Compassion in Dying v. Washington , 49 F.3d 586 ( 1995 )

Opinion by Judge NOONAN; Dissent by Judge WRIGHT.

NOONAN, Circuit Judge:

The State of Washington (Washington) appeals the decision of the district court holding unconstitutional Washington’s statute on promoting a suicide attempt. Finding no basis for concluding that the statute violates the Constitution, we reverse the district court.

The Statute

The challenged statute reads as follows:

Promoting a suicide attempt

(1) A person is guilty of promoting a suicide attempt when he knowingly causes or aids another person to attempt suicide.

(2) Promoting a suicide is a Class C felony. Wash.Rev.Code 9A.36.060.

The Plaintiffs

Compassion in Dying is a nonprofit incorporated in the state of Washington. Its avowed purpose is to assist persons described by it as “competent” and “terminally ill” to hasten their deaths by providing them information, counselling, and emotional support but not by administering fatal medication.

Three individuals were plaintiffs in their own right. Their identities are cloaked by an order permitting them to litigate under pseudonyms. They are now deceased. Jane Roe was a 69-year-old physician, suffering from cancer; she had been bedridden for seven months at the time the suit was brought and died before judgment was entered by the district court. John Doe was a 44-year-old artist, who was partially blind at the time of suit and was also suffering from AIDS; he had been advised that his disease was incurable; he died prior to judgment. James Poe was a 69-year-old patient suffering from chronic obstructive pulmonary disease; he was connected to an oxygen tank at all times. He died after judgment but prior to the hearing of this appeal.

Four physicians also joined the suit asserting their own rights and those of their patients. Harold Glucksberg has specialized in the care of cancer since 1985 and is a clinical assistant professor at the University of Washington School of Medicine. According to his sworn declaration, he “occasionally” encounters patients whom he believes he should assist in terminating their fives, but does not because of the statute; he refers to two such patients, both deceased. Abigail Halpern is the medical director of Uptown Family Practice in Seattle and serves as a clinical faculty member at the University of Washington School of Medicine. In her practice, according to her sworn declaration, she “occasionally” treats patients dying of cancer or AIDS, whose death she believes she should hasten but does not because of the statute; she refers to one such patient, now deceased. Thomas A. Preston is chief of cardiology at Pacific Medical Center in Seattle and professor of Medicine at the University of Washington School of Medicine. According to his sworn declaration, he “occasionally” treats patients whose death he believes he should hasten but does not on account of the statute; he refers to one such patient, now deceased. Peter Shalit is in private practice in Seattle and the medical director of the Seattle Gay Clinic; he is a clinical instructor at the University of Washington School of Medicine. According to his sworn declaration, he “occasionally” treats patients whose death he believes he should hasten, but does not on account of the statute; he refers to one such patient, now deceased.

PROCEEDINGS

On January 29,1994, the plaintiffs brought suit against Washington, seeking a declaration that the statute violated 42 U.S.C. § 1983 and the Constitution of the United States; additionally, they asked that enforcement of the statute be enjoined.

The plaintiffs introduced the declarations of the physicians already noted, together with declarations from the executive director of Compassion in Dying and from Jane Roe, John Doe, and James Poe. They also introduced the sworn declaration of John P. Gey-man, who had served from 1976 through 1990 as professor and chairman of the Department of Family Medicine at the School of Medicine of the University of Washington and is now engaged in rural practice at Friday Harbor. According to him, there is “often a severe adverse emotional and psychological effect” on patients unable because of the statute to broach the subject of their desire to hasten their deaths or who do broach the subject and are rebuffed.

The plaintiffs moved for summary judgment, and the defendants made a cross-motion for summary judgment. On May 3, 1994, the district court ruled on these motions. It denied the motion of the four physician plaintiffs asserting their own claims “on the grounds that the basis for those claims has not been adequately addressed.” It denied Compassion in Dying’s claim- on its own behalf “for the same reason.” It denied the cross-motion of Washington. It granted the motion for summary judgment of Jane Roe, John Doe and James Poe and' the similar motion of the physician plaintiffs “on behalf of their terminally ill patients.” The court declined to enjoin enforcement of the statute but declared the statute to violate the Constitution of the United States:

The district court reached its conclusion as to unconstitutionally on two grounds. First, the court held that the statute violated the liberty guaranteed by the Fourteenth Amendment against deprivation by a state. The court reached this conclusion by noting “a long line of cases” protecting “personal decisions relating to marriage, procreation, contraception, family relationships, child rearing and education.” The court quoted as the explanation of this line the statement made in Planned Parenthood v. Casey, — U.S. —, —, 112 S.Ct. 2791, 2807, 120 L.Ed.2d 674 (1992): “These matters, including the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment. 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.”

