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1
COMMONWEALTH OF MASSACHUSETTS
APPEALS COURT
No. 2021-P-0156
DR. ROGER M. KLIGLER AND DR. ALAN STEINBACH,
Appellants (Plaintiffs Below),
v.
MAURA T. HEALEY, IN HER OFFICIAL CAPACITY AS THE ATTORNEY GENERAL OF THE COMMONWEALTH OF
MASSACHUSETTS, AND MICHAEL O’KEEFE, IN HIS OFFICIAL CAPACITY AS DISTRICT ATTORNEY OF CAPE & ISLANDS DISTRICT,
Appellees (Defendants Below),
On Appeal from the Suffolk County Superior Court Civil Action No. 16-3254F
OPENING BRIEF OF APPELLANTS
Jonathan M. Albano, BBO No. 013850 [email protected] Nathaniel P. Bruhn, BBO No. 681994 [email protected] MORGAN, LEWIS & BOCKIUS LLP One Federal Street Boston, MA 02110-1726 617.951.8651 Attorneys for Appellants
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TABLE OF CONTENTS Page
2
I. STATEMENT OF THE ISSUES ................................................................... 5
II. STATEMENT OF THE CASE ...................................................................... 5
III. STATEMENT OF THE FACTS .................................................................... 6
A. Background .......................................................................................... 6
1. The Parties .................................................................................. 6
2. End Of Life Care ........................................................................ 8
B. This Lawsuit ....................................................................................... 10
C. Superior Court’s Summary Judgment Order ...................................... 12
IV. SUMMARY OF THE ARGUMENT ........................................................... 12
V. ARGUMENT ................................................................................................ 14
A. The Superior Court Erred When It Determined That Common Law Involuntary Manslaughter Is Applicable To MAID .................. 15
B. Common Law Involuntary Manslaughter Is Unconstitutionally Vague As Applied To MAID ............................................................. 25
C. The Superior Court Erred When It Determined That Prohibiting MAID Does Not Implicate A Fundamental Right ............................. 27
D. The Trial Court Erred In Determining That The Commonwealth’s Purported Prohibition On MAID Meets The Rational Basis Test For Both Due Process And Equal Protection ............................................................................................ 32
VI. CONCLUSION ............................................................................................. 40
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TABLE OF AUTHORITIES
Pages
3
Cases
Brophy v. New England Sinai Hosp., Inc., 398 Mass. 417, 497 N.E.2d 626 (1986) .................................................. 29, 30, 32
Chambers v. RDI Logistics, Inc., 476 Mass. 95, 65 N.E.3d 1 (2016) ....................................................................... 14
City Elec. Supply Co. v. Arch Ins. Co., 481 Mass. 784, 119 N.E.3d 735 (2019) ............................................................... 22
Commonwealth v. Atencio, 345 Mass. 627, 189 N.E.2d 223 (1963) ............................................................... 19
Commonwealth v. Carrillo, 483 Mass. 269, 131 N.E.3d 812 (2019) ............................................................... 23
Commonwealth v. Carter, 474 Mass. 624, 52 N.E.3d 1054 (2016) ............................................ 13, 19, 26, 27
Commonwealth v. Carter, 481 Mass. 352, 115 N.E.3d 559 (2019) ....................................................... passim
Commonwealth v. Guaman, 90 Mass. App. Ct. 36, 56 N.E.3d 830 (2016) ...................................................... 15
Commonwealth v. Jasmin, 396 Mass. 653, 487 N.E.2d 1383 (1986) ............................................................. 25
Commonwealth v. Orlando, 371 Mass. 732, 359 N.E. 2d 310 (1977) .............................................................. 13
Commonwealth v. Welansky, 316 Mass. 383, 55 N.E.2d 902 (1944) ................................................................. 15
Custody of a Minor, 375 Mass. 733, 379 N.E.2d 1053 (1978) ............................................................. 37
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TABLE OF AUTHORITIES (continued)
Page(s)
4
Dulgarian v. Stone, 420 Mass. 843 (1995) .......................................................................................... 14
Flesner v. Tech. Commc'ns Corp., 410 Mass. 805, 575 N.E.2d 1107 (1991) ............................................................. 23
Goodridge v. Dep't of Pub. Health, 440 Mass. 309, 798 N.E.2d 941 (2003) ............................................ 31, 32, 33, 37
Loving v. Virginia, 388 U.S. 1 (1967) ................................................................................................. 31
Obergefell v. Hodges, 576 U.S. 644 (2015) ............................................................................................. 31
Persampieri v. Commonwealth. 343 Mass. 19, 175 N.E.2d 387 (1961) ................................................................. 21
R.L. Currie Corp. v. E. Coast Sand & Gravel, Inc., 93 Mass. App. Ct. 782, 109 N.E.3d 524 (2018) .................................................. 14
Superintendent of Belchertown State Sch. v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977) ........................................................ 29, 32
Statutes
Or. Rev. Stat. §127.800-.897 ............................................................................ 34, 36
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I. Statement Of The Issues
This case raises the issues of whether: (1) criminal manslaughter charges
apply to physicians who follow a medical standard of care and write a prescription
to terminally ill, competent adults who request such aid and choose to self-ingest
medication consistent with the practice of Medical Aid In Dying (MAID); (2) the
application of common law manslaughter to a physician who engages in
prescribing MAID medication violates the Massachusetts Constitution because the
law is impermissibly vague; (3) the application of common law manslaughter to
physicians who prescribe MAID medication violates Plaintiff’s privacy rights
under the Massachusetts Constitution; (4) the application of common law
manslaughter to physicians who prescribe MAID medication violates Plaintiffs’
liberty rights under the Massachusetts Constitution; and (5) the application of
common law manslaughter to physicians who prescribe MAID medication violates
Plaintiffs’ constitutional right to equal protection under the Massachusetts
Constitution.
II. Statement Of The Case
This is an appeal of the Superior Court’s December 31, 2019 Memorandum
of Decision and Order on the Parties’ Cross-Motions for Summary Judgment
Addendum 47-70; RAIII/339-362 (the “Summary Judgment Order”), granting
Defendants’ Motion for Summary Judgment as to Counts I, II, III, IV, and VI.
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III. Statement Of The Facts
A. Background
1. The Parties
Plaintiff Roger Kligler, M.D. (“Dr. Kligler”), is a retired physician who
resides in Falmouth Massachusetts and spent the final 32 years of his career
treating patients in the Commonwealth. Dr. Kligler has Stage 4 Metastatic
Castrate-Resistant Prostate Cancer. Impounded RAI/26-27 at 20:21-21:14. Stage
4 is the most severe form of cancer. Dr. Kligler’s cancer has metastasized to his
bones. Impounded RAI/75 at 69:17-22; 69:1-3. Dr. Kligler's physician, Dr.
Christopher Sweeney, estimated, at the time of his deposition, that there is a 50
percent chance that Dr. Kligler will die within five years. Impounded RAI/35-37
at 29:20-31:4. Dr. Sweeney further cautions that the prognosis for cancer patients
can quickly turn negative. Impounded RAI/72-73 at 66:12-67:12. Due to the
uncertainty in predicting the course of any cancer, Dr. Sweeney checks Dr.
Kligler's condition every three months. Id. at 66:2-6; 67:4-8. Prostate-specific
antigen (“PSA”) is a diagnostic marker that indicates the existence of prostate
cancer cells and allows Dr. Sweeney to monitor the progression of Dr. Kligler’s
disease. Impounded RAI/19-20 at 13:24-14:13. Dr. Kligler’s PSA levels were
rising as of Dr. Sweeney’s deposition, and continued rising thereafter. Impounded
RAI/74 at 68:4-24; Impounded RAI/536, at ¶ 2, Impounded RAI/539-541.
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Dr. Kligler wants to consult with his physicians about the full range of end-
of-life options and ultimately obtain a prescription for medication that, if he
chooses to take, will allow Dr. Kligler to pass peacefully and without further
suffering. Like many other terminally ill patients, Dr. Kligler believes that having
access to such medication will alleviate his anxiety related to the dying process and
allow him to live his final days confident that, if his suffering becomes too great,
he has the option to self-ingest a prescription that will end his suffering.
Impounded RAI/536-537 at ¶¶ 3-4; Impounded RAI/302-304, at 78:4-80:18. Dr.
Kligler's desire to have access to this medication stems from his own experiences
as a physician where he witnessed the suffering of terminally ill patients.
Impounded RAI/115-118, at 33:15-36:21. Dr. Kligler fears he may not find a
doctor in Massachusetts willing to provide the requested prescription due to fear of
criminal prosecution. Impounded RAI/537 at ¶ 4.
Plaintiff Alan Steinbach, M.D. (“Dr. Steinbach”) is a licensed Massachusetts
physician. Some of the patients he has cared for have considered end-of-life issues
in connection with organ system failure. Impounded RAI/438-444 at 90:16-92:12.
As of his deposition, Dr. Steinbach had no current patients with a six-month
prognosis, although he has cared for patients with a six-month or shorter prognosis
in the past. Impounded RAI/440 at 92:1-6. In the month before his deposition,
one of Dr. Steinbach’s patients who was in the six-month window died.
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Impounded RAI/440-441 at 92:1-93:11. Another of Dr. Steinbach’s patients for
whom he has made house calls and who requested assistance with end-of-life
issues also died during the pendency of this litigation. Impounded RAI/449-453 at
101:5-104:2. Dr. Steinbach had two patients who are ill who expressed an interest
in MAID but who are not yet terminally ill—one received a heart transplant and
the other did not have a six-month prognosis. Impounded RAI/485-486 at 137:5-
138:14. Dr. Steinbach wishes, if requested, to provide information regarding, and
to write prescriptions for, medication for MAID. RAII/162 at ¶ 4. He does not
provide information regarding MAID or write MAID medication prescriptions
because he fears criminal prosecution under the laws of the Commonwealth of
Massachusetts. Id.
2. End Of Life Care
There are several options for treating a dying person experiencing severe
pain, agitation, or other acute discomfort at the end of life. The most common
course is to administer strong narcotics, which, depending upon the cause and
source of the pain, may be largely effective in resolving the patient's problems,
although often with the unwanted side-effect of decreased mental alertness.
RAII/170 at ¶ 13; RAI/88 at 33:10-19. However, even with medical care, 25% of
patients die with uncontrolled pain and 21% die with uncontrolled shortness of
breath. When normal doses are not sufficient and the patient is in extreme,
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unrelieved distress, doctors sometimes increase the level of morphine to where it
interferes with respiratory and heart function, even to the point of causing death.
When a terminally ill patient’s pain is not relieved with pain medication, to
provide relief without causing immediate death, the treating physician may sedate
the patient into unconsciousness while withholding hydration and nutrition.
RAI/275-280, at 33:4-38:15. The patient eventually has an expedited death from a
combination of dehydration, starvation, medication effects causing respiratory
depression and hypotension along with the underlying disease. RAI/625-626, at
227:12-228:3. Doctors refer to this process as “terminal sedation” or, more
commonly, “palliative sedation,” which is a legal and accepted practice in in
Massachusetts. RAII/170-171 at ¶¶ 14-15.
A patient’s death resulting from withdrawal of life-sustaining treatment is
not deemed “suicide” under Massachusetts law, and physicians who follow a
patient’s direction to withdraw life-sustaining treatment are not prosecuted under
Massachusetts law. And this is so even where physicians further administer
medications to the patient to alleviate pain and discomfort resulting from the
withdrawal of treatment, and even where the foreseeable result of the medication is
death. RAI/171-173, RAI/188-189 at ¶¶ 15-17, 19-20, 59. Similarly, a patient’s
death resulting from palliative sedation is not deemed “suicide” under
Massachusetts law, and physicians who follow a patient’s wishes for palliative
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sedation are not prosecuted under Massachusetts law even though the foreseeable
result of end-of-life palliative sedation is death. Id.
