US Supreme Court Decision 1997
AMICI CURIAE BRIEF (Request sent to the Court against Euthanasia)
Decision Brief of the U.S. Supreme Court: Syllabus: VACCO, ATTORNEY GENERAL OF NEW YORK, et al. v. QUILL et al. (970626)
Opinion of the Supreme Court Of The United States: No. 95-1858 (970626)
Decision Brief of the U.S. Supreme Court: Syllabus: WASHINGTON et al. v. GLUCKSBERG et al. (970626)
Opinion of the Supreme Court Of The United States No. 96-110 (970626)
OF NOT DEAD YET AND
AMERICAN DISABLED FOR ATTENDANT PROGRAMS TODAY
SUPREME COURT OF THE UNITED STATES
October Term, 1995
DENNIS C. VACCO, et al.,
TIMOTHY E. QUILL, et al.,
ON WRIT OF CERTIORARI TO THE UNITED
STATES COURT OF APPEALS FOR THE
AMICI CURIAE BRIEF OF
NOT DEAD YET and AMERICAN DISABLED FOR
ATTENDANT PROGRAMS TODAY IN SUPPORT OF
INTERESTS OF AMICI CURIAE
Amici are two national organizations composed primarily of persons with disabilities, including persons with spina bifida, cerebral palsy, muscular dystrophy, spinal cord injuries, multiple sclerosis, quadriplegia, paraplegia, head and brain injuries, polio, amyotrophic lateral sclerosis, as well as many other disabilities. Most of these persons use assistive devices, including motorized and manual wheelchairs, ventilators, and personal assistance services for meeting their personal hygiene needs, transferring from bed to wheelchair and preparing food.
NOT DEAD YET is a national organization of people with severe disabilities who oppose the legalization of assisted suicide because it singles out people with significant health impairments for assistance to die, denying them the equal protection of laws and medical practice standards automatically applied to healthy individuals who are suicidal. Since 1985, individuals who are now Not Dead Yet members have participated actively in numerous states in the formulation of public policy concerning the so-called “right to die,” have written numerous published articles on the issue, and were invited and testified recently before the Constitution Subcommittee of the Judiciary Committee of the U.S. House of Representatives on assisted suicide.
AMERICAN DISABLED FOR ATTENDANT PROGRAMS TODAY (ADAPT) is a national organization, most of whose members have severe disabilities and have been institutionalized in nursing facilities and other public institutions solely because they have disabilities. ADAPT has a long history and record of enforcing the civil rights of people with disabilities and was one of the key organizations that participated in the political and legislative process that resulted in the passage in 1990 of the Americans With Disabilities Act, 42 U.S.C. section 12101 et seq., (“ADA”) . It was the plaintiff in the case ADAPT v. Skinner, U.S. Department of Transportation, 867 F.2d 1471, 881 F.2d 1184 (3d Cir. 1989). (1)
SUMMARY OF ARGUMENT
Discrimination against people with severe disabilities pervades our society. Assisted suicide is the most lethal form of such discrimination. Applied only to people with significant health impairments, assisted suicide is the ultimate expression of society’s fear and revulsion regarding disability. Health status becomes the basis of a double standard in which people with disabilities, a “discrete and insular minority,” 42 U.S.C. section 12101(a)(7), are discriminatorily denied the protection of suicide prevention laws, medical practice standards, and statutes prohibiting abuse, neglect and homicide that nondisabled persons receive. This double standard based on health status violates the ADA.
Given the pervasive prejudice against and social devaluation of people with severe disabilities and the absence of adequate health care and appropriate supportive services, safeguards cannot be established to prevent abuses resulting in the wrongful death of numerous disabled persons, old and young.
If, however, this Court were to uphold a constitutional right to assisted suicide or authorize its legalization by states, such provisions should apply to everyone -- regardless of health status or disability -- on a nondiscriminatory basis.
The outcome of this case potentially threatens the lives and well-being of a significant number of the 23,588,000 noninstitutionalized people in the United States who have severe disabilities.(2) They comprise 12.1 percent of the total population, 15 years old and over in the United States. The outcome will also affect the only minority group, people with disabilities, that is open to all regardless of race, gender, nationality, sexual orientation, income, place of residency, political affiliation, or any other characteristic, and the only minority group, from a statistical viewpoint, which only 9 percent of its members join at birth.
There are five primary bases for asserting that people with severe disabilities, including nonterminal disabilities, are the actual and potential victims of a right to assisted suicide:
1. Courts in numerous jurisdictions have ruled that people with severe but nonterminal disabilities may legally be denied suicide prevention that nondisabled people routinely receive, but are to be treated like terminally ill people, with respect to the withholding and withdrawal of life sustaining medical treatment. (3)
2. The diagnosis and prognosis of terminal illness is inherently uncertain, as respondents themselves admit.(4) In addition, many doctors conclude that lives of people with severe disabilities are not worth saving, solely because of their disabilities. The potential for error and abuse against people with severe disabilities is too great.
3. Over three quarters of Jack Kevorkian’s assisted suicides involved people who were clearly not terminally ill under accepted medical definitions, but were only severely disabled. (5)
4. In the Netherlands, a country in which assisted suicide has been widely accepted and practiced for many years and the country often referred to as “the model” for the United States, a governmental report demonstrates that many people with nonterminal disabilities have been killed, and thousands have been killed involuntarily. (6)
5. Well-known proponents of assisted suicide have written that it should be applied to people with nonterminal disabilities. In Final Exit, Hemlock Society founder Derek Humphry writes,
What can those of us who sympathize with a justified suicide by a handicapped person do to help? When we have statutes on the books permitting lawful physician aid-in-dying for the terminally ill, I believe that along with this reform there will come a more tolerant attitude to the other exceptional cases.
Many cases in which state courts have expanded the right to refuse treatment demonstrate that prejudice, stereotypes and devaluation of people with disabilities have already had a substantial adverse impact on members of this minority group. Flagrant prejudice against people with disabilities pervades each decision.
Elizabeth Bouvia wanted medical support while starving herself to death. She had blamed herself for her parents’ divorce. When she was ten her mother placed her in an institution, visiting her only twice in eight years. At eighteen, she moved to her own apartment, earned a college degree and began working on a master’s degree. She had a series of emotional blows, including a miscarriage, the death of her brother, serious financial distress, withdrawal from graduate school because of discrimination, and separation from her new husband.(7) A nondisabled person with this history, who refused nutrition and requested physician assistance to commit suicide, would have been diagnosed as suicidal and provided suicide intervention and treatment. But because Ms. Bouvia also had cerebral palsy, a lifelong, nonterminal disability, it was concluded that her decision to die was reasonable and not deserving of intervention.(8) However, only following two years of lengthy court proceedings did Ms. Bouvia decide not to exercise her newly won right.
Kenneth Bergstedt had quadriplegia and used a ventilator. Throughout his 30 years of life, Mr. Bergstedt was dependent on his father, who, fearing he would soon die of lung cancer, supported his son’s decision to die. A psychiatric report before a lower court declared Mr. Bergstedt to be depressed but presumed this was due to “the quality of life for this man....”(9) Mr. Bergstedt believed that he would be forced to live in a nursing home after his father’s death and was unaware of in-home service alternatives. The Nevada Supreme Court pointed out that Mr. Bergstedt’s
suffering resulted more from his fear of the unknown than any source of physical pain.... It is equally clear that if Kenneth had enjoyed sound physical health, but had viewed life as unbearably miserable because of his mental state, his liberty interest would provide no basis for asserting a right to terminate his own life with or without the assistance of others.(10)
Ruling after his death, even the Nevada Supreme Court, which had supported Mr. Bergstedt’s request for physician assisted suicide, recognized that he had not been properly informed and had not made a free and intelligent life-or-death decision. If he were still alive, the court said “it would have been necessary to fully inform him of the care alternatives that would have been available to him after his father’s death or incapacity.”(11)
David Rivlin was paralyzed as a result of a surfing accident a full eighteen years before he committed suicide with the aid of medical support. He had no terminal illness, but he used a ventilator. He was confined to a nursing home in Michigan against his will because of the lack of adequate in-home support services at that time. In addition, his relationship with his fiance had recently ended.(12) Mr. Rivlin was given his “right to die” but was never offered the options he expressly requested to live in the community.
Larry McAfee, a thirty-four year old man with quadriplegia as a result of an accident, was transferred from one institution to another “like a sack of potatoes” over a period of four years.(13) Georgia did not pay for community support but would pay only for the cost of nursing home care(14) and for intensive care in a hospital unit where he lived for eight months, even though he was not ill, let alone critically or terminally ill.(15) The Georgia Supreme Court affirmed the lower court’s assessment that Mr. McAfee was hopelessly injured.(16) In the nursing home, he was told when to eat, sleep, and even what he could watch on his own video recorder.(17) Nevertheless, after disability rights advocates including members of the amici communicated with Mr. McAfee, he changed his mind. By the time Mr. McAfee won his so-called “right to die,” he had worked with disability advocates to get out of the nursing home and pursue work as an engineer using computer aided drafting. Mr. McAfee had experienced how people with severe disabilities are devalued as human beings and was quoted as saying,
You’re looked upon as a second-rate citizen. People say, ‘you’re using my taxes. You don’t deserve to be here. You should hurry up and leave.’ You reach a point where you just can’t take it anymore.(18)
These four cases are examples of discrimination against and devaluation of people with disabilities. These decisions occurred because the general public, including judges and physicians, share common societal reactions to people with severe disabilities:
1. nondisabled persons fear that they will become disabled themselves and assume that having a severe disability is worse than death itself;
2. nondisabled persons often view people with severe disabilities as lacking in “quality of life,” and such people are to be pitied instead of being granted civil rights or equal legal protections; and
3. to many nondisabled persons, disability falsely implies entrapment, loss of control, and loss of dignity.
As a consequence of these reactions, persons with severe disabilities are segregated, put out of sight in institutions, or neglected, abandoned, abused, and increasingly assisted to die. These public misconceptions, however, are refuted by research studies on disabled people’s quality of life.(19)
Each of these cases dismissed the state interest in protecting the lives of these disabled individuals and found a “right to die” through the withdrawal of life-sustaining treatment. However, the courts specifically distinguished any right involving active physician-assisted suicide. Before this Court is the request to obliterate this distinction.
Reviewing the people whom Jack Kevorkian assisted in committing suicide also demonstrates the potential for uncontrolled discrimination against people with disabilities, if this Court sanctions active physician-assisted suicide. Of the 40 people who died between June 4,1990 and September 7, 1996 with the assistance of Kevorkian, at least 28 people had diseases that were not life-threatening and autopsies revealed they were not terminally ill.(20) For example, nine of them had multiple sclerosis. As the New York Times recently reported in connection with these people,
multiple sclerosis is not a fatal disease.... Its tendency to wax and wane repeatedly and unpredictably can have patients wavering back and forth between elation and despair.... [T]he depression that often accompanies the disease is a treatable condition.... [S]ervices are available to help every person with illness live a more productive and comfortable life and that whatever the state of a person’s disability, life need not be worthless.(21)
Like those people who had multiple sclerosis, most of Kevorkian’s other “patients” did not have terminal illnesses nor did they receive appropriate services to help make life meaningful. For example, Janet Adkins, age 54, who died June 4, 1990, was in the early stages of Alzheimer’s, was not terminally ill, and her own doctor said she had ten years of productive life ahead of her. She never met or spoke with Kevorkian until two days before her death. According to an aunt, “She did not want to be a burden to her husband and family.”(22) Marjorie Wantz, age 58, who died October 23, 1991, had no life-threatening condition, had reportedly experienced pelvic pain, but an autopsy found she had no apparent illness or disease.(23) Sherry Miller, 42, who died October 23,1991, had multiple sclerosis and could have lived for many years but felt she was “becoming a burden on people,” and she had suffered from depression but did not want to take the medication for it.(24) Elaine Goldbaum had financial problems and feared losing her house,(25) Jonathan Grenz was said to be depressed and “overwhelmed with grief” following his mother’s death,(26) and Ali Khalili had told his doctor that “the quality of his life had been compromised by an anxiety state.”(27) Kevorkian assisted them all to die.
These people represent the extent of discrimination that exists in our society; with appropriate treatment and services, many of them would be alive today. It is against the backdrop of these and other cases, reflecting society’s growing support of a “right to die” for people with severe disabilities, that your amici request protection from the very real threat to the lives of people with disabilities that will result from a right to assisted suicide through active measures.
Lethal discrimination against people with severe disabilities and functional limitations is an integral and pervasive part of America’s twentieth century history. The forms of this lethal discrimination include:
1. euthanasia, where nondisabled persons advocated for the involuntary euthanasia of 60,000 disabled persons in institutions and five times as many outside, since in these “hopeless” cases “we have no fear of error”;(28)
2. eugenics “favoring the killing of defective children;”(29)
3. involuntary sterilization of persons with developmental and physical disabilities;(30)
4. denial of life-saving medical assistance especially to children with severe physical disabilities;(31) and
5. withdrawal of medical treatment.(32)
This Court has acknowledged that at least one of the forms of this discrimination, the practice of withholding lifesaving medical assistance by medical professionals from children with lifelong severe disabilities, has a “history of unfair and often grotesque mistreatment” arising from a legacy of “prejudice and ignorance” and continuing well into the 20th century. City of Cleburne, Texas v. Cleburne Living Center, 105 S. Ct. 3249, 3262 (Stevens, J., joined by Burger, C.J., concurring), 3266 (Marshall, joined by Brennan & Blackmun, JJ., concurring)(1985).
Congress clearly understood this history when, in 1990, it enacted the ADA, the basic civil rights statute for people with disabilities. After extensive hearings, Congress made extensive Findings:
historically, society has tended to isolate and segregate individuals with disabilities, and despite some improvements, such forms of discrimination continue to be a serious and pervasive social problem;
unlike individuals who have experienced discrimination on the basis of race, color, sex, national origin, religion, or age, individuals who have experienced discrimination on the basis of disability have often had no legal recourse to redress such discrimination;
individuals with disabilities continually encounter various forms of discrimination, including outright intentional exclusion..., segregation, and relegation to lesser ... benefits...;
census data, national polls, and other studies have documented that people with disabilities, as a group, occupy an inferior status in our society, and are severely disadvantaged...;
individuals with disabilities are a discrete and insular minority..., subjected to a history of purposeful unequal treatment, and relegated to a position of political powerlessness in our society, based on characteristics that are beyond the control of such individuals and resulting from stereotypic assumptions not truly indicative of the individual ability of such individuals to participate in, and contribute to society; and
the continuing existence of unfair and unnecessary discrimination and prejudice denies people with disabilities the opportunity ... to pursue those opportunities for which our free society is justifiably famous.
42 U.S.C. sections 12101(a)(2),(4)-(7)and (9)(emphases added).
To address and remedy this pervasive and relentless discrimination, Congress substantively required that “no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of any public entity....” 42 U.S.C. section 12132. The same prohibition applies to hospitals and physicians. 42 U.S.C. section 12182(b)(2)(A)(iii). Elizabeth Bouvia, Kenneth Bergstedt, Janet Adkins, Marjorie Wantz, Sherry Miller and the other people discussed above had disabilities (or were perceived to have disabilities) and all of them, “by reasons of [their] disability,” were denied the state’s benefits of suicide prevention and/or enforcement of abuse, neglect, and homicide statutes. The states concluded that their fundamental interests in saving lives applied only to people without severe disabilities.
Pursuant to the ADA’s explicit statutory mandate, 42 U.S.C. section 12134, the U.S. Department of Justice promulgated federal regulations elaborating on the statutory definition of discrimination. Specifically, the regulations provide that a state, as well as hospitals and doctors, discriminate when they either deny or do not afford an opportunity for people with disabilities to benefit from services either equal to or as effective as that afforded nondisabled persons. See e.g., 28 C.F.R. section 35.130(b).
Providing assisted suicide only for people with severe disabilities and conversely denying suicide prevention services only for people with severe disabilities violates the ADA in at least four respects:
1. The presence or absence of a severe disability determines whether state and local governments enforce laws requiring health professionals to protect individuals who pose a danger to themselves. The disability, instead of the risk of suicide, determines the enforcement.