The district court analogized the “terminally ill person’s choice to commit suicide” to the choice of abortion protected by Casey, stating: “this court finds the reasoning in Casey highly instructive and almost prescriptive.” Like the abortion decision, the court found the decision by a terminally ill person to end his or her life to be one of the most intimate and personal that could be made in a lifetime and a choice central to personal autonomy and dignity.

The district court also found Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990) to be “instructive.” It quoted that ease’s reference to “the recognition of a general liberty interest in refusing medical treatment,” Cruzan at 278, 110 S.Ct. at 2851, and the assumption for purposes of the decision in Cru-zan “that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition.” Id. at 279, 110 S.Ct. at 2852. The district court stated that it did not believe that a distinction of constitutional significance could be drawn “between refusing life-sustaining medical treatment and physician-assisted suicide by an uncoerced, mentally competent, terminally ill adult.” Combining its exegesis of Casey and Cruzan, the district court reached its conclusion that there was a constitutional right to physician-assisted suicide.

The district court then reviewed the statute to determine whether, on its face, it imposed an “undue burden” on a personal right of the Casey kind. See Casey, — U.S. at —, 112 S.Ct. at 2830 (concluding that a statute regulating abortion was invalid on its face because “in a large fraction of the cases” in which the statute would operate it would “operate as a substantial obstacle to a woman’s choice to undergo an abortion” and therefore placed “an undue burden”). The district court declared that there was “no question” that the “total ban” on physician-assisted suicide for the terminally ill was “an undue burden” on the constitutional right that the district court had discovered. Consequently, the statute was invalid.

Secondly, the district court held that the statute violated the Equal Protection Clause of the Fourteenth Amendment, requiring that all similarly situated persons be treated alike. Washington law, enacted in 1992, provides: “Any adult person may execute a directive directing the withholding or withdrawal of life-sustaining treatment in a terminal condition or permanent unconscious condition.” Wash.Rev.Code 70.122.030. Any physician who participates in good faith “in the withholding or withdrawal of life-sustaining treatment” in accordance with such a directive is immune from civil or criminal or professional liability. Id. 70.122.051. The district court could see no constitutional distinction between the terminally ill able to direct the withdrawal or withholding of life support and the terminally ill seeking medical aid to end their lives. Accordingly, it found an unequal application of the laws.

Washington appeals.

ANALYSIS

The conclusion of the district court that the statute deprived the plaintiffs of a liberty protected by the Fourteenth Amendment and denied them the equal protection of the laws cannot be sustained.

First. The language taken from Casey, on which the district court pitched its principal argument, should not be removed from the context in which it was uttered. Any reader of judicial opinions knows they often attempt a generality of expression and a sententiousness of phrase that extend far beyond the problem addressed. It is commonly accounted an error to lift sentences or even paragraphs out of one context and insert the abstracted thought into a wholly different context. To take three sentences out of an opinion over thirty pages in length dealing with the highly charged subject of abortion and to find these sentences “almost prescriptive” in ruling on a statute proscribing the promotion of suicide is to make an enormous leap, to do violence to the context, and to ignore the differences between the regulation of reproduction and the prevention of the promotion of killing a patient at his or her request.

The inappropriateness of the language of Casey in the situation of assisted suicide is confirmed by considering what this language, as applied by the district court, implies. The decision to choose death, according to the district court’s use of Casey’s terms, involves “personal dignity and autonomy” and “the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life.” The district court attempted to tie these concepts to the decision of a person terminally ill. But there is no way of doing so. The category created is inherently unstable. The depressed twenty-one year old, the romantically-devastated twenty-eight year old, the alcoholic forty-year old who choose suicide are also expressing their views of the existence, meaning, the universe, and life; they are also asserting their personal liberty. If at the heart of the liberty protected by the Fourteenth Amendment is this uncurtailable ability to believe and to act on one’s deepest beliefs about life, the right to suicide and the right to assistance in suicide are the prerogative of at least every sane adult. The attempt to restrict such rights to the. terminally ill is illusory. If such liberty exists in this context, as Casey asserted in the context of reproductive rights, every man and woman in the United States must enjoy it. See Yale Kamisar, “Are Laws Against Assisted Suicide Unconstitutional?” 23 Hastings Center Report 32, 36-37 (May-June 1993). The conclusion is a reductio ad absurdum.

