Quill v. Vacco

80 F.3d 716, 1996 WL 148605

• Court: Court of Appeals for the Second Circuit
• Decided: April 2, 1996
• Docket: No. 60, Docket 95-7028
• Status: Published

Opinions

MINER, Circuit Judge.

Plaintiffs-appellants Timothy E. Quill, Samuel C. Klagsbrun and Howard A. Gross-man appeal from a summary judgment entered in the United States District Court for the Southern District of New York (Griesa, Ch. J.) dismissing their 42 U.S.C. § 1983 action against defendants-appellees. The action was brought by plaintiffs-appellants, all of whom are physicians, to declare unconstitutional in part two New York statutes penalizing assistance in suicide. The physicians contend that each statute is invalid to the extent that it prohibits them from acceding to the requests of terminally-ill, mentally competent patients for help in hastening death. In granting summary judgment in favor of defendants-appellees, the district court considered and rejected challenges to the statutes predicated upon the Due Process and Equal Protection Clauses of the Fourteenth Amendment to the United States Constitution. Quill v. Koppell, 870 F.Supp. 78 (S.D.N.Y.1994). We reverse in part, holding that physicians who are willing to do so may prescribe drugs to be self-administered by mentally competent patients who seek to end their lives during the final stages of a terminal illness.

BACKGROUND

The action giving rise to this appeal was commenced by a complaint filed on July 20, 1994. The plaintiffs named in that complaint were the three physicians who are the appellants here and three individuals then in the final stages of terminal illness: Jane Doe (who chose to conceal her actual identity), George A. Kingsley and William A. Barth. The sole defendant named in that complaint was G. Oliver Koppell, then the Attorney General of the State of New York. He has been succeeded as Attorney General by Dennis C. Vacco, who has been substituted for him as an appellee on this appeal. According to the complaint, Jane Doe was a 76-year-old retired physical education instructor who was dying of thyroid cancer; Mr. Kingsley was a 48-year-old publishing executive suffering from AIDS; and Mr. Barth was a 28-year-old former fashion editor under treatment for AIDS. Each of these plaintiffs alleged that she or he had been advised and understood that she or he was in the terminal stage of a terminal illness and that there was no chance of recovery. Each sought to hasten death “in a certain and humane manner” and for that pmpose sought “necessary medical assistance in the form of medications prescribed by [her or his] physician to be self-administered.”

The physician plaintiffs alleged that they encountered, in the course of their medical practices, “mentally competent, terminally ill patients who request assistance in the voluntary self-termination of life.” Many of these patients apparently “experience chronic, intractable pain and/or intolerable suffering” and seek to hasten their deaths for those reasons. Mr. Barth was one of the patients who sought the assistance of Dr. Grossman. Each of the physician plaintiffs has alleged that “[u]nder certain circumstances it would be consistent with the standards of [his] medical practice” to assist in hastening death by prescribing drugs for patients to self-administer for that purpose. The physicians alleged that they were unable to exercise them best professional judgment to prescribe the requested drugs, and the other plaintiffs alleged that they were unable to receive the requested drugs, because of the prohibitions contained in sections 125.15(3) and 120.30 of the New York Penal Law, all plaintiffs being residents of New York.

Section 125.15 of the New York Penal Law provides in pertinent part:

A person is guilty of manslaughter in the second degree when:

3. He intentionally ... aids another person to commit suicide.

A violation of this provision is classified as a class C felony. Id.

Section 120.30 of the New York Penal Law provides:

A person is guilty of promoting a suicide attempt when he intentionally ... aids another person to attempt suicide.

A violation of this provision is classified as a class E felony. Id.

Count I of the complaint included an allegation that “[t]he Fourteenth Amendment guarantees the liberty of mentally competent, terminally ill adults with no chance of recovery to make decisions about the end of their lives.” It also included an allegation that

[t]he Fourteenth Amendment guarantees the liberty of physicians to practice medicine consistent with their best professional judgment, including using their skills and powers to facilitate the exercise of the decision of competent, terminally ill adults to hasten inevitable death by prescribing suitable medications for the patient to self-administer for that purpose.

Count II of the complaint included an allegation that

[t]he relevant portions of ... the New York Penal Law deny the patient-plaintiffs and the patients of the physician-plaintiffs the equal protection of the law by denying them the right to choose to hasten inevitable death, while terminally ill persons whose treatment includes life support are able to exercise this choice with necessary medical assistance by directing termination of such treatment.

In their prayer for relief the plaintiffs requested judgment declaring the New York statutes complained of constitutionally invalid and therefore in violation of 42 U.S.C. § 1983 “as applied to physicians who assist mentally competent, terminally ill adults who choose to hasten inevitable death.” Plaintiffs also sought an order permanently enjoining defendants from enforcing the statutes and an award of attorney’s fees.

By order to show cause filed on September 16, 1994, the plaintiffs moved for a preliminary injunction to enjoin then-Attorney General Koppell “and all persons acting in concert and participation with him from enforcing New York Penal Law sections 125.15(3) and 120.30 against physicians who prescribe medications which mentally competent, terminally ill patients may use to hasten their impending deaths.” A declaration by each of the plaintiffs was submitted in support of the application, although Jane Doe had died prior to the filing of the order to show cause. Plaintiffs Kingsley and Barth were then in the advanced stages of AIDS and therefore sought an immediate determination by the district court.

In her declaration, Jane Doe stated:

I have a large cancerous tumor which is wrapped around the right carotid artery in my neck and is collapsing my esophagus and invading my voice box. The tumor has significantly reduced my ability to swallow and prevents me from eating anything but very thin liquids in extremely small amounts. The cancer has metastasized to my plural [sic] cavity and it is painful to yawn or cough.... In early July 1994 I had the [feeding] tube implanted and have suffered serious problems as a result.... I take a variety of medications to manage the pain.... It is not possible for me to reduce my pain to an acceptable ■level of comfort and to retain an alert state.... At this time, it is clear to me, based on the advice of my doctors, that I am in the terminal phase of this disease .... At the point at which I can no longer endure the pain and suffering associated with my cancer, I want to have drugs available for the purpose of hastening my death in a humane and certain manner. I want to be able to discuss freely with my treating physician my intention of hastening my death through the consumption of drugs prescribed for that purpose.