2. The presence or absence of a severe disability determines whether the state and medical practitioners respond to expressions of suicidal intent in people with disabilities with the application of lethal measures that are never applied to people without disabilities. The existence of a severe disability will be the reason for the denial of treatment that nondisabled persons routinely receive. Society’s growing support of such discrimination is founded on inaccurate assumptions about the needs of persons with incurable health conditions, the role and authority of physicians, and the nature and significance of requests to die as they are understood and valued by physicians.(33)
3. The presence or absence of a severe disability determines whether state and local governments investigate or enforce potential medical malpractice, such as failure to provide pain medication, failure to establish an accurate diagnosis, prognosis and treatment plan, and failure to ensure informed consent. If one has a severe disability, each of these are treated differently than if one were nondisabled, resulting in a double standard that depends only on the existence of a severe disability.
4. The presence or absence of severe disability determines whether and the extent to which state and local governments investigate and enforce abuse and neglect and homicide statutes in cases reported as assisted suicides. Amici’s experiences demonstrate that noninvestigation and nonenforcement are common practices when it comes to the death of people with disabilities.(34)
The existence of a disability should never be the basis for these distinctions.
Given the “history of purposeful unequal treatment” to which people with disabilities are subjected and the “continuing existence of unfair ... discrimination and prejudice,” 42 U.S.C. section 12101 (a)(7) & (9), adequate assisted-suicide safeguards cannot and will not prevent abuse against people with disabilities. History, contemporary attitudes and biases, the Netherlands, as well as prior judicial decisions, demonstrate that safeguards against abuse in assisted suicide cannot be developed. Amici discussed the current practices which demonstrate that assisted suicide has not and will not be limited to terminally ill persons.(35) As long as society, including the medical profession, demonstrates ignorance and prejudice regarding the lives of people with disabilities, no safeguards can be trusted to contain the torrent of discrimination that will be unleashed by lifting the ban on assisted suicide.
At issue in the present case is nondisabled peoples’ intense fear of becoming disabled. When a person with a disability states a desire to die, nondisabled people believe the request is natural and reasonable because they believe that living with a severe disability is a life of dependency, indignity and helplessness; in short, worse than death. The wish to die agrees with the nondisabled view that the primary problem for disabled people is the permanent disability and/or dependence on life aids. Medical professionals, jurists and the public consistently ignore underlying treatable depression, lack of health care or other supports, and exhaustion from confronting systemic discrimination. When medical professionals and the media use phrases like “imprisoned by her body,” “helpless,” “suffering needlessly,” and “quality versus quantity of life,” purportedly in a humanistic and compassionate way, they are really expressing very primitive human fears of severe disability and a very misguided condemnation, “I could never live like that.” Society translates these primitive emotions into a supposedly rational social policy of assisted suicide. Whenever
permanent disability is [defined] as the problem, death is the solution.... [T]he wish to die is transformed into a desire for freedom, not suicide. If it is suicide at all, it is ‘rational’ and, thereby, different from suicides resulting from [the same] emotional disturbance or illogical despair [that nondisabled persons face]. (36)
The medical profession is not immune to these erroneous assumptions. Research shows that doctors frequently project the “quality of life of chronically ill persons to be poorer than patients themselves hold it to be, and give this conclusion great weight in inferring, incorrectly, that such persons would choose to forgo life-prolonging treatment.”(37) It is particularly important to note that research on suicidal feelings among people with terminal illnesses demonstrates that such feelings are remediable through other means, including pain management, hospice services and counselling.(38) As long as physicians believe that a person with a severe disability has a “life unworthy of living,”(39) lethal errors and abuses will occur.
As long as people with disabilities are treated as unwelcome and costly burdens on society, assisted suicide is not voluntary but is a forced “choice.” Amici are profoundly disturbed by the finding of a constitutional right for assisted suicide in a society which refuses to find a right to adequate and appropriate health care to stay alive. Until society is committed to providing life supports, including in-home personal assistance services, health care, and technological supports, then there is not voluntary choice.
Our nation’s health care system has not responded adequately or consistently to the health needs of people with disabilities. Now managed health care, with its emphasis on cost containment and the inevitable denial of health care, will further abridge the choices and endanger the lives of people with disabilities.
Without access to competent medical care, options and information about disability, people with severe disabilities are not able to make informed decisions. Without the professional commitment to help make living worthwhile for people with disabilities, which is the core of suicide prevention, people with disabilities will not receive the support necessary for informed and voluntary decisions. Additionally, there is substantial evidence that physicians and other health care providers will engage in euthanasia in the absence of a patient’s clear request to die, and even in opposition to a clear request to live:
1. Recent medical studies indicate that involuntary “do not resuscitate” (“DNR”) orders are not uncommon.(40) Many members of your amici have been repeatedly requested and pressured to sign DNR requests. Maria Matzik, a Not Dead Yet and ADAPT member and a 34 year old ventilator user, was told by health care professionals in a hospital that a DNR order would apply to her because she uses a ventilator, despite her express demand to the contrary.
2. Cases have been brought by health care professionals seeking authority to withhold treatment in opposition to express patient and family directives to the contrary.(41)
3. Evidence from the Netherlands demonstrates quite unequivocally that involuntary euthanasia has become widespread and frequent, even with established written safeguards in place. Specifically, according to a 1990 governmental report, 5,941 persons were given lethal injections without their consent. Of those, 1,474 were fully competent, according to their physicians. In 8% of the cases, doctors admitted there were unexplored options. Regardless of options, they euthanized unconsenting patients because of such express reasons as “low quality of life,” “no prospect of improvement,” “and “the family could not take any more.”(42) There is no reason to believe that safeguards will work any better in the United States. To the contrary, once assisting disabled people to their deaths becomes routine in medical training and practice, no safeguards are possible behind the closed doctors’ doors to protect people with disabilities against well-intentioned, but lethal prejudice exhibited by many physicians.
4. If a right to assisted suicide is created, then, as existing court precedent and state statutes involving refusal of treatment indicate, such a “right” will soon be extended in practice to incompetent persons through the use of advanced directives and surrogate decision-makers. Research shows that families are likely to believe that assisted suicide is a desirable option, and that a disabled family member would want assisted suicide, even though that family member in fact does not want aid in dying.(43) Amici contend that a right to assisted suicide for competent adults will increase the danger of lethal decisions by families, whether well-intentional or otherwise.
5. The history of discrimination against persons with disabilities in health care settings, coupled with current developments in managed care, demonstrates that assisted suicide is the easiest and most financially profitable way to address the needs of persons with disabilities. With assisted suicide, a doctor under a capitated health care system will not have to exceed his utilization rate on a severely disabled patient. There are no safeguards that can protect against these prejudices and realities.
Finally, no system of safeguards can control conduct which results in the death of the primary witness to any wrongdoing or duress. The only “safeguard” that offers some protection against abuse is that assisted suicide remain illegal and socially condemned for all citizens equally. As assisted suicide becomes more and more acceptable, the threat of criminal prosecution is the only remaining protection to which people with severe disabilities, including terminal illnesses, can turn. For example, 16% of nurses report engaging in the practices, sometimes without the consent of the patient. In the absence of any potential for criminal liability, no meaningful barrier to active involuntary euthanasia will exist to protect the lives of members of this minority group.
The proposed right to assisted suicide discriminates, singling out people with severe disabilities as fit to die. Since this discrimination is so pervasive in our society, amici urge that if any right to obtain assistance to control one’s death exists, it should apply to everyone in a nondiscriminatory manner and not be limited to persons with severe disabilities, including terminal illnesses.
If the Constitution requires that the state’s interest in the preservation of life (through suicide prevention and other laws) is vitiated for some people because of their health status, then why should the state interest not also be discounted for other persons? Why should one’s autonomy or right to control one’s death be limited to persons with severe disabilities? Why exclude from this right persons enduring extreme, unabating psychological suffering due to the irreversable loss of loved ones? There is no constitutional basis for drawing a bright line on a continuum between disabled and nondisabled. Such a distinction would stand on shifting sands of arbitrary classifications and assessments, as well as changing medical and technological expertise and developments.
Moreover, if proponents of assisted suicide believe that adequate safeguards against treatable suicidal feelings can be established, then they should be willing to allow physician assistance for every citizen, regardless of their health status, after those safeguards have been observed.
Amici ask the Court to be believe them when they state that disability-based discrimination in this culture is deep-seated, virtually unconscious, pervasive and overwhelming. This discrimination against millions of Americans must be understood and reversed, in ways that few can even envision, long before we discuss expanding the ways in which society’s unwanted can be killed. But if physician-assisted suicide will become a right for some, then it should be for all. The same safeguards, or lack of safeguards, that apply to some must apply to all, without discrimination.
The circuit courts’ conclusions that people with disabilities are not threatened by physician-assisted suicide is false, based on virtually every court decision to date, as well as on the actual practice in our society. The fact that proponents of assisted suicide continue to dismiss and marginalize the input of the disability rights community on this topic leads amici to believe that they may actually feel that their untimely deaths are ultimately acceptable in the interest of the “greater good,” or even only in the interest of their individual need to maintain control in an uncertain and often cruel world.
People with disabilities request this Court protects their lives, to stand as perhaps the last barrier to the “right to die” juggernaut of the recent decade, to recognize that cloaked in the false rhetoric of “personal autonomy,” physician assisted suicide threatens the remaining rights of a profoundly oppressed and marginalized people.
NAME, AGE, DATE DIED, STATUS AND CONDITION AT TIME OF DEATH
JANET AKINS, 54, 6/4/90. Not Terminal. Had Alzheimer’s disease.
SHERRY MILLER, 43, 10/23/91. Not Terminal. Had multiple sclerosis with disorganization of motor control in legs and arms.
MARJORIE WANTZ, 58, 10/23/91.Not terminal. Had severe pelvic pain.
SUSAN WILLIAMS, 52, 5/15/92.Not terminal. Had multiple sclerosis and was blind.
LOIS HAWES, 52, 9/26/92. Terminal stages of lung cancer.
CATHERINE ANDREYEV, 46, 11/23/92. Terminal stages of breast cancer.
MARCELLA LAWRENCE, 67, 12/15/92. Not terminal. Had heart disease, emphysema and arthritis.
MARGUERITE TATE, 70, 12/15/92.Terminal stages of Lou Gehrig’s disease.
JACK MILLER,53, 1/20/93. Terminal stages of bone cancer. Also had emphysema.
STANLEY BALL, 82, 2/4/93. Not terminal. Had pancreatic cancer.
MARY BIERNAT, 73, 2/4/93. Had breast and chest cancer. Unclear whether terminal.
ELAINE GOLDBAUM,47, 2/8/93. Not terminal. Had multiple sclerosis, was blind and use a wheelchair.
HUGH GALE, 70, 2/15/93. Unclear whether terminal. Had emphysema and congestive heart disease.
JONATHAN GRENZ, 44, 2/18/93. Terminal. Had throat cancer.
MARTHA RUWART, 41, 2/18/93. Terminal. Had duodenal and ovarian cancer.
RON MANSUR, 54, 5/16/93. Unclear whether terminal. Had lung and bone cancer.
THOMAS HYDE, 30, 8/4/93. Terminal. Had Lou Gehrig’s disease.
DONALD O’KEEFE,73, 9/9/93. Terminal. Had bone cancer.
MERIAN FREDERICK, 72, 10/22/93. Not terminal stage of Lou Gehrig’s disease.
ALI KHALILI, 61, 11/22/93.Not terminal. Had progressive bone disease and multiple myeloma.
MARGARET GARRISH, 72, 11/26/94. Not terminal. Had double amputation from chronic degenerative joint disease.
JOHN EVANS, 77, 5/895. Not terminal. Had chronic lung disease.
NICHOLAS LOVING, 27, 5/12/95. Not terminal stage of Lou Gehrig’s disease.
ERIKA GARCELLANO, 60, 626/95. Not terminal stage of Lou Gehrig’s disease.
ESTHER COHAN, 46 8/25/95. Not terminal. Had multiple sclerosis.
PATRICIA CASHMAN, 58, 11/8/95. Not terminal. Had breast cancer.
LINDA HENSLEE, 48, 1/29/96. Not terminal. Had multiple sclerosis.
AUSTIN BASTABLE, 53, 5/6/96. Not terminal. Had multiple sclerosis.
RUTH NEUMAN, 69, 6/10/96. Not terminal. Was overweight and had diabetes.
LONA JONES, 58, 6/18/96. Not terminal. Had a brain tumor.
BETTE LOU HAMILTON, 67, 6/20/96. Not terminal. Had a degenerative neurological disease.
SHIRLEY CLINE, 63, 7/4/96. Not terminal. Had colon cancer.
REBECCA BADGER,39, 7/9/96. Not terminal. Had multiple sclerosis.
ELIZABETH MERCZ, 59, 8/6/96.Not terminal. Had Lou Gehrig’s disease.
JUDITH CURREN, 42 8/15/96. Not terminal. Had chronic fatigue syndrome and muscle disorder.
DORTHA SIEBENS, 76, 8/20/96. Not terminal. Had Lou Gehrig’s disease.
PATRICIA SMITH, 40, 8/22/96.Not terminal. Had multiple sclerosis.
PAT DIGANGL, 66, 8/22/96. Not Terminal. Had debilitating muscle illness.
JACK LEATHERMAN, 73, 9/2/96. Terminal. Had pancreatic cancer.
ISABEL CORREA, 60, 9/7/96.Not terminal. Had severe pain from a spinal cord condition.
I am a clinical psychologist specializing in issues affecting persons with disabilities, pain, and/or chronic illnesses. . . My former positions include: Director of Rehabilitation Psychology at Glendale Adventist Center; Commissioner in Psychology on the Los Angeles County Commission on Disability ; and Acting Director of the Program in Disability and Society at the University of Southern California . . . In addition . . . I have been physically disabled since contracting polio in childhood and relying on a power wheelchair for mobility and a ventilator for respiration during the night . . .
I have observed that a primary source of depression and despair in clients with disabilities and chronic progressive illnesses is their demoralization by social discrimination in daily life. After struggling with employment bias, unaccommodating and selective health services, lack of accessible and affordable housing, and lack of accessible transportation, many of my clients and research subjects have expressed feelings of severe emotional exhaustion commonly referred to as “burn-out.” In fact, the most frequently repeated theme from persons with disabilities and illnesses that I have encountered in the last decade has been, “I can live with my physical condition but I’m tired of struggling against the way I’m treated.”
In the case of spinal cord injury, for example . . . [it] is quite common for persons who first learn of their paralysis and are confronted with assistive technology and unfamiliar procedures to express the desire to die; and to express it forcefully and consistently for weeks. Months later, however, most of those patients thank their doctors and families for supporting their lives instead of concluding with their earlier despair . . . .
[W]hen the “critical life stress” involves a life-threatening illness or disability, the process of adjustment often takes considerably longer. Therapists experienced in working with terminally ill and irreversibly disabled individuals report a series of stages - including shock, grief, despair, and resolution - that are navigated before such individuals regain basic emotional control . . . However, emotional disorder can well be hidden and remain undetected unless carefully assessed by properly trained professionals. Most physicians are not trained to identify hidden depression, treatable suicidal intent, and other non-flagrant psychiatric disorders. Studies have revealed that a significant portion of persons who attempt suicide seek medical attention shortly before the event and that their physicians typically remain unaware of their emotional distress and need for psychological intervention . . . Attending physicians, therefore, have not proven to be qualified gatekeepers in determining a patient’s need for psychological services.
In my clinical practice and in my subsequent education and research contacts, I have heard repeated complaints from persons with incurable health conditions that their physicians are often unaware of their needs, devaluing their lifestyles, and uninformed about such important options as personal in-home assistance, independent living centers, and assistive technology. These complaints are confirmed by research . . . For example, research ... reveals that health professionals often prejudge the lives of ventilator-users as poor in quality. These negative judgments are not only at odds with the generally high life satisfaction ratings of ventilator-users themselves, but are also associated with a lack of knowledge about options for assisted ventilation and a tendency to withhold such options from patients . . . Those of us who have worked extensively with suicidal persons realize that the wish to die can sound unwavering and can persist for many weeks and yet be characterized by deep ambivalence. The presence of a terminal illness or even substantial physical suffering does not in any way diminish the possibility of significant conflict between the wish to die and the desire to live.
It is extremely dangerous to respond to the expression of a death wish by providing the means to die. That type of response, especially if it comes from a respected authority or representative of society (e.g., a physician), can unduly influence a vulnerable individual to embrace death as the “right” solution . . .