B. This Lawsuit
On October 24, 2016, Plaintiffs Drs. Kligler and Steinbach sued the
Attorney General of the Commonwealth of Massachusetts (the “AG”) and the
District Attorney of Cape & Islands Districts (the “DA”) at the Suffolk County
Superior Court. The complaint asserts six counts for declaratory and injunctive
relief.
Count I seeks a declaration that “manslaughter charges are not applicable to
physicians who follow a medical standard of care and write a prescription to
terminally ill, competent adults who request such aid and may choose to self-
ingest the medication consistent with the practice of [MAID].” RAI/25 at ¶ 43.
Count II asserts that applying common law manslaughter to a physician who
engages in the conduct described above violates the Massachusetts Constitution
because the law is impermissibly vague. RAI/25-26 at ¶ 46. Counts III and IV
allege that applying common law manslaughter to such a physician impermissibly
restricts a patient's constitutional right to privacy “by interfering with [their] basic
autonomy in deciding how to confront their own mortality and choose their own
destiny,” RAI/26 at ¶ 51, and impermissibly restricts a patient's fundamental
liberty interests “the right of competent adults to control decisions relating to the
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rendering of their own health care,” RAI/27 at ¶ 55. Counts II, III, and IV each
request a declaration "that physicians who follow a medical standard of care and
write a prescription pursuant to the practice of [MAID] to terminally ill, competent
adults who request such aid do not violate criminal law, including the common-law
crime of manslaughter." RAI/26-28 at ¶¶ 47, 52, 57. Each count also seeks an
injunction prohibiting the AG and the DA from prosecuting physicians who engage
in that conduct.
Count V asserts that application of common law manslaughter to a physician
based on his or her provision of information and advice about MAID to competent,
terminally ill adults, who later voluntarily ingest lethal prescribed medication,
constitutes an unlawful restraint on the constitutional right to freedom of speech by
hindering the physicians' ability to discuss medically appropriate end-of-life
treatment options. RAI/28 at ¶ 61. Count V seeks a declaration that giving such
advice is not manslaughter and an injunction prohibiting the AG and the DA from
prosecuting physicians who inform, advise, or counsel patients about MAID.
RAI/29 at ¶ 63.
Last, Count VI asserts that applying common law manslaughter to
physicians who follow a medical standard of care and provide MAID medication
violates the constitutional right to equal protection of law by treating differently
terminally ill adults who wish to receive MAID and terminally ill adults who wish
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to hasten death by voluntarily stopping of eating and drinking (VSED), withdrawal
of life support, or end-of-life palliative sedation. RAI/29-30 at ¶ 66. Count VI
seeks a declaration that providing MAID medication is not manslaughter, and
seeks an injunction against prosecution. RAI/30 at ¶ 69.
C. Superior Court’s Summary Judgment Order
The parties filed cross motions for summary judgment. Plaintiffs sought
summary judgment on their declaratory judgment of no manslaughter (Count I),1
free speech (Count V), and equal protection (Count VI) claims. The defendants
sought summary judgment on all of Plaintiffs’ claims. On December 31, 2019, the
Superior Court issued its memorandum of decision and order on the parties’ cross-
motions for summary judgment, concluding that although the plaintiffs are entitled
to summary judgment on Count V, the defendants are entitled to summary
judgment on all other counts.
IV. Summary Of The Argument
The Superior Court erred in granting summary judgement favoring
defendants on Counts I-IV, and VI.
First, the Superior Court erred in determining that common law involuntary
manslaughter applies to MAID. A doctor’s prescription of MAID medication does
1 Plaintiff did not initially move for a summary judgment on Count I, but requested that the Superior Court “enter judgment against Defendants on Count I under Mass. R. Civ. P. 56(b) and (c)” during supplemental briefing ordered by the court.
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not cause the death of a patient who voluntarily and consciously seeks MAID, fills
the prescription, and self-ingests the medication. The patient causes their own
death. And the “chain of self-causation” is not broken such that the doctor could
then intervene to become the cause of death. Instead, the patient’s death is left to
the patient alone. The Superior Court also erred in granting summary judgment to
defendants because a genuine dispute of material fact exists as to whether the
prescribing doctor is wanton or reckless.
Second, in Carter, the SJC intentionally distinguished MAID from the facts
that supported the charge of involuntary manslaughter, which suggests that
common law manslaughter is not applicable to MAID. Commonwealth v. Carter,
474 Mass. 624, 637, 52 N.E.3d 1054, 1065 (2016) (“Carter I”) (citing
Commonwealth v. Orlando, 371 Mass. 732, 734, 359 N.E. 2d 310 (1977) ). Given
the SJC distinguished MAID from the facts of Carter I, applying involuntary
manslaughter to MAID creates a situation where “men of common intelligence
must guess” at the scope of involuntary manslaughter, making involuntary
manslaughter unconstitutionally vague.
Third, the Superior Court erred in holding that the prohibition against MAID
does not implicate a fundamental right. The Superior Court erred because (1) it
failed to recognize there is no meaningful distinction between MAID and other
end-of-life options; (2) it failed to consider the SJC’s recognition in Brophy and
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Saikewicz that an individual has a fundamental right to accept or reject a medical
treatment; and (3) it refused to consider that the denial of a right to make the
healthcare decision to have the option of MAID implicates a fundamental right
because, in the Superior Court’s view, MAID is not “deeply rooted in this Nation’s
history and tradition.”
Last, the Superior Court further erred because even if the rational basis
standard applies, Massachusetts’s prohibition of MAID would not pass the rational
basis test for either due process or equal protection.
V. Argument
The Appeals Court's review of a grant of summary judgment is de novo.
Chambers v. RDI Logistics, Inc., 476 Mass. 95, 99, 65 N.E.3d 1, 7 (2016).
Summary judgment can be only granted “where, viewing the evidence in the light
most favorable to the nonmoving party, there are no genuine issues as to any
material fact and the moving party is entitled to judgment as a matter of law.” R.L.
Currie Corp. v. E. Coast Sand & Gravel, Inc., 93 Mass. App. Ct. 782, 783, 109
N.E.3d 524, 526 (2018). “[The] party moving for summary judgment in a case in
which the opposing party will have the burden of proof at trial is entitled to
summary judgment if he demonstrates . . . that the party opposing the motion has
no reasonable expectation of proving an essential element of that party's case.” Id.,
quoting Dulgarian v. Stone, 420 Mass. 843, 846 (1995).
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A. The Superior Court Erred When It Determined That Common Law Involuntary Manslaughter Is Applicable To MAID
“Involuntary manslaughter is an unlawful homicide, unintentionally
caused…by an act which constitutes such a disregard of probable harmful
consequences to another as to constitute wanton or reckless conduct.”
Commonwealth v. Carter, 481 Mass. 352, 364, 115 N.E.3d 559, 569 (2019)
(“Carter II”). The elements of involuntary manslaughter are “(1) that the defendant
caused the victim's death, (2) that the defendant intended the conduct that caused
the victim's death, and (3) that the defendant's conduct was wanton or reckless.”
Commonwealth v. Guaman, 90 Mass. App. Ct. 36, 40, 56 N.E.3d 830, 836 (2016);
see also Commonwealth v. Welansky, 316 Mass. 383, 55 N.E.2d 902 (1944). The
Superior Court erred in determining that common law involuntary manslaughter
applies to MAID because the prescribing doctor does not cause the patient’s death
and the prescribing doctor’s conduct is not wanton or reckless.
The Superior Court first erred in finding that a doctor’s prescription of
MAID medication causes the death of a patient who voluntarily and consciously
seeks MAID, fills the prescription, and self-ingests the medication. The patient
causes their own death. And the “chain of self-causation” is not broken such that
the doctor could then intervene, as did the defendant in Carter, to become the
cause of death. Carter II, 481 Mass. at 362-363.
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In Carter II, the SJC found that a causal link between defendant’s actions
and the victim’s death was only established when the defendant overpowered the
victim’s will by instructing him to get back into the gas-infused truck and thus
caused his death. Id. at 363. The SJC held that the victim broke the “chain of self-
causation” by exiting the truck, and when the defendant thereafter overpowered the
victim’s will by coercing the victim to go back in, the defendant caused the
victim’s death. Id. at 362-363.
There, the victim, who was not terminally ill, and defendant exchanged
numerous messages regarding the details of the planned suicide in the days leading
to the victim’s death. Id. at 354. For example, on July 7, 2014, five days before
the victim’s eventual suicide, defendant advised the victim to google the ways to
make carbon monoxide. Id. at 355 n.3. The victim “secur[ed] a water pump that he
would use to generate carbon monoxide in his closed truck.” Id. at 357. During
the days leading to his suicide, he conducted extensive research, and spoke of [the
planned suicide] continually. Id. at 362. He secured the generator and the water
pump for the suicide. Id. “As the victim continued researching suicide methods
and sharing his findings with the defendant, the defendant helped plan how, where,
and when he would do so, and downplayed his fears about how his suicide would
affect his family.” Id. at 355.
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Then on the night of his death, “the victim drove his truck to a local store’s
parking lot and started the pump. While the pump was operating, filling the truck
with carbon monoxide, the defendant and victim were in contact by cell phone.”
Id. at 357-358. At some point, however, “the victim got out of the truck, seeking
fresh air, in a way similar to how he had abandoned his prior suicide attempts.” Id.
at 358-359. “[W]hen defendant realized [the victim] had gotten out of the truck,
she instructed him to get back in, knowing that it had become a toxic
environment…. The victim followed that instruction.” Id. at 359.
Reviewing this sequence of events, the SJC found significant the fact that
defendant “instruct[ed] the victim to get back into the truck” after the victim has
gotten out of the truck. Id. at 370. Even though there had been multiple text
messages with defendant, and even though defendant’s text messages during the
days leading to the victim’s death “constituted wanton or reckless conduct in
serious disregard of the victim's well-being,” the trial judge found—and the SJC
affirmed—“this behavior did not cause his death.” Id. at 357. In other words, the
defendant in Carter II would not have been criminally liable for counselling,
advising, and encouraging the victim had the victim stayed in the truck on his own
and died. That is so because until the victim exited the vehicle, there was a “chain
of self-causation.” Id. at 362. This “chain of self-causation” was, however, broken
when the victim exited the truck. Id. It was only when “the defendant
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overpowered the victim's will” by instructing him to get back into the truck, and
“in [a] weakened state [the victim] was badgered back into the gas-infused truck by
defendant,” that a causal link between defendant’s actions and the victim’s death
was established. Id. at 363 (“Once the victim left the truck, the judge found that
the defendant overpowered the victim’s will and thus caused his death.”). As the
SJC explained, “until the victim got out of the truck…the victim [was] the cause of
his own suicidal actions and reactions,” regardless of the many text messages
defendant exchanged with the victim. Id. at 362.
A patient who fills the MAID medication prescription, and self-ingests the
medication causes their own death and the “chain of self-causation” is not broken
such that the doctor could then become the cause of a resulting death. Moreover,
the standard of care requires the physician to inform the patient they can change
their mind and that they do not have to self-ingest even if they obtain a
prescription. A doctor who provides a MAID medication prescription is no more
criminally liable than the persons who provided the carbon monoxide generator or
the water pump to the victim in Carter II. There is no indication those who
provided the portable generator or the water pump were even charged with any
wrongdoing in relation to the victim’s death. The doctor does not cause the death
of a patient any more than the seller of the generator and water pump caused the
death of the victim in Carter II.
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There is also no causal link if the victim’s death is left to the victim alone.
For example, in Commonwealth v. Atencio, the SJC noted that a driver was not
guilty of involuntary manslaughter for participating in a drag race with her
competitor because “much [of the competitor’s death] is left to the skill, or lack of
it, of the competitor,” and therefore the accused driver did not cause the death. 345
Mass. 627, 631, 189 N.E.2d 223, 225 (1963). Similarly, a doctor’s MAID
medication prescription cannot cause the patient’s death, because so much further
action is left to the patient—she has to fill the prescription and self-ingest the drug
to herself to cause her own death.
