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Report No. 196

(3) Vacco, Attorney General of New York et al vs. Quill et al, (1997) 117 SCt 2293.

This case refers to the validity of the New York's statute prohibiting assisted suicide and as to how its validity was upheld after rejecting the plea that the Act violated the Equal Protection Clause.

The main opinion was given by Rehnquist CJ, with whom O'Connor, Scalia, Kennedy and Thomas joined. O'Connor filed a concurring opinion with which Ginsburg and Breyer JJ agreed in part. Stevens, Souter, Ginsburg, Breyer filed separate opinions also.

The New York statute prohibits assisted suicide. (N.Y. Penal Law, section 125.19). Section 120.30 makes it an offence if a person intentionally causes or aids a person to attempt suicide. Promoting suicide attempt is a E class felony. However, N.Y. law permits refusal of medical treatment, even if the withdrawal of such treatment will result in death. N.Y. Public Health Law Article 29-B.

Respondents are physicians who claim a right to prescribe lethal medication for mentally competent, terminally-ill patients who are suffering great pain and who desire doctor's help in taking their own lives, but are deterred from doing so because of the New York Act. They contend that this is no different from permitting a person to refuse life sustaining medical treatment and hence, the Act is discriminatory.

This plea was not accepted by the US Supreme Court. The Equal Protection Clause states that no State shall 'deny to any person within its jurisdiction the equal protection of the laws'. This provision creates no substantive rights. It embodies a general rule that the State must treat like cases alike but may however, treat unlike cases differently. Everyone, regardless of physical condition is entitled, if competent, to refuse unwanted life-saving medical treatment, but no one is permitted to assist a suicide.

The "distinction between assisted 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'. '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. (Death which occurs after the removal of life-sustaining systems is from natural causes). (When a lifesustaining treatment is declined, the patient dies primarily because of an underlying fatal disease).

In the debates before the Sub-Committee of the House, it was pointed out that withdrawal of treatment and assisted suicide are different. 'Furthermore, a physician who withdraws or honours 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. 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 may be, only to ease his patient's pain."

A doctor who assists a suicide, however, "most, necessarily and indubitably, intends primarily that the patient be made dead". Similarly, a patient who commits suicide with a doctor's aid necessarily has the specific intent to end his or her life, while a patient who refuses or discontinues treatment might not. See e.g. Matter of Conroy, (1985) 98 N.J. 321 (at 351), (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).

"it is not surprising that many Courts, including New York Courts, have carefully distinguished refusing life-sustaining treatment from suicide. See e.g. Fosmire vs. Nicolean, 75 NY 2d 218 (Merely declining medical ..... care is not considered a suicidal act'). In fact, the first State Court decision explicitly to authorize withdrawing life-sustaining treatment noted the 'real distinction between self infliction of deadly harm and a self determination against artificial life support. (In re Quinlan 70 NJ 10: 355 A.2d. 647)

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 significanc.- a meaningless exercise in semantic gymnastics', insisting that 'the Cruzan majority disagreed and so do we. ("Kevorkian: 447 Mich at 471)"

Similarly, the overwhelming majority of State legislatures have drawn a clear line between assisting suicide and withdrawing or permitting the refusal of unwanted life-saving medical treatment by prohibiting the former and permitting the latter. Washington vs.Glucksberg (1997) 117 S.Ct 2258, 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. Thus, even as the States move to protect and promote patient's dignity at the end of life, they remain opposed to physician assisted suicide'.

The Court then said that the New York State enacted the current assisted suicide statutes in 1965 prohibiting assisted suicide. Since then, New York has acted several times to protect patient's common law-rights to refuse treatment. Act of Aug 7, 1987, Ch 818, ss. 1,; 1987 NY Laws 3140 ('Do not Resuscitate Orders')(Codified as amended at NY Pub Health Law, see 2960-2979 (McKinney 1994 U Supp. 1997); Act of July 22, 1990, Ch 752, section 2, 1990 NY Law, 3547 (Health Care Agents and Proxies)(Codified as amended NY Pub. Health Law, paras 2980-2994 (McKinney 1994 & Suppl 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 NY Pub. Health Law Article 2989 (3)(McKinney 1994) ("This article is not intended to permit or promote suicide, assisted suicide or euthanasia").

More recently the New York Task Force on 'life and the law', studied assisted suicide and euthanasia and, in 1994, unanimously recommended against legalization. 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."

'This Court has also recognized, at least implicitly, the distinction between letting a patient die and making that patient die. In Cruzan vs. Director, MO, Deptt. of Health, 497 US 261, 278 p 1990), we concluded that 'the 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.

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 obtrusive (right to hasten death), but on wellestablished, traditional rights to bodily integrity and freedom from unwanted touching.... 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. Cruzan therefore provided no support for the notion that refusing life sustaining medical treatment is 'nothing more nor less than suicide'.

The Court declared that they were disagreeing with the respondent's claim that the distinction between refusing life saving medical treatment and assisted suicide is 'arbitrary' and 'irrational'. Granted, in some cases, the line between the two may not be clear, but certainly is not required, even if it were 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. By permitting everyone to refuse unwanted medical treatment while prohibiting anyone from assisting a suicide, New York law follows a long standing and rational distinction.

New York's reasons for recognizing and acting on this distinctio.- including prohibitory intentional killing and preserving life; preventing suicide; maintaining physician's role as their patient's healers; protecting vulnerable people from indifference, prejudice and psychological and financial pressure to end their lives' and avoiding a possible slide towards euthanasi.- are discussed in greater detail in the judgment in Washington vs. Glucksberg, ante. These valid and important public interests easily satisfy the constitutional requirement that a legislative clarification bear a rational relation to some legitimate end."

For the above reasons, the Supreme Court reversed the Court of Appeal and upheld the New York ban against assisted suicide.

Medical Treatment to Terminally Ill Patients (Protection of Patients and Medical Practitioners) Back

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