Second. While Casey was not about suicide at all, Cruzan was about the termination of life. The district court found itself unable to distinguish between a patient refusing life support and a patient seeking medical help to bring about death and therefore interpreted Cruzan’s limited acknowledgment of a right to refuse treatment as tantamount to an acceptance of a terminally ill patient’s right to aid in self-killing. The district court ignored the far more relevant part of the opinion in Cruzan that “there can be no gainsaying” a state’s interest “in the protection and preservation of human life” and, as evidence of that legitimate concern, the fact that “the majority of States in this country have laws imposing criminal penalties on one who assists another to commit suicide.” Cruzan, 497 U.S. at 280, 110 S.Ct. at 2852. Whatever difficulty the district court experienced in distinguishing one situation from the other, it was not experienced by the majority in Cru-zan.

Third. Unsupported by the gloss on “liberty” written by Casey, a gloss on a gloss, inasmuch as Casey developed an interpretation of “liberty” first elaborated in Eisenstadt v. Baird, 405 U.S. 438, 453, 92 S.Ct. 1029, 1038, 31 L.Ed.2d 349 (1972), and implicitly controverted by Cruzan, the decision of the district court lacks foundation in recent precedent. It also lacks foundation in the traditions of our nation. See Snyder v. Massachusetts, 291 U.S. 97, 105, 54 S.Ct. 330, 332, 78 L.Ed. 674 (1934) (Cardozo, J.); Lochner v. New York, 198 U.S. 45, 76, 25 S.Ct. 539, 547, 49 L.Ed. 937 (1905) (Holmes, J., dissenting). In 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. Unless the federal judiciary is to be a floating constitutional convention, a federal court should not invent a constitutional right unknown to the past and antithetical to' the defence of human life that has been a chief responsibility of our constitutional government.

Fourth. The district court extrapolated from Casey to hold the statute invalid on its face. That extrapolation, like the quotation from Casey, was an unwarranted extension of abortion jurisprudence, often unique, to a very different field. The normal rulé — the rule that governs here — is that a facial challenge to a statute “must establish that ho set of circumstances exists under which the Act would be valid.” United States v. Salerno, 481 U.S. 739, 745, 107 S.Ct. 2095, 2100, 95 L.Ed.2d 697 (1987). The district court indeed conceded that there were circumstances in which the statute could operate constitutionally,- for example to deter suicide by teenagers or to prevent fraud upon the elderly. The district court did not even attempt the calculation carried out in Casey to show that in “a large fraction of the cases” the statute would operate unconstitutionally. From the declarations before it the district court had at most the opinion of several physicians that they “occasionally” met persons whom the statute affected detrimentally and their recitation of five case histories. There was no effort made to pom-pare this number with the number of persons whose lives were guarded by the statute. The facial invalidation of the statute was wholly unwarranted.

Fifth. The district court declared the statute unconstitutional on its face without adequate consideration of Washington’s interests that, individually and convergently, outweigh any alleged liberty of suicide. The most comprehensive study of our subject by a governmental body is When Death Is Sought. Assisted Suicide and Euthanasia in the Medical Context (1994). The study was conducted by the New York State Task Force, a commission appointed by Governor Cuomo in 1985, which filed its report in May, 1994. The Task Force was composed of twenty-four members representing a broad spectrum of ethical and religious views and ethical, health, legal, and medical competencies. Its membership disagreed on the morality of suicide. Unanimously the members agreed against recommending a change in New York law to permit assisted suicide. Washington’s interest in preventing such suicides is as strong as the interests that moved this diverse commission to its unanimous conclusion. A Michigan commission, set up in 1992, by majority vote in June 1994 recommended legislative change in the Michigan law against assisted suicide and set out a proposed new statute as a legislative option; the commission did not challenge the constitutionality of the existing Michigan legislation. Michigan Commission on Death and Dying, Final Report (1994). Neither the New York nor the Michigan reports were available to the district court. We take them into account on this appeal as we take into account the legal and medical articles cited by the parties and amici as representative professional judgments, in this area of law. In the light of all these materials, Washington’s interests are at least these:

1.The interest in not having.physicians in the role of killers of their patients. “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer,” declares the American Medical Association’s Code of Medical Ethics (1994) § 2.211. From the Hippocratic Oath with its promise “to do no harm,” see T.L. Beauchamp and J.F. Childress, Principles of Biomedical Ethics (1993) 330, to the AMA’s code, the ethics of the medical profession have proscribed killing. Washington has an interest in preserving the integrity of the physician’s practice as understood by physicians.