Second, the Superior Court further erred in concluding that the Carter
decisions were only “narrowly focused on whether the use of words alone could
constitute involuntary manslaughter.” Summary Judgement Order at 7. The
Superior Court held that because MAID involves more than words, the Carter
decisions do not suggest that the crime requires coercion in the MAID context. Id.
The SJC, however, states that the Carter case differs from a “person offering
support, comfort, and even assistance to a mature adult who, confronted with such
circumstances, has decided to end his or her life.” Commonwealth v. Carter, 474
Mass. 624, 636, 52 N.E.3d 1054, 1064 (2016)(“Carter I”)(emphasis added).
Therefore, in the Carter decisions, the SJC did not limit its discussion about MAID
to only speech associated with MAID.
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In the Carter decisions, the current case is easily distinguishable from
Carter because in MAID the doctor does not “procure[] a suicide” by “pressuring
[] a vulnerable person to commit suicide, overpowering that person’s will to live.”
Carter II, 481 Mass. at 367. MAID allows a prescription only to a terminally-ill,
mentally capable adult patient who requests it—i.e., a patient who already intends
to have the option to take the medication if the patient deems her suffering too
great to endure, such that self-ingesting is the best choice for her own
circumstances. Moreover, the doctor does not “overcome[e] [the patient’s]
willpower to live” in order to “procure” the patient’s death. While a doctor may
offer information and counseling regarding various end of life options so the
patient may make an informed decision, it is the patient chooses to seek MAID.
And while a doctor may even offer a prescription for the MAID medication, it is
the patient who chooses to fill the prescription and ultimately to self-ingest the
medication. In such a case, there is no “procuring suicide” by the doctor who
provides the prescription for the MAID medication. The SJC in Carter II noted
that “end-of-life discussions between a doctor, family member, or friend and a
mature, terminally ill adult confronting the difficult choices that must be made
when faced with the certain physical and mental suffering brought upon by
impending death” differs from the conduct found criminally liable in Carter II. Id.
at 368 and n. 15.
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Similarly, the current case is easily distinguishable from Persampieri v.
Commonwealth. 343 Mass. 19, 22-23, 175 N.E.2d 387, 389 (1961). There, the
petitioner “told his wife that he intended to get a divorce . . . . She then said that
she was going to commit suicide. The [defendant] reminded her she had attempted
suicide on two prior occasions and said she was ‘chicken—and wouldn't do it.’”
Id. at 22. Petitioner also “loaded the gun for her, at which time he noticed the
safety was off,” and “handed the gun [] to his wife.” And when his wife held the
gun against her forehead and unsuccessfully tried to reach the trigger, he told her
“Why don't you take off your shoes, then maybe you can reach the trigger.” Id. at
22-23. She followed that instruction and shot herself, resulting in her death. Id.
The SJC noted that “[t]he petitioner's wife was emotionally disturbed, she had been
drinking, and she had threatened to kill herself. The petitioner, instead of trying to
bring her to her senses, taunted her, told her where the gun was, loaded it for her,
saw that the safety was off, and told her the means by which she could pull the
trigger.” Id. at 23. Under those circumstances, the SJC held that it had not been
error to accept defendant’s plea of guilty to charges of manslaughter. Id.
Here, the patient who seeks MAID cannot be an “emotionally disturbed”
person who exhibits suicidal tendencies. Otherwise the patient would not qualify
for MAID under the medical standard of care. Dr. Kligler is transparent in his
desire to have MAID available as an end-of-life option. When his cancer
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progresses to where he would have six months or less to live, Dr. Kligler intends,
by his own volition, to seek a MAID medication prescription. Impounded
RAI/536, at ¶ 3; RAIII/336, at ¶¶ 2-3.
A doctor who satisfies Dr. Kligler’s request would not be “overcoming [Dr.
Kligler’s] willpower to live” or forcing him to end his life. And when (and if) Dr.
Kligler chooses to self-ingest the MAID medication, Dr. Kligler expects it to be at
his own volition and at the time of his choosing. Id. at ¶ 4. Under these
circumstances, the doctor who provides a MAID medication prescription cannot be
penalized for the acts that Dr. Kligler freely and voluntarily performs without
duress or any pressure from the doctor. And because there would be no “killing”
achieved by “overpower[ing] [Dr. Kligler’s] will to live” by the doctor providing
the MAID medication prescription, any homicide prosecution against the doctor
should not be sustainable. Carter II, 481 Mass. at 365 .
Third, the Superior Court also erred in granting summary judgment to
defendants because a genuine dispute of material fact exists as to whether the
prescribing doctor is wanton or reckless. Summary judgment is only appropriate
“where there are no genuine issues of material fact and the moving party is entitled
to judgment as a matter of law.” City Elec. Supply Co. v. Arch Ins. Co., 481 Mass.
784, 788, 119 N.E.3d 735, 739 (2019). “In cases where motive, intent, or other
state of mind questions are at issue, summary judgment is often inappropriate.”
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Flesner v. Tech. Commc'ns Corp., 410 Mass. 805, 809, 575 N.E.2d 1107, 1110
(1991).
“The essence of wanton or reckless conduct is intentional conduct, by way
either of commission or of omission where there is a duty to act, which conduct
involves a high degree of likelihood that substantial harm will result to another.”
Commonwealth v. Carrillo, 483 Mass. 269, 275, 131 N.E.3d 812, 819 (2019). In
Commonwealth v. Carrillo, the SJC rejected the argument that in Massachusetts,
“the distribution of heroin alone is sufficient to support a guilty finding of
involuntary manslaughter where the heroin causes the user's death.” Id. at 824.
Rather, the SJC noted that “[u]sually wanton or reckless conduct consists of an
affirmative act, like driving an automobile or discharging a firearm, in disregard of
probable harmful consequences to another . . . and the harm to another person must
be substantial, involving death or grave bodily injury.” Id. at 820.
Here, a genuine issue of material fact exists as to whether the prescribing
doctor’s conduct is “in disregard of probable harmful consequences to another.”
For many doctors, prescribing MAID medication is a way to help a terminally ill
patient obtain peace of mind, rather than causing harm or death of the patient.
Patients interested in MAID seek to avoid intolerable pain or unbearable suffering,
and seek the peace of mind that MAID offers. RAIII/170 at ¶ 46. For others, the
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availability of MAID boosts the patient’s courage to attempt “longshot” therapies
that may leave them in even greater suffering if the therapy fails. RAIII/211 at ¶ 8.
Even if a patient could have their pain adequately treated through palliative
care, MAID can offer the additional peace of mind that the patient has an exit more
consistent with their values should palliative care fail to treat their pain. Id. In
requesting and prescribing MAID medication, the immediate goal of both patient
and physician may be nothing more than to give the patient a greater sense of
control over the process of dying, and both may hope that the patient is never
forced to take this final step in order to relieve their suffering. RAIII/164-165,
RAIII/171 at ¶¶ 32, 49. Indeed, in the jurisdictions where MAID is permitted,
many patients who are prescribed MAID medication never take it. RAIII/171 at ¶¶
48, 49. Thus, the prescribing doctor is not acting in disregard of probable harmful
consequences to the patient. Rather, the doctor carefully considers the potential
consequences of the prescription and determines that the patient would benefit
from having the prescription and the peace of mind it offers. The doctor’s action is
a result of thoughtful consideration to ensure that MAID is an appropriate option
for a specific patient under the medical standard of care. The doctor’s actions are
not wanton or reckless.
Therefore, the Superior Court erred in denying plaintiffs-appellants’
summary judgment motion and granting summary judgment in defendants-
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appellees’ favor. At the very least, the evidence on the prescribing doctors’
considerations in weighing the pros and cons of MAID, which shows the doctors’
conduct would not be wonton or reckless, should have precluded the grant of
summary judgment in defendants’ favor so this issue of fact could be resolved at
trial.
B. Common Law Involuntary Manslaughter Is Unconstitutionally Vague As Applied To MAID
A law is unconstitutionally vague and a denial of due process of law “if it
fails to provide a reasonable opportunity for a person of ordinary intelligence to
know what is prohibited or if it does not provide explicit standards for those who
apply it.” Commonwealth v. Jasmin, 396 Mass. 653, 655, 487 N.E.2d 1383, 1385
(1986).
While the Superior Court ruled that common law manslaughter is not vague
as applied to MAID, it cited no judicial explanation that clarified the statute in that
context. Carter II, 481 Mass. at 354. Nor do the Carter cases, which found
manslaughter not unconstitutionally vague as applied to Carter, clarify the statute
as applied to MAID. In Carter I, the SJC found it “important” to specifically state
that MAID is “easily distinguishable” from Carter, where there was an allegation
of “a systematic campaign of coercion on which the virtually present defendant
embarked—captured and preserved through her text messages—that targeted the
equivocating young victim's insecurities and acted to subvert his willpower in
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favor of her own.” 474 Mass. at 636. Finding the defendant in Carter was guilty
of involuntary manslaughter, the SJC noted that it was “important to articulate
what this case is not about…a person offering support, comfort, and even
assistance to a mature adult who, confronted with such circumstances [imminent
death], has decided to end his or her life.” Id.
The vagueness of manslaughter as applied to MAID is demonstrated by the
differing interpretations of the Carter cases by the Superior Court and the
defendants. Defendants argued below that Carter permits the broad application of
the common law of manslaughter to physicians who provide information and
counseling on MAID. RAIII/394. In contrast, the Superior Court stated that “the
Carter decisions were not interpreted to prohibit speech associated with physician
assisted suicide (e.g., a physician informing a terminally ill patient where MAID is
legal or advising the patient to travel to a state where MAID is legal.” Addendum
56; RAIII/348 (emphasis original). The fact that the Superior Court and the
Defendants on the one hand, and the Attorney General and the District Attorney on
the other hand have differing interpretations on whether the common law of
manslaughter, as interpreted in Carter, applies to MAID speaks volumes. A
person of common intelligence, without the benefit of legal training and
knowledge possessed by the Superior Court, the Attorney General, or the District
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Attorney, would have no hope of discerning whether the common law of
manslaughter would apply to the practice of MAID.
The SJC in Carter I has not limited its decision to speech associated with
MAID as suggested by the Superior Court. Rather, it states the Carter case is
distinguishable from “a person offering support, comfort, and even assistance to a
mature adult who, confronted with such circumstances, has decided to end his or
her life.” Carter I, 474 Mass. at 636 (emphasis added). Thus, the SJC has not
limited its discussion of MAID to the context of speech associated with MAID.
Therefore, Plaintiffs maintain that because the SJC did not resolve the applicability
of involuntary manslaughter to MAID, common law manslaughter is
unconstitutionally vague as applied to MAID because “men of common
intelligence must necessarily guess at its meaning.”
C. The Superior Court Erred When It Determined That Prohibiting MAID Does Not Implicate A Fundamental Right
The Superior Court held that a prohibition against MAID does not implicate
a fundamental right. The Superior Court erred because (1) it failed to recognize
there is no meaningful distinction between MAID and other end-of-life options; (2)
it failed to consider the SJC’s recognition in Brophy and Saikewicz that an
individual has a fundamental right to accept or reject a medical treatment; and (3)
it refused to consider the prohibition of MAID as implicating a fundamental right
because MAID is not “deeply rooted in this Nation’s history and tradition.”
