Vacco v. Quill

Respondents, physicians operating in New York and gravelly-ill patients (who had died prior to the appeal), asserted that, though it was consistent with the standards of medical practice 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 [were] deterred from doing so by New York’s ban on assisting suicide.” Respondents claimed that because New York permits a competent person to refuse life-sustaining medical treatment and because refusal of such treatment is basically the same thing as physician-assisted suicide, the specific ban on assisted suicide violated the Equal Protection Clause of the Fourteenth Amendment.

The District Court had found for the petitioners, noting the difference between allowing nature to take its course and artificially inducing death, but the Court of Appeals for the Second Circuit reversed, stating that “’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 situation, except for the previous attachment of life-sustaining equipment, are not allowed to hasten death by self-administering prescribed drugs.’” The Court of Appeals determined such unequal treatment was not rationally related to any legitimate state interest.

The court held that New York’s prohibition on assisting suicide does not violate the Equal Protection Clause of the Fourteenth Amendment.

The Court noted that, on its face, New York’s ban on assisted suicide does not draw any distinctions between persons as everyone is entitled to refuse treatment and no one is permitted to assist a suicide and that generally, laws that apply evenhandedly to everyone comply with the Equal Protection Clause. The Court disagreed with the Court of Appeals conclusion that refusal of life-saving treatment is basically the same thing as suicide, noting that the distinction comports with the fundamental legal principles of causation and intent (i.e., if a patient withdraws life-saving treatment, he is killed by the underlying disease but if a patient ingests lethal medication, he is killed by the medication. If a doctor withdraws life-saving treatment he intends to respect the patient’s wishes, but if a doctor assists suicide he intends to kill the patient). The Court further noted that the right to refuse treatment was grounded not on the proposition that patients have a right to hasten death, but “on well-established, traditional rights to bodily integrity and freedom from unwanted touching” and therefore confirmed that the distinction between refusing treatment and assisted suicide was neither arbitrary nor irrational. Finally, the Court recognized New York’s reasons for acting on the distinction between refusing treatment and assisted 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.”

“On their faces, neither New York's ban on assisting suicide nor its statutes permitting patients to refuse medical treatment treat anyone differently from  anyone else or draw any distinctions between persons. Everyone, regardless of  physical condition, is entitled, if competent, to refuse unwanted life saving 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.” p.800.

“The Court of Appeals, however, concluded that some terminally ill people—those who are on life-support systems—are treated differently from 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 life saving 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 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 with in a  class are ordinarily of no constitutional concern").

The distinction comports with fundamental legal principles of causation and intent. First, when a patient refuses lifesustaining 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. . . . 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, pain killing drugs may hasten a patient's death, but the physician's purpose and intent is, or may be, 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. . . .” pp800-802.