudes. Ancient societies, including the Jews at Masada, the Sythians, and Vikings, often viewed suicide with acceptance or honor. Biblical accounts of suicides, such as those of Samson and Judas Iscariot, lack condemnation, suggesting a nuanced view of the act. Legal approaches to suicide have evolved, with historical punishments for the act reflected in 17th-century Virginia laws. By 1986, no state explicitly prohibited suicide or attempted suicide, although assisting suicide faced legal restrictions in many states. Public opinion on euthanasia and physician-assisted suicide has shifted, with significant support, as evidenced by a 1995 California poll indicating that 70% favored terminally ill patients having access to lethal medication. Legal challenges, such as the injunction against the Oregon statute, highlight ongoing debates surrounding this issue. Proposals for legalizing physician-assisted suicide have emerged in several states, including Iowa, Maine, Michigan, and New Hampshire. Surveys indicate increasing public support for allowing doctors to end the suffering of terminally ill patients, with affirmative responses rising from 37% in 1947 to 63% by 1983. Notable cases include Dr. Jack Kevorkian, facing criminal charges for assisting patients in death, and Dr. Timothy Quill, who was not indicted after admitting to prescribing lethal medication for a terminally ill patient. Historical precedents include acquittals of physicians in 1973 and 1950 for similar actions. Despite criminal sanctions, estimates suggest that physicians may facilitate the deaths of approximately 6,000 terminally ill patients daily, often through pain relief methods that hasten death. Surveys reveal that a significant number of doctors, including 10% in one poll, have admitted to assisting in patient deaths, with higher rates reported among specialists, particularly those treating AIDS patients in the San Francisco Bay Area. Timothy E. Quill's work highlights the shift in how Americans experience death, noting that advancements in medicine have led to a predominance of deaths from chronic illnesses, with over 87% of deaths in 1978 attributed to such conditions. The trend has moved away from home deaths, with only 37% occurring at home in 1939, compared to 80-85% in institutions today. Among those dying in institutions, about 70% do so after decisions to withdraw or withhold medical treatment. The excerpt also references a notable case involving President Francois Mitterrand of France, who chose to hasten his death by stopping medication, a decision viewed as courageous and dignified. Furthermore, the text discusses the implications of the Due Process Clause of the Fourteenth Amendment and its parallel in the Fifth Amendment, highlighting the complexity of defining fundamental rights, as illustrated by historical references to liberty interests in cases like Palko v. Connecticut. The dissent’s argument regarding the sacrifice of liberty or justice is critiqued for its impracticality in application. The excerpt addresses the relationship between liberty, justice, and the right to refuse life-sustaining treatment, contrasting it with the precedent set in Bowers v. Hardwick. It emphasizes that the ruling in Bowers, which denied a constitutional right for homosexuals to engage in sodomy, does not dictate the outcome regarding the liberty interest in dying with dignity. The excerpt highlights that the Court, in Cruzan v. Director, Missouri Department of Health, acknowledged a constitutionally protected right for a competent individual to refuse life-sustaining hydration and nutrition, framing it as a matter of liberty interest. The ruling affirmed that states cannot prohibit the exercise of this right, although it allowed for the requirement of clear and convincing evidence of a patient’s wishes. Justice Scalia’s concurring opinion is noted, which seemingly disputes the existence of a liberty interest in rejecting forced nourishment, equating it to suicide. The excerpt counters this interpretation, asserting that Scalia's views do not undermine the majority opinion. Furthermore, dissenting opinions from Justices Brennan and Stevens affirm the existence of a fundamental right to refuse unwanted artificial nutrition and hydration, reinforcing the notion that the right to die with dignity is constitutionally protected. At least eight justices acknowledged a strong due process liberty interest in rejecting unwanted medical treatment, including the artificial provision of food and water. Even if the majority opinion did not explicitly encompass this rejection, five justices (including Justice O’Connor and four dissenters) clearly supported the liberty interest in refusing artificial sustenance. The Supreme Court has previously recognized that concurring and dissenting opinions can form a controlling majority on a particular issue when they do not conflict with the majority's holding, which is applicable here. The proposition recognized in Cruzan is broadly applicable and not limited to the terminally ill. Nancy Cruzan herself was not terminally ill, with medical experts indicating she could live for another thirty years, thus the ruling could not be confined to terminal cases. Prior to Cruzan, over 15 states prohibited advance directives for terminating artificial nutrition and hydration, but this number decreased significantly afterward, suggesting that such prohibitions are likely unconstitutional under Cruzan. The majority of a three-judge panel identified five state interests: (1) preventing physicians from acting as killers, (2) protecting vulnerable individuals from psychological pressure to end their lives, (3) safeguarding the poor and minorities from exploitation, (4) ensuring care for the handicapped, and (5) preventing abuse similar to that seen in the Netherlands regarding euthanasia. In contrast, the district court identified two broader state interests: preventing suicide and avoiding undue influence and abuse. Additionally, in two cases involving the cessation of life-sustaining treatment for patients in vegetative states, the Washington Supreme Court noted four countervailing state interests: (1) preservation of life, (2) protection of innocent third-party interests, (3) prevention of suicide, and (4) maintaining the integrity of the medical profession. Similar interests were identified in a Massachusetts case discussed in Cruzan, reaffirming the preservation of life and integrity within the medical