Not only would the self-understanding of physicians be affected by removal of the state’s support for their professional stance; the physician’s constant search for ways to combat disease would be affected, if killing were as acceptable an option for the physician as curing. See Alexander M. Capron, “Euthanasia in the Netherlands: American Observations,” 22 Hastings Center Report 30, 32 (Mar.-Apr.1992). The physician’s commitment to curing is the medical profession’s commitment to medical progress. Medically-assisted suicide as an acceptable alternative is a blind alley; Washington has a stake in barring it.

2. The interest in not subjecting the elderly and even the not-elderly but infirm to psychological pressure to consent to their own deaths. For all medical treatments, physicians decide which patients are the candidates. If assisted suicide was acceptable professional practice, physicians would make a judgment as to who was a good candidate for it. Physician neutrality and patient autonomy, independent of their physician’s advice, are largely myths. Most patients do what their doctors recommend. As an eminent commission concluded, “Once the physician suggests suicide or euthanasia, some patients will feel that they have few, if any alternatives, but to accept the recommendation.” New York State Task Force, When Death Is Sought, 122. Washington has an interest in preventing such persuasion.

3. The interest in protecting the poor and minorities from exploitation. The poor and minorities would be especially open to manipulation in a regime of assisted suicide for two reasons: Pain is a significant factor in creating a desire for assisted suicide, and the poor and minorities are notoriously less provided for in the alleviation of pain. Id. at 100. The desire to reduce the cost of public assistance by quickly terminating a prolonged illness cannot be ignored: “the cost of treatment is viewed as relevant to decisions at the bedside.” Id. at 129. Convergently, the reduction of untreated (although treatable) pain and economic logic would make the poorest the primest candidates for physician-assisted and physician-recommended suicide.

4. The interest in protecting all of the handicapped from societal indifference and antipathy. Among the many briefs we have received from amici curiae there is one on behalf of numerous residents of nursing homes and long-term care facilities. The vulnerability of such persons to physician-assisted suicide is foreshadowed in the discriminatory way that a seriously-disabled person’s expression of a desire to die is interpreted. When the nondisabled say they want to die, they are labelled as suicidal; if they are disabled, it is treated as “natural” or “reasonable”. See Carol J. Gill, “Suicide Intervention for Persons with Disabilities: A Lesson in Inequality,” 8 Issues in Law & Med. 37, 38-39 (1993). In the climate of our achievement-oriented society, “simply offering the option of ‘self-deliverance’ shifts a burden of proof, so that helpless patients must ask themselves why they are not availing themselves of it.” Richard Doerflinger, “Assisted Suicide: Pro-choice or Anti-Life,?” 19 Hastings Center Report S. 16, S. 17 (Jan-Feb.1989). An insidious bias against the handicapped — again coupled with a cost-saving mentality — makes them especially in need of Washington’s statutory protection.

5. An interest in preventing abuse similar to what has occurred in the Netherlands where, since 1984, legal guidelines have tacitly allowed assisted suicide or euthanasia in response to a repeated request from a suffering, competent patient. In 1990, approximately 1.8 per cent of all deaths resulted from this practice. At least an additional .8 percent of all deaths, and arguably more, come from direct measures taken to end the person’s life without a contemporaneous request to end it. New York State Task Force, When Death Is Sought, 133-134.

Sixth. The scope of the district court’s judgment is; perhaps necessarily, indefinite. The judgment of the district court was entered in favor of Jane Roe and John Doe although they were dead. This unheard-of judgment was a nullity. The judgment in favor of James Poe lapsed with his death pending appeal. The judgment in favor of Doctors Glucksberg, Halperin, Preston and Shalit was “insofar as they raise claims On behalf of their terminally ill patients.” No such patients were identified by these doctors except patients who were already deceased. Presumably, then, the judgment was behalf of terminally ill patients that these doctors might encounter in the future. The term “terminally ill” was not defined by the court. No class was certified by the court. There is a good deal of uncertainty on whose behalf the judgment was entered.