For example, the desire to die may result from the previously mentioned exhaustion after a struggle to live in the face of thwarting social barriers and discrimination. Self-destructive impulses may also represent an internalization of the stigma and devaluation society inflicts on persons with incurable conditions - an internalization of the pervasive message that physical weakness is “undignified” but that dying is “humane and dignified.” Suicide may be a desperate attempt to control one’s life when the surrounding environment is dismissive of one’s needs or unwilling to support alternative ways to enhance self-determination, e.g., assistive technology and dignified personal assistance in one’s own home. Embracing death may be a tragic effort to escape the imprisonment of a nursing home or other intolerable institutional setting. It may be an attempt to ward off impending abandonment or rejection from others who cannot cope with a loved one’s physical decline. It may be a self-sacrificing measure to spare family members from the financial strain that often accompanies lingering illness in our society. The expression of a desire to die may be a poignant way of testing the waters to see if others feel it is time for the ill individual to get out of the way. These are all socially mediated reasons for wanting to die. They should be addressed through modifying the social environment, not accepting the individual’s self-elimination.
The expressed desire to escape illness by dying can also be a sign of treatable clinical depression, anxiety disorder, or other mental illness. Researchers who studied terminally ill people seeking a hastened death found that most, in fact, had a psychiatric disorder . . . Preoccupation with physical discomfort and the tendency to express emotional distress in somatic complaints is a common symptom of clinical depression. We cannot assume that simply because a person is physically ill, he or she is immune from the treatable psychiatric problems that visit many physically healthy persons have. . . . Not all persons with incurable conditions enjoy the middle-class ideal of the stable doctor-patient relationship. Many are impoverished and see a series of doctors who are assigned to them. They may opt for death because they cannot afford many of the comforts and options available to others. If they qualify for a lethal prescription, it is likely to come from a stranger who knows little about them instead of the trusted family physician envisioned by many of the more privileged . . .
In light of the disturbing facts presented above, I submit that the Oregon death with Dignity Act singles out a class of persons that society has already too quick to discard and further reduces support for and protections of their lives . . . That bias is an insidious form of prejudice that disability rights activists call “ableism” or “physicalism.” A society that weighs the value of a citizen’s life according to health or physical attributes is entering risky territory. When physicians are instructed to adopt such a scale with impunity, the silent and far-reaching effects on health care and on society as a whole will be as impossible to predict as to control. One of the most certain and tragic outcomes, however, is that it will lead to the wrongful premature deaths of persons who, if given basic support and reasonable options instead of a socially and medically sanctioned exit, would prefer to live.
certiorari to the united states court of appeals for the second circuit
Argued January 8, 1997
Decided June 26, 1997
In New York, as in most States, it is a crime to aid another to commit or attempt suicide, but patients may refuse even lifesaving medical treatment. Respondent New York physicians assert that, although it would be consistent with the standards of their medical practices to prescribe lethal medication for mentally competent, terminally ill patients who are suffering great pain and desire a doctor’s help in taking their own lives, they are deterred from doing so by New York’s assisted suicide ban. They, and three gravely ill patients who have since died, sued the State’s Attorney General, claiming that the ban violates the Fourteenth Amendment’s Equal Protection Clause. The Federal District Court disagreed, but the Second Circuit reversed, holding (1) that New York accords different treatment to those competent, terminally ill persons who wish to hasten their deaths by self administering prescribed drugs than it does to those who wish to do so by directing the removal of life support systems, and (2) that this supposed unequal treatment is not rationally related to any legitimate state interests.
Held: New York’s prohibition on assisting suicide does not violate the Equal Protection Clause. Pp. 3-14.
(a) The Equal Protection Clause embodies a general rule that States must treat like cases alike but may treat unlike cases accordingly. E.g., Plyler v. Doe, 457 U.S. 202, 216 . The New York statutes outlawing assisted suicide neither infringe fundamental rights nor involve suspect classifications, e.g., Washington v. Glucksberg, ante, at 14-24, and are therefore entitled to a strong presumption of validity, Heller v. Doe, 509 U.S. 312, 319 . On their faces, neither the assisted suicide ban nor the law permitting patients to refuse medicaltreatment treats anyone differently from anyone else or draws any distinctions between persons. Everyone, regardless of physical condition, is entitled, if competent, to refuse unwanted lifesaving medical treatment; no one is permitted to assist a suicide. Generally, laws that apply evenhandedly to all unquestionably comply with equal protection. E.g., New York City Transit Authority v. Beazer, 440 U.S. 568, 587 . This Court disagrees with the Second Circuit’s submission that ending or refusing lifesaving medical treatment “is nothing more nor less than assisted suicide.” The distinction between letting a patient die and making that patient die is important, logical, rational, and well established: It comports with fundamental legal principles of causation, see, e.g., People v. Kevorkian, 447 Mich. 436, 470-472, 527 N. W. 2d 714, 728, cert. denied, 514 U.S. 1083 , and intent, see, e.g., United States v. Bailey, 444 U.S. 394, 403 -406; has been recognized, at least implicitly, by this Court in Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 261, 278 -280; id., at 287-288 (O’Connor, J., concurring); and has been widely recognized and endorsed in the medical profession, the state courts, and the overwhelming majority of state legislatures, which, like New York’s, have permitted the former while prohibiting the latter. The Court therefore disagrees with respondents’ claim that the distinction is “arbitrary” and “irrational.” The line between the two acts may not always be clear, but certainty is not required, even were it possible. Logic and contemporary practice support New York’s judgment that the two acts are different, and New York may therefore, consistent with the Constitution, treat them differently. Pp. 3-13.
(b) New York’s reasons for recognizing and acting on the distinction between refusing treatment and assisting a suicide--including prohibiting intentional killing and preserving life; preventing suicide; maintaining physicians’ role as their patients’ healers; protecting vulnerable people from indifference, prejudice, and psychological and financial pressure to end their lives; and avoiding a possible slide towards euthanasia--are valid and important public interests that easily satisfy the constitutional requirement that a legislative classification bear a rational relation to some legitimate end. See Glucksberg, ante. Pp. 13-14.
80 F. 3d 716, reversed.
Rehnquist, C. J., delivered the opinion of the Court, in which O’Connor, Scalia, Kennedy, and Thomas, JJ., joined. O’Connor, J., filed a concurring opinion, in which Ginsburg and Breyer, JJ., joined in part. Stevens, J., Souter, J., Ginsburg, J., and Breyer, J., filed opinions concurring in the judgment.
DENNIS C. VACCO, ATTORNEY GENERAL OF NEW YORK, et al., PETITIONERS v. TIMOTHY E. QUILL et al.
on writ of certiorari to the united states court of appeals for the second circuit
[June 26, 1997]
Chief Justice Rehnquist delivered the opinion of the Court.
In New York, as in most States, it is a crime to aid another to commit or attempt suicide, [n.1] but patients may refuse even lifesaving medical treatment. [n.2] The question presented by this case is whether New York’s prohibition on assisting suicide therefore violates the Equal Protection Clause of the Fourteenth Amendment. We hold that it does not.
Petitioners are various New York public officials. Respondents Timothy E. Quill, Samuel C. Klagsbrun, and Howard A. Grossman are physicians who practice in New York. They assert that although it would be “consistent with the standards of [their] medical practice[s]” to prescribe lethal medication for “mentally competent, terminally ill patients” who are suffering great pain and desire a doctor’s help in taking their own lives, they are deterred from doing so by New York’s ban on assisting suicide. App. 25-26. [n.3] Respondents, and three gravely ill patients who have since died, [n.4] sued the State’s Attorney General in the United States District Court. They urged that because New York permits a competent person to refuse life sustaining medical treatment, and because the refusal of such treatment is “essentially the same thing” as physician assisted suicide, New York’s assisted suicide ban violates the Equal Protection Clause. Quill v. Koppell, 870 F. Supp. 78, 84-85 (SDNY 1994).
The District Court disagreed: “[I]t is hardly unreasonable or irrational for the State to recognize a difference between allowing nature to take its course, even in the most severe situations, and intentionally using an artificial death producing device.” Id., at 84. The court noted New York’s “obvious legitimate interests in preserving life, and in protecting vulnerable persons,” and concluded that “[u]nder the United States Constitution and the federal system it establishes, the resolution of this issue is left to the normal democratic processes within the State.” Id., at 84-85.
The Court of Appeals for the Second Circuit reversed. 80 F. 3d 716 (1996). The court determined that, despite the assisted suicide ban’s apparent general applicability, “New York law does not treat equally all competent persons who are in the final stages of fatal illness and wish to hasten their deaths,” because “those in the final stages of terminal illness who are on life support systems are allowed to hasten their deaths by directing the removal of such systems; but those who are similarly situated, except for the previous attachment of life sustaining equipment, are not allowed to hasten death by self administering prescribed drugs.” Id., at 727, 729. In the court’s view, “[t]he ending of life by [the withdrawal of life support systems] is nothing more nor less than assisted suicide.” Id., at 729 (emphasis added) (citation omitted). The Court of Appeals then examined whether this supposed unequal treatment was rationally related to any legitimate state interests, [n.5] and concluded that “to the extent that [New York’s statutes] prohibit a physician from prescribing medications to be self administered by a mentally competent, terminally ill person in the final stages of his terminal illness, they are not rationally related to any legitimate state interest.” Id., at 731. We granted certiorari, 518 U. S. ___ (1996), and now reverse.
The Equal Protection Clause commands that no State shall “deny to any person within its jurisdiction the equal protection of the laws.” This provision creates no substantive rights. San Antonio Independent School Dist. v. Rodriguez, 411 U.S. 1, 33 (1973); id., at 59 (Stewart, J., concurring). Instead, it embodies a general rule that States must treat like cases alike but may treat unlike cases accordingly. Plyler v. Doe, 457 U.S. 202, 216 (1982) (“ ‘[T]he Constitution does not require things which are different in fact or opinion to be treated in law as though they were the same’ “) (quoting Tigner v. Texas, 310 U.S. 141, 147 (1940)). If a legislative classification or distinction “neither burdens a fundamental right nor targets a suspect class, we will uphold [it] so long as it bears a rational relation to some legitimate end.” Romer v. Evans, 517 U. S. ___, ___ (slip op., at 10) (1996).
New York’s statutes outlawing assisting suicide affect and address matters of profound significance to all New Yorkers alike. They neither infringe fundamental rights nor involve suspect classifications. Washington v. Glucksberg, ante, at 15-24; see 80 F. 3d, at 726; San Antonio School Dist., 411 U. S., at 28 (“The system of alleged discrimination and the class it defines have none of the traditional indicia of suspectness”); id., at 33-35 (courts must look to the Constitution, not the “importance” of the asserted right, when deciding whether an asserted right is “fundamental”). These laws are therefore entitled to a “strong presumption of validity.” Heller v. Doe, 509 U.S. 312, 319 (1993).
On their faces, neither New York’s ban on assisting suicide nor its statutes permitting patients to refuse medical treatment treat anyone differently than anyone else or draw any distinctions between persons. Everyone, regardless of physical condition, is entitled, if competent, to refuse unwanted lifesaving medical treatment; no one is permitted to assist a suicide. Generally speaking, laws that apply evenhandedly to all “unquestionably comply” with the Equal Protection Clause. New York City Transit Authority v. Beazer, 440 U.S. 568, 587 (1979); see Personnel Administrator of Mass. v. Feeney, 442 U.S. 256, 271-273 (1979) (“[M]any [laws] affect certain groups unevenly, even though the law itself treats them no differently from all other members of the class described by the law”).
The Court of Appeals, however, concluded that some terminally ill people--those who are on life support systems--are treated differently than those who are not, in that the former may “hasten death” by ending treatment, but the latter may not “hasten death” through physician assisted suicide. 80 F. 3d, at 729. This conclusion depends on the submission that ending or refusing lifesaving medical treatment “is nothing more nor less than assisted suicide.” Ibid. Unlike the Court of Appeals, we think the distinction between assisting suicide and withdrawing life sustaining treatment, a distinction widely recognized and endorsed in the medical profession [n.6] and in our legal traditions, is both important and logical; it is certainly rational. See Feeney, supra, at 272 (“When the basic classification is rationally based, uneven effects upon particular groups within a class are ordinarily of no constitutional concern”).
The distinction comports with fundamental legal principles of causation and intent. First, when a patient refuses life sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication. See, e.g., People v. Kevorkian, 447 Mich. 436, 470-472, 527 N. W. 2d 714, 728 (1994), cert. denied, 514 U.S. 1083 (1995); Matter of Conroy, 98 N. J. 321, 355, 486 A. 2d 1209, 1226 (1985) (when feeding tube is removed, death “result[s] . . . from [the patient’s] underlying medical condition”); In re Colyer, 99 Wash. 2d 114, 123, 660 P. 2d 738, 743 (1983) (“[D]eath which occurs after the removal of life sustaining systems is from natural causes”); American Medical Association, Council on Ethical and Judicial Affairs, Physician Assisted Suicide, 10 Issues in Law & Medicine 91, 92 (1994) (“When a life sustaining treatment is declined, the patient dies primarily because of an underlying disease”).
Furthermore, a physician who withdraws, or honors a patient’s refusal to begin, life sustaining medical treatment purposefully intends, or may so intend, only to respect his patient’s wishes and “to cease doing useless and futile or degrading things to the patient when [the patient] no longer stands to benefit from them.” Assisted Suicide in the United States, Hearing before the Subcommittee on the Constitution of the House Committee on the Judiciary, 104th Cong., 2d Sess., 368 (1996) (testimony of Dr. Leon R. Kass). The same is true when a doctor provides aggressive palliative care; in some cases, painkilling drugs may hasten a patient’s death, but the physician’s purpose and intent is, or maybe, only to ease his patient’s pain. A doctor who assists a suicide, however, “must, necessarily and indubitably, intend primarily that the patient be made dead.” Id., at 367. Similarly, a patient who commits suicide with a doctor’s aid necessarily has the specific intent to end his or her own life, while a patient who refuses or discontinues treatment might not. See, e.g., Matter of Conroy, supra, at 351, 486 A. 2d, at 1224 (patients who refuse life sustaining treatment “may not harbor a specific intent to die” and may instead “fervently wish to live, but to do so free of unwanted medical technology, surgery, or drugs”); Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 743, n. 11, 370 N. E. 2d 417, 426, n. 11 (1977) (“[I]n refusing treatment the patient may not have the specific intent to die”).
The law has long used actors’ intent or purpose to distinguish between two acts that may have the same result. See, e.g., United States v. Bailey, 444 U.S. 394, 403-406 (1980) (“[T]he . . . common law of homicide often distinguishes . . . between a person who knows that another person will be killed as the result of his conduct and a person who acts with the specific purpose of taking another’s life”); Morissette v. United States, 342 U.S. 246, 250 (1952) (distinctions based on intent are “universal and persistent in mature systems of law”); M. Hale, 1 Pleas of the Crown 412 (1847) (“If A., with an intent to prevent gangrene beginning in his hand doth without any advice cut off his hand, by which he dies, he is not thereby felo de se for tho it was a voluntary act, yet it was not with an intent to kill himself”). Put differently, the law distinguishes actions taken “because of” a given end from actions taken “in spite of” their unintended but foreseen consequences. Feeney, 442 U. S., at 279; Compassion in Dying v. Washington, 79 F. 3d 790, 858 (CA9 1996) (Kleinfeld, J., dissenting) (“When General Eisenhower ordered American soldiers onto the beaches of Normandy, he knew that he was sending many American soldiers to certain death . . . . His purpose, though, was to . . . liberate Europe from the Nazis”).
