Caseflicks

Supreme Court of the United States • 1997

Vacco v. Quill

521 U.S. 793

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Takeaway

In short, this case holds that equal protection permits a State to allow patients to refuse unwanted life-sustaining treatment while prohibiting physician-assisted suicide, because the State may rationally distinguish letting a disease cause death from intentionally causing death.

Background

New York made it a crime to intentionally cause or aid another person’s suicide, including by prescribing lethal medication. At the same time, New York recognized that a competent patient could refuse unwanted life-sustaining treatment, even when refusal would result in death.

Three physicians and several terminally ill patients challenged the assisted-suicide prohibition. They argued that patients dependent on life-support equipment could hasten death by directing the withdrawal of treatment, while similarly situated terminally ill patients who were not on such equipment could not obtain a physician’s help in ending their lives. They claimed that this difference violated the Fourteenth Amendment’s Equal Protection Clause.

The District Court rejected the claim, reasoning that New York could rationally distinguish allowing a disease to take its course from intentionally using a death-producing device. The Second Circuit reversed. It concluded that withdrawing life support was effectively assisted suicide and that the State lacked a rational basis for permitting one means of hastening death while prohibiting the other. The Supreme Court granted review and reversed the Second Circuit.

Issues

Issue #1

Whether New York’s prohibition on assisting suicide required heightened equal-protection scrutiny because it burdened a fundamental right or classified persons in a suspect manner.

Holding

No. The statutes were subject to rational-basis review.

Reasoning

The Equal Protection Clause generally requires States to treat like cases alike, but it does not itself create substantive rights. A law that neither burdens a fundamental right nor draws a suspect classification is constitutional so long as it bears a rational relation to a legitimate governmental end.

New York’s prohibition applied to everyone: no person could assist another’s suicide, regardless of physical condition. Likewise, every competent person could refuse unwanted life-sustaining treatment. The Court’s companion decision in Washington v. Glucksberg established that physician-assisted suicide was not a fundamental right, and the challenged laws did not target a suspect class. They therefore carried a strong presumption of validity.

Issue #2

Whether New York violated equal protection by allowing competent patients to refuse life-sustaining treatment while prohibiting physicians from assisting suicide.

Holding

No. New York could rationally treat withdrawal or refusal of treatment differently from physician-assisted suicide.

Reasoning

The Second Circuit’s contrary conclusion depended on treating withdrawal of life support as simply another form of assisted suicide. The Supreme Court rejected that premise. The distinction between letting a patient decline treatment and affirmatively helping cause death was longstanding in legal doctrine, medical ethics, and state legislation.

The Court relied first on causation. When a patient refuses life-sustaining treatment, the patient dies from the underlying disease or pathology. When a patient takes lethal medication supplied for the purpose of death, the medication itself causes death. New York could reasonably regard those events as materially different.

The Court also relied on intent. A physician who honors a refusal of treatment may intend to respect the patient’s bodily integrity and to stop futile or unwanted intervention. A physician who provides medication for suicide must intend that the patient die. Similarly, a patient may reject invasive or unwanted treatment without specifically intending death, whereas a patient who takes prescribed lethal medication necessarily intends to end life.

That same distinction explains why New York may permit aggressive palliative care even when pain medication foreseeably risks hastening death. In that setting, the physician’s purpose may be pain relief rather than causing death. The law commonly distinguishes an act undertaken because of a result from one undertaken despite a foreseeable but unintended result.

New York’s line between killing and letting die served legitimate interests: preserving life, preventing suicide, maintaining the physician’s role as healer, protecting vulnerable people from pressure or abuse, and avoiding movement toward euthanasia. Those interests easily satisfied rational-basis review, even if difficult cases at the margins might make the line imperfect.

Concurrences

Justice Souter

Reasoning

Justice Souter concurred only in the judgment. Consistent with his separate opinion in Washington v. Glucksberg, he did not conclude that assisted suicide was a fundamental right, but he regarded the patients’ and physicians’ claims as highly important and believed they required a correspondingly substantial justification.

In his view, the reasons showing that a general prohibition on assisted suicide was not arbitrary under due process analysis also justified New York’s distinction between prohibited assistance to suicide and permitted practices such as ending artificial life support or providing pain medication that may hasten death.

Justice O'Connor

Reasoning

Justice O'Connor joined the Court's result, but justice O’Connor joined the Court’s judgment and emphasized that the case did not require the Court to decide whether a mentally competent, terminally ill person enduring great suffering has a constitutionally protected interest in controlling the circumstances of an imminent death.

She stressed that the record did not show New York barred a dying patient from receiving medication adequate to relieve severe pain merely because the medication might risk hastening death. Thus, the facial challenge to New York’s assisted-suicide prohibition did not resolve whether a State could constitutionally deny palliative care in a particular case.

Justice Stevens

Reasoning

Justice Stevens agreed that the broad facial challenge failed, but he cautioned against treating the Court’s holding as a complete answer to every end-of-life claim. In his view, the strength of the patient’s liberty interest and the State’s interests may vary substantially with the patient’s condition, level of suffering, prognosis, and ability to make an informed decision.

He therefore understood the judgment to leave open the possibility that a particular application of New York’s statute could impose an intolerable intrusion on a patient’s freedom. A future plaintiff, however, would need to present a more concrete and substantially stronger claim than the general challenge before the Court.

Justice Ginsburg

Reasoning

Justice Ginsburg concurred in the judgment substantially for the reasons set out in Justice O’Connor’s separate opinion. She did not read the Court’s rejection of a general right to physician-assisted suicide as foreclosing all possible constitutional questions involving relief from a terminally ill patient’s severe suffering.

Justice Breyer

Reasoning

Justice Breyer concurred in the judgment but did not treat the case as requiring a final determination whether the asserted liberty interest should be labeled fundamental. He considered the relevant interest more narrowly: a competent terminally ill patient’s interest in avoiding severe physical pain and suffering.

Because the cases did not establish that New York denied adequate palliative medication, he agreed that the patients had not shown that the State’s general prohibition was unconstitutional. He nevertheless understood the judgment to leave open an as-applied challenge if a State effectively prevented a dying patient from obtaining medication needed to relieve extreme pain.