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First, there is no meaningful distinction between MAID and other end-of-life
options. In palliative sedation in the context of end-of-life care, as in MAID, a
patient’s death is the intended consequence of the course of treatment. RAIII/159
at ¶ 18. While sedation is used in other contexts, such as trauma, burn,
postsurgical, and intensive care, in those cases ventilation, hydration, and nutrition
are maintained and death is not intended and does not typically result. Id. But in
the end-of-life context, hydration and nutrition are withheld by design during the
administration of palliative sedation, which results in death. RAIII/159-160 at ¶
19; RAIII/211-212 at ¶ 9. Likewise, death is certain and intended for voluntary
stopping of eating and drinking. RAIII/209, RAIII/212-213 at ¶¶ 5, 10.
While Defendants argue that doctors intend that the patient not suffer when
they employ permitted remedies, including end-of-life palliative sedation, the same
is true for MAID—the doctor’s intent is that the patient not suffer. RAIII/212-213
at ¶ 10; see also supra pp. 19-20. In end-of-life palliative sedation to
unconsciousness (when the patient declines fluids and a ventilator), removal of life
support, and VSED—all of which are legal in Massachusetts—the physician
performs an action to assist the patient in reaching the unavoidable result of death
and the physician knows that her assistance will result in the patient’s death.
RAIII/210-211, RAIII/212-213 at ¶¶ 7, 10. The intent of the doctor and the patient
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do not distinguish MAID from palliative sedation and other permissible remedies.
RAIII/212-213 at ¶ 10.
Nor is MAID distinguishable from end-of-life palliative sedation by the
degree of medical intervention. In undergoing palliative sedation, patients do not
merely “reject treatment”—palliative sedation “usually requires a subcutaneous or
intravenous infusion and intensive involvement by the health care team for
observation, monitoring, and support.” RAIII/158 at ¶ 16. Criminalizing MAID,
therefore, treats patients seeking MAID differently from patients seeking other
end-of-life options without justification.
Second, although the SJC has not decided a case involving MAID,
Massachusetts has long recognized a terminally ill patient’s fundamental right to
make her own medical decisions, even if such decisions result in death. For
example, in Superintendent of Belchertown State Sch. v. Saikewicz, the SJC
confirmed that a patient’s right to refuse medical treatment was grounded in her
right to “human dignity and self-determination.” 373 Mass. 728, 370 N.E.2d 417,
424 (1977). Similarly, in Brophy v. New England Sinai Hosp., Inc., the SJC again
found that restricting a patient’s right to refuse medical treatment impacted the
“fundamental principles of individual autonomy.” 398 Mass. 417, 430-431, 497
N.E.2d 626, 633 (1986). The Court explained that a person has the right “to make
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[his] own decision to accept or reject treatment, whether that decision is wise or
unwise.” Id. at 430 (citations omitted, emphasis added).
The Superior Court held that the Brophy decision “signal[s] that the SJC, if
directly faced with the issue, would . . . maintain[] a strong distinction between
MAID, and the withdrawal of treatment and palliative care.” Addendum 63;
RAIII/355 at 17. In concluding this, the Superior Court cited to a footnote in
Brophy, which notes that individuals do not have “unlimited self-determination” or
an “unqualified free choice over life.” But MAID does not ask the court to grant a
person this broad right. As made clear in Plaintiffs’ Motion for Partial Summary
Judgment, the question in this case is very narrow—“whether a doctor who
determines, according to accepted medical standards, that her adult, terminally ill
patient is mentally competent may, at her patient’s request, prescribe medication
that her patient can self-ingest to hasten the time of their death.” RAIII/369.
Terminally ill patients have few choices—they face certain death within a short
while from an existing, incurable illness. See RAIII/369-370 at 1-2. The only
choice at issue is the choice of medical treatment during this irreversible dying
process.
Third, the Superior Court refused to find that the prohibition on MAID
implicates on a fundamental right because a “fundamental right is one that is
deeply rooted in this Nation’s history and tradition.” But if “history and tradition”
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governed what constitutes a fundamental right, interracial and same-sex marriages
would still be illegal. “For decades, indeed centuries, in much of this country
(including Massachusetts) no lawful marriage was possible between white and
black Americans.” Goodridge v. Dep't of Pub. Health, 440 Mass. 309, 327, 798
N.E.2d 941, 958 (2003). And history and tradition have not only prohibited, but
often criminalized, same-sex relationships. See Obergefell v. Hodges, 576 U.S.
644, 650-656, 663 (2015). Nevertheless, restrictions against interracial and same-
sex marriage impinged on fundamental rights. See id.; Loving v. Virginia, 388
U.S. 1, 12 (1967). “History and tradition . . . do not set [the] outer boundaries” of
fundamental rights, and “individuals who are harmed need not await legislative
action before asserting a fundamental right.” Obergefell, 576 U.S. at 644, 648.
While the Superior Court acknowledged that rights to same-sex marriage arise
“from a better informed understanding of how constitutional imperatives define a
liberty that remains urgent in our own era,” it refused to recognize that the
prohibition of MAID violates a terminally ill patients’ fundamental right of self-
determination. Id. at 671-672.
The same rationale applies to this case—irrespective of tradition and
legislative history, Massachusetts’s purported prohibition of MAID violates a
terminally ill patients’ fundamental right of self-determination. Massachusetts has
recognized that terminally ill patients may avoid prolonged suffering during the
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dying process, even if their decisions may hasten death. See, e.g., Saikewicz, 373
Mass. at 742 (“The interest of the State in prolonging a life must be reconciled
with the interest of an individual to reject the traumatic cost of that prolongation.”);
Brophy, 398 Mass. at 430-31 (“It is in recognition of these fundamental principles
of individual autonomy that we sought, in Saikewicz, to shift the emphasis away
from a paternalistic view of what is ‘best’ for a patient toward a reaffirmation that
the basic question is what decision will comport with the will of the person
involved….”).
Therefore, because Massachusetts’s purported prohibition against MAID
restricts patients’ choices against their will, it implicates the fundamental right of
self-determination and individual autonomy in the context of end-of-life medical
care. See id.
D. The Trial Court Erred In Determining That The Commonwealth’s Purported Prohibition On MAID Meets The Rational Basis Test For Both Due Process And Equal Protection
For due process claims, rational basis analysis requires that statutes “bear[] a
real and substantial relation to the public health, safety, morals, or some other
phase of the general welfare.” Goodridge, 440 Mass. at 330 (citation omitted).
For equal protection challenges, the rational basis test requires that “an impartial
lawmaker could logically believe that the classification would serve a legitimate
public purpose that transcends the harm to the members of the disadvantaged
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class.” Id. Even if the rational basis standard applies, Massachusetts’s common
law prohibition of MAID would not pass for either due process or equal protection.
As an initial matter, involuntary manslaughter in Massachusetts is a common
law crime, and therefore there cannot be any legislative intent. The legislature also
has not passed any statute specifically applying the common law crime of
involuntary manslaughter to MAID. The Superior Court, therefore, erred by
arbitrarily ascribing a legislative rationale where none exists.
Even if, for the sake of argument, it were permissible to ascribe some
hypothetical legislative intent to a common law crime, the Superior Court’s
rationale is flawed. First, the Superior Court erred in finding that the Legislature
could rationally conclude that difficulty in determining and ensuring that a patient
is “mentally competent” warrants the continued prohibition of MAID. Addendum
66; RAIII/358 at 20. Competency could easily be determined by the patient’s
doctor because treating physicians are frequently called upon to determine
competency of their patients for guardianship and other legal proceedings. MAID
should be no different.
The Superior Court first noted that many patients faced with a diagnosis of
terminal illness are depressed. But patients who are depressed may nevertheless
continue to be competent. Depression is a spectrum from sadness to psychotic
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depression, and it is possible for a patient to feel depressed without being suicidal.2
RAIII/220 at ¶ 25. More important, however, physicians routinely evaluate
patients for depression under the current standard of care when handling existing
end-of-life care, including patient requests to discontinue life support. RAIII/169 ¶
44. This holds true for MAID. In the State of Oregon, the physician must also
refer the patient to another physician who will confirm the relevant diagnosis,
including the patient’s mental competence before prescribing MAID medication.
Or. Rev. Stat. §127.800-.897. Addendum 71-119.
As to the measurement of competence at the moment of self-ingestion, no
other self-ingested prescriptions written by physicians in the Commonwealth bear
this requirement. Such a requirement would be inconsistent with the concept of
“self-ingestion.” Physicians routinely write prescriptions for medications with
instructions for self-ingestion which, if taken against the instructions of the
physician or pharmacist, could cause serious harm or death. Physicians are not
present to monitor whether the patient is competent when they take their
medications. Physicians make those determinations when the prescription is
written, and upon further check-ups and examinations. That is what the standard
2 Being depressed at the prospect of dying is not the same as being unable to make medical decisions for oneself.
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of care requires. Thus, it is irrational to create a new, additional requirement for
self-ingested MAID prescriptions in the Commonwealth.
Second, the Superior Court found that the Legislature could rationally
conclude that predicting when a patient has six months to live is too difficult and
risky for MAID. Addendum 67; RAIII/359. The Superior Court erred, first
because the applicable laws are not statutes enacted by the Legislature. Moreover,
this argument does not provide a rational basis for distinguishing between MAID
and other permissible end-of-life options, such as VSED and palliative sedation.
Each jurisdiction, including Massachusetts, has an established medical standard of
care for diagnosing terminal illness. RAIII/177-178 at ¶ 64. And important
medical decisions, including life and death decisions, are made based on these
diagnoses. RAIII/217 at ¶ 19. In hospice, for example, there is a long tradition of
using a definition of terminal illness of six months or less. RAIII/177-178 at ¶ 64.
Physicians currently may determine when patients are eligible for palliative
sedation. Physicians are accustomed to making these determinations and those
physicians who deal most frequently with terminally ill patients—such as
oncologists and palliative care doctors—are especially adept at making these
determinations. RAIII/217 at ¶ 19. And most importantly, nothing requires a
physician to offer MAID if they cannot reasonably determine that the patient is
likely to die in the near future. But when that determination can be made, the
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Commonwealth allows for the decision to administer palliative sedation—so too
should the Commonwealth allow MAID as one option provided to the patient.
Moreover, in all jurisdictions that allow MAID, the physician must also refer the
patient to another physician to confirm the terminal diagnosis before prescribing
MAID medication. See, e.g., Or. Rev. Stat. §127.800-.897. Addendum 71-119.
The fact that physicians cannot predict with absolute certainty when a particular
patient will die is not an impediment to allow other end-of-life options, and it is not
a sufficient reason to justify denial of MAID. RAIII/217 at ¶ 19.
Third, the Superior Court found that the Legislature could rationally
conclude that a general medical standard of care cannot protect those seeking
MAID. Addendum 67; RAIII/359. The Superior Court first noted that the
Commonwealth put forward expert testimony that MAID “is neither a medical
treatment nor a medical procedure and thus there can be no applicable medical
standard of care. See id. This expert testimony, however, conflicts with the fact
that in all jurisdictions where MAID is authorized, only medical personnel are
authorized to prescribe MAID medication. If MAID were not a medical treatment,
then anyone could order MAID medication, which is plainly not the case.
The Superior Court further held that regulating MAID is difficult even
where statutory standards are in place. Addendum 68; RAIII/360. But the
Commonwealth offered no evidence that the specific authorization of MAID in
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other jurisdictions has contributed to a decline in the “ethical integrity of the
medical profession.” Custody of a Minor, 375 Mass. 733, 754-55, 379 N.E.2d
1053, 1065-66 (1978); see Goodridge, 440 Mass. at 334 (rejecting bare assertion
without evidence that forbidding same sex marriage would increase the number of
couples entering heterosexual marriages to have children). There is no evidence
from Oregon or the other states where MAID is permitted that the medical
profession has suffered. MAID is ethically similar to other legal means of
respecting a patient’s wishes, such as withdrawal of life-sustaining treatment,
VSED, or palliative sedation even though doing so hastens the time of death.