Given these general principles, it is not surprising that many courts, including New York courts, have carefully distinguished refusing life sustaining treatment from suicide. See, e.g., Fosmire v. Nicoleau, 75 N. Y. 2d 218, 227, and n. 2, 551 N. E. 2d 77, 82, and n. 2 (1990) (“[M]erely declining medical . . . care is not considered a suicidal act”). [n.7] In fact, the first state court decision explicitly to authorize withdrawing lifesaving treatment noted the “real distinction between the self infliction of deadly harm and a self determination against artificial life support.” In re Quinlan, 70 N. J. 10, 43, 52, and n. 9, 355 A. 2d 647, 665, 670, and n. 9, cert. denied sub nom. Garger v. New Jersey, 429 U.S. 922 (1976). And recently, the Michigan Supreme Court also rejected the argument that the distinction “between acts that artificially sustain life and acts that artificially curtail life” is merely a “distinction without constitutional significance--a meaningless exercise in semantic gymnastics,” insisting that “the Cruzan majority disagreed and so do we.” Kevorkian, 447 Mich., at 471, 527 N. W. 2d, at 728. [n.8]
Similarly, the overwhelming majority of state legislatures have drawn a clear line between assisting suicide and withdrawing or permitting the refusal of unwanted lifesaving medical treatment by prohibiting the former and permitting the latter. Glucksberg, ante, at 4-6, 11-15. And “nearly all states expressly disapprove of suicide and assisted suicide either in statutes dealing with durable powers of attorney in health care situations, or in ‘living will’ statutes.” Kevorkian, 447 Mich., at 478-479, and nn. 53-54, 527 N. W. 2d, at 731-732, and nn. 53-54. [n.9] Thus, even as the States move to protect and promote patients’ dignity at the end of life, they remain opposed to physician assisted suicide.
New York is a case in point. The State enacted its current assisted suicide statutes in 1965. [n.10] Since then, New York has acted several times to protect patients’ common law right to refuse treatment. Act of Aug. 7, 1987, ch. 818, §1, 1987 N. Y. Laws 3140 (“Do Not Resuscitate Orders”) (codified as amended at N. Y. Pub. Health Law §§2960-2979 (McKinney 1994 and Supp. 1997)); Act of July 22, 1990, ch. 752, §2, 1990 N. Y. Laws 3547 (“Health Care Agents and Proxies”) (codified as amended at N. Y. Pub. Health Law §§2980-2994 (McKinney 1994 and Supp. 1997)). In so doing, however, the State has neither endorsed a general right to “hasten death” nor approved physician assisted suicide. Quite the opposite: The State has reaffirmed the line between “killing” and “letting die.” See N. Y. Pub. Health Law §2989(3) (McKinney 1994) (“This article is not intended to permit or promote suicide, assisted suicide, or euthanasia”); New York State Task Force on Life and the Law, Life Sustaining Treatment: Making Decisions and Appointing a Health Care Agent 36-42 (July 1987); Do Not Resuscitate Orders: The Proposed Legislation and Report of the New York State Task Force on Life and the Law 15 (Apr. 1986). More recently, the New York State Task Force on Life and the Law studied assisted suicide and euthanasia and, in 1994, unanimously recommended against legalization. When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context vii (1994). In the Task Force’s view, “allowing decisions to forego life sustaining treatment and allowing assisted suicide or euthanasia have radically different consequences and meanings for public policy.” Id., at 146.
This Court has also recognized, at least implicitly, the distinction between letting a patient die and making that patient die. In Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 261, 278 (1990), we concluded that “[t]he principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions,” and we assumed the existence of such a right for purposes of that case, id., at 279. But our assumption of a right to refuse treatment was grounded not, as the Court of Appeals supposed, on the proposition that patients have a general and abstract “right to hasten death,” 80 F. 3d, at 727-728, but on well established, traditional rights to bodily integrity and freedom from unwanted touching, Cruzan, 497 U. S., at 278-279; id., at 287-288 (O’Connor, J., concurring). In fact, we observed that “the majority of States in this country have laws imposing criminal penalties on one who assists another to commit suicide.” Id., at 280. Cruzan therefore provides no support for the notion that refusing life sustaining medical treatment is “nothing more nor less than suicide.”
For all these reasons, we disagree with respondents’ claim that the distinction between refusing lifesaving medical treatment and assisted suicide is “arbitrary” and “irrational.” Brief for Respondents 44. [n.11] Granted, in some cases, the line between the two may not be clear, but certainty is not required, even were it possible. [n.12] Logic and contemporary practice support New York’s judgment that the two acts are different, and New York may therefore, consistent with the Constitution, treat them differently. By permitting everyone to refuse unwanted medical treatment while prohibiting anyone from assisting a suicide, New York law follows a longstanding and rational distinction.
New York’s reasons for recognizing and acting on this distinction--including prohibiting intentional killing and preserving life; preventing suicide; maintaining physicians’ role as their patients’ healers; protecting vulnerable people from indifference, prejudice, and psychological and financial pressure to end their lives; and avoiding a possible slide towards euthanasia--are discussed in greater detail in our opinion in Glucksberg, ante. These valid and important public interests easily satisfy the constitutional requirement that a legislative classification bear a rational relation to some legitimate end. [n.13]
The judgment of the Court of Appeals is reversed.
It is so ordered.
1 N. Y. Penal Law §125.15 (McKinney 1987) (“Manslaughter in the second degree”) provides: “A person is guilty of manslaughter in the second degree when . . . (3) He intentionally causes or aids another person to commit suicide. Manslaughter in the second degree is a class C felony.” Section 120.30 (“Promoting a suicide attempt”) states: “A person is guilty of promoting a suicide attempt when he intentionally causes or aids another person to attempt suicide. Promoting a suicide attempt is a class E felony.” See generally, Washington v. Glucksberg, ___ U. S. ___ (1997), ante, at 4-15.
2 “It is established under New York law that a competent person may refuse medical treatment, even if the withdrawal of such treatment will result in death.” Quill v. Koppell, 870 F. Supp. 78, 84 (SDNY 1994); see N. Y. Pub. Health Law, Art. 29-B, §§2960-2979 (McKinney 1993 & Supp. 1997) (“Orders Not to Resuscitate”) (regulating right of “adult with capacity” to direct issuance of orders not to resuscitate); id., §§2980-2994 (“Health Care Agents and Proxies”) (allowing appointment of agents “to make . . . health care decisions on the principal’s behalf,” including decisions to refuse lifesaving treatment).
3 Declaration of Timothy E. Quill, M. D., App. 42-49; Declaration of Samuel C. Klagsbrun, M. D., id., at 68-74; Declaration of Howard A. Grossman, M. D., id., at 84-89; 80 F. 3d 716, 719 (CA2 1996).
4 These three patients stated that they had no chance of recovery, faced the “prospect of progressive loss of bodily function and integrity and increasing pain and suffering,” and desired medical assistance in ending their lives. App. 25-26; Declaration of William A. Barth, id., at 96-98; Declaration of George A. Kingsley, id., at 99-102; Declaration of Jane Doe, id., at 105-109.
5 The court acknowledged that because New York’s assisted suicide statutes “do not impinge on any fundamental rights [or] involve suspect classifications,” they were subject only to rational basis judicial scrutiny. 80 F. 3d, at 726-727.
6 The American Medical Association emphasizes the “fundamental difference between refusing life sustaining treatment and demanding a life ending treatment.” American Medical Association, Council on Ethical and Judicial Affairs, Physician Assisted Suicide, 10 Issues in Law & Medicine 91, 93 (1994); see also American Medical Association, Council on Ethical and Judicial Affairs, Decisions Near the End of Life, 267 JAMA 2229, 2230-2231, 2233 (1992) (“The withdrawing or withholding of life sustaining treatment is not inherently contrary to the principles of beneficence and nonmaleficence,” but assisted suicide “is contrary to the prohibition against using the tools of medicine to cause a patient’s death”); New York State Task Force on Life and the Law, When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context 108 (1994) (“[Professional organizations] consistently distinguish assisted suicide and euthanasia from the withdrawing or withholding of treatment, and from the provision of palliative treatments or other medical care that risk fatal side effects”); Brief for the American Medical Association et al. as Amici Curiae 18-25. Of course, as respondents’ lawsuit demonstrates, there are differences of opinion within the medical profession on this question. See New York Task Force, When Death is Sought, supra, at 104-109.
7 Thus, the Second Circuit erred in reading New York law as creating a “right to hasten death”; instead, the authorities cited by the court recognize a right to refuse treatment, and nowhere equate the exercise of this right with suicide. Schloendorff v. Society of New York Hospital, 211 N. Y. 125, 129-130, 105 N. E. 92, 93 (1914), which contains Justice Cardozo’s famous statement that “[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body,” was simply an informed consent case. See also Rivers v. Katz, 67 N. Y. 2d 485, 495, 495 N. E. 2d 337, 343 (1986) (right to refuse antipsychotic medication is not absolute, and may be limited when “the patient presents a danger to himself”); Matter of Storar, 52 N. Y. 2d 363, 377, n. 6, 420 N. E. 2d 64, 71, n. 6, cert. denied, 454 U.S. 858 (1981).
8 Many courts have recognized this distinction. See, e.g., Kevorkian v. Thompson, 947 F. Supp. 1152, 1178, and nn. 20-21 (ED Mich. 1997); In re Fiori, 543 Pa. 592, 602, 673 A. 2d 905, 910 (1996); Singletary v. Costello, 665 So. 2d 1099, 1106 (Fla. App. 1996); Laurie v. Senecal, 666 A. 2d 806, 808-809 (R. I. 1995); State ex rel. Schuetzle v. Vogel, 537 N. W. 2d 358, 360 (N. D. 1995); Thor v. Superior Court, 5 Cal. 4th 725, 741-742, 855 P. 2d 375, 385-386 (1993); DeGrella v. Elston, 858 S. W. 2d 698, 707 (Ky. 1993); People v. Adams, 216 Cal. App. 3d 1431, 1440, 265 Cal. Rptr. 568, 573-574 (1990); Guardianship of Jane Doe, 411 Mass. 512, 522-523, 583 N. E. 2d 1263, 1270, cert. denied sub nom. Doe v. Gross, 503 U.S. 950 (1992); In re L. W., 167 Wis. 2d 53, 83, 482 N. W. 2d 60, 71 (1992); In re Rosebush, 195 Mich. App. 675, 681, n. 2, 491 N. W. 2d 633, 636, n. 2 (1992); Donaldson v. Van de Kamp, 2 Cal. App. 4th 1614, 1619-1625, 4 Cal. Rptr. 2d 59, 61-64 (1992); In re Lawrance, 579 N. E. 2d 32, 40, n. 4 (Ind. 1991); McKay v. Bergstedt, 106 Nev. 808, 822-823, 801 P. 2d 617, 626-627 (1990); In re Browning, 568 So. 2d 4, 14 (Fla. 1990); McConnell v. Beverly Enterprises Connecticut, Inc., 209 Conn. 692, 710, 553 A. 2d 596, 605 (1989); State v. McAfee, 259 Ga. 579, 581, 385 S. E. 2d 651, 652 (1989); In re Grant, 109 Wash. 2d 545, 563, 747 P. 2d 445, 454-455 (1987); In re Gardner, 534 A. 2d 947, 955-956 (Me. 1987); Matter of Farrell, 108 N. J. 335, 349-350, 529 A. 2d 404, 411 (1987); Rasmussen v. Fleming, 154 Ariz. 207, 218, 741 P. 2d 674, 685 (1987); Bouvia v. Superior Court, 179 Cal. App. 3d 1127, 1144-1145, 225 Cal. Rptr. 297, 306 (1986); Von Holden v. Chapman, 87 App. Div. 2d 66, 70, 450 N. Y. S. 2d 623, 627 (1982); Bartling v. Superior Court, 163 Cal. App. 3d 186, 196-197, 209 Cal. Rptr. 220, 225-226 (1984); Foody v. Manchester Memorial Hospital, 40 Conn. Sup. 127, 137, 482 A. 2d 713, 720 (1984); In re P. V. W., 424 So. 2d 1015, 1022 (La. 1982); Leach v. Akron General Medical Center, 68 Ohio Misc. 1, 10, 426 N. E. 2d 809, 815 (Ohio Comm. Pleas 1980); In re Severns, 425 A. 2d 156, 161 (Del. Ch. 1980); Satz v. Perlmutter, 362 So. 2d 160, 162-163 (Fla. App. 1978); Application of the President and Directors of Georgetown College, 331 F. 2d 1000, 1009 (CADC), cert. denied, 377 U.S. 978 (1964); Brophy v. New England Sinai Hospital, 398 Mass. 417, 439, 497 N. E. 2d 626, 638 (1986). The British House of Lords has also recognized the distinction. Airedale N. H. S. Trust v. Bland, 2 W. L. R. 316, 368 (1993).
9 See Ala. Code §22-8A--10 (1990); Alaska Stat. Ann. §§18.12.080(a), (f) (1996); Ariz. Rev. Stat. Ann. §36-3210 (Supp. 1996); Ark. Code Ann. §§20-13-905(a), (f), 20-17-210(a),(g) (1991 and Supp. 1995); Cal. Health & Safety Code Ann. §§7191.5(a), (g) (West Supp. 1997); Cal. Prob. Code Ann. §4723 (West. Supp. 1997); Colo. Rev. Stat. §§15-14-504(4), 15-18-112(1), 15-18.5-101(3), 15-18.6-108 (1987 and Supp. 1996); Conn. Gen. Stat. §19a--575 (Supp. 1996); Del. Code Ann., Tit. 16, §2512 (Supp. 1996); D. C. Code Ann. §§6-2430, 21-2212 (1995 and Supp. 1996); Fla. Stat. §§765.309(1), (2) (Supp. 1997); Ga. Code Ann. §§31-32-11(b), 31-36-2(b) (1996); Haw. Rev. Stat. §327D--13 (1996); Idaho Code §39-152 (Supp. 1996); Ill. Comp. Stat., ch. 755, §§35/9(f), 40/5, 40/50, 45/2-1 (1992); Ind. Code §§16-36-1-13, 16-36-4-19, 30-5-5-17 (1994 and Supp. 1996); Iowa Code §§144A.11.1-144A.11.6, 144B.12.2 (1989 and West Supp. 1997); Kan. Stat. Ann. §65-28,109 (1985); Ky. Rev. Stat. Ann. §311.638 (Baldwin Supp. 1992); La. Rev. Stat. Ann. 40: §§1299.58.10(A), (B) (West 1992); Me. Rev. Stat. Ann., Tit. 18-A, §§5-813(b), (c) (West Supp. 1996); Mass. Gen. Laws 201D, §12 (Supp. 1997); Md. Health Code Ann. §5-611(c) (1994); Mich. Comp. Laws Ann. §700.496(20) (West 1995); Minn. Stat. §§145B.14, 145C.14 (Supp. 1997); Miss. Code Ann. §§41-41-117(2),41-41-119(1) (Supp. 1992); Mo. Rev. Stat. §§459.015.3, 459.055(5) (1992); Mont. Code Ann. §§50-9-205(1), (7), 50-10-104(1), (6) (1995); Neb. Rev. Stat. §§20-412(1), (7), 30-3401(3) (1995); N. H. Rev. Stat. Ann. §§137-H:10, 137-H:13, 137 J:1 (1996); N. J. Stat. Ann. §§26:2H--54(d), (e), 26:2H--77 (West 1996); N. M. Stat. Ann. §§24-7A--13(B)(1), (C) (Supp. 1995); N. Y. Pub. Health Law §2989(3) (1993); Nev. Rev. Stat. §449.670(2) (1996); N. C. Gen. Stat. §§90-320(b), 90-321(f) (1993); N. D. Cent. Code §§23-06.4-01, 23-06.5-01 (1991); Ohio Rev. Code Ann. §2133.12(A), (D) (Supp. 1996); Okla. Stat. Ann., Tit. 63, §§3101.2(C),3101.12(A),(G) (1996); 20 Pa. Cons. Stat. §5402(b) (Supp. 1996); R. I. Gen. Laws §§23-4.10-9(a), (f), 23-4.11-10(a), (f) (1996); S. C. Code Ann. §§44-77-130, 44-78-50(A), (C), 62-5-504(O) (Supp. 1996); S. D. Codified Laws §§34-12D--14, 34-12D--20 (1994); Tenn. Code Ann. §§32-11-110(a), 39-13-216 (Supp. 1996); Tex. Health & Safety Code Ann. §§672.017, 672.020, 672.021 (1992); Utah Code Ann. §§75-2-1116,75-2-1118 (1993); Va. Code Ann. §54.1-2990 (1994); Vt. Stat. Ann., Tit. 18, §5260 (1987); V. I. Code Ann.,Tit. 19, §§198(a), (g) (1995); Wash. Rev. Code §§70.122.070(1), 70.122.100 (Supp. 1997); W. Va. Code §§16-30-10, 16-30A--16(a), 16-30B--2(b), 16-30B--13, 16-30C--14 (1995); Wis. Stat. §§154.11(1), (6), 154.25(7), 155.70(7) (Supp. 1996); Wyo. Stat. §§3-5-211, 35-22-109, 35-22-208 (1994 & Supp. 1996). See also, 42 U.S.C. § 14402(b)(1), (2), (4) (“Assisted Suicide Funding Restriction Act of 1997”).