It was suggested in argument that a definition of the terminally ill could be supplied from the Washington statute on the refusal of life-sustaining treatment which does define “terminal condition.” Wash.Rev.Code 70.122.020(9). There are three difficulties: “terminal condition” and “terminally ill” are different terms; the examples given by the plaintiffs show considerable variation in whom they considered terminally ill to be; there is wide disagreement in definition of the terminally ill among the states. See New York State Task Force, When Death Is Sought, 23-35. Life itself is a terminal condition, unless terminal condition is otherwise defined by a specific statute. A terminal illness can vary from a sickness causing death in days or weeks to cancer, which Dr. Glucksberg notes is “very slow” in its deadly impact, to a heart condition which Dr. Preston notes can be relieved by a transplant, to AIDS, which Dr. Shalit declares is fatal once contracted. One can only guess which definition of the terminally ill would satisfy the constitutional criteria of the district court. Consequently, an amorphous class of beneficiaries has been created in this non-class action; and the district court has mandated Washington to reform its law against the promotion of. suicide to safeguard the constitutional rights of persons whom the district court has not identified.

Seventh. At the heart of the district court’s decision appears to be its refusal to distinguish between actions taking life and actions by which life is not supported or ceases to be supported. This refusal under-girds the district court’s reading of Cruzan as well as its holding that the statute violates equal protection. The distinction, being drawn by the legislature not on the basis of race, gender or religion or membership in any protected class and not infringing any fundamental constitutional right, must be upheld unless the plaintiffs can show “that the legislature’s actions were irrational.” Kadrmas v. Dickinson Public Schools, 487 U.S. 450, 458, 108 S.Ct. 2481, 2487, 101 L.Ed.2d 399 (1988). The plaintiffs have not sustained this burden.

Against the broad background of moral experience that everyone acquires, the law of torts and the law of criminal offenses against the person have developed. “At common law, even the touching of one person by another without consent and without legal justification was a battery.” Cruzan, 497 U.S. at 269, 110 S.Ct. at 2846. The physician’s medical expertness is not a license to inflict medical procedures against your will. Protected by the law of torts, you can have or reject such medical treatment as you see fit. You can be left alone if you want. Privacy in the primordial sense in which it entered constitutional parlance — “the right to be let alone”—is yours. See Olmstead v. United States, 277 U.S. 438, 478, 48 S.Ct. 564, 572, 72 L.Ed. 944 (1928) (Brandéis, J., dissenting).

Tort law and criminal law have never recognized a right to let others enslave you, mutilate you, or kill you. When you assert a claim that another — and especially another licensed by the state — should help you bring about your death, you ask for more than being let alone; you ask that the state, in protecting its own interest, not prevent its licensee from killing. The difference is not of degree but of kind. You no longer seek the ending of unwanted medical attention. You seek the right to have a second person collaborate in your death. To protect all the interests enumerated under Fifth above, the statute rightly and reasonably draws the line.

Compassion, according to the reflections of Prince Myshkin, is “the most important, perhaps the sole law of human existence.” Feodor Dostoevsky, The Idiot, 292 (Alan Myers, trans.) (1991). In the vernacular, compassion is trumps. No one can read the accounts of the sufferings of the deceased plaintiffs supplied by their declarations, or the accounts of the sufferings of their patients supplied by the physicians, without being moved by them. No one would inflict such sufferings on another or want them inflicted on himself; and since the horrors recounted are those that could attend the end of life anyone who reads of them must be aware that they could be attendant on his own death. The desire to have a good and kind way of forestalling them is understandably evident in the declarations of the plaintiffs and in the decision of the district court.

Compassion is a proper, desirable, even necessary component of judicial character; but compassion is not the most important, certainly not the sole law of human existence. Unrestrained by other virtues, as The Idiot illustrates, it leads to catastrophe. Justice, prudence, and fortitude are necessary too. Compassion cannot be the compass of a federal judge. That compass is the Constitution of the United States. Where, as here in the case of Washington, the statute of a state comports with that compass, the validity of the statute must be upheld.

For all the foregoing reasons, the judgment appealed from is REVERSED.