Mr. Kingsley subscribed to a declaration that included the following:

At this time I have almost no immune system function.... My first major illness associated with AIDS was cryptospo-ridiosis, a parasitic infection which caused me severe fevers and diarrhea and associated pain, suffering and exhaustion- I also suffer from cytomegalovirus (“CMV”) retinitis, an AIDS-related virus which attacks the retina and causes blindness. To date I have become almost completely blind in my left eye. I am at risk of losing my sight altogether from this condition. ... I also suffer from toxoplasmosis, a parasitic infection which has caused lesions to develop on my brain.... I ... take daily infusions of cytovene for the ... retinitis condition. This medication, administered for an hour through a Hickman tube which is connected to an artery in my chest, prevents me from ever taking showers and makes simple routine functions burdensome. In addition, I inject my leg daily with neupogen to combat the deficient white cell count in my blood. The daily injection of this medication is extremely painful.... At this point it is clear to me, based on the advice of my doctors, that I am in the terminal phase of [AIDS]_ It is my desire that my physician prescribe suitable drugs for me to consume for the purpose of hastening my death when and if my suffering becomes intolerable.

In his declaration, Mr. Barth stated:

In May 1992,1 developed a Kaposi’s sarcoma skin lesion. This was my first major illness associated with AIDS. I underwent radiation and chemotherapy to treat this cancer.... In September 1993, I was diagnosed with cytomegalovirus (“CMV”) in my stomach and colon which caused severe diarrhea, fevers and wasting_ In February 1994, I was diagnosed with micros-poridiosis, a parasitic infection for which there is effectively no treatment.... At approximately the same time, I contracted AIDS-related pneumonia. The pneumonia’s infusion therapy treatment was so extremely toxic that I vomited with each infusion.... In March 1994, I was diagnosed with cryptosporidiosis, a parasitic infection which has caused severe diarrhea, sometimes producing 20 stools a day, extreme abdominal pain, nausea and additional significant wasting. I have begun to lose bowel control.... For each of these conditions I have undergone a variety of medical treatments, each of which has had significant adverse side effects.... While I have tolerated some [nightly intravenous] feedings, I am unwilling to accept this for an extended period of time_ I understand that there are no cures.... I can no longer endure the pain and suffering ... and I want to have drugs available for the purpose of hastening my death.

A cross-motion for judgment on the pleadings was filed by Attorney General Koppell on October 11,1994. Thereafter, on October 14, 1994, an amended complaint was filed by the three physicians and Mr. Kingsley naming as defendants Attorney General Koppell and New York State Governor Mario M. Cuomo. The counts of the complaint were the same as set forth in the original complaint, alleging violations of liberty interests guaranteed by the Fourteenth Amendment in Count I and violation of equal protection rights guaranteed by the Fourteenth Amendment in Count II. The prayer for relief remained the same as in the original complaint. Supplemental declarations in support of the plaintiffs motion for preliminary injunction also were filed on October 14, 1994. In their supplemental declarations, Doctors Klagsbrun and Grossman reiterated their desire “to prescribe drugs, if and when medically and psychiatrieally appropriate, for such patients to self-administer at the time and place of their choice for the purpose of hastening their impending deaths.”

In his supplemental declaration, Dr. Quill declared:

The removal of a life support system that directly results in the patient’s death requires the direct involvement by the doctor, as well as other medical personnel. When such patients are mentally competent, they are consciously choosing death as preferable to life under the circumstances that they are forced to live. Their doctors do a careful clinical assessment, including a full exploration of the patient’s prognosis, mental competence to make such decisions, and the treatment alternatives to stopping treatment. It is legally and ethically permitted for physicians to actively assist patients to die who are dependent on life-sustaining treatments_

Unfortunately, some dying patients who are in agony that can no longer be relieved, yet are not dependent on life-sustaining treatment, have no such options under current legal restrictions. It seems unfair, discriminatory, and inhumane to deprive some dying patients of such vital choices because of arbitrary elements of their condition which determine whether they are on life-sustaining treatment that can be stopped.

Along with the supplemental declarations filed on October 14th, an original declaration in support of the motion was filed by Dr. Jack Froom, a physician and Professor of Family Medicine with substantial experience in detecting depression in primary care patients. He declared:

Physicians can determine whether a patient’s request to hasten death is rational and competent or motivated by depression or other mental illness or instability. Physicians currently make these determinations as to patient capacity to make end-of-life decisions with respect to orders not to resuscitate and refusal of life-sustaining treatment.... Terminally ill persons who seek to hasten death by consuming drugs need medical counseling regarding the type of drugs and the amount and manner in which they should be taken, as well as a prescription, which only a licensed medical doctor can provide.... Knowing what drug, in what amount, will hasten death for a particular patient, in light of the patient’s medical condition and medication regimen, is a complex medical task.... It is not uncommon, in light of present legal constraints on physician assistance, that patients seeking to hasten their deaths try to do so without medical advice.... Very often, patients who survive a failed suicide attempt find themselves in worse condition than before the attempt. Brain damage, for example, is one result of failed suicide attempts.

A second amended complaint was filed on October 20, 1994. The parties, allegations and prayer for relief were the same as those contained in the first amended complaint, except that Robert M. Morgenthau, District Attorney of New York County, was added as a defendant in his official capacity. Both Dr. Grossman and Dr. Klagsbrun practice medicine in New York City, and Mr. Morgenthau is responsible for the prosecution of crimes occurring in New York County. The physician plaintiffs each filed second supplemental declarations on November 28, 1994, in support of the motion for a preliminary injunction. Each stated that he was currently treating mentally competent, terminally-ill patients who desired to hasten their deaths by self-administering drugs to be provided by the physicians “if and when medically and psychiatrically appropriate.” These patients, according to the physicians, understood “their condition, diagnosis, and prognosis and wish[ed] to avoid prolonged suffering by hastening their deaths if and when their suffering [became] intolerable.” None of the three terminally-ill plaintiffs named in the original complaint survived to the date of the district court’s decision.