10 It has always been a crime, either by statute or under the common law, to assist a suicide in New York. See Marzen, O’Dowd, Crone, & Balch, Suicide: A Constitutional Right?, 24 Duquesne L. Rev. 1, 205-210 (1985) (Appendix).
11 Respondents also argue that the State irrationally distinguishes between physician assisted suicide and “terminal sedation,” a process respondents characterize as “induc[ing] barbiturate coma and then starv[ing] the person to death.” Brief for Respondents 48-50; see 80 F. 3d, at 729. Petitioners insist, however, that “ ‘[a]lthough proponents of physician assisted suicide and euthanasia contend that terminal sedation is covert physician assisted suicide or euthanasia, the concept of sedating pharmacotherapy is based on informed consent and the principle of double effect.’ “ Reply Brief for Petitioners 12 (quoting P. Rousseau, Terminal Sedation in the Care of Dying Patients, 156 Archives Internal Med. 1785, 1785-1786 (1996)). Just as a State may prohibit assisting suicide while permitting patients to refuse unwanted lifesaving treatment, it may permit palliative care related to that refusal, which may have the foreseen but unintended “double effect” of hastening the patient’s death. See New York Task Force, When Death is Sought, supra, n. 6, at 163 (“It is widely recognized that the provision of pain medication is ethically and professionally acceptable even when the treatment may hasten the patient’s death, if the medication is intended to alleviate pain and severe discomfort, not to cause death”).
12 We do not insist, as Justice Stevens suggests, ante, at 14-15 (concurring opinion), that “in all cases there will in fact be a significant difference between the intent of the physicians, the patients or the families [in withdrawal of treatment and physician assisted suicide cases].” See 6-7, supra (“[A] physician who withdraws, or honors a patient’s refusal to begin, life sustaining medical treatment purposefully intends, or may so intend, only to respect his patient’s wishes . . . . The same is true when a doctor provides aggressive palliative care; . . . the physician’s purpose and intent is, or may be, only to ease his patient’s pain”) (emphasis added). In the absence of omniscience, however, the State is entitled to act on the reasonableness of the distinction.
13 Justice Stevens observes that our holding today “does not foreclose the possibility that some applications of the New York statute may impose an intolerable intrusion on the patient’s freedom.” Ante, at 16 (concurring opinion). This is true, but, as we observe in Glucksberg, ante, at 31-32, n. 24, a particular plaintiff hoping to show that New York’s assisted suicide ban was unconstitutional in his particular case would need to present different and considerably stronger arguments than those advanced by respondents here.
certiorari to the united states court of appeals for the ninth circuit
Argued January 8, 1997
Decided June 26, 1997
It has always been a crime to assist a suicide in the State of Washington. The State’s present law makes “[p]romoting a suicide attempt” a felony, and provides: “A person is guilty of [that crime] when he knowingly causes or aids another person to attempt suicide.” Respondents, four Washington physicians who occasionally treat terminally ill, suffering patients, declare that they would assist these patients in ending their lives if not for the State’s assisted suicide ban. They, along with three gravely ill plaintiffs who have since died and a nonprofit organization that counsels people considering physician assisted suicide, filed this suit against petitioners, the State and its Attorney General, seeking a declaration that the ban is, on its face, unconstitutional. They assert a liberty interest protected by the Fourteenth Amendment’s Due Process Clause which extends to a personal choice by a mentally competent, terminally ill adult to commit physician assisted suicide. Relying primarily on Planned Parenthood of Southeastern Pa. v. Casey, 505 U.S. 833 , and Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 261 , the Federal District Court agreed, concluding that Washington’s assisted suicide ban is unconstitutional because it places an undue burden on the exercise of that constitutionally protected liberty interest. The en banc Ninth Circuit affirmed.
Held: Washington’s prohibition against “caus[ing]” or “aid[ing]” a suicide does not violate the Due Process Clause. Pp. 5-32.
(a) An examination of our Nation’s history, legal traditions, and practices demonstrates that Anglo American common law has punished or otherwise disapproved of assisting suicide for over 700 years; that rendering such assistance is still a crime in almost every State; that such prohibitions have never contained exceptions for those whowere near death; that the prohibitions have in recent years been reexamined and, for the most part, reaffirmed in a number of States; and that the President recently signed the Federal Assisted Suicide Funding Restriction Act of 1997, which prohibits the use of federal funds in support of physician assisted suicide. Pp. 5-15.
(b) In light of that history, this Court’s decisions lead to the conclusion that respondents’ asserted “right” to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause. The Court’s established method of substantive due process analysis has two primary features: First, the Court has regularly observed that the Clause specially protects those fundamental rights and liberties which are, objectively, deeply rooted in this Nation’s history and tradition. E.g., Moore v. East Cleveland, 431 U.S. 494, 503 (plurality opinion). Second, the Court has required a “careful description” of the asserted fundamental liberty interest. E.g., Reno v. Flores, 507 U.S. 292, 302 . The Ninth Circuit’s and respondents’ various descriptions of the interest here at stake--e.g., a right to “determin[e] the time and manner of one’s death,” the “right to die,” a “liberty to choose how to die,” a right to “control of one’s final days,” “the right to choose a humane, dignified death,” and “the liberty to shape death”--run counter to that second requirement. Since the Washington statute prohibits “aid[ing] another person to attempt suicide,” the question before the Court is more properly characterized as whether the “liberty” specially protected by the Clause includes a right to commit suicide which itself includes a right to assistance in doing so. This asserted right has no place in our Nation’s traditions, given the country’s consistent, almost universal, and continuing rejection of the right, even for terminally ill, mentally competent adults. To hold for respondents, the Court would have to reverse centuries of legal doctrine and practice, and strike down the considered policy choice of almost every State. Respondents’ contention that the asserted interest is consistent with this Court’s substantive due process cases, if not with this Nation’s history and practice, is unpersuasive. The constitutionally protected right to refuse lifesaving hydration and nutrition that was discussed in Cruzan, supra, at 279, was not simply deduced from abstract concepts of personal autonomy, but was instead grounded in the Nation’s history and traditions, given the common law rule that forced medication was a battery, and the long legal tradition protecting the decision to refuse unwanted medical treatment. And although Casey recognized that many of the rights and liberties protected by the Due Process Clause sound in personal autonomy, 505 U.S., at 852 , it does not follow that any and all important, intimate, and personal decisions are so protected, see San Antonio School Dist. v. Rodriguez, 411 U.S. 1, 33 -34. Casey did notsuggest otherwise. Pp. 15-24.
(c) The constitutional requirement that Washington’s assisted suicide ban be rationally related to legitimate government interests, see e.g., Heller v. Doe, 509 U.S. 312, 319 -320, is unquestionably met here. These interests include prohibiting intentional killing and preserving human life; preventing the serious public health problem of suicide, especially among the young, the elderly, and those suffering from untreated pain or from depression or other mental disorders; protecting the medical profession’s integrity and ethics and maintaining physicians’ role as their patients’ healers; protecting the poor, the elderly, disabled persons, the terminally ill, and persons in other vulnerable groups from indifference, prejudice, and psychological and financial pressure to end their lives; and avoiding a possible slide towards voluntary and perhaps even involuntary euthanasia. The relative strengths of these various interests need not be weighed exactingly, since they are unquestionably important and legitimate, and the law at issue is at least reasonably related to their promotion and protection. Pp. 24-31.
79 F. 3d 790, reversed and remanded.
Rehnquist, C. J., delivered the opinion of the Court, in which O’Connor, Scalia, Kennedy, and Thomas, JJ., joined. O’Connor, J., filed a concurring opinion, in which Ginsburg and Breyer, JJ., joined in part. Stevens, J., Souter, J., Ginsburg, J., and Breyer, J., filed opinions concurring in the judgment.
WASHINGTON, et al., PETITIONERS v. HAROLD GLUCKSBERG et al.
on writ of certiorari to the united states court of appeals for the ninth circuit
[June 26, 1997]
Chief Justice Rehnquist delivered the opinion of the Court.
The question presented in this case is whether Washington’s prohibition against “caus[ing]” or “aid[ing]” a suicide offends the Fourteenth Amendment to the United States Constitution. We hold that it does not.
It has always been a crime to assist a suicide in the State of Washington. In 1854, Washington’s first Territorial Legislature outlawed “assisting another in the commission of self murder.” [n.1] Today, Washington law provides: “A person is guilty of promoting a suicide attempt when he knowingly causes or aids another person to attempt suicide.” Wash. Rev. Code 9A.36.060(1) (1994). “Promoting a suicide attempt” is a felony, punishable by up to five years’ imprisonment and up to a $10,000 fine. §§9A.36.060(2) and 9A.20.021(1)(c). At the same time, Washington’s Natural Death Act, enacted in 1979, states that the “withholding or withdrawal of life sustaining treatment” at a patient’s direction “shall not, for any purpose, constitute a suicide.” Wash. Rev. Code §70.122.070(1). [n.2]
Petitioners in this case are the State of Washington and its Attorney General. Respondents Harold Glucksberg, M. D., Abigail Halperin, M. D., Thomas A. Preston, M. D., and Peter Shalit, M. D., are physicians who practice in Washington. These doctors occasionally treat terminally ill, suffering patients, and declare that they would assist these patients in ending their lives if not for Washington’s assisted suicide ban. [n.3] In January 1994, respondents, along with three gravely ill, pseudonymous plaintiffs who have since died and Compassion in Dying, a nonprofit organization that counsels people considering physician assisted suicide, sued in the United States District Court, seeking a declaration that Wash Rev. Code 9A.36.060(1) (1994) is, on its face, unconstitutional. Compassion in Dying v. Washington, 850 F. Supp. 1454, 1459 (WD Wash. 1994). [n.4]
The plaintiffs asserted “the existence of a libertyinterest protected by the Fourteenth Amendment which extends to a personal choice by a mentally competent, terminally ill adult to commit physician assisted suicide.” Id., at 1459. Relying primarily on Planned Parenthood v. Casey, 505 U.S. 833 (1992), and Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261 (1990), the District Court agreed, 850 F. Supp., at 1459-1462, and concluded that Washington’s assisted suicide ban is unconstitutional because it “places an undue burden on the exercise of [that] constitutionally protected liberty interest.” Id., at 1465. [n.5] The District Court also decided that the Washington statute violated the Equal Protection Clause’s requirement that “‘all persons similarly situated . . . be treated alike.’” Id., at 1466 (quoting Cleburne v. Cleburne Living Center, Inc., 473 U.S. 432, 439 (1985)).
A panel of the Court of Appeals for the Ninth Circuit reversed, emphasizing that “[i]n the two hundred and five years of our existence no constitutional right to aid in killing oneself has ever been asserted and upheld by a court of final jurisdiction.” Compassion in Dying v. Washington, 49 F. 3d 586, 591 (1995). The Ninth Circuit reheard the case en banc, reversed the panel’s decision, and affirmed the District Court. Compassion in Dying v. Washington, 79 F. 3d 790, 798 (1996). Like the District Court, the en banc Court of Appeals emphasized our Casey and Cruzan decisions. 79 F. 3d, at 813-816. The court also discussed what it described as “historical” and “current societal attitudes” toward suicide and assisted suicide, id., at 806-812, and concluded that “the Constitution encompasses a due process liberty interest in controlling the time and manner of one’s death--that there is, in short, a constitutionally recognized ‘right to die.’ “ Id., at 816. After “[w]eighing and then balancing” this interest against Washington’s various interests, the court held that the State’s assisted suicide ban was unconstitutional “as applied to terminally ill competent adults who wish to hasten their deaths with medication prescribed by their physicians.” Id., at 836, 837. [n.6] The court did not reach the District Court’s equal protection holding. Id., at 838. [n.7] We granted certiorari, 519 U. S. ___ (1996), and now reverse.
We begin, as we do in all due process cases, by examining our Nation’s history, legal traditions, and practices. See, e.g., Casey, 505 U. S., at 849-850; Cruzan, 497 U. S., at 269-279; Moore v. East Cleveland, 431 U.S. 494, 503 (1977) (plurality opinion) (noting importance of “careful ‘respect for the teachings of history’”). In almost every State--indeed, in almost every western democracy--it is a crime to assist a suicide. [n.8] The States’ assisted suicide bans are not innovations. Rather, they are longstanding expressions of the States’ commitment to the protection and preservation of all human life. Cruzan, 497 U. S., at 280 (“[T]he States--indeed, all civilized nations--demonstrate their commitment to life by treating homicide as a serious crime. Moreover, the majority of States in this country have laws imposing criminal penalties on one who assists another to commit suicide”); see Stanford v. Kentucky, 492 U.S. 361, 373 (1989) (“[T]he primary and most reliable indication of [a national] consensus is . . . the pattern of enacted laws”). Indeed, opposition to and condemnation of suicide--and, therefore, of assisting suicide--are consistent and enduring themes of our philosophical, legal, and cultural heritages. See generally, Marzen, O’Dowd, Crone & Balch, Suicide: A Constitutional Right?, 24 Duquesne L. Rev. 1, 17-56 (1985) (hereinafter Marzen); New York State Task Force on Life and the Law, When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context 77-82 (May 1994) (hereinafter New York Task Force).
More specifically, for over 700 years, the Anglo American common law tradition has punished or otherwise disapproved of both suicide and assisting suicide. [n.9] Cruzan, 497 U. S., at 294-295 (Scalia, J., concurring). In the 13th century, Henry de Bracton, one of the first legal treatise writers, observed that “[j]ust as a man may commit felony by slaying another so may he do so by slaying himself.” 2 Bracton on Laws and Customs of England 423 (f. 150) (G. Woodbine ed., S. Thorne transl., 1968). The real and personal property of one who killed himself to avoid conviction and punishment for a crime were forfeit to the king; however, thought Bracton, “if a man slays himself in weariness of life or because he is unwilling to endure further bodily pain . . . [only] his movable goods [were] confiscated.” Id., at 423-424 (f. 150). Thus, “[t]he principle that suicide of a sane person, for whatever reason, was a punishable felony was . . . introduced into English common law.” [n.10] Centuries later, Sir William Blackstone, whose Commentaries on the Laws of England not only provided a definitive summary of the common law but was also a primary legal authority for 18th and 19th century American lawyers, referred to suicide as “self murder” and “the pretended heroism, but real cowardice, of the Stoic philosophers, who destroyed themselves to avoid those ills which they had not the fortitude to endure . . . .” 4 W. Blackstone, Commentaries *189. Blackstone emphasized that “the law has . . . ranked [suicide] among the highest crimes,” ibid, although, anticipating later developments, he conceded that the harsh and shameful punishments imposed for suicide “borde[r] a little upon severity.” Id., at *190.
For the most part, the early American colonies adopted the common law approach. For example, the legislators of the Providence Plantations, which would later become Rhode Island, declared, in 1647, that “[s]elf murder is by all agreed to be the most unnatural, and it is by this present Assembly declared, to be that, wherein he that doth it, kills himself out of a premeditated hatred against his own life or other humor: . . .his goods and chattels are the king’s custom, but not his debts nor lands; but in case he be an infant, a lunatic, mad or distracted man, he forfeits nothing.” The Earliest Acts and Laws of the Colony of Rhode Island and Providence Plantations 1647-1719, p. 19 (J. Cushing ed. 1977). Virginia also required ignominious burial for suicides, and their estates were forfeit to the crown. A. Scott, Criminal Law in Colonial Virginia 108, and n. 93, 198, and n. 15 (1930).
Over time, however, the American colonies abolished these harsh common law penalties. William Penn abandoned the criminal forfeiture sanction in Pennsylvania in 1701, and the other colonies (and later, the other States) eventually followed this example. Cruzan, 497 U. S., at 294 (Scalia, J., concurring). Zephaniah Swift, who would later become Chief Justice of Connecticut, wrote in 1796 that
“[t]here can be no act more contemptible, than to attempt to punish an offender for a crime, by exercising a mean act of revenge upon lifeless clay, that is insensible of the punishment. There can be no greater cruelty, than the inflicting [of] a punishment, as the forfeiture of goods, which must fall solely on the innocent offspring of the offender. . . . [Suicide] is so abhorrent to the feelings of mankind, and that strong love of life which is implanted in the human heart, that it cannot be so frequently committed, as to become dangerous to society. There can of course be no necessity of any punishment.” 2 Z. Swift, A System of the Laws of the State of Connecticut 304 (1796).