profession as key state interests. Capital punishment and military drafts could be deemed unconstitutional if states could not uphold certain legal standards. Washington's statute from 1979 defines a "terminal condition" as an irreversible and incurable state due to injury, disease, or illness, which will lead to death within a reasonable timeframe, where life-sustaining treatment only extends the dying process. Other states, such as Alabama and Alaska, recognize similar fundamental rights for individuals to control their medical decisions, particularly when it comes to unnecessary prolongation of life, which is seen as causing undue suffering. Legal provisions like living wills and durable powers of attorney allow competent adults to dictate their medical treatment preferences in advance. In cases where individuals lack such legal instruments, some states authorize courts to appoint guardians for medical decisions. The Washington Supreme Court has noted that the state's interest in preserving life diminishes significantly when treatment only prolongs the dying process for individuals with incurable conditions. The excerpt references numerous state statutes affirming these rights and principles. A prognosis of a life expectancy of six months or less, whether or not life-sustaining treatment is provided, is sufficient for a diagnosis of a 'terminal condition' without needing a specific life expectancy determination. Various state statutes outline this definition, including provisions for patients in a persistent vegetative state or irreversible coma. Many states now classify terminal conditions to encompass permanent unconsciousness. Some statutes define a "qualified patient" as someone who is in a terminal condition or a persistent vegetative state. For instance, Hawaii's law redefines "qualified patient" by focusing on the inability to communicate medical treatment decisions. Other states have separate definitions for persistent vegetative state or permanent unconsciousness, solidifying the legal framework surrounding end-of-life decisions. Definitions of "persistently unconscious" and "permanent unconscious condition" are provided by various state statutes, including Oklahoma, Pennsylvania, South Carolina, Utah, Virginia, Washington, Wisconsin, and Wyoming. The Federal Patient Self-Determination Act mandates that healthcare providers inform adult patients about state laws on advance directives and document any such directives, applicable to those receiving Medicare or Medicaid. An analysis of the state's interest in preserving life is included, referencing data from Washington State's Department of Health. The text discusses differing viewpoints on legalizing physician-assisted suicide, highlighting recommendations from the New York State Task Force and the Michigan Commission. The district court argued that the state's interest in preventing suicide does not extend to terminally ill, competent adults who choose to end their suffering, asserting that preventing suicide in such cases merely prolongs suffering, which the state should not aim to do. The excerpt also notes literary references and legal precedents relevant to the discussion of assisted suicide. Withholding and withdrawing treatment raises significant ethical and legal questions, as illustrated in the cases of In Re Conroy and Cruzan v. Harmon. The New Jersey Supreme Court noted that prohibiting the discontinuation of treatment could lead to hasty decisions regarding a patient's care. The Missouri Supreme Court emphasized that the case of Nancy Cruzan is not about allowing a patient to die but rather about the medical profession facilitating her death through starvation and dehydration after she had been maintained on artificial feeding for nearly eight years. Following a U.S. Supreme Court remand, a Missouri court concluded that Cruzan had previously expressed a desire not to be kept alive artificially and subsequently ordered the cessation of artificial feeding, leading to her death twelve days later. This case illustrates that her death resulted from the deliberate removal of sustenance, not from her prior accident. Additionally, the American Medical Association's Council on Ethical and Judicial Affairs recognizes that administering pain relief that may shorten life can be appropriate medical treatment, provided that a competent patient makes this decision. Respect for patient autonomy is crucial in determining the acceptability of such treatment decisions. The concept of "double effect," derived from Roman Catholic moral theology, posits that it can be morally acceptable to cause harm in the pursuit of a greater good. In the context of palliative care, the American Medical Association (AMA) has stated that while the primary intention is to alleviate pain and suffering, the treatment may unintentionally hasten a patient's death. Increasing medication doses, especially opioids like morphine, can lead to respiratory depression and death, which, while foreseeable, is considered ethically justifiable when the intent is relief from suffering. However, the AMA's framing of potential outcomes as merely "possible" can obscure the reality of medical practices and their legal implications. The act of administering such medication is deemed acceptable not because the consequences are misunderstood but because it aligns with medical and ethical standards, despite the resulting death being both expected and intended in some instances. There is evidence suggesting that prohibitive laws against assisted suicide may inadvertently increase the rate of suicides among terminally ill patients. Judge Richard Posner argues that allowing physician-assisted suicide for those with severe physical incapacities could reduce overall suicide rates by providing individuals with the assurance of control over their death, thereby alleviating immediate suicidal impulses. This perspective is illustrated by the case of physicist Percy Bridgman, who, at the end of his cancer battle, chose to end his life due to societal pressures and lack of options, highlighting the complexities surrounding end-of-life choices and the disparities faced by marginalized groups in accessing reproductive rights and healthcare. 