The opinion of the district court was filed on December 16, 1994. The district court denied the motion for a preliminary injunction and granted the defendants’ cross motion to dismiss the action, treating the cross motion as one for summary judgment “since the court has considered matters outside the pleadings — ie., declarations filed on the motion for preliminary injunction.” Quill, 870 F.Supp. at 79. After finding that the action presented a justiciable case or controversy, the district court first addressed the due process issue. The court determined that physician assisted suicide could not be classified as a fundamental right within the meaning of the Constitution:

The Supreme Court has described the considerations which are appropriate before there can be a declaration that rights “not readily identifiable in the Constitution’s text” are deserving of constitutional protection. Such rights must be implicit in the concept of ordered liberty so that neither liberty nor justice would exist if they were sacrificed. The Supreme Court has also characterized such rights as those liberties that are deeply rooted in the nation’s history and traditions.

The trouble is that plaintiffs make no attempt to argue that physician assisted suicide, even in the case of terminally ill patients, has any historic recognition as a legal right.

Id. at 83 (internal citations omitted). Accordingly, the district court concluded “that the type of physician assisted suicide at issue in this case does not involve a fundamental liberty interest protected by the Due Process Clause of the Fourteenth Amendment.” Id. at 84.

Turning to the equal protection issue, the district court identified a reasonable and rational basis for the distinction drawn by New York law between the refusal of treatment at the hands of physicians and physician assisted suicide:

[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. The State has obvious legitimate interests in preserving .life, and in protecting vulnerable persons. The State has the further right to determine how these crucial interests are to be treated when the issue is posed as to whether a physician can assist a patient in committing suicide.

Id. at 84-85. Accordingly, the court held “that plaintiffs have not shown a violation of the Equal Protection Clause of the Fourteenth Amendment.” Id. at 85.

DISCUSSION

I. Justiciability

As they did in the district court, the state defendants contend on appeal that this action does not present a justiciable case or controversy. We reject this contention.

In Babbitt v. United Farm Workers Nat’l Union, 442 U.S. 289, 99 S.Ct. 2301, 60 L.Ed.2d 895 (1979), the Supreme Court was faced with a constitutional challenge to an Arizona farm labor statute. The Court stated that, when contesting the constitutionality of a state criminal statute, it is not necessary that the plaintiff first expose himself to actual prosecution. Id. at 298, 99 S.Ct. at 2308-09. Rather,

[w]hen the plaintiff has alleged an intention to engage in a course of conduct arguably affected with a constitutional interest, but proscribed by a statute, and there exists a credible threat of prosecution thereunder, he “should not be required to await and undergo a criminal prosecution as the sole means of seeking relief.”

Id. (quoting Doe v. Bolton, 410 U.S. 179, 188, 93 S.Ct. 739, 745, 35 L.Ed.2d 201 (1973)). The Court in Doe held that plaintiff physicians had presented a justiciable controversy despite the fact that none had been threatened with prosecution. 410 U.S. at 188, 93 S.Ct. at 745-46. The law that the physicians challenged was a criminal statute that directly criminalized the physician’s participation in abortion. Accordingly, a sufficiently concrete controversy was presented.

The same principles lead to the conclusion that there is a case or controversy at issue here. Dr. Quill has had a criminal proceeding instituted against him in the past, and the state nowhere disclaims an intent to repeat a prosecution in the event of further assisted suicides. The other two physician plaintiffs also face the threat of criminal prosecution. Like the physicians in Doe, they “should not be required to await and undergo a criminal prosecution as the sole means of seeking relief.” Finally, under Doe, the physicians may raise the rights of their terminally-ill patients. See id.

Although District Attorney Morgenthau argues in his brief on appeal that appellants have not shown that they are in any jeopardy of prosecution in New York County, a recent indictment by a New York County grand jury demonstrates the contrary. A newspaper report printed on December 15, 1995 disclosed the following:

Yesterday, District Attorney Robert M. Morgenthau of Manhattan announced that a grand jury had indicted [George] Delury, an editor who lives on the Upper West Side, on manslaughter charges for helping his 52-year-old wife, Myrna Lebov, commit suicide last summer.

Carey Goldberg, Suicide’s Husband Is Indicted; Diary Records Pain of 2 Lives, N.Y. Times, Dec. 15, 1995, at Bl.¹ The physician plaintiffs have good reason to fear prosecution in New York County.

II. Substantive Due Process

Plaintiffs argue for a right to assisted suicide as a fundamental liberty under the substantive component of the Due Process Clause of the Fourteenth Amendment. This Clause assures the citizenry that any deprivation of life, liberty or property by a state will be attended by appropriate legal processes. However,

despite the language of the Due Process Clause[ ] of the ... Fourteenth Amendment! ]> which appears to .focus only on the processes by which life, liberty, or property is taken, the cases are legion in which th[at] Clause!] ha[s] been interpreted to have substantive content, subsuming rights that to a great extent are immune from ... state regulation or proscription. Among such cases are those recognizing rights that have little or no textual support in the constitutional language.

Bowers v. Hardwick, 478 U.S. 186, 191, 106 S.Ct. 2841, 2844, 92 L.Ed.2d 140 (1986).