RAIII/165 at ¶ 33. In fact, doing nothing until patients develop intolerable pain or
other forms of unbearable suffering is viewed by many as the inhumane and
unethical option. RAIII/170 at ¶ 46.
Last, the Superior Court held that the Legislature (which, again, has not
enacted any statutes here applicable) could rationally conclude that MAID is not
equivalent to permissible alternatives. Summary Judgement Order at 22. The
Superior Court erred because there is no meaningful distinction between MAID
and the other end of life options.
The Superior Court noted that VSED and withdrawal of life support differ
from MAID because both VSED and withdrawal of life support concern the right
to discontinue unwanted treatment and the physicians do not necessarily act to
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cause the patient’s death. See id. But in VSED and withdrawal of life support, the
physician performs an action to assist the patient in reaching the unavoidable result
of death and the physician knows that her assistance will result in the patient’s
death. RAIII/210-213 at ¶¶ 7, 10. Thus, the intent of the doctor and the patient do
not distinguish MAID from VSED and withdrawal of life support. RAIII/212-213
at ¶ 10.
The Superior Court further noted that palliative sedation differs from MAID
because it does not necessarily involve an intent to shorten life nor does it
necessarily cause or hasten death. Summary Judgement Order at 22. But the same
can be said of MAID—the intent of the physician is to alleviate suffering, not that
his patient die. Statistics show that in over 30% of MAID prescriptions the
medication does not hasten death because the patient does not take the medication.
Simply having the prescription on hand provides peace of mind that the patient will
not suffer. And where the patient elects to ingest the MAID medication there still is
no real distinction from palliative sedation because in both cases the physician
understands that the patient’s death would be hastened. Patients choose to refuse
life support and undergo palliative sedation with the specific intent of bringing
about their death. RAIII/159 at ¶ 18; RAIII/212-213 at ¶ 10. And “[t]here is broad
agreement that physicians must respect such refusals, even when the patient’s
intention is to die.” RAIII/212-213 at ¶18. Doctors and their staff take specific
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actions to facilitate the resulting death. “Continuous sedation usually requires a
subcutaneous or intravenous infusion and intensive involvement by the health care
team for observation, monitoring, and support.” RAIII/158at ¶ 16. An impartial
lawmaker would well understand that doctors engaged in palliative sedation
understand that their actions are intended to hasten their patients’ death.
RAIII/212-213 at ¶ 10. Thus, there is no logical distinction between the intents
and purposes behind end-of-life palliative sedation and MAID.
The Superior Court further noted that palliative sedation may be conducted
in such a fashion as to ensure that the underlying disease, not the sedation causes
death. This is not true. Sedation is used in other contexts, such as trauma, burn,
postsurgical, and intensive care. RAIII/157 at ¶ 13. In those contexts, ventilation,
hydration, and nutrition are maintained and obviously death is not intended.
RAIII211-212 at ¶ 9. But in the end-of-life context—which is what this action is
all about—hydration and nutrition are withheld during the administration of
palliative sedation. Id. It is “implausible” in those circumstances to claim that
death is unintended, or that the continuous administration of sedation would not
alter the timing or mechanism of death. RAIII/159-160 at ¶ 19. Rather, death is
certain, and in most cases caused by a mechanism (e.g., dehydration) different
from the underlying disease (e.g., cancer). Id.
Thus, there is no logical distinction between palliative sedation and MAID
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because both involves actions taken by a medical professional that likely alter the
timing and mechanism of a terminally ill patient’s death. Even if a statutory
prohibition existed it would be irrational and illogical for an impartial legislator to
refuse to offer MAID on the grounds that some people who undergo palliative
sedation (in a different context) do not die. RAIII/211-212 at ¶¶ 9-10.
The Superior Court further held that other end of life alternatives differ from
MAID because they occur in hospitals or other institutions devoted to medical
treatment so they potentially involve less risk than MAID. But this assertion is
factually incorrect because most hospice care is administered at home. Moreover,
the Commonwealth offered no evidence that the legalization of MAID in other
jurisdictions has caused more risks than other end of life alternatives. The fact that
MAID does not occur in hospitals does not make it rational for the Court to ignore
the equal protection violation suffered by Plaintiffs.
Therefore, the trial court erred in determining that the Commonwealth’s
prohibition on MAID meets the rational basis test for both due process and equal
protection.
VI. Conclusion
For the foregoing reasons, this Court should reverse the judgment of the
Superior Court.
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DR. ROGER M. KLIGLER AND DR. ALAN STEINBACH
By their attorneys,
Date: May 10, 2021
/s/ Jonathan M. Albano Jonathan M. Albano, BBO #013850 Nathaniel P. Bruhn, BBO #681994 MORGAN, LEWIS & BOCKIUS LLP One Federal Street Boston, MA 02110-1726 617.951.8000
Of Counsel:
John Kappos (pro hac vice) Bo Moon (pro hac vice) Meng Xu (pro hac vice) O’MELVENY & MYERS LLP 610 Newport Center Drive, 17th Floor Newport Beach, CA 92660 949.823.6900
Kevin Díaz (pro hac vice) Compassion & Choices 101 SW Madison Street, Unit 8009 Portland, OR 97207 503.943.6532
Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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RULE 16(K) CERTIFICATION
The undersigned hereby certifies that this brief complies with the rules of
court that pertain to the filing of briefs, including but not limited to Mass. R. App.
P. 16(a)(6)(pertinent findings or memorandum of decision); Mass. R. App. P. 16(e)
(references in briefs to the record); Mass. R. App. P. 16(f) (reproduction of
statutes, rules and regulations), Mass. R. App. P. 16(h) (length of briefs); Mass. R.
App. P. 18 (appendix to the briefs); and Mass. R. App. P. 20 (forms of briefs,
appendices, and other papers).
This brief complies with Mass. R. App. P. 20(a)(2)(A) because it has been
produced in proportionally spaced typeface using Times New Roman 14-point font
and, excluding the parts of the document exempt by Mass. R. App. P. 20(a)(2)(D),
contains 8,386 words.
/s/ Jonathan M. Albano Jonathan M. Albano BBO No. 013850 MORGAN, LEWIS & BOCKIUS LLP One Federal Street Boston, MA 02110-1726 617.951.8000
Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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COMMONWEALTH OF MASSACHUSETTS
APPEALS COURT
No. 2021-P-0156
DR. ROGER M. KLIGLER AND DR. ALAN STEINBACH,
Appellants (Plaintiffs Below),
v.
MAURA T. HEALEY, IN HER OFFICIAL CAPACITY AS THE ATTORNEY GENERAL OF THE COMMONWEALTH OF
MASSACHUSETTS, AND MICHAEL O’KEEFE, IN HIS OFFICIAL CAPACITY AS DISTRICT ATTORNEY OF CAPE & ISLANDS DISTRICT,
Appellees (Defendants Below),
CERTIFICATE OF SERVICE
I, Jonathan M. Albano, hereby certify that on May 10, 2021, I caused the
foregoing Brief of Appellant to be served electronically by means provided by the
clerk, and by e-mail, to counsel of record for appellees:
Julie Green Maria Granik Jim Sweeney Assistant Attorneys General OFFICE OF THE ATTORNEY GENERAL One Ashburton Place Boston MA 02108-1698
Elizabeth A Sweeney Assistant District Attorney Cape & Islands District 3231 Main St PO Box 455 Barnstable MA 02630
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/s/ Jonathan M. Albano
Jonathan M. Albano, BBO No. #013850 Nathaniel P. Bruhn, BBO No. #681994 MORGAN, LEWIS & BOCKIUS LLP One Federal Street Boston, MA 02110-1726 617.951.8000
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ADDENDUM
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TABLE OF CONTENTS Date Document Page
12/31/2019 Memorandum of Decision and Order On The Parties’ Cross-Motions For Summary Judgment
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N/A Or. Rev. Stat. 127.800-.897 71
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SUFOLK, ss.
NOTIFY COMMONWEALTH OF MASSACHUSETTS
SUPERIOR COURT CIVIL ACTION NO. 2016-03254-F
ROGER KLIGLER & another1
~-MAURA T. HEALEY, in her official capacity,2
& another3
MEMORANDUM OF DECISION AND ORDER ON THE PARTIES' CROSS-MOTIONS FOR SUMMARY JUDGMENT
In recent years there has been growing public acceptance of physician assisted suicide or
Medical Aid in Dying (MAID). The practice is now permitted and regulated in Oregon,
Washington, Vermont, Colorado, California, Hawaii, Maine, and New Jersey as well as in
Washington D.C.4 Plaintiffs Roger Kligler, M.D., who is suffering from Stage 4 Metastatic
Prostate Cancer, and Alan Steinbach, M.D., who treats competent, terminally ill patients
(including Dr. Kligler) considering end-of-life issues, filed this action against Attorney General
Maura Healey (AG) and Cape and Islands District Attorney Michael O'Keefe (DA) seeking a
determination as to whether there is a right to physician assisted suicide or Medical Aid in Dying
(MAID) reflected in Massachusetts law and/or the Massachusetts Constitution. Specifically,
1 Dr. Alan Steinbach.
2 As the Attorney General of the Commonwealth of Massachusetts.
3 Michael O'Keefe, in his official capacity as District Attorney of Cape & Island District.
4 Both the Maine and New Jersey laws went into effect this year (2019). The Court also notes that Montana's Supreme Court determined in 2009 that pursuant to a Montana statute providing a consent defense to homicide, patient consent could constitute a defense to a homicide charge against a physician who engages in MAID. See Baxter v. Montana, 354 Mont. 234, 224 (2009).
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they seek declarations on whether the practice of MAID constitutes involuntary manslaughter
and if so, whether application of the law of involuntary manslaughter to MAID violates the
Massachusetts Constitution. They also seek a declaration that a physician is free to provide
information and advice about MAID to terminally ill patients. The matter is now before the
Court on the plaintiffs' Motion for Partial Summary Judgment on their equal protection and free
speech claims and the defendants' Cross-Motion for Summary Judgment on All Counts. This
court has immense compassion for Dr. Kligler's desire to avoid a potentially painful death and
for Dr. Steinbach's desire to ease his patients' suffering, however, the Court concludes, for the
reasons discussed below, that the plaintiffs' arguments concerning the right to utilize MAID are
unavailing. The Court further concludes that providing advice and information about MAID is .
permitted in the Commonwealth. Accordingly, the parties' motions are ALLOWED in part and
DENIED in part.
BACKGROUND
Dr. Kligler is diagnosed with Stage4 Prostate Cancer, which has metastasized to his
bones. Dr. Kligler's physician, Dr. Christopher Sweeney, estimates that there is a 50 percent
chance that Dr. Kligler will die within five years. Dr. Sweeney further cautions that the
prognosis for cancer patients can quickly turn negative. Due to the uncertainty in predicting the
course of any cancer, Dr. Sweeney checks Dr. Kligler's condition every three months.
Dr. Kligler wants to consult with his physicians about the full range of end-of-life options
and ultimately obtain a prescription for lethal medication. According to Dr. Kligler, such
medication will alleviate anxiety related to the dying process and allow him to live his final days
confident that if his suffering becomes too great, he may self-administer a prescription that will
end his life. Dr. Kligler's desire to have access to the medication stems, in part, from his own
2
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experiences as a physician where he witnessed the suffering of terminally ill patients. Dr.
Kligler believes he may be unable to find a doctor in Massachusetts who is willing to provide the
prescription due to fear of criminal prosecution.
Dr. Steinbach is a licensed Massachusetts physician. Some of the patients he has cared
for have considered end-of-life issues in connection with organ system failure. As of the date of
his deposition, Dr. Steinbach did not have any current patients with a six-month prognosis,
although he has cared for patients with a six-month or shorter prognosis in the past. Dr.
Steinbach wishes, if requested, to provide information regarding, and write prescriptions for,
lethal medication for purposes of MAID. He does not currently provide information regarding
MAID or write MAID prescriptions because he fears criminal prosecution.