This statement makes it clear, however, that the movement away from the common law’s harsh sanctions did not represent an acceptance of suicide; rather, as Chief Justice Swift observed, this change reflected the growing consensus that it was unfair to punish the suicide’s family for his wrongdoing. Cruzan, supra, at
294 (Scalia, J., concurring). Nonetheless, although States moved away from Blackstone’s treatment of suicide, courts continued to condemn it as a grave public wrong. See, e.g., Bigelow v. Berkshire Life Ins. Co., 93 U.S. 284, 286 (1876) (suicide is “an act of criminal self destruction”); Von Holden v. Chapman, 87 App. Div. 2d 66, 70-71, 450 N. Y. S. 2d 623, 626-627 (1982); Blackwood v. Jones, 111 Fla. 528, 532, 149 So. 600, 601 (1933) (“No sophistry is tolerated . . . which seek[s] to justify self destruction as commendable or even a matter of personal right”).
That suicide remained a grievous, though nonfelonious, wrong is confirmed by the fact that colonial and early state legislatures and courts did not retreat from prohibiting assisting suicide. Swift, in his early 19th century treatise on the laws of Connecticut, stated that “[i]f one counsels another to commit suicide, and the other by reason of the advice kills himself, the advisor is guilty of murder as principal.” 2 Z. Swift, A Digest of the Laws of the State of Connecticut 270 (1823). This was the well established common law view, see In re Joseph G., 34 Cal. 3d 429, 434-435, 667 P. 2d 1176, 1179 (1983); Commonwealth v. Mink, 123 Mass. 422, 428 (1877) (“‘Now if the murder of one’s self is felony, the accessory is equally guilty as if he had aided and abetted in the murder’”) (quoting Chief Justice Parker’s charge to the jury in Commonwealth v. Bowen, 13 Mass. 356 (1816)), as was the similar principle that the consent of a homicide victim is “wholly immaterial to the guilt of the person who cause[d] [his death],” 3 J. Stephen, A History of the Criminal Law of England 16 (1883); see 1 F. Wharton, Criminal Law §§451-452 (9th ed. 1885); Martin v. Commonwealth, 184 Va. 1009, 1018-1019, 37 S. E. 2d 43, 47 (1946) (“ ‘The right to life and to personal security is not only sacred in the estimation of the common law, but it is inalienable’ “). And the prohibitions against assisting suicide never contained exceptions for those who were near death. Rather, “[t]he life of those to whom life ha[d] become a burden--of those who [were] hopelessly diseased or fatally wounded--nay, even the lives of criminals condemned to death, [were] under the protection of law, equally as the lives of those who [were] in the full tide of life’s enjoyment, and anxious to continue to live.” Blackburn v. State, 23 Ohio St. 146, 163 (1872); see Bowen, supra, at 360 (prisoner who persuaded another to commit suicide could be tried for murder, even though victim was scheduled shortly to be executed).
The earliest American statute explicitly to outlaw assisting suicide was enacted in New York in 1828, Act of Dec. 10, 1828, ch. 20, §4, 1828 N. Y. Laws 19 (codified at 2 N. Y. Rev. Stat. pt. 4, ch. 1, tit. 2, art. 1, §7, p. 661 (1829)), and many of the new States and Territories followed New York’s example. Marzen 73-74. Between 1857 and 1865, a New York commission led by Dudley Field drafted a criminal code that prohibited “aiding” a suicide and, specifically, “furnish[ing] another person with any deadly weapon or poisonous drug, knowing that such person intends to use such weapon or drug in taking his own life.” Id., at 76-77. By the time the Fourteenth Amendment was ratified, it was a crime in most States to assist a suicide. See Cruzan, supra, at 294-295 (Scalia, J., concurring). The Field Penal Code was adopted in the Dakota Territory in 1877, in New York in 1881, and its language served as a model for several other western States’ statutes in the late 19th and early 20th centuries. Marzen 76-77, 205-206, 212-213. California, for example, codified its assisted suicide prohibition in 1874, using language similar to the Field Code’s. [n.11] In this century, the Model Penal Code also prohibited “aiding” suicide, prompting many States to enact or revise their assisted suicide bans. [n.12] The Code’s drafters observed that “the interests in the sanctity of life that are represented by the criminal homicide laws are threatened by one who expresses a willingness to participate in taking the life of another, even though the act may be accomplished with the consent, or at the request, of the suicide victim.” American Law Institute, Model Penal Code §210.5, Comment 5, p. 100 (Official Draft and Revised Comments 1980).
Though deeply rooted, the States’ assisted suicide bans have in recent years been reexamined and, generally, reaffirmed. Because of advances in medicine and technology, Americans today are increasingly likely to die in institutions, from chronic illnesses. President’s Comm’n for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life Sustaining Treatment 16-18 (1983). Public concern and democratic action are therefore sharply focused on how best to protect dignity and independence at the end of life, with the result that there have been many significant changes in state laws and in the attitudes these laws reflect. Many States, for example, now permit “living wills,” surrogate health care decisionmaking, and the withdrawal or refusal of life sustaining medical treatment. See Vacco v. Quill, post, at 9-11; 79 F. 3d, at 818-820; People v. Kevorkian, 447 Mich. 436, 478-480, and nn. 53-56, 527 N. W. 2d 714, 731-732, and nn. 53-56 (1994). At the same time, however, voters and legislators continue for the most part to reaffirm their States’ prohibitions on assisting suicide.
The Washington statute at issue in this case, Wash. Rev. Code §9A.36.060 (1994), was enacted in 1975 as part of a revision of that State’s criminal code. Four years later, Washington passed its Natural Death Act, which specifically stated that the “withholding or withdrawal of life sustaining treatment . . . shall not, for any purpose, constitute a suicide” and that “[n]othing in this chapter shall be construed to condone, authorize, or approve mercy killing . . . .” Natural Death Act, 1979 Wash. Laws, ch. 112, §§8(1), p. 11 (codified at Wash. Rev. Code §§70.122.070(1), 70.122.100 (1994)). In 1991, Washington voters rejected a ballot initiative which, had it passed, would have permitted a form of physician assisted suicide. [n.13] Washington then added a provision to the Natural Death Act expressly excluding physician assisted suicide. 1992 Wash. Laws, ch. 98, §10; Wash. Rev. Code §70.122.100 (1994).
California voters rejected an assisted suicide initiative similar to Washington’s in 1993. On the other hand, in 1994, voters in Oregon enacted, also through ballot initiative, that State’s “Death With Dignity Act,” which legalized physician assisted suicide for competent, terminally ill adults. [n.14] Since the Oregon vote, many proposals to legalize assisted suicide have been and continue to be introduced in the States’ legislatures, but none has been enacted. [n.15] And just last year, Iowa and Rhode Island joined the overwhelming majority of States explicitly prohibiting assisted suicide. See Iowa Code Ann. §§707A.2, 707A.3 (Supp. 1997); R. I. Gen. Laws §§ 11-60-1, 11-60-3 (Supp. 1996). Also, on April 30, 1997, President Clinton signed the Federal Assisted Suicide Funding Restriction Act of 1997, which prohibits the use of federal funds in support of physician assisted suicide. Pub. L. 105-12, 111 Stat. 23 (codified at 42 U.S.C. § 14401 et seq). [n.16]
Thus, the States are currently engaged in serious, thoughtful examinations of physician assisted suicide and other similar issues. For example, New York State’s Task Force on Life and the Law--an ongoing, blue ribbon commission composed of doctors, ethicists, lawyers, religious leaders, and interested laymen--was convened in 1984 and commissioned with “a broad mandate to recommend public policy on issues raised by medical advances.” New York Task Force vii. Over the past decade, the Task Force has recommended laws relating to end of life decisions, surrogate pregnancy, and organ donation. Id., at 118-119. After studying physician assisted suicide, however, the Task Force unanimously concluded that “[l]egalizing assisted suicide and euthanasia would pose profound risks to many individuals who are ill and vulnerable. . . . [T]he potential dangers of this dramatic change in public policy would outweigh any benefit that might be achieved.” Id., at 120.
Attitudes toward suicide itself have changed since Bracton, but our laws have consistently condemned, and continue to prohibit, assisting suicide. Despite changes in medical technology and notwithstanding an increased emphasis on the importance of end of life decisionmaking, we have not retreated from this prohibition. Against this backdrop of history, tradition, and practice, we now turn to respondents’ constitutional claim.
The Due Process Clause guarantees more than fair process, and the “liberty” it protects includes more than the absence of physical restraint. Collins v. Harker Heights, 503 U.S. 115, 125 (1992) (Due Process Clause “protects individual liberty against ‘certain government actions regardless of the fairness of the procedures used to implement them’ “) (quoting Daniels v. Williams, 474 U.S. 327, 331 (1986)). The Clause also provides heightened protection against government interference with certain fundamental rights and liberty interests. Reno v. Flores, 507 U.S. 292, 301-302 (1993); Casey, 505 U. S., at 851. In a long line of cases, we have held that, in addition to the specific freedoms protected by the Bill of Rights, the “liberty” specially protected by the Due Process Clause includes the rights to marry, Loving v. Virginia, 388 U.S. 1 (1967); to have children, Skinner v. Oklahoma ex rel. Williamson, 316 U.S. 535 (1942); to direct the education and upbringing of one’s children, Meyer v. Nebraska, 262 U.S. 390 (1923); Pierce v. Society of Sisters, 268 U.S. 510 (1925); to marital privacy, Griswold v. Connecticut, 381 U.S. 479 (1965); to use contraception, ibid; Eisenstadt v. Baird, 405 U.S. 438 (1972); to bodily integrity, Rochin v. California, 342 U.S. 165 (1952), and to abortion, Casey, supra. We have also assumed, and strongly suggested, that the Due Process Clause protects the traditional right to refuse unwanted lifesaving medical treatment. Cruzan, 497 U. S., at 278-279.
But we “ha[ve] always been reluctant to expand the concept of substantive due process because guideposts for responsible decisionmaking in this unchartered area are scarce and open ended.” Collins, 503 U. S., at 125. By extending constitutional protection to an asserted right or liberty interest, we, to a great extent, place the matter outside the arena of public debate and legislative action. We must therefore “exercise the utmost care whenever we are asked to break new ground in this field,” ibid, lest the liberty protected by the Due Process Clause be subtly transformed into the policy preferences of the members of this Court, Moore, 431 U. S., at 502 (plurality opinion).
Our established method of substantive due process analysis has two primary features: First, we have regularly observed that the Due Process Clause specially protects those fundamental rights and liberties which are, objectively, “deeply rooted in this Nation’s history and tradition,” id., at 503 (plurality opinion); Snyder v. Massachusetts, 291 U.S. 97, 105 (1934) (“so rooted in the traditions and conscience of our people as to be ranked as fundamental”), and “implicit in the concept of ordered liberty,” such that “neither liberty nor justice would exist if they were sacrificed,” Palko v. Connecticut, 302 U.S. 319, 325, 326 (1937). Second, we have required in substantive due process cases a “careful description” of the asserted fundamental liberty interest. Flores, supra, at 302; Collins, supra, at 125; Cruzan, supra, at 277-278. Our Nation’s history, legal traditions, and practices thus provide the crucial “guideposts for responsible decisionmaking,” Collins, supra, at 125, that direct and restrain our exposition of the Due Process Clause. As we stated recently in Flores, the Fourteenth Amendment “forbids the government to infringe . . . ‘fundamental’ liberty interests at all, no matter what process is provided, unless the infringement is narrowly tailored to serve a compelling state interest.” 507 U. S., at 302.
Justice Souter, relying on Justice Harlan’s dissenting opinion in Poe v. Ullman, would largely abandon this restrained methodology, and instead ask “whether [Washington’s] statute sets up one of those ‘arbitrary impositions’ or ‘purposeless restraints’ at odds with the Due Process Clause of the Fourteenth Amendment,” post, at 1 (quoting Poe, 367 U.S. 497, 543 (1961) (Harlan, J., dissenting)). [n.17] In our view, however, the development of this Court’s substantive due process jurisprudence, described briefly above, supra, at 15, has been a process whereby the outlines of the “liberty” specially protected by the Fourteenth Amendment--never fully clarified, to be sure, and perhaps not capable of being fully clarified--have at least been carefully refined by concrete examples involving fundamental rights found to be deeply rooted in our legal tradition. This approach tends to rein in the subjective elements that are necessarily present in due process judicial review. In addition, by establishing a threshold requirement--that a challenged state action implicate a fundamental right--before requiring more than a reasonable relation to a legitimate state interest to justify the action, it avoids the need for complex balancing of competing interests in every case.
Turning to the claim at issue here, the Court of Appeals stated that “[p]roperly analyzed, the first issue to be resolved is whether there is a liberty interest in determining the time and manner of one’s death,” 79 F. 3d, at 801, or, in other words, “[i]s there a right to die?,” id., at 799. Similarly, respondents assert a “liberty to choose how to die” and a right to “control of one’s final days,” Brief for Respondents 7, and describe the asserted liberty as “the right to choose a humane, dignified death,” id., at 15, and “the liberty to shape death,” id., at 18. As noted above, we have a tradition of carefully formulating the interest at stake in substantive due process cases. For example, although Cruzan is often described as a “right to die” case, see 79 F. 3d, at 799; post, at 9 (Stevens, J., concurring in judgment) (Cruzan recognized “the more specific interest in making decisions about how to confront an imminent death”), we were, in fact, more precise: we assumed that the Constitution granted competent persons a “constitutionally protected right to refuse lifesaving hydration and nutrition.” Cruzan, 497 U. S., at 279; id., at 287 (O’Connor, J., concurring) (“[A] liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions”). The Washington statute at issue in this case prohibits “aid[ing] another person to attempt suicide,” Wash. Rev. Code §9A.36.060(1) (1994), and, thus, the question before us is whether the “liberty” specially protected by the Due Process Clause includes a right to commit suicide which itself includes a right to assistance in doing so. [n.18]
We now inquire whether this asserted right has any place in our Nation’s traditions. Here, as discussed above, supra, at 4-15, we are confronted with a consistent and almost universal tradition that has long rejected the asserted right, and continues explicitly to reject it today, even for terminally ill, mentally competent adults. To hold for respondents, we would have to reverse centuries of legal doctrine and practice, and strike down the considered policy choice of almost every State. See Jackman v. Rosenbaum Co., 260 U.S. 22, 31 (1922) (“If a thing has been practiced for two hundred years by common consent, it will need a strong case for the Fourteenth Amendment to affect it”); Flores, 507 U. S., at 303 (“The mere novelty of such a claim is reason enough to doubt that ‘substantive due process’ sustains it”).
Respondents contend, however, that the liberty interest they assert is consistent with this Court’s substantive due process line of cases, if not with this Nation’s history and practice. Pointing to Casey and Cruzan, respondents read our jurisprudence in this area as reflecting a general tradition of “self sovereignty,” Brief of Respondents 12, and as teaching that the “liberty” protected by the Due Process Clause includes “basic and intimate exercises of personal autonomy,” id., at 10; see Casey, 505 U. S., at 847 (“It is a promise of the Constitution that there is a realm of personal liberty which the government may not enter”). According to respondents, our liberty jurisprudence, and the broad, individualistic principles it reflects, protects the “liberty of competent, terminally ill adults to make end of life decisions free of undue government interference.” Brief for Respondents 10. The question presented in this case, however, is whether the protections of the Due Process Clause include a right to commit suicide with another’s assistance. With this “careful description” of respondents’ claim in mind, we turn to Casey and Cruzan.
In Cruzan, we considered whether Nancy Beth Cruzan, who had been severely injured in an automobile accident and was in a persistive vegetative state, “ha[d] a right under the United States Constitution which would require the hospital to withdraw life sustaining treatment” at her parents’ request. Cruzan, 497 U. S., at 269. We began with the observation that “[a]t common law, even the touching of one person by another without consent and without legal justification was a battery.” Ibid. We then discussed the related rule that “informed consent is generally required for medical treatment.” Ibid. After reviewing a long line of relevant state cases, we concluded that “the common law doctrine of informed consent is viewed as generally encompassing the right of a competent individual to refuse medical treatment.” Id., at 277. Next, we reviewed our own cases on the subject, and stated that “[t]he principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions.” Id., at 278. Therefore, “for purposes of [that] case, we assume[d] that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition.” Id., at 279; see id., at 287 (O’Connor, J., concurring). We concluded that, notwithstanding this right, the Constitution permitted Missouri to require clear and convincing evidence of an incompetent patient’s wishes concerning the withdrawal of life sustaining treatment. Id., at 280-281.