Rights that have no textual support in the language of the Constitution but qualify for heightened judicial protection include fundamental liberties so “implicit in the concept of ordered liberty” that “neither liberty nor justice would exist if they were sacrificed.” Palko v. Connecticut, 302 U.S. 319, 325-26, 58 S.Ct. 149, 152, 82 L.Ed. 288 (1937). Fundamental liberties also have been described as those that are “deeply rooted in this Nation’s history and tradition.” Moore v. City of East Cleveland, 431 U.S. 494, 503, 97 S.Ct. 1932, 1938, 52 L.Ed.2d 531 (1977); see also Griswold v. Connecticut, 381 U.S. 479, 506, 85 S.Ct. 1678, 1693-94, 14 L.Ed.2d 510 (1965) (White, J., concurring). It is well settled that the state must not infringe fundamental liberty interests unless the infringement is narrowly tailored to serve a compelling state interest. Reno v. Flores, 507 U.S. 292, 301-03, 113 S.Ct. 1439, 1447, 123 L.Ed.2d 1 (1993). The list of rights the Supreme Court has actually or impliedly identified as fundamental, and therefore qualified for heightened judicial protection, include the fundamental guarantees of the Bill of Rights as well as the following: freedom of association; the right to participate in the electoral process and to vote; the right to travel interstate; the right to fairness in the criminal process; the right to procedural fairness in regard to claims for governmental deprivations of life, liberty or property; and the right to privacy. 2 Ronald D. Rotunda & John E. Nowak, Treatise on Constitutional Law § 15.7, at 434-36 (2d ed.1992). The right of privacy has been held to encompass personal decisions relating to marriage, procreation, family relationships, child rearing and education, contraception and abortion. See Carey v. Population Servs. Int’l, 431 U.S. 678, 684-85, 97 S.Ct. 2010, 2015-16, 52 L.Ed.2d 675 (1977). While the Constitution does not, of course, include any explicit mention of the right of privacy, this right has been recognized as encompassed by the Fourteenth Amendment’s Due Process Clause. Id. at 684, 97 S.Ct. at 2015-16. Nevertheless, the Supreme Court has been reluctant to further expand this particular list of federal rights, and it would be most speculative for a lower court to do so. See Rotunda & Nowak, Treatise on Constitutional Law, supra, § 15.7, at 433-37.

In any event, the Supi*eme Court has drawn a line, albeit a shaky one, on the expansion of fundamental rights that are without support in the text of the Constitution. In Boivers, the Supreme Court framed the issue as “whether the Federal Constitution confers a fundamental right upon homosexuals to engage in sodomy and hence invalidates the laws of the many States that still make such conduct illegal and have done so for a very long time.” 478 U.S. at 190, 106 S.Ct. at 2843. Holding that there was no fundamental right to engage in consensual sodomy, the Court noted that the statutes proscribing such conduct had “ancient roots.” Id. at 192, 106 S.Ct. at 2844-45. The Court noted that sodomy was a common law criminal offense, forbidden by the laws of the original 13 states when they ratified the Bill of Rights, and that 25 states and the District of Columbia still penalize sodomy performed in private by consenting adults. Id. at 192— 93, 106 S.Ct. at 2844-46.

As in Bowers, the statutes plaintiffs seek to declare unconstitutional here cannot be said to infringe upon any fundamental right or liberty. As in Bowers, the right contended for here cannot be considered so implicit in our understanding of ordered liberty that neither justice nor liberty would exist if it were sacrificed. Nor can it be said that the right to assisted suicide claimed by plaintiffs is deeply rooted in the nation’s traditions and history. Indeed, the very opposite is true. The Common Law of England, as received by the American colonies, prohibited suicide and attempted suicide. See Thomas J. Mar-zen et al., Suicide: A Constitutional Right?, 24 Duq. L.Rev. 1, 56-67 (1985). Although neither suicide nor attempted suicide is any longer a crime in the United States, 32 states, including New York, continue to make assisted suicide an offense. The New York State Task Force on Life and the Law, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context, 55 (1994) (“When Death Is Sought”). Clearly, no “right” to assisted suicide ever has been recognized in any state in the United States. See generally Mark E. Chopko & Michael F. Moses, Assisted Suicide: Still a Wonderful Life?, 70 Notre Dame L.Rev. 519, 561 (1995); Yale Kamisar, Are Laws against Assisted Suicide Unconstitutional?, 23 Hastings Center Rep., May-June 1993, at 32.

In rejecting the due process-fundamental rights argument of the plaintiffs, we are mindful of the admonition of the Supreme Court:

Nor are we inclined to take a more expansive view of our authority to discover new fundamental rights imbedded in the Due Process Clause. The Court is most vulnerable and comes nearest to illegitimacy when it deals with judge-made constitutional law having little or no cognizable roots in the language or design of the Constitution.

Bowers, 478 U.S. at 194, 106 S.Ct. at 2846. The right to assisted suicide finds no cognizable basis in the Constitution’s language or design, even in the very limited cases of those competent persons who, in the final stages of terminal illness, seek the right to hasten death. We therefore decline the plaintiffs’ invitation to identify a new fundamental right, in the absence of a clear direction from the Court whose precedents we are bound to follow. The limited room for expansion of substantive due process rights and the reasons therefor have been clearly stated: “As a general matter, the Court has 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 v. City of Harker Heights, 503 U.S. 115, 125, 112 S.Ct. 1061, 1068, 117 L.Ed.2d 261 (1992). Our position in the judicial hierarchy constrains us to be even more reluctant than the Court to undertake an expansive approach in this unchartered area.

III. Equal Protection

According to the Fourteenth Amendment, the equal protection of the laws cannot be denied by any State to any person within its jurisdiction. U.S. Const, amend. XIV, § 1. This constitutional guarantee simply requires the states to treat in a similar manner all individuals who are similarly situated. See 3 Rotunda & Nowak, Treatise on Constitutional Law, supra, § 18.2, at 7. But disparate treatment is not necessarily a denial of the equal protection guaranteed by the Constitution. The Supreme Court has described the wide discretion afforded to the states in establishing acceptable classifications:

The Equal Protection Clause directs that “all persons similarly circumstanced shall be treated alike.” But so too, “[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.” The initial discretion to determine what is “different” and what is ‘The same” resides in the legislatures of the States. A legislature must have substantial latitude to establish classifications that roughly approximate the nature of the problem perceived, that accommodate competing concerns both public and private, and that account for limitations on the practical ability of the State to remedy every ill. In applying the Equal Protection Clause to most forms of state action, we thus seek only the assurance that the classification at issue bears some fair relationship to a legitimate public purpose.