Doctors Kligler and Steinbach filed this action against the AG and the DA on October 24,
2016. Their complaint asserts six counts for declaratory and injunctive relief,
Count I of the complaint seeks a declaration that "manslaughter charges are not
applicable to physicians who follow a medical standard of care and write a prescription to
terminally ill, competent adults who request such aid and may choose to self-administer the
medication consistent with the practice of [MAID]." Complaint at 143. The plaintiffs define the
term MAID in their complaint to mean "the recognized medical practice of allowing mentally
competent, terminally ill adults to obtain medication that they may choose to take to bring about
a quick and peaceful death." Id. at 12.
Count II asserts that the application of common law manslaughter to a physician who
engages in the conduct described above violates the Massachusetts Constitution because the law
is impermissibly vague. Counts III and IV allege that the application of common law
manslaughter to such a physician impermissibly restricts a patient's constitutional right to
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privacy "by interfering with [their] basic autonomy in deciding how to confront their own
mortality and choose their own destiny," Complaint at ,r 51, and impermissibly restricts a
patient's fundamental liberty interests, namely, "the right of competent adults to control
decisions relating to the rendering of their own health care," id. at ,r 55. Counts II, III, and IV
each request a declaration "that physicians who follow a medical standard of care and write a
prescription pursuant to the practice of [MAID] to terminally ill, competent adults who request
such aid do not violate criminal law, including the common-law crime of manslaughter."
Complaint at ,r,r 47, 52, 57. Each count also seeks an injunction prohibiting the AG and the DA
from prosecuting physicians who engage in that conduct.
Count V asserts that the application of common law manslaughter to a physician based on
his or her provision of information and advice about MAID to competent, terminally ill patients,
who later voluntarily ingest lethal prescribed medication, constitutes an unlawful restraint on the
constitutional right to freedom of speech by hindering physicians' ability to discuss medically
appropriate end-of-life treatment options. Count V seeks a declaration that giving such advice is
not manslaughter and an injunction prohibiting the AG and the DA from prosecuting physicians
who inform, advise; or counsel patients about MAID.
Lastly, Count VI asserts that the application of common law manslaughter to physicians
who follow a medical standard of care and provide MAID violates the constitutional right to the
equal protection of law by treating differently terminally ill adults who wish to receive MAID
and terminally ill adults who wish to hasten death by the voluntarily stopping of eating and
drinking (VSED), withdrawal oflife support, or palliative sedation. Count VI seeks a
declaration that physician assisted suicide is not manslaughter as well as an injunction against
prosecution.
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DISCUSSION
The parties have filed cross motions for summary judgment. The plaintiffs seek
summary judgment on their equal protection and free speech claims. The defendants seek
summary judgment on all of the plaintiffs' claims. The Court concludes that although the
plaintiffs are entitled to summary judgment on Count V, the defendants are entitled to summary
. judgment on all other counts. 5
A. Applicability of Common Law Involuntary Manslaughter to MAID (Count I)
Involuntary manslaughter involves "an unlawful homicide unintentionally caused by
wanton or reckless conduct." Commonwealth v. Catalina, 407 Mass. 779, 789 (1990). See also
Commonwealth v. Life Care Centers of America, Inc., 456 Mass. 826,832 (2010), quoting
Commonwealth v. Gonzalez, 443 Mass. 799,808 (2005) (defining involuntary manslaughter as
"an unlawful homicide unintentionally caused by an act which constitutes such a disregard of
probable harmful consequences to another as to amount to wanton or reckless conduct.").
"Wanton or reckless conduct" for purposes of the crime is "intentional conduct, by way either of
commission or of omission where there is a duty to act, which conduct involves a high degree of
likelihood that substantial harm will result to another." Catalina, 407 Mass. at 789, quoting
Commonwealth v. Welansky, 316 Mass. 383,399 (1944). Whether conduct is reckless or wanton
may be determined on a subjective basis (the defendant was actually aware of the potential harm
from his or her conduct) or on an objective basis (a reasonable person would be aware of such
potential harm). Commonwealth v. Perry, 34 Mass. App. Ct. 127, 129-130 (1993).
5 Although the counts in the plaintiffs' complaint reference common law manslaughter, the defendants only contend that physicians who provide MAID may be charged with involuntary manslaughter. They do not contend that voluntary manslaughter or any other crime is applicable. As a result, when analyzing plaintiffs' claims, the parties largely focus on the crime of involuntary manslaughter. The Court does the same.
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In relation to Count I, the plaintiffs seek a declaration that physicians who follow a
medical standard of care and write lethal prescriptions to competent, terminally ill adults who
may choose to self-administer the medication (i.e., who engage in MAID) cannot be criminally
prosecuted for common law involuntary manslaughter. The plaintiffs argue that MAID cannot
constitute involuntary manslaughter for three reasons. None are availing.
The plaintiffs first argue that two decisions in Carter v. Commonwealth stand for the
proposition that a defendant who participates in another's suicide can only be liable for
involuntary manslaughter if the defendant occasions the suicide by "overcoming the individual's
will to live" (i.e., coerces the victim) and that therefore MAID can never constitute involuntary
manslaughter because the practice does not involve any coercion. See Commonwealth v. Carter,
474 Mass. 624 (2016) (Carter I); Commonwealth v. Carter, 481 Mass. 352 (2019) (Carter JI).
The plaintiffs, however, misread the Carter decisions.
The two decisions concerned a defendant who was charged and convicted of involuntary
manslaughter after she encouraged and directed her boyfriend via cellphone text messages and
voice calls to complete a suicide attempt while it was in progress. In Carter I, the Supreme
Judicial Court (SJC) rejected the defendant's contention that verbally encouraging someone to
commit suicipe, no matter how forcefully, could not constitute wanton or reckless conduct for
purposes of involuntary manslaughter, and held that there was probable cause to sustain the
indictment against the defendant because the evidence before the grand jury suggested that she
"overbore the victim's willpower" at the moment the victim was expressing reservations about
committing suicide.6 474 Mass. at 635. The SJC explained that the "defendant's virtual
6 The victim was using a water pump to generate carbon monoxide in his truck. At one point, the victim expressed
reservations about going through with the suicide and got out of the truck. The defendant instructed him to return to
the truck and he died shortly thereafter. Carter I, 474 Mass. at 625,629.
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presence [ via cellphone] at the time of the suicide, the previous constant pressure the defendant
had put on the victim [to commit suicide], ... [the victim's] already delicate mental state" and
their romantic relationship lent a "coercive quality" to the defendant's words that caused the
victim to follow through with his suicide. Id. at 634-636. In Carter II, the SJC upheld the
defendant's conviction for involuntary manslaughter because the evidence showed that: the
defendant was the victim's "girlfriend and closest, if not only, confidant in this suicidal
planning;" that the defendant "had been constantly pressuring him to complete their often
discussed plan, fulfill his promise to her, and finally commit suicide;" and that when the victim
abandoned his suicide attempt, the defendant ''badgered" him into resuming it and thereafter "did
absolutely nothing to help him .... " 481 Mass. at 363. The SJC also rejected the defendant's
arguments that common law involuntary manslaughter wa:s constitutionally vague as applied to
her and that the conviction violated her free speech rights. Id. at 363-369.
Neither decision purported to establish a new involuntary manslaughter analysis in the
suicide context more generally. Rather, the cases were narrowly focused on whether the use of
words alone could constitute involuntary manslaughter. MAID comprises of more than words; it
involves conduct - the prescription of lethal medication to patients in order to provide them with
an otherwise unavailable means to end their own lives. Thus, the Carter decisions do not, as the
plaintiffs contend, suggest that the crime requires coercion in the assisted suicide context.
The plaintiffs next argue that MAID is not punishable as involuntary manslaughter
because the act of providing a lethal prescription cannot constitute "wanton and reckless
conduct." The Court disagrees. As noted above, "wanton or reckless conduct" for purposes of
the crime is "intentional conduct, by way either of commission or of omission where there is a
duty to act, which conduct involves a high degree of likelihood that substantial harm will result
7
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to another." Catalina, 407 Mass. at 789, quoting Welansky, 316 Mass. at 399. See also
Commonwealth v. Carrillo, 483 Mass. 269, 275-277 (2019) (explaining meaning of"wanton or
reckless conduct"). The writing of a lethal prescription is an intentional action that, given its
very purpose, is highly likely to result in death. Cf. Carrillo, 483 Mass. at 287, clarifying scope
of Catalina ("Where there is specific evidence that the defendant knew or should have known
that his or her conduct created a high degree of likelihood that substantial harm will result, the
Commonwealth may indeed convict the person who sold or gave the heroin to the decedent of
involuntary manslaughter.") (internal quotation marks and citation omitted).
Lastly, the plaintiffs argue that a physician cannot be liable for prescribing lethal
medication for purposes of MAID because the patient's self-administration of the medication is
an independent intervening cause of death. The Court disagrees. The causation element of
involuntary manslaughter can be satisfied even where the intervening conduct by the victim
leads to death as long as the intervening conduct was "reasonably foreseeable." Catelina, 407
Mass at 791. In the context of MAID, it is reasonably foreseeable that the patient will self
administer the lethal medication, causing his or her own death. Compare id. ( causal link between
defendant's sale of heroin to the victim and the victim's death from the heroin was not broken by
the victim's intervening conduct of injecting herself). See also Carrillo, 483 Mass. at 287.
B. Vagueness (Count II)
"A statute is unconstitutionally vague if men of common intelligence must necessarily
guess at its meaning." Commonwealth v. Crawford, 430 Mass. 683, 689 (2000). In connection
with Count II of their complaint, the plaintiffs maintain that common law involuntary
manslaughter is unconstitutionally vague as applied to MAID. This argument is unpersuasive.
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"Manslaughter is a common-law crime that has not been codified by statute in
Massachusetts. It has long been established in our common law that wanton or reckless conduct
that causes a person's death constitutes involuntary manslaughter." Carter II, 481 Mass. at 364
(internal quotations and citations omitted). Analogous conduct has been deemed unlawful. See
Catelina at 407 Mass at 791 ( defendant could be charged with involuntary manslaughter for sale
of heroin to the victim who died from overdose); Carrillo, 483 Mass. at 287 ("Where there is
specific evidence that the defendant knew or should have known that his·or her conduct created a
high degree oflikelihood that substantial harm will result, the Commonwealth may indeed
convict the person who sold or gave the heroin to the decedent of involuntary manslaughter.")
(internal quotation marks and citation omitted); Commonwealth v. Atencio, 345 Mass. 627, 629
(1963) (individuals who cooperated in bringing about suicide by participation in Russian roulette
game could be convicted of involuntary manslaughter). Cf. Carter II, 481 Mass. at 364, quoting
Crawford, 430 Mass. at 689 ("If a statute has been clarified by judicial explanation ... it will
withstand a challenge on grounds of unconstitutional vagueness."). Thus, the common law
provides sufficient notice that a physician might be charged with involuntary manslaughter for
engaging in MAID. The law is not unconstitutionally vague as applied to MAID.
As with Count I, the plaintiffs rely on the Carter decisions to support their vagueness
argument. In Carter I, the SJC concluded its decision by stating the following:
It is important to articulate what this case is not about. It is not about a person seeking to ameliorate the anguish of someone coping with a terminal illness and questioning the value oflife. Nor is it about a person offering support, comfort, and even assistance to a mature adult who, confronted with such circumstances, has decided to end his or her life. These situations are easily distinguishable from the present case, in which the grand jury heard evidence suggesting a systematic campaign of coercion on which the virtually present defendant embarked- captured and preserved through her text messages - that targeted the equivocating young victim's insecurities and acted to subvert his willpower in favor of her own.