42 U.S.C. § 300a-6 prohibits the use of Title X grants in programs that perform abortions or offer abortion counseling. In *Planned Parenthood Affiliates of Cal. v. Swoap*, the California Court of Appeal ruled that a state budget act section restricting family planning funds for abortion-related services violated the state constitution. Compassion In Dying requires terminally ill patients to obtain approval from family or close relationships before assistance is offered. Although the merits of this protocol are not evaluated, implementing a similar state requirement raises constitutional concerns. Private organizations may set higher standards than those the state can impose. The American Medical Association (AMA) argues that doctors administering medication with a dual effect, including hastening death, should not be penalized under Washington's assisted suicide law, but struggles to legally differentiate between dual and single effect medication. The AMA’s stance is criticized for inconsistency, particularly regarding the legality of prescribing life-ending medication at a patient's request. The central issue is the terminally ill patient's voluntary and informed wish for assistance in dying. The AMA's dual effect practices may be seen as euthanasia, raising further inconsistencies. The Oregon AMA did not take a stance on a ballot initiative to legalize physician-assisted suicide due to divided member opinions. Susan W. Tolle's article discusses the implications of Oregon's assisted suicide vote, referencing various studies and perspectives on physician-assisted suicide (PAS) and voluntary euthanasia. The state is noted to have an interest in advancing medical science, and the argument that allowing PAS might deter research for terminally ill patients is dismissed. Evidence from patients with cancer and AIDS suggests a strong desire for hope and exploration of treatment options, indicating that the potential for research participation remains robust. The American Medical Association (AMA) expresses concerns regarding the societal risks of involving physicians in ending patients' lives, citing ethical considerations. The Hippocratic Oath's prohibition against providing lethal drugs is mentioned, with historical context indicating that some ancient physicians did not strictly adhere to this principle. Patients fearing painful deaths would have the option to choose physicians aligned with their views on assisted dying, aided by proposed mechanisms for patient transfer if a physician refuses to assist. The dissenting opinion references the Netherlands' experience with physician-assisted dying to argue against the regulation of PAS and to highlight risks of non-consensual euthanasia. However, the text acknowledges that reports from the Netherlands present conflicting evaluations, complicating conclusions about the effectiveness and morality of such practices. The Dutch experience regarding physician-assisted suicide and euthanasia presents challenges for application in the United States due to cultural, legal, and psychological differences. Commentators caution against generalizing from the Netherlands, highlighting that even within that country, interpretations can vary. A model act defines a terminal condition as one that is incurable and irreversible, leading to death without life-sustaining treatment. The text distinguishes between physician aid-in-dying and euthanasia, with euthanasia defined as the act of painlessly ending the life of a person suffering from an incurable disease, performed without the person's request. While euthanasia is placed outside the constitutional framework for this case, its legal implications are not addressed. Additionally, decisions made by surrogate decision-makers are legally equivalent to the patient’s own decisions. The document references the Supreme Court cases Carey v. Population Services International and Griswold, which emphasize individual rights in accessing medical assistance. It notes various procedural safeguards in state laws, such as Oregon's Death With Dignity Act, while leaving the determination of necessary safeguards to state legislatures. Posner’s opposing view suggests that laws against assisted suicide for the terminally ill should be reconsidered at the state level based on Millsian principles. The reasoning for leaving certain legal questions, particularly regarding moral values and liberty interests, to individual states is based on the belief that state boundaries often reflect differing moral perspectives, making a national rule on such matters premature. The case of abortion is cited, arguing that Roe v. Wade improperly restricted states' authority to address the issue. A major concern with state-by-state decision-making is the potential for human suffering caused by inconsistent laws, exemplified by situations like assisted suicide, where legal approval may vary across state lines. This inconsistency can lead to legal complications as families attempt to navigate the process of transferring patients to states with more permissive laws, often resulting in distressing delays that undermine the intended relief. The excerpt references various cases and scholarly works to illustrate the complexities and human impact of these legal issues, including specific instances of assisted suicide and the legal ramifications faced by individuals involved. Several incidents highlight the ongoing debate surrounding assisted suicide, particularly in the context of terminal illness. For instance, a California man suffering from leukemia and diabetes committed suicide with a shotgun after a ballot initiative to legalize assisted suicide failed, illustrating the profound impact of legislative outcomes on individual choices regarding death. The legal analysis references the Supreme Court case Cruzan, noting that even if the "undue burden" test were applied, Washington's ban on assisted suicide would still pose a significant obstacle for terminally ill, competent adults seeking to control the timing and manner of their deaths. The excerpt critiques the equal protection analysis from a previous case (Lee), arguing against the notion that a rational basis exists for treating terminally ill patients differently based on their means of dying. It highlights Judge Rothstein's view that it is unconstitutional to allow one group of terminally ill individuals to hasten their deaths through medical treatment while denying the same options to another group without such means. The ruling extends to include those who assist in the process, such as pharmacists and healthcare workers, affirming that their involvement in facilitating a patient's access to necessary medication is covered under the legal determination.