Plyler v. Doe, 457 U.S. 202, 216, 102 S.Ct 2382, 2394, 72 L.Ed.2d 786 (1982) (internal citations omitted and alteration in original).

The general rule, then, is that state legislation carries a presumption of validity if the statutory classification is “rationally related to a legitimate state interest.” City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 440, 105 S.Ct. 3249, 3254, 87 L.Ed.2d 313 (1985). In Cleburne, the equal protection issue revolved around a zoning ordinance that required a special use permit for homes for the mentally retarded but not for other multiple-dwelling and care-giving facilities. The Supreme Court resolved the issue as follows:

Because in our view the record does not reveal any rational basis for believing that the Featherston home [for the mentally retarded] would pose any special threat to the city’s legitimate interests, we affirm the judgment below insofar as it holds the ordinance invalid as applied in this case.

Id. at 448, 105 S.Ct. at 3258. In arriving at this conclusion, the Court rejected the city’s claims that the disparate classification was justified by the negative attitudes of property owners in the neighborhood of the proposed facility, the location of the facility across the street from a junior high school and on a 500-year flood plain, concerns about legal responsibility for actions that might be taken by the mentally retarded, or concerns about the size of the facility and the number of occupants. Id. at 448-50, 105 S.Ct. at 3258-60. The Court carefully examined each of these claims before finding that there was no acceptable reason for the disparate classification in any of them.

Also found invalid under the Equal Protection Clause for failure to survive rational basis scrutiny was a New Mexico statute providing a partial exemption from the state’s property tax for certain honorably discharged veterans. Hooper v. Bernalillo County Assessor, 472 U.S. 612, 105 S.Ct. 2862, 86 L.Ed.2d 487 (1985). The exemption was limited to veterans who had served on active duty during the Vietnam War for at least 90 continuous days and were New Mexico residents before May 8, 1976. In finding the residence requirement invalid under the Equal Protection Clause, the Court analyzed the New Mexico statute in light of the following principles: “When a state distributes benefits unequally, the distinctions it makes are subject to scrutiny under the Equal Protection Clause of the Fourteenth Amendment. Generally, a law will survive that scrutiny if the distinction rationally furthers a legitimate state purpose.” Id. at 618, 105 S.Ct. at 2866 (footnote omitted). The Court determined that the distinction made between veterans who arrived in the state prior to May 8, 1976 and those who arrived thereafter bore no rational relationship to the state’s declared objectives of encouraging veterans to settle in the state and of rewarding citizens who resided in the state prior to the cut-off date for their military service. Id. at 619-20,105 S.Ct. at 2866-67.

As to the first objective, the Court wrote:

The distinction New Mexico makes between veterans who established residence before May 8, 1976, and those veterans who arrived in the State thereafter bears no rational relationship to one of the State’s objectives- — encouraging Vietnam veterans to move to New Mexico. The legislature set this eligibility date long after the triggering event occurred. The legislature cannot plausibly encourage veterans to move to the State by passing such retroactive legislation.

Id. at 619, 105 S.Ct. at 2866-67 (internal citation omitted). As to the second declared objective, the Court noted that a state court may legitimately compensate resident veterans for past services by providing various advantages, but that “the New Mexico statute’s distinction between resident veterans is not rationally related to the State’s asserted legislative goal.” Id. at 621-22, 105 S.Ct. at 2868. The Court held:

The State may not favor established residents over new residents based on the view that the State may take care of “its own,” if such is defined by prior residence. Newcomers, by establishing bona fide residence in the State, become the State’s “own” and may not be discriminated against solely on the basis of their arrival in the State after May 8,1976.

Id. at 623, 105 S.Ct. at 2868; see also Zobel v. Williams, 457 U.S. 55, 102 S.Ct. 2309, 72 L.Ed.2d 672 (1982) (holding that Alaska statute using length of residence as basis for distribution of oil reserve dividends violated Equal Protection Clause.)

While rational basis scrutiny governs judicial review of the constitutionality of legislation in the areas of social welfare and economics, see Bowen v. Owens, 476 U.S. 340, 345, 106 S.Ct. 1881, 1885, 90 L.Ed.2d 316 (1986), strict scrutiny is the standard of review where a classification “impermissibly interferes with the exercise of a fundamental right or operates to the peculiar disadvan tage of a suspect class,” Massachusetts Bd. of Retirement v. Murgia, 427 U.S. 307, 312, 96 S.Ct. 2562, 2566, 49 L.Ed.2d 520 (1976) (footnotes omitted). Suspect classes are those identified by race, alienage or national origin, Cleburne, 473 U.S. at 440, 105 S.Ct. at 3254-55, and fundamental rights are those explicitly or implicitly derived from the Constitution itself, see San Antonio Indep. Sch. Dist. v. Rodriguez, 411 U.S. 1, 33-34, 93 S.Ct. 1278, 1296-97, 36 L.Ed.2d 16 (1973). For the reasons described in Part II, supra, the New York statutes prohibiting assisted suicide during the terminal stages of illness do not impinge on any fundamental rights nor can it be said that they involve suspect classifications. Laws subject to strict scrutiny will survive such review only if they are suitably tailored to serve a compelling state interest. Cleburne, 473 U.S. at 440, 105 S.Ct. at 3254-55.