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474 Mass. at 636. Subsequently, in Carte'r II, in rejecting the defendant's contention that her
conviction violated her free speech rights, the SJC cited to the above comments in Carter I and
''reemphasize[ d]" that:
[T]his case does not involve the prosecution of end-of-life discussions between a
doctor, family member, or friend and a mature, terminally ill adult confronting the
difficult personal choices that must be made when faced with the certain physical
and mental suffering brought upon by impending death. Nor does it involve
prosecutions of general discussions about euthanasia or suicide targeting the ideas
themselves .... Nothing in Carter I, our decision today, or our earlier involuntary
manslaughter cases involving verbal conduct suggests that involuntary
manslaughter prosecutions could be brought in these very different contexts
without raising important First Amendment concerns.... [T]he verbal conduct
targeted here and in our past involuntary manslaughter cases is different in kind and , not degree, and raises no such concerns. Only the wanton or reckless pressuring of
a person to commit suicide that overpowers that person's will to live has been
proscribed.
481 Mass. at 368 & n.15 (internal citations omitted). Based on these comments, the plaintiffs
suggest that the decisions have rendered it unclear whether involuntary manslaughter applies to
MAID. The plaintiffs, however, misunderstand these passages. Read together and viewed in the
context of the issue before the SJC (whether the use of words alone could constitute involuntary
manslaughter), it is evident that the SJC's comments were not intended to suggest that MAID
may never constitute involuntary manslaughter, but rather to ensure that the Carter decisions
were not interpreted to prohibit speech associated with physician assisted suicide ( e.g., a
physician informing a terminally ill patient where MAID is legal or advising the patient to travel
to a state where MAID is legal).
C. Freedom of Speech (Count V)
With regard to Count V, the plaintiffs assert that the application of common law
involuntary manslaughter to a physician based on his/her provision of information and advice
about MAID to competent, terminally ill patients, who then voluntarily ingest lethal prescribed
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medication, constitutes an unlawful restraint on the constitutional right to freedom of speech by
hindering the physician's ability to discuss medically appropriate end-of-life treatment options.
As made plain by Carter II, the plaintiffs are correct that the law of involuntary manslaughter
does not prohibit such provision of information and advice. See Carter II, 481 Mass. at 368.
Indeed, the Commonwealth does not contend otherwise. Any physician is free to provide
information on the jurisdictions where MAID is legal, guidance and information on the
procedures and requirements in those jurisdictions, and referrals to physicians who can provide
MAID in those jurisdictions. Such conduct, without more, does not constitute involuntary
manslaughter.7 However, this Court declines to issue an injunction because there now appears
little or no risk that such prosecutions will occur.
D. Due Process and Equal Protection (Counts III, and IV, and VI)
With regard to Counts Ill, IV, and VI, the plaintiffs assert that the application of
involuntary manslaughter to MAID: (1) impermissibly restricts the plaintiffs' fundamental
· liberty interests and thereby violates their due process rights; and (2) violates their rights to equal
protection because it treats differently terminally ill adults who wish to receive MAID and
terminally ill adults who wish to hasten death by VSED, withdrawal oflife support, or palliative
sedation.8 As explained below, the Court concludes this is not the case.
7 In their complaint, plaintiffs seek, in addition to declaratory relief, an injunction prohibiting the AG and the DA
from prosecuting physicians who inform, advise, or counsel patients about MAID. Although "[!]rial judges have
broad discretion to grant or deny injunctive relief," "[a] permanent iajunction should not be granted to prohibit acts
that there is no reasonable basis to fear will occur." light/ab Imaging, Inc. v. Axsun Techs., Inc., 469 Mass. 181,
194 (2014). The Court declines to issue an injunction because there now appears little or no risk that such
prosecutions will occur.
8 As noted above, Count Ill alleges that application of common law manslaughter to a physician that practices
MAID impermissibly restricts the constitutional right to privacy "by interfering with a person's basic autonomy in
deciding how to confront their own mortality and choose their own destiny." Complaint at~ 51. Count IV similarly
alleges that it impermissibly restricts fundamental liberty interests, namely, "the right of competent adults to control
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I. Standard of Review
In order to determine whether the application of common law involuntary manslaughter
to MAID violates the plaintiffs' equal protection and due process rights under the Massachusetts
Constitution, the Court must first examine which standard of review is applicable - strict
scrutiny review, which is required if a statute burdens a suspect group or a fundamental right, or
rational basis review, which is the default form of review. See Goodridge v. Department of Pub.
Health, 440 Mass. 309, 330 (2003) ("Where a statute implicates a fundamental right or uses a
suspect classification, we employ strict judicial scrutiny .... For all other statutes, we employ the
rational basis test.) (internal quotation marks and citation omitted). The plaintiffs argue that
strict scrutiny applies because the prohibition against MAID implicates a fundamental right,
which they define as "Dr. Kliger's fundamental right of self-determination and individual
autonomy in making end-of-life medical decisions ..... " Pl. Opp. Brief at 5. The Court
disagrees.
At the outset, the Court notes that the United States Supreme Court (Supreme Court) has
already determined that an individual does not have a fundamental right to MAID under the U.S.
Constitution. See Washington v. Glucksberg, 521 U.S. 702 (1997); Vacca v. Quill, 521 U.S. 793
(1997). In Glucksberg, the Supreme Court held that Washington state's law prohibiting assisted
suicide did not violate the substantive due process rights of physicians who wished to provide
lethal medications to their competent, terminally ill patients.9 In so ruling, the Court looked to
the "Nation's traditions".to determine whether the right to physician assisted suicide was a
fundamental liberty interest protected by the Fourteenth Amendment's Due Process Clause and
decisions relating to the rendering of their. own health care." Id. at 155. Both the Commonwealth and the plaintiffs
appear to treat these Counts as asserting substantive due pro~ess claims.
9 The ban has since been overturned by legislation in that state.
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determined that it was not because there was an "almost universal tradition that has long rejected
the asserted right, and continues explicitly to reject it today." 521 U.S. at 723, 728. The Court
explained that even though "many rights and liberties protected by the Due Process Clause [ of
the Fourteenth Amendment] sound in personal autonomy" not "all important, intimate, and
personal decisions" were similarly protected. Id. at 727. The Court then went on to apply the
rational basis test and conclude that Washington's assisted suicide ban was rationally related to
legitimate government interests, including: an unqualified interest in the preservation of human
life; an interest in preventing suicide, and in studying, identifying, and treating its causes; an
interest in protecting the integrity and ethics of the medical profession; an interest in protecting
vulnerable groups (e.g., the poor, the elderly, and disabled persons) from abuse, neglect, and
mistakes; and an interest in preventing the societal acceptance of voluntary and involuntary
euthanasia. Id. at 728-73 5.
In Vacca, decided on the same day as Glucksberg, the Supreme Court rejected the
plaintiffs' contention that New York's law against assisted suicide, as applied to physician
assisted suicide, violated the Fourteenth Amendment's Equal Protection Clause by differently
treating mentally competent, terminally ill patients seeking to self-administer prescribed lethal
medication and mentally competent, terminally ill patients who refused life-saving medical
treatment. 521 U.S. at 799-809. The Supreme Court reiterated that the law did not "infringe
fundamental rights" and, applying the rational basis review standard, concluded that the law
"follow[ed] a longstanding and rational distinction." Id. at 799,808. In so ruling, the Supreme
Court stated that drawing a distinction between assisting suicide and withdrawing life-sustaining
treatment "comports with fundamental legal principles of causation and intent." Id. at 801. It
explained that:
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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. . . . 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 .... 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 .. . . 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. . . . The law has long used actors' intent or purpose to distinguish between two acts that may have the same result. ... Put differently, the law distinguishes aotions taken because of a given end from actions taken in spite of their unintended but foreseen consequences.
Id. at 801-803 (internal quotation marks and citations omitted).
This Court also notes that since the rulings in Glucksberg and Vacca, other state appellate
courts have either concluded for the first time or reaffirmed that MAID does not implicate a
fundamental right. S~e, e.g., Morris v. Brandenburg, 376 P. 3d 836 (N.M. 2016); Myers v.
Schneiderman, 31 N.Y.S. 3d 45 (2016); Donorovich-Odonnell v. Harris, 241 Cal. App. 4th 1118
(2015); Sampson v. State, 31 P. 3d 88 (Alaska 2001); Krischer v. Mciver, 697 So. 2d 97 (Fla.
1997). Indeed, despite the apparent growing acceptance of MAID, no state appellate court has
yet to render a ruling inconsistent with Glucksberg or Vacca. See Morris, 376 P. 3d at 839 ("No
appellate court has held that there is a constitutional right to physician aid in dying."); Baxter v.
Montana, 354 Mont. 234., 239 (2009) (finding that a statutory consent defense to a homicide
charge could apply to physicians who practiced MAID but declining to address the parties'
constitutional arguments).
The plaintiffs acknowledge the rulings in Glucksberg and Vacca but point to the SJC's
recognition in Goodridge that the "Massachusetts Constitution is in some instances more
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protective of individual liberty interests than is the Federal Constitution" even in instances
"where both Constitutions employ essentially the same language." 440 Mass. at 328. See also
Commonwealth v. Freeman, 472 Mass. 503,505 n.5 (2015). The plaintiffs maintain that,
although our Appellate Courts have not directly addressed MAID, the holdings of
Superintendent v. Saikewicz, 373 Mass. 728 (1977) and Brophy v. New Engl. Sinai Hosp., 398
Mass. 417 (1986), "make clear that restricting a patient's decision to accept or reject treatment
implicates a fundamental right" and that therefore prohibiting MAID implicates a fundamental
right because it "restricts a patient's decision to accept a medical treatment." PL Opp. Br. at 6-7
(internal quotation marks omitted). However, neither Saikewicz nor Brophy go as far as the
plaintiffs suggest.
Saikewicz concerned a severely mentally handicapped individual who suffered from a
form of leukemia, which if left untreated, would likely cause him to die within weeks or several
months without pain. 3 73 Mass. at 731-734. Chemotherapy would temporarily prolong his life
but could also result in significant adverse side effects and discomfort. Id. The question before
the SJC was whether the individual, through his guardian ad !item, could refuse chemotherapy
treatment. The SJC held that the individual could do so. Id. at 730, 759. In rendering its ruling,
the SJC explained that in situations in which a patient refuses medical intervention and treatment
both the patient and the State have countervailing interests which must be balanced. Id. at 744.
The patient has a right "to reject, or refuse to consent to, intrusions of his bodily integrity and
privacy" rooted in the common law and in a constitutional right to privacy. Id. at 738-740, 745.
The State, on the other hand, has an interest in "(l) the preservation of life; (2) the protection of
the interests of innocent third parties; (3) the prevention of suicide; and ( 4) maintaining the
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ethical integrity of the medical profession." Id. at 741. The SJC found that in the case before it,
the balance favored permitting the individual to forgo treatment. Id. at 744-745, 759.
Similarly, in Brophy, the SJC held that a patient's guardian could remove a gastrostomy
tube through which the patient received nutrition and hydration that artificially continued his life
where there was no hope of his recovery from a persistent vegetative state. 398 Mass. at 421-
422. It balanced the patient's "right to refuse medical treatment" against the four State interests
discussed in Saikewicz and concluded that the Commonwealth's interests did not overcome the
patient's right, as represented by his guardian, to discontinue treatment. Id. at 429-440.
Both of these decisions were narrowly focused on a patient's right to bodily integrity (the
freedom to avoid medical treatment as a form of unwanted touching), rather than, as is the case
with MAID, a patient's desire to have medical treatment to end his or her life. And in each
decision, the SJC was careful not to suggest that the right to refuse medical treatment
encompasses or relates to the right to assisted suicide. It took pains to preserve what it viewed as
a meaningful distinction between death that results naturally from the withdrawal of medical
equipment and death that results from affirmative human efforts. In Saikewicz, the SJC, in
concluding that the Commonwealth's interest in preventing suicide was "inapplicable" to the
case before it, explained that:
In the case of the competent adult's refusing medical treatment such an act does not necessarily constitute suicide since (I) in refusing treatment the patient may not have the specific intent to die, and (2) even if he did, to the extent that the cause of death was from natural causes the patient did not set the death producing agent in motion with the intent of causing his own death. . . . Furthermore, the underlying State interest in this area lies in the prevention of irrational self-destruction. What we consider here is a competent, rational decision to refuse treatment when death is inevitable and the treatment offers no hope of cure or preservation of life. There is no connection between the conduct here in issue and any State concern to prevent suicide.