Respondents contend that in Cruzan we “acknowledged that competent, dying persons have the right to direct the removal of life sustaining medical treatment and thus hasten death,” Brief for Respondents 23, and that “the constitutional principle behind recognizing the patient’s liberty to direct the withdrawal of artificial life support applies at least as strongly to the choice to hasten impending death by consuming lethal medication,” id., at 26. Similarly, the Court of Appeals concluded that “Cruzan, by recognizing a liberty interest that includes the refusal of artificial provision of life sustaining food and water, necessarily recognize[d] a liberty interest in hastening one’s own death.” 79 F. 3d, at 816.
The right assumed in Cruzan, however, was not simply deduced from abstract concepts of personal autonomy. Given the common law rule that forced medication was a battery, and the long legal tradition protecting the decision to refuse unwanted medical treatment, our assumption was entirely consistent with this Nation’s history and constitutional traditions. The decision to commit suicide with the assistance of another may be just as personal and profound as the decision to refuse unwanted medical treatment, but it has never enjoyed similar legal protection. Indeed, the two acts are widely and reasonably regarded as quite distinct. See Quill v. Vacco, post, at 5-13. In Cruzan itself, we recognized that most States outlawed assisted suicide--and even more do today--and we certainly gave no intimation that the right to refuse unwanted medical treatment could be somehow transmuted into a right to assistance in committing suicide. 497 U. S., at 280.
Respondents also rely on Casey. There, the Court’s opinion concluded that “the essential holding of Roe v. Wade should be retained and once again reaffirmed.” Casey, 505 U. S., at 846. We held, first, that a woman has a right, before her fetus is viable, to an abortion “without undue interference from the State”; second, that States may restrict post-viability abortions, so long as exceptions are made to protect a woman’s life and health; and third, that the State has legitimate interests throughout a pregnancy in protecting the health of the woman and the life of the unborn child. Ibid. In reaching this conclusion, the opinion discussed in some detail this Court’s substantive due process tradition of interpreting the Due Process Clause to protect certain fundamental rights and “personal decisions relating to marriage, procreation, contraception, family relationships, child rearing, and education,” and noted that many of those rights and liberties “involv[e] the most intimate and personal choices a person may make in a lifetime.” Id., at 851.
The Court of Appeals, like the District Court, found Casey “‘highly instructive’” and “‘almost prescriptive’” for determining “‘what liberty interest may inhere in a terminally ill person’s choice to commit suicide’”:
“Like the decision of whether or not to have an abortion, the decision how and when to die is one of ‘the most intimate and personal choices a person may make in a lifetime,’ a choice ‘central to personal dignity and autonomy.’ “ 79 F. 3d, at 813-814.
Similarly, respondents emphasize the statement in Casey that:
“At the heart of liberty is the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life. Beliefs about these matters could not define the attributes of personhood were they formed under compulsion of the State.” Casey, 505 U. S., at 851.
Brief for Respondents 12. By choosing this language, the Court’s opinion in Casey described, in a general way and in light of our prior cases, those personal activities and decisions that this Court has identified as so deeply rooted in our history and traditions, or so fundamental to our concept of constitutionally ordered liberty, that they are protected by the Fourteenth Amendment. [n.19] The opinion moved from the recognition that liberty necessarily includes freedom of conscience and belief about ultimate considerations to the observation that “though the abortion decision may originate within the zone of conscience and belief, it is more than a philosophic exercise.” Casey, 505 U. S., at 852 (emphasis added). That many of the rights and liberties protected by the Due Process Clause sound in personal autonomy does not warrant the sweeping conclusion that any and all important, intimate, and personal decisions are so protected, San Antonio Independent School Dist. v. Rodriguez, 411 U.S. 1, 33-35 (1973), and Casey did not suggest otherwise.
The history of the law’s treatment of assisted suicide in this country has been and continues to be one of the rejection of nearly all efforts to permit it. That being the case, our decisions lead us to conclude that the asserted “right” to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause. The Constitution also requires, however, that Washington’s assisted suicide ban be rationally related to legitimate government interests. See Heller v. Doe, 509 U.S. 312, 319-320 (1993); Flores, 507 U. S., at 305. This requirement is unquestionably met here. As the court below recognized, 79 F. 3d, at 816-817, [n.20] Washington’s assisted suicide ban implicates a number of state interests. [n.21] See 49 F. 3d, at 592-593; Brief for State of California et al. as Amici Curiae 26-29; Brief for United States as Amicus Curiae 16-27.
First, Washington has an “unqualified interest in the preservation of human life.” Cruzan, 497 U. S., at 282. The State’s prohibition on assisted suicide, like all homicide laws, both reflects and advances its commitment to this interest. See id., at 280; Model Penal Code §210.5, Comment 5, at 100 (“[T]he interests in the sanctity of life that are represented by the criminal homicide laws are threatened by one who expresses a willingness to participate in taking the life of another”). [n.22] This interest is symbolic and aspirational as well as practical:
“While suicide is no longer prohibited or penalized, the ban against assisted suicide and euthanasia shores up the notion of limits in human relationships. It reflects the gravity with which we view the decision to take one’s own life or the life of another, and our reluctance to encourage or promote these decisions.” New York Task Force 131-132.
Respondents admit that “[t]he State has a real interest in preserving the lives of those who can still contribute to society and enjoy life.” Brief for Respondents 35, n. 23. The Court of Appeals also recognized Washington’s interest in protecting life, but held that the “weight” of this interest depends on the “medical condition and the wishes of the person whose life is at stake.” 79 F. 3d, at 817. Washington, however, has rejected this sliding scale approach and, through its assisted suicide ban, insists that all persons’ lives, from beginning to end, regardless of physical or mental condition, are under the full protection of the law. See United States v. Rutherford, 442 U.S. 544, 558 (1979) (“. . . Congress could reasonably have determined to protect the terminally ill, no less than other patients, from the vast range of self styled panaceas that inventive minds can devise”). As we have previously affirmed, the States “may properly decline to make judgments about the ‘quality’ of life that a particular individual may enjoy,” Cruzan, 497 U. S., at 282. This remains true, as Cruzan makes clear, even for those who are near death.
Relatedly, all admit that suicide is a serious public health problem, especially among persons in otherwise vulnerable groups. See Washington State Dept. of Health, Annual Summary of Vital Statistics 1991, pp. 29-30 (Oct. 1992) (suicide is a leading cause of death in Washington of those between the ages of 14 and 54); New York Task Force 10, 23-33 (suicide rate in the general population is about one percent, and suicide is especially prevalent among the young and the elderly). The State has an interest in preventing suicide, and in studying, identifying, and treating its causes. See 79 F. 3d, at 820; id., at 854 (Beezer, J., dissenting) (“The state recognizes suicide as a manifestation of medical and psychological anguish”); Marzen 107-146.
Those who attempt suicide--terminally ill or not--often suffer from depression or other mental disorders. See New York Task Force 13-22, 126-128 (more than 95% of those who commit suicide had a major psychiatric illness at the time of death; among the terminally ill, uncontrolled pain is a “risk factor” because it contributes to depression); Physician Assisted Suicide and Euthanasia in the Netherlands: A Report of Chairman Charles T. Canady to the Subcommittee on the Constitution of the House Committee on the Judiciary, 104th Cong., 2d Sess., 10-11 (Comm. Print 1996); cf. Back, Wallace, Starks, & Pearlman, Physician Assisted Suicide and Euthanasia in Washington State, 275 JAMA 919, 924 (1996) (“[I]ntolerable physical symptoms are not the reason most patients request physician assisted suicide or euthanasia”). Research indicates, however, that many people who request physician assisted suicide withdraw that request if their depression and pain are treated. H. Hendin, Seduced by Death: Doctors, Patients and the Dutch Cure 24-25 (1997) (suicidal, terminally ill patients “usually respond well to treatment for depressive illness and pain medication and are then grateful to be alive”); New York Task Force 177-178. The New York Task Force, however, expressed its concern that, because depression is difficult to diagnose, physicians and medical professionals often fail to respond adequately to seriously ill patients’ needs. Id., at 175. Thus, legal physician assisted suicide could make it more difficult for the State to protect depressed or mentally ill persons, or those who are suffering from untreated pain, from suicidal impulses.
The State also has an interest in protecting the integrity and ethics of the medical profession. In contrast to the Court of Appeals’ conclusion that “the integrity of the medical profession would [not] be threatened in any way by [physician assisted suicide],” 79 F. 3d, at 827, the American Medical Association, like many other medical and physicians’ groups, has concluded that “[p]hysician assisted suicide is fundamentally incompatible with the physician’s role as healer.” American Medical Association, Code of Ethics §2.211 (1994); see Council on Ethical and Judicial Affairs, Decisions Near the End of Life, 267 JAMA 2229, 2233 (1992) (“[T]he societal risks of involving physicians in medical interventions to cause patients’ deaths is too great”); New York Task Force 103-109 (discussing physicians’ views). And physician assisted suicide could, it is argued, undermine the trust that is essential to the doctor patient relationship by blurring the time honored line between healing and harming. Assisted Suicide in the United States, Hearing before the Subcommittee on the Constitution of the House Committee on the Judiciary, 104th Cong., 2d Sess., 355-356 (1996) (testimony of Dr. Leon R. Kass) (“The patient’s trust in the doctor’s whole hearted devotion to his best interests will be hard to sustain”).
Next, the State has an interest in protecting vulnerable groups--including the poor, the elderly, and disabled persons--from abuse, neglect, and mistakes. The Court of Appeals dismissed the State’s concern that disadvantaged persons might be pressured into physician assisted suicide as “ludicrous on its face.” 79 F. 3d, at 825. We have recognized, however, the real risk of subtle coercion and undue influence in end of life situations. Cruzan, 497 U. S., at 281. Similarly, the New York Task Force warned that “[l]egalizing physician assisted suicide would pose profound risks to many individuals who are ill and vulnerable. . . . The risk of harm is greatest for the many individuals in our society whose autonomy and well being are already compromised by poverty, lack of access to good medical care, advanced age, or membership in a stigmatized social group.” New York Task Force 120; see Compassion in Dying, 49 F. 3d, at 593 (“[A]n insidious bias against the handicapped--again coupled with a cost saving mentality--makes them especially in need of Washington’s statutory protection”). If physician assisted suicide were permitted, many might resort to it to spare their families the substantial financial burden of end of life health care costs.
The State’s interest here goes beyond protecting the vulnerable from coercion; it extends to protecting disabled and terminally ill people from prejudice, negative and inaccurate stereotypes, and “societal indifference.” 49 F. 3d, at 592. The State’s assisted suicide ban reflects and reinforces its policy that the lives of terminally ill, disabled, and elderly people must be no less valued than the lives of the young and healthy, and that a seriously disabled person’s suicidal impulses should be interpreted and treated the same way as anyone else’s. See New York Task Force 101-102; Physician Assisted Suicide and Euthanasia in the Netherlands: A Report of Chairman Charles T. Canady, at 9, 20 (discussing prejudice toward the disabled and the negative messages euthanasia and assisted suicide send to handicapped patients).
Finally, the State may fear that permitting assisted suicide will start it down the path to voluntary and perhaps even involuntary euthanasia. The Court of Appeals struck down Washington’s assisted suicide ban only “as applied to competent, terminally ill adults who wish to hasten their deaths by obtaining medication prescribed by their doctors.” 79 F. 3d, at 838. Washington insists, however, that the impact of the court’s decision will not and cannot be so limited. Brief for Petitioners 44-47. If suicide is protected as a matter of constitutional right, it is argued, “every man and woman in the United States must enjoy it.” Compassion in Dying, 49 F. 3d, at 591; see Kevorkian, 447 Mich., at 470, n. 41, 527 N. W. 2d, at 727-728, n. 41. The Court of Appeals’ decision, and its expansive reasoning, provide ample support for the State’s concerns. The court noted, for example, that the “decision of a duly appointed surrogate decision maker is for all legal purposes the decision of the patient himself,” 79 F. 3d, at 832, n. 120; that “in some instances, the patient may be unable to self administer the drugs and . . . administration by the physician . . . may be the only way the patient may be able to receive them,” id., at 831; and that not only physicians, but also family members and loved ones, will inevitably participate in assisting suicide. Id., at 838, n. 140. Thus, it turns out that what is couched as a limited right to “physician assisted suicide” is likely, in effect, a much broader license, which could prove extremely difficult to police and contain. [n.23] Washington’s ban on assisting suicide prevents such erosion.
This concern is further supported by evidence about the practice of euthanasia in the Netherlands. The Dutch government’s own study revealed that in 1990, there were 2,300 cases of voluntary euthanasia (defined as “the deliberate termination of another’s life at his request”), 400 cases of assisted suicide, and more than 1,000 cases of euthanasia without an explicit request. In addition to these latter 1,000 cases, the study found an additional 4,941 cases where physicians administered lethal morphine overdoses without the patients’ explicit consent. Physician Assisted Suicide and Euthanasia in the Netherlands: A Report of Chairman Charles T. Canady, at 12-13 (citing Dutch study). This study suggests that, despite the existence of various reporting procedures, euthanasia in the Netherlands has not been limited to competent, terminally ill adults who are enduring physical suffering, and that regulation of the practice may not have prevented abuses in cases involving vulnerable persons, including severely disabled neonates and elderly persons suffering from dementia. Id., at 16-21; see generally C. Gomez, Regulating Death: Euthanasia and the Case of the Netherlands (1991); H. Hendin, Seduced By Death: Doctors, Patients, and the Dutch Cure (1997). The New York Task Force, citing the Dutch experience, observed that “assisted suicide and euthanasia are closely linked,” New York Task Force 145, and concluded that the “risk of . . . abuse is neither speculative nor distant,” id., at 134. Washington, like most other States, reasonably ensures against this risk by banning, rather than regulating, assisting suicide. See United States v. 12 200-ft Reels of Super 8MM Film, 413 U.S. 123, 127 (1973) (“Each step, when taken, appear[s] a reasonable step in relation to that which preceded it, although the aggregate or end result is one that would never have been seriously considered in the first instance”).
We need not weigh exactingly the relative strengths of these various interests. They are unquestionably important and legitimate, and Washington’s ban on assisted suicide is at least reasonably related to their promotion and protection. We therefore hold that Wash. Rev. Code §9A.36.060(1) (1994) does not violate the Fourteenth Amendment, either on its face or “as applied to competent, terminally ill adults who wish to hasten their deaths by obtaining medication prescribed by their doctors.” 79 F. 3d, at 838. [n.24]
* * *
Throughout the Nation, Americans are engaged in an earnest and profound debate about the morality, legality, and practicality of physician assisted suicide. Our holding permits this debate to continue, as it should in a democratic society. The decision of the en banc Court of Appeals is reversed, and the case is remanded for further proceedings consistent with this opinion.
It is so ordered.
1 Act of Apr. 28, 1854, §17, 1854 Wash. Laws 78 (“Every person deliberately assisting another in the commission of self murder, shall be deemed guilty of manslaughter”); see also Act of Dec. 2, 1869, §17, 1869 Wash. Laws 201; Act of Nov. 10, 1873, §19, 1873 Wash. Laws 184; Criminal Code, ch. 249, §§135-136, 1909 Wash. Laws, 11th sess., 929.
2 Under Washington’s Natural Death Act, “adult persons have the fundamental right to control the decisions relating to the rendering of their own health care, including the decision to have life sustaining treatment withheld or withdrawn in instances of a terminal condition or permanent unconscious condition.” Wash. Rev. Code §70.122.010 (1994). In Washington, “[a]ny adult person may execute a directive directing the withholding or withdrawal of life sustaining treatment in a terminal condition or permanent unconscious condition,” §70.122.030, and a physician who, in accordance with such a directive, participates in the withholding or withdrawal of life sustaining treatment is immune from civil, criminal, or professional liability. §70.122.051.
3 Glucksberg Declaration, App. 35; Halperin Declaration, id., at 49-50; Preston Declaration, id., at 55-56; Shalit Declaration, id., at 73-74.