An intermediate level of scrutiny has been applied in analyzing certain equal protection guarantee violations. To pass this scrutiny, the classification must be substantially related to an important governmental objective. Clark v. Jeter, 486 U.S. 456, 461, 108 S.Ct. 1910, 1914, 100 L.Ed.2d 465 (1988). This sort of examination has been applied to classifications based on sex or illegitimacy. Id.; see also Kadrmas v. Dickinson Pub. Sch., 487 U.S. 450, 459, 108 S.Ct. 2481, 2488, 101 L.Ed.2d 399 (1988); Mississippi Univ. for Women v. Hogan, 458 U.S. 718, 723-24, 102 S.Ct. 3381, 3335-36, 73 L.Ed.2d 1090 (1982). A heightened level of equal protection scrutiny also was applied in Plyler, where the Supreme Court struck down a Texas statute withholding from local school districts funding for the education of children not legally admitted into the United States. 457 U.S. at 202, 102 S.Ct. at 2387.

Applying the foregoing principles to the New York statutes criminalizing assisted suicide, it seems clear that: 1) the statutes in question fall within the category of social welfare legislation and therefore are subject to rational basis scrutiny upon judicial review; 2) 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; 3) the distinctions made by New York law with regard to such persons do not further any legitimate state purpose; and 4) accordingly, to the extent that the statutes in question prohibit persons in the final stages of terminal illness from having assistance in ending their lives by the use of self-administered, prescribed drugs, the statutes lack any rational basis and are violative of the Equal Protection Clause.

The right to refuse medical treatment long has been recognized in New York. In 1914 Judge Cardozo wrote that, under New York law, “[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body.” Schloendorff v. Society of New York Hosp., 211 N.Y. 125, 129, 105 N.E. 92 (1914). In 1981, the New York Court of Appeals held that this right extended to the withdrawal of life-support systems. In re Eichner (decided with In re Storar), 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64, cert. denied, 454 U.S. 858, 102 S.Ct. 309, 70 L.Ed.2d 153 (1981). The Eichner case involved a terminally-ill, 83-year-old patient whose guardian ultimately was authorized to withdraw the patient’s respirator. The Court of Appeals determined that the guardian had proved by clear and convincing evidence that the patient, pri- or to becoming incompetent due to illness, had consistently expressed his view that life should not be prolonged if there was no hope of recovery. Id. at 379-80, 438 N.Y.S.2d 266, 420 N.E .2d 64. In Storar, the companion case to Eichner, the Court of Appeals determined that a profoundly retarded, terminally-ill patient was incapable of making a decision to terminate blood transfusions. There, the patient was incapable of making a reasoned decision, having never been competent at any time in his life. Id. at 380, 438 N.Y.S.2d 266, 420 N.E.2d 64. In both these eases, the New York Court of Appeals recognized the right of a competent, terminally-ill patient to hasten his death upon proper proof of his desire to do so.

The Court of Appeals revisited the issue in Rivers v. Katz, 67 N.Y.2d 485, 504 N.Y.S.2d 74, 495 N.E.2d 337 (1986) (establishing the right of mentally incompetent persons to refuse certain drugs). In that case, the Court recognized the right to bring on death by refusing medical treatment not only as a “fundamental common-law right” but also as “coextensive with [a] patient’s liberty interest protected by the due process clause of our State Constitution.” Id. at 493, 504 N.Y.S.2d 74, 495 N.E.2d 337. The following language was included in the opinion:

In our system of a free government, where notions of individual autonomy and free choice are cherished, it is the individual who must have the final say in respect to decisions regarding his medical treatment in order to insure that the greatest possible protection is accorded his autonomy and freedom from unwanted interference with the furtherance of his own desires.

Id.

After these cases were decided, the New York legislature placed its imprimatur upon the right of competent citizens to hasten death by refusing medical treatment and by directing physicians to remove life-support systems already in place. In 1987, the legislature enacted Article 29-B of the New York Public Health Law, entitled “Orders Not to Resuscitate.” N.Y. Pub. Health Law §§ 2960-79 (McKinney 1993). The Article provides that an “adult with capacity” may direct the issuance of an order not to resuscitate. § 2964. “Order not to resuscitate” is defined as “an order not to attempt cardiopulmonary resuscitation in the event a patient suffers cardiac or respiratory arrest.” § 2961(17). “Cardiopulmonary resuscitation” is defined as “measures ... to restore cardiac function or to support ventilation- in the event of a cardiac or respiratory arrest.” § 2961(4). An elaborate statutory scheme is in place, and it provides, among other things, for surrogate decision-making, § 2965, revocation of consent, § 2969, physician review, § 2970, dispute mediation, § 2972, and judicial review, § 2973.

In 1990, the New York legislature enacted Article 29-C of the Public Health Law, entitled “Health Care Agents and Proxies.” N.Y. Pub. Health Law §§ 2980-94 (McKinney 1993). This statute allows for a person to sign a health care proxy, § 2981, for the purpose of appointing an agent with “authority to make any and all health care decisions on the principal’s behalf that the principal could make.” § 2982(1). These decisions include those relating to the administration of artificial nutrition and hydration, provided the wishes of the principal are known to the agent. § 2982(2). The agent’s decision is made “[ajfter consultation with a licensed physician, registered nurse, licensed clinical psychologist or certified social worker.” Id. Accordingly, a patient has the right to hasten death by empowering an agent to require a physician to withdraw life-support systems. The proxy statute also presents a detailed scheme, with provisions for a determination that the principal lacks capacity to make health care decisions, for such a determination to be made only by the attending physician in consultation with another physician “[f]or a decision to withdraw or withhold life-sustaining treatment,” § 2983, for provider’s obligations, § 2984, for revocation, § 2985, and for special proceedings, § 2992, among other matters.