4 John Doe, Jane Roe, and James Poe, plaintiffs in the District Court, were then in the terminal phases of serious and painful illnesses. They declared that they were mentally competent and desired assistance in ending their lives. Declaration of Jane Roe, id., at 23-25; Declaration of John Doe, id., at 27-28; Declaration of James Poe, id., at 30-31; Compassion in Dying, 850 F. Supp., at 1456-1457.
5 The District Court determined that Casey’s “undue burden” standard, 505 U. S., at 874 (joint opinion), not the standard from United States v. Salerno, 481 U.S. 739, 745 (1987) (requiring a showing that “no set of circumstances exists under which the [law] would be valid”), governed the plaintiffs’ facial challenge to the assisted suicide ban. 850 F. Supp., at 1462-1464.
6 Although, as Justice Stevens observes, post, at 2-3 (opinion concurring in judgment), “[the court’s] analysis and eventual holding that the statute was unconstitutional was not limited to a particular set of plaintiffs before it,” the court did note that “[d]eclaring a statute unconstitutional as applied to members of a group is atypical but not uncommon.” 79 F. 3d, at 798, n. 9, and emphasized that it was “not deciding the facial validity of [the Washington statute],” id., at 797-798, and nn. 8-9. It is therefore the court’s holding that Washington’s physician assisted suicide statute is unconstitutional as applied to the “class of terminally ill, mentally competent patients,” post, at 14 (Stevens, J., concurring in judgment), that is before us today.
7 The Court of Appeals did note, however, that “the equal protection argument relied on by [the District Court] is not insubstantial,” 79 F. 3d., at 838, n. 139, and sharply criticized the opinion in a separate case then pending before the Ninth Circuit, Lee v. Oregon, 891 F. Supp. 1429 (Ore. 1995) (Oregon’s Death With Dignity Act, which permits physician assisted suicide, violates the Equal Protection Clause because it does not provide adequate safeguards against abuse), vacated, Lee v. Oregon, 107 F. 3d 1382 (CA9 1997) (concluding that plaintiffs lacked Article III standing). Lee, of course, is not before us, any more than it was before the Court of Appeals below, and we offer no opinion as to the validity of the Lee courts’ reasoning. In Vacco v. Quill, post, however, decided today, we hold that New York’s assisted suicide ban does not violate the Equal Protection Clause.
8 See Compassion in Dying v. Washington, 79 F. 3d 790, 847, and nn. 10-13 (CA9 1996) (Beezer, J., dissenting) (“In total, forty four states, the District of Columbia and two territories prohibit or condemn assisted suicide”) (citing statutes and cases); Rodriguez v. British Columbia (Attorney General), 107 D. L. R. (4th) 342, 404 (Can. 1993) (“[A] blanket prohibition on assisted suicide . . . is the norm among western democracies”) (discussing assisted suicide provisions in Austria, Spain, Italy, the United Kingdom, the Netherlands, Denmark, Switzerland, and France). Since the Ninth Circuit’s decision, Louisiana, Rhode Island, and Iowa have enacted statutory assisted suicide bans. La. Rev. Stat. Ann. §14:32.12 (Supp. 1997); R. I. Gen. Laws §§11-60-1, 11-60-3 (Supp. 1996); Iowa Code Ann. §§707A.2, 707A.3 (Supp. 1997). For a detailed history of the States’ statutes, see Marzen, O’Dowd, Crone & Balch, Suicide: A Constitutional Right?, 24 Duquesne L. Rev. 1, 148-242 (1985) (Appendix) (hereinafter Marzen).
9 The common law is thought to have emerged through the expansion of pre-Norman institutions sometime in the 12th century. J. Baker, An Introduction to English Legal History 11 (2d ed. 1979). England adopted the ecclesiastical prohibition on suicide five centuries earlier, in the year 673 at the Council of Hereford, and this prohibition was reaffirmed by King Edgar in 967. See G. Williams, The Sanctity of Life and the Criminal Law 257 (1957).
10 Marzen 59. Other late medieval treatise writers followed and restated Bracton; one observed that “man slaughter” may be “[o]f [one]self; as in case, when people hang themselves or hurt themselves, or otherwise kill themselves of their own felony” or “[o]f others; as by beating, famine, or other punishment; in like cases, all are man slayers.” A. Horne, The Mirrour of Justices, ch. 1, §9, pp. 41-42 (W. Robinson ed. 1903). By the mid 16th century, the Court at Common Bench could observe that “[suicide] is an Offence against Nature, against God, and against the King. . . . [T]o destroy one’s self is contrary to Nature, and a Thing most horrible.” Hales v. Petit, 1 Plowd. Com. 253, 261, 75 Eng. Rep. 387, 400 (1561-1562).
In 1644, Sir Edward Coke published his Third Institute, a lodestar for later common lawyers. See T. Plucknett, A Concise History of the Common Law 281-284 (5th ed. 1956). Coke regarded suicide as a category of murder, and agreed with Bracton that the goods and chattels--but not, for Coke, the lands--of a sane suicide were forfeit. 3 E. Coke, Institutes *54. William Hawkins, in his 1716 Treatise of the Pleas of the Crown, followed Coke, observing that “our laws have always had . . . an abhorrence of this crime.” 1 W. Hawkins, Pleas of the Crown, ch. 27, §4, p. 164 (T. Leach ed. 1795).
11 In 1850, the California legislature adopted the English common law, under which assisting suicide was, of course, a crime. Act of Apr. 13, 1850, ch. 95, 1850 Cal. Stats. 219. The provision adopted in 1874 provided that “[e]very person who deliberately aids or advises, or encourages another to commit suicide, is guilty of a felony.” Act of Mar. 30, 1874, ch. 614, §13, 400, 255 (codified at Cal. Penal Code §400 (T. Hittel ed. 1876)).
12 %A person who purposely aids or solicits another to commit suicide is guilty of a felony in the second degree if his conduct causes such suicide or an attempted suicide, and otherwise of a misdemeanor.” American Law Institute, Model Penal Code §210.5(2) (Official Draft and Revised Comments 1980).
13 Initiative 119 would have amended Washington’s Natural Death Act, Wash. Rev. Code §70.122.010 et seq. (1994), to permit “aid in dying”, defined as “aid in the form of a medical service provided in person by a physician that will end the life of a conscious and mentally competent qualified patient in a dignified, painless and humane manner, when requested voluntarily by the patient through a written directive in accordance with this chapter at the time the medical service is to be provided.” App. H to Pet. for Cert. 3-4.
14 Ore. Rev. Stat. §§127.800 et seq. (1996); Lee v. Oregon, 891 F. Supp. 1429 (Ore. 1995) (Oregon Act does not provide sufficient safeguards for terminally ill persons and therefore violates the Equal Protection Clause), vacated, Lee v. Oregon, 107 F. 3d 1382 (CA9 1997).
15 See, e.g., Alaska H. B. 371 (1996); Ariz. S. B. 1007 (1996); Cal. A. B. 1080, A. B. 1310 (1995); Colo. H. B. 1185 (1996); Colo. H. B. 1308 (1995); Conn. H. B. 6298 (1995); Ill. H. B. 691, S. B. 948 (1997); Me. H. P. 663 (1997); Me. H. P. 552 (1995); Md. H. B. 474 (1996); Md. H. B. 933 (1995); Mass. H. B. 3173 (1995); Mich. H. B. 6205 (1996); Mich. S. B. 556 (1996); Mich. H. B. 4134 (1995); Miss. H. B. 1023 (1996); N. H. H. B. 339 (1995); N. M. S. B. 446 (1995); N. Y. S. B. 5024 (1995); N. Y. A. B. 6333 (1995); Neb. L. B. 406 (1997); Neb. L. B. 1259 (1996); R. I. S. 2985 (1996); Vt. H. B. 109 (1997); Vt. H. B. 335 (1995); Wash. S. B. 5596 (1995); Wis. A. B. 174, S. B. 90 (1995); Senate of Canada, Of Life and Death, Report of the Special Senate Committee on Euthanasia and Assisted Suicide
A--156 (June 1995) (describing unsuccessful proposals, between 1991-1994, to legalize assisted suicide).
16 Other countries are embroiled in similar debates: The Supreme Court of Canada recently rejected a claim that the Canadian Charter of Rights and Freedoms establishes a fundamental right to assisted suicide, Rodriguez v. British Columbia (Attorney General), 107 D. L. R. (4th) 342 (1993); the British House of Lords Select Committee on Medical Ethics refused to recommend any change in Great Britain’s assisted suicide prohibition, House of Lords, Session 1993-94 Report of the Select Committee on Medical Ethics, 12 Issues in Law & Med. 193, 202 (1996) (“We identify no circumstances in which assisted suicide should be permitted”); New Zealand’s Parliament rejected a proposed “Death With Dignity Bill” that would have legalized physician assisted suicide in August 1995, Graeme, MPs Throw out Euthanasia Bill, The Dominion (Wellington), Aug. 17, 1995, p. 1; and the Northern Territory of Australia legalized assisted suicide and voluntary euthanasia in 1995. See Shenon, Australian Doctors Get Right to Assist Suicide, N.Y. Times, July 28, 1995, p. A8. As of February 1997, three persons had ended their lives with physician assistance in the Northern Territory. Mydans, Assisted Suicide: Australia Faces a Grim Reality, N. Y. Times, Febr. 2, 1997, p. A3. On March 24, 1997, however, the Australian Senate voted to overturn the Northern Territory’s law. Thornhill, Australia Repeals Euthanasia Law, Washington Post, March 25, 1997, p. A14; see Euthanasia Laws Act 1997, No. 17, 1997 (Austl.). On the other hand, on May 20, 1997, Colombia’s Constitutional Court legalized voluntary euthanasia for terminally ill people. Sentencia No. C 239/97 (Corte Constitucional, Mayo 20, 1997); see Colombia’s Top Court Legalizes Euthanasia, Orlando Sentinel, May 22, 1997, p. A18.
17 In Justice Souter’s opinion, Justice Harlan’s Poe dissent supplies the “modern justification” for substantive due process review. Post, at 5, and n. 2 (Souter, J., concurring in judgment). But although Justice Harlan’s opinion has often been cited in due process cases, we have never abandoned our fundamental rights based analytical method. Just four Terms ago, six of the Justices now sitting joined the Court’s opinion in Reno v. Flores, 507 U.S. 292, 301-305 (1993); Poe was not even cited. And in Cruzan, neither the Court’s nor the concurring opinions relied on Poe; rather, we concluded that the right to refuse unwanted medical treatment was so rooted in our history, tradition, and practice as to require special protection under the Fourteenth Amendment. Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 261, 278-279 (1990); id., at 287-288 (O’Connor, J., concurring). True, the Court relied on Justice Harlan’s dissent in Casey, 505 U. S., at 848-850, but, as Flores demonstrates, we did not in so doing jettison our established approach. Indeed, to read such a radical move into the Court’s opinion in Casey would seem to fly in the face of that opinion’s emphasis on stare decisis. 505 U. S., at 854-869.
18 See, e.g., Quill v. Vacco, 80 F. 3d 716, 724 (CA2 1996) (“right to assisted suicide finds no cognizable basis in the Constitution’s language or design”); Compassion in Dying v. Washington, 49 F. 3d 586, 591 (CA9 1995) (referring to alleged “right to suicide,” “right to assistance in suicide,” and “right to aid in killing oneself”); People v. Kevorkian, 447 Mich. 436, 476, n. 47, 527 N. W. 2d 714, 730, n. 47 (1994) (“[T]he question that we must decide is whether the [C]onstitution encompasses a right to commit suicide and, if so, whether it includes a right to assistance”).
19 See Moore v. East Cleveland, 431 U.S. 494, 503 (1977) (“[T]he Constitution protects the sanctity of the family precisely because the institution of the family is deeply rooted in this Nation’s history and tradition”) (emphasis added); Griswold v. Connecticut, 381 U.S. 479, 485-486 (1965) (intrusions into the “sacred precincts of marital bedrooms” offend rights “older than the Bill of Rights”); id., at 495-496 (Goldberg, J., concurring) (the law in question “disrupt[ed] the traditional relation of the family--a relation as old and as fundamental as our entire civilization”); Loving v. Virginia, 388 U.S. 1, 12 (1967) (“The freedom to marry has long been recognized as one of the vital personal rights essential to the orderly pursuit of happiness”); Turner v. Safley, 482 U.S. 78, 95 (1987) (“[T]he decision to marry is a fundamental right”); Roe v. Wade, 410 U.S. 113, 140 (1973) (stating that at the Founding and throughout the 19th century, “a woman enjoyed a substantially broader right to terminate a pregnancy”); Skinner v. Oklahoma ex rel. Williamson, 316 U.S. 535, 541 (1942) (“Marriage and procreation are fundamental”); Pierce v. Society of Sisters, 268 U.S. 510, 535 (1925); Meyer v. Nebraska, 262 U.S. 390, 399 (1923) (liberty includes “those privileges long recognized at common law as essential to the orderly pursuit of happiness by free men”).
20 The court identified and discussed six state interests: (1) preserving life; (2) preventing suicide; (3) avoiding the involvement of third parties and use of arbitrary, unfair, or undue influence; (4) protecting family members and loved ones; (5) protecting the integrity of the medical profession; and (6) avoiding future movement toward euthanasia and other abuses. 79 F. 3d, at 816-832.
21 Respondents also admit the existence of these interests, Brief for Respondents 28-39, but contend that Washington could better promote and protect them through regulation, rather than prohibition, of physician assisted suicide. Our inquiry, however, is limited to the question whether the State’s prohibition is rationally related to legitimate state interests.
22 The States express this commitment by other means as well:
“[N]early all states expressly disapprove of suicide and assisted suicide either in statutes dealing with durable powers of attorney in health care situations, or in ‘living will’ statutes. In addition, all states provide for the involuntary commitment of persons who may harm themselves as the result of mental illness, and a number of states allow the use of nondeadly force to thwart suicide attempts.” People v. Kevorkian, 447 Mich., at 478-479, and nn. 53-56, 527 N. W. 2d, at 731-732, and nn. 53-56.
23 Justice Souter concludes that “[t]he case for the slippery slope is fairly made out here, not because recognizing one due process right would leave a court with no principled basis to avoid recognizing another, but because there is a plausible case that the right claimed would not be readily containable by reference to facts about the mind that are matters of difficult judgment, or by gatekeepers who are subject to temptation, noble or not.” Post, at 36-37 (opinion concurring in judgment). We agree that the case for a slippery slope has been made out, but--bearing in mind Justice Cardozo’s observation of “[t]he tendency of a principle to expand itself to the limit of its logic,” The Nature of the Judicial Process 51 (1932)--we also recognize the reasonableness of the widely expressed skepticism about the lack of a principled basis for confining the right. See Brief for United States as Amicus Curiae 26 (“Once a legislature abandons a categorical prohibition against physician assisted suicide, there is no obvious stopping point”); Brief for Not Dead Yet et al. as Amici Curiae 21-29; Brief for Bioethics Professors as Amici Curiae 23-26; Report of the Council on Ethical and Judicial Affairs, App. 133, 140 (“[I]f assisted suicide is permitted, then there is a strong argument for allowing euthanasia”); New York Task Force 132; Kamisar, The “Right to Die”: On Drawing (and Erasing) Lines, 35 Duquesne L. Rev. 481 (1996); Kamisar, Against Assisted Suicide--Even in a Very Limited Form, 72 U. Det. Mercy L. Rev. 735 (1995).
24 Justice Stevens states that “the Court does conceive of respondents’ claim as a facial challenge--addressing not the application of the statute to a particular set of plaintiffs before it, but the constitutionality of the statute’s categorical prohibition . . . .” Post, at 4 (opinion concurring in judgment). We emphasize that we today reject the Court of Appeals’ specific holding that the statute is unconstitutional “as applied” to a particular class. See n. 6, supra. Justice Stevens agrees with this holding, see post, at 14, but would not “foreclose the possibility that an individual plaintiff seeking to hasten her death, or a doctor whose assistance was sought, could prevail in a more particularized challenge,” ibid. Our opinion does not absolutely foreclose such a claim. However, given our holding that the Due Process Clause of the Fourteenth Amendment does not provide heightened protection to the asserted liberty interest in ending one’s life with a physician’s assistance, such a claim would have to be quite different from the ones advanced by respondents here.