The concept that a competent person may order the removal of life-support systems found Supreme Court approval in Cruzan v. Director, Missouri Dep’t of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990). There the Court upheld a determination of the Missouri Supreme Court that required proof by clear and convincing evidence of a patient’s desire for the withdrawal of life-sustaining equipment. The patient in that case, Nancy Cruzan, was in a persistent vegetative state as the result of injuries sustained in an automobile accident. Her parents sought court approval in the State of Missouri to terminate the artificial nutrition and hydration with which she was supplied at the state hospital where she was confined. The hospital employees refused to withdraw the life-support systems, without which Cru-zan would suffer certain death. The trial court authorized the withdrawal after finding that Cruzan had expressed some years before to a housemate friend some thoughts that suggested she would not wish to live on a life-support system. The trial court also found that one in Cruzan’s condition had a fundamental right to refuse death-prolonging procedures.

The Missouri Supreme Court, in reversing the trial court, refused to find a broad right of privacy in the state constitution that would support a right to refuse treatment. Moreover, that court doubted that such a right existed under the United States Constitution. It did identify a state policy in the Missouri Living Will Statute favoring the preservation of life and concluded that, in the absence of compliance with the statute’s formalities or clear and convincing evidence of the patient’s choice, no person could order the withdrawal of medical life-support sendees.

In affirming the Missouri Supreme Court, the United States Supreme Court stated: “The 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 278,110 S.Ct. at 2851. The Court noted that the inquiry is not ended by the identification of a liberty interest, because there also must be a balancing of the state interests and the individual’s liberty interests before there can be a determination that constitutional rights have been violated. Id. at 279, 110 S.Ct. at 2851-52. The Court all but made that determination in the course of the following analysis:

Petitioners insist that under the general holdings of our cases, the forced administration of life-sustaining medical treatment, and even of artificially-delivered food and water essential to life, would implicate a competent person’s liberty interest. Although we think the logic of the cases discussed above would embrace such a liberty interest, the dramatic consequences involved in refusal of such treatment would inform the inquiry as to whether the deprivation of that interest is constitutionally permissible. But for purposes of this case, we assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition.

The Court went on to find that Missouri allowed a surrogate to “act for the patient in electing to have hydration and nutrition withdrawn in such a way as to cause death,” subject to “a procedural safeguard to assure that the action of the surrogate conforms as best it may to the wishes expressed by the patient while competent.” Id. at 280, 110 S.Ct. at 2852. The Court then held that the procedural safeguard or requirement imposed by Missouri — the heightened eviden-tiary requirement that the incompetent’s wishes be proved by clear and convincing evidence — was not forbidden by the United States Constitution. Id. at 280-82, 110 S.Ct. at 2852-53.

In view of the foregoing, it seems clear that New York does not treat similarly circumstanced persons alike: 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 sueh 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. The district judge has identified “a difference between allowing nature to take its course, even in the most severe situations, and intentionally using an artificial death-producing device.” Quill, 870 F.Supp. at 84. But Justice Scalia, for one, has remarked upon “the irrelevance of the action-inaction distinction,” noting that “the cause of death in both cases is the suicide’s conscious decision to ‘pu[t] an end to his own existence.’ ” Cruzan, 497 U.S. at 296-297, 110 S.Ct. at 2861 (citations omitted and alteration in original) (Scalia, J., concurring); see also Note, Physician-Assisted Suicide and the Right to Die with Assistance, 105 Harv. L.Rev. 2021, 2028-31 (1992) (arguing that there is no distinction between assisted suicide and the withholding or withdrawal of treatment).

Indeed, there is nothing “natural” about causing death by means other than the original illness or its complications. The withdrawal of nutrition brings on death by starvation, the withdrawal of hydration brings on death by dehydration, and the withdrawal of ventilation brings about respiratory failure. By ordering the discontinuance of these artificial life-sustaining processes or refusing to accept them in the first place, a patient hastens his death by means that are not natural in any sense. It certainly cannot be said that the death that immediately ensues is the natural result of the progression of the disease or condition from which the patient suffers.

Moreover, the writing of a prescription to hasten death, after consultation with a patient, involves a far less active role for the physician than is required in bringing about death through asphyxiation, starvation and/or dehydration. Withdrawal of life support requires physicians or those acting at their direction physically to remove equipment and, often, to administer palliative drugs which may themselves contribute to death. The ending of life by these means is nothing more nor less than assisted suicide. It simply cannot be said that those mentally competent, terminally-ill persons who seek to hasten death but whose treatment does not include life support are treated equally.

A finding of unequal treatment does not, of course, end the inquiry, unless it is determined that the inequality is not rationally related to some legitimate state interest. The burden is upon the plaintiffs to demonstrate irrationality. See Kadrmas, 487 U.S. at 463, 108 S.Ct. at 2490. At oral argument and in its brief, the state’s contention has been that its principal interest is in preserving the life of all its citizens at all times and under all conditions. But what interest can the state possibly have in requiring the prolongation of a life that is all but ended? Surely, the state’s interest lessens as the potential for life diminishes. See In re Quin-lan, 70 N.J. 10, 41, 355 A.2d 647, cert. denied, 429 U.S. 922, 97 S.Ct. 319, 50 L.Ed.2d 289 (1976). And what business is it of the state to require the continuation of agony when the result is imminent and inevitable? What concern prompts the state to interfere with a mentally competent patient’s “right to define [his] own concept of existence, of meaning, of the universe, and of the mystery of human life,” Planned Parenthood v. Casey, 505 U.S. 833, 851, 112 S.Ct. 2791, 2807, 120 L.Ed.2d 674 (1992), when the patient seeks to have drugs prescribed to end life during the final stages of a terminal illness? The greatly reduced interest of the state in preserving life compels the answer to these questions: “None.”

A panel of the Ninth Circuit attempted to identify some state interests in reversing a district court decision holding unconstitutional a statute of the state of Washington criminalizing the promotion of a suicide attempt. Compassion in Dying v. Washington, 49 F.3d 586 (9th Cir.1995).² The plaintiffs in the Washington case contended for physician-assisted suicide for the terminally-ill, but the panel majority found that the statute prohibiting suicide promotion furthered the following: the interest in denying to physicians “the role of killers of their patients”; the interest in avoiding psychological pressure upon the elderly and infirm to consent to death; the interest of preventing the exploitation of the poor and minorities; the interest in protecting handicapped persons against societal indifference; the interest in preventing the sort of abuse that “has occurred in the Netherlands where ... legal guidelines have tacitly allowed assisted suicide or euthanasia in response to a repeated request from a suffering, competent patient.” Id. at 592-93. The panel majority also raised a question relative to the lack of clear definition of the term “terminally ill.” Id. at 593.

The New York statutes prohibiting assisted suicide, which are similar to the Washington statute, do not serve any of the state interests noted, in view of the statutory and common law schemes allowing suicide through the withdrawal of life-sustaining treatment. Physicians do not fulfill the role of “killer” by prescribing drugs to hasten death any more than they do by disconnecting life-support systems. Likewise, “psychological pressure” can be applied just as much upon the elderly and infirm to consent to withdrawal of life-sustaining equipment as to take drugs to hasten death. There is no clear indication that there has been any problem in regard to the former, and there should be none as to the latter. In any event, the state of New York may establish rules and procedures to assure that all choices are free of such pressures. With respect to the protection of minorities, the poor and the non-mentally handicapped, it suffices to say that these classes of persons are entitled to treatment equal to that afforded to all those who now may hasten death by means of life-support withdrawal. In point of fact, these persons themselves are entitled to hasten death by requesting such withdrawal and should be free to do so by requesting appropriate medication to terminate life during the final stages of terminal illness.

As to the interest in avoiding abuse similar to that occurring in the Netherlands, it seems clear that some physicians there practice nonvoluntary euthanasia, although it is not legal to do so. When Death Is Sought, supra, at 133-34. The plaintiffs here do not argue for euthanasia³ at all but for assisted suicide for terminally-ill, mentally competent patients, who would self-administer the lethal drugs. It is difficult to see how the relief the plaintiffs seek would lead to the abuses found in the Netherlands. Moreover, note should be taken of the fact that the Royal Dutch Medical Association recently adopted new guidelines for those physicians who choose to accede to the wishes of patients to hasten death. Under the new guidelines, patients must self-administer drugs whenever possible, and physicians must obtain a second opinion from another physician who has no relationship with the requesting physician or his patient. Marlise Simons, Dutch Doctors to Tighten Rules on Mercy Killings, N.Y. Times, Sept. 11, 1995, at A3.

Finally, it seems clear that most physicians would agree on the definition of “terminally ill,” at least for the purpose of the relief that plaintiffs seek. The plaintiffs seek to hasten death only where a patient is in the “final stages” of “terminal illness,” and it seems even more certain that physicians would agree on when this condition occurs. Physicians are accustomed to advising patients and them families in this regal’d and frequently do so when decisions are to be made regarding the furnishing or withdrawal of life-support systems. Again, New York may define that stage of illness with greater particularity, require the opinion of more than one physician or impose any other obligation upon patients and physicians who collaborate in hastening death.⁴

The New York statutes criminalizing assisted suicide violate the Equal Protection Clause because, to the extent that they 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.

CONCLUSION

We reverse the judgment of the district court and remand for entry of judgment in favor of the plaintiffs in accordance with the foregoing. No costs are awarded to either side. See Fed.R.App.P. 39(a).

1 . On March 15, 1996, Delury pleaded guilty to second-degree attempted manslaughter. Pam Belluck, Man Will Get Prison Term for Helping His Wife Kill Herself, N.Y. Times, Mar. 16, 1996, at 23, 26.

2 . On rehearing in banc, the Ninth Circuit vacated the decision of the panel and affirmed the decision of the district court. Compassion in Dying v. Washington, 19 F.3d 790 (9th Cir.1996) (in banc).

3 . There are those who use the terms "assisted suicide” and "euthanasia” interchangeably. See Patricia A. Unz, Note, Euthanasia: A Constitutionally Protected Peaceful Death, 37 N.Y.L. Sch. L.Rev. 439, 439 n. 8 (1992). While euthanasia is derived from the Greek words meaning "good death,” id. at 441, it seems clear that most states, including New York, make a distinction between the two acts. See Wlten Death Is Sought, supra, at 63. In euthanasia, one causes the death of another by direct and intentional acts. Id. Accordingly, euthanasia falls within the definition of murder in New York. See N.Y. Penal Law § 125.25(1) (McKinney 1987).

4 . For example, the state might take steps to assure the competence of prescribing physicians by imposing education and training qualifications, including pain management; it may require the establishment of local ethics committees as resources for physicians faced with questions relating to requests for lethal medications; it could specify the information to be furnished to the patient to ascertain that the patient's choice is a fully voluntary one; it might require consultations with other physicians for further diagnosis and prognosis in regard to the patient's illness, for psychiatric evaluation, and for evaluation of pain control possibilities; it may provide a time delay between a request for lethal medication and the prescription in order to allow a time for reflection; and it may suggest some sort of notification to the patient's family.

Recently, a group of physicians known as "Physicians for Mercy” proposed ten guidelines for doctor-assisted suicide. Doctors Offer Some Support to Kevorkian: Urge 10 Guidelines in Assisting Suicide, N.Y. Times, Dec. 5, 1995, at A21. These guidelines call for a physician who assists in suicide, called an "obitiatrist,” to refer his patients to a psychiatrist, a specialist in the patient’s specific illness, and, if necessary, a specialist in pain management, before acting at the behest of a mentally competent person with an incurable affliction. Id. "Physicians for Mercy” has decided to call the practice of physician assisted suicide "patholysis,” a term coined by Dr. Jack Kevorkian, who has assisted in more than two dozen suicides. Id. However, Dr. Kevorkian’s assistance has not been rendered exclusively to those beset by terminal illnesses. Bruce Fein, The Right to Determine One's Exit from Life, Wash. Times, Jan. 23, 1996, at A14.