3 73 Mass. at 743 n.11 (internal citation omitted). The SJC similarly explained in Brophy:
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[W]e [do not] consider [the patient's] death to be against the State's interest in the
prevention of suicide. [The patient] suffers an affliction, ... which makes him
incapable of swallowing. The discontinuance of the G-tube feedings will not be the
death producing agent set in motion with the intent of causing his own death ....
Prevention of suicide is ... an inapplicable consideration. ... A death which occurs
after the removal of life sustaining systems is from natural causes, neither set in
motion nor intended by the patient. . . . [D]eclining life-sustaining medical
treatment may not properly be viewed as an attempt to commit suicide. Refusing
medical intervention merely allows the disease to take its natural course; if death
were eventually to occur, it would be the result, primarily, of the underlying disease,
and not the result of a self-inflicted injury.
398 Mass. at 439 (internal quotation marks and citations omitted). Significantly, the SJC in
Brophy also acknowledged that although the "law recognizes the individual's right to preserve
his humanity, even if to preserve his humanity means to allow the natural processes of a disease
or affliction to bring about a death with dignity,". the. law "does not permit suicide" and thus,
"unlimited self-determination," or "unqualified free choice over life." Id. at 4 34 & n.29.
Neither decision suggests that the principles that underlie the right to refuse medical
treatment apply to the affirmative act of taking one's own life with the assistance of a willing
physician. Instead, they signal that the SJC, if directly faced with the issue, would rule in a
manner consistent with Vacca and Glucksberg, which also maintained a strong distinction
between MAID, and the withdrawal of treatment and palliative care. Compare Glucksberg, 521
U.S. at 727 ("That many of the rights and liberties protected by the Due Process Clause sound in
personal autonomy does not warrant the sweeping conclusion that any and all important,
intimate, and personal decisions are so protected."), with Brophy, 398 at 434 n.29 (individuals do
not have "unlimited self-determination" or an "unqualified free choice over life").
The Court acknowledges that these decisions were issued more than thirty years ago and
may not reflect the SJC's current thinking on the issue. Moreover, since Glucksberg and Vacca,
the Supreme Court recognized that in identifying fundamental rights, a court may consider
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evolving social views in addition to history and tradition. See Obergefell v. Hodges, 13 5 S. Ct.
2584, 2598, 2602 (2015) (noting that "[h]istory and tradition guide and discipline [the
fundamental rights] inquiry but do not set its outer boundaries" and explaining that although the
Glucksberg's "central reference to specific historical practices" may have been appropriate for
the right in that case, it was inconsistent with the Court's approach in discussing "other
fundamental •rights"). Our own courts have indicated they would perhaps apply this same
analysis. See Goodridge, 440 Mass. at 328 ("history must yield to a more fully developed
understanding of the invidious quality of the discrimination"). But see Gillespie v. Northampton,
460 Mass. 148, 153 (201 !) ("fundamental right is one that is deeply rooted in this Nation's
history and tradition") (internal quotation marks omitted); Doe v. Secretary of Educ., 4 79 Mass.
375,392 n. 29 (2018), citing Obergefell 135 S. Ct. at 2598 ("In addition to those rights afforded
explicit protection under our Constitution, [h ]istory and tradition guide and discipline the process
of identifying and protecting fundamental rights implicit in liberty") (internal quotation marks
omitted). However, the evidence before the Court does not sufficiently establish that the
prohibition on MAID represents an outmoded viewpoint and that therefore the distinction
established in our case law between MAID and other end of life options should be disregarded.
Compare Obergefell, 135 S. Ct. at 2602 (right to same-sex marriage arises, in part, "from a better
informed understanding of how constitutional imperatives define a liberty that remains urgent in
our own era"). Indeed, although this issue has been repeatedly litigated, the plaintiffs are unable
to cite to any jurisdiction where its appellate courts have concluded otherwise. 10
10 The Court finds the plaintiffs' reliance on the SJC's decision in Goodridge and the Supreme Court's decision in
Obergefell addressing the right to same-sex marriage unpersuasive. In those cases, the courts were faced with the
question of whether a state could exclude certain persons from obtaining state-sanctioned marriage licenses or put
differently, whether the constitution required an extension of an already established right. In this case, the plaintiffs
seek the declaration of a right that has never been previously recognized for any person.
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Accordingly, the Court concludes that a prohibition against MAID does not implicate a
fundamental right and that therefore the plaintiffs' due process and equal protection claims are
subject to a rational basis review and not a strict scrutiny analysis.
2. Rational Basis Analysis
"For due process claims, rational basis analysis requires that [laws] bear[] areal and
substantial relation to the public health, safety, morals, or some other phase of the general
welfare .... " Goodridge, 440 Mass. at 330 (internal quotation marks omitted). Similarly, "[f]or
equal protection challenges, the rational basis test requires that an impartial lawmaker could
logically believe that the classification would serve a legitimate public purpose that transcends
the harm to the members of the disadvantaged class." Id. (internal quotation marks omitted).
See also Chebacco Liquor Mart, Inc. v. Alcoholic Beverages Control Comm 'n, 429 Mass. 721,
723 (1999) ("A classification will be considered rationally related to a legitimate purpose ifthere
is any reasonably conceivable state of facts that could provide a rational basis for the
classification.") (internal quotation marks omitted); Marshfield Family Skate/and, Inc. v.
Marshfield, 389 Mass. 436, 446 (1983), quoting Commonwealth v. Henry's Drywall Co., 366
Mass. 539, 541 (1974) ("a statutory classification will not be set aside as a denial of equal
protection or due process if any state of facts reasonably may be conceived to justify it."). In
conducting this analysis, the Court does not "weigh conflicting evidence supporting or opposing
a legislative enactment." Shell Oil Co. v. City of Revere, 383 Mass. 682,687 (1981). The Court
concludes that the Commonwealth's prohibition on MAID, meets the rational basis test for both
due process and equal protection. 11
11 Given the nature of the rational basis analysis, the Court rejects the plaintiffs' assertion that summary judgment in favor of the defendants should be denied because there are "at a minimum, factual disputes relating to" the evidence
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First, the Legislature could rationally conclude that difficulty in determining and ensuring
that a patient is "mentally competent" warrants the continued prohibition of MAID. There is
expert testimony in the record that many patients faced with a diagnosis of terminal illness are
depressed, that this depression and accompanying demoralization may interfere with their ability
to make a rational choice between MAID and other available alternatives, and that most
Massachusetts physicians are unaware of the best practices in responding to requests for MAID
given this context. See Forrow Aff., Joint Appendix (J.A.) Ex. 39, at 114; Greene Aff., J.A. Ex.
40, at 16; Farrow Disclosure, J.A. Ex. 13, at 13(a). 12 There is also evidence that the problem of
competency is particularly acute at the time at which a patient self-administers the medication
because patients may be alone or accompanied by those who support his or her end-of-life
decision. See Oregon Health Authority, 2014-17 Data Sununaries, J,A.Ex. 20 (prescribing
physician present at time of death in the case of only 13.9% of patients in 2014; 10.8% in 2015;
IO.I% in 2016; 16.1 % in 2017); Green Disclosure, J.A. Ex. 14, at 6; Green Aff., J.A. Ex. 40, at 1
11; Farrow Aff., J.A. Ex. 39, at 122. In such a situation, there is a greater risk that temporary
anger, depression, a misunderstanding of one's prognosis, ignorance of alternatives, financial
considerations, strain on family members or significant others, or improper persuasion may
impact the decision. The concern that the decision will be motivated by financial considerations
are potentially heightened when MAID is being used by members of disadvantaged socio-
the defendants have put forward to support their contention that the prohibition on MAID has a rational basis. See Pl. Opp. Brief at 21.
12 The Alaskan Supreme Court has expressed similar concerns about competency. It has explained that: "While mental competency is certainly well accepted as a measure for determining when physicians may render life-
. prolonging medical treatment, it is potentially far more controversial as a measure for determining when a physician is entitled to terminate a patient's life. This is so not only because the prescription oflife-ending medication is a unique and absolute form of medical 'treatment,' but also because the mental competency of terminally ill patients is uniquely difficult to determine." Sampson, 31 P.3d at 97.
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economic groups. See Forrow Disclosure, J.A. Ex. 13, at,r 9(d); Greene Depo., J.A Ex. 7, at
129-130.
Second, the Legislature could rationally conclude that predicting when a patient has six
months to live is too difficult and risky for purposes of MAID, given that it involves the
irreversible use of a lethal prescription. The Commonwealth put forward expert testimony that
while doctors may be able to accurately predict death within two or three weeks of its
occurrence, predictions of death beyond that time frame are likely to be inaccurate. See Greene
Disclosure, J .A. Ex. 14, at 5 ("Research has shown that physicians cannot predict imminent
death sooner than a few weeks before the event. ... At six months, a fatal outcome is wholly
unpredictable other than recognizing the presence of an incurable condition."); Green Aff., J .A.
Ex. 40, at ,r 7; Green Depo., J.A. Ex. 7, 76-79; Forrow Aff., J.A. Ex. 39, at ,r 17 ("It is crucial to
recognize that the limits in any physician's ability to predict a patient's future have dramatically
different implications when what is at stake is possible referral to hospice, rather than the
possible provision of a lethal prescription"). 13
Third, the Legislature could rationally eonclnde that a general medical standard of care is
not sufficient to protect those seeking MAID. The Commonwealth put forward expert testimony
that MAID "is neither a medical treatment nor a medical procedure and thus there can be no
applicable medical standard of care" and that "[t]he legalization of [MAID] is an attempt to
carve out a special ease outside of the norms of medical practice." Greene Disclosure, J.A. Ex.
14, at 7. See also Forrow Rebuttal Disclosure, J.A. Ex. 15, at 10 ("In states where [MAID] has
been legalized by statute, the standard of care consists of doing it in accordance with regulations
" The Court notes that the plaintiffs seek a declaration that would apply to all physkians, even though most
physicians likely do not have substantial experience dealing with tenninal stages of disease. See Green Disclosure,
J.A. Ex 14, at 6.
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that the law put in place. There would be no analogous standard of care if [MAID] were
legalized by court order. . . . The average doctor in Massachusetts does not have the experience
and expertise required to provide [MAID] responsibly .... "); Forrow Aff., J.A. Ex. 39, at ,r,r 19-
20.14 The Commonwealth also put forward evidence that regulating MAID is difficult even
where statutory standards, such as those in Oregon, are in place. Its expert opined that: "Data
collected [in Oregon] paint[s] a picture of patients receiving [MAID] for whom alternative
approaches have not been exhausted. Psychological referrals are scant. The cited basis for
requests largely consists of problems that are manageable via palliative care and hospice. What
Oregon officials do not do is monitor the actual process for terminating patients. Yet the data
that is available is troubling." Green Disclosure, J.A. Ex. 14, at 8. See also Green Aff., J.A. Ex.
40, at ,r 1 L
Lastly, the Legislature could rationally conclude that MAID is not equivalent to
permissible alternatives. The Commonwealth introduced expert testimony that both VSED and
withdrawal of life support differ significantly from MAID because both VSED and withdrawal
of life support concern the recognized right to discontinue unwanted treatment and in neither
circumstance does the physician necessarily act for the purpose of causing the patient's death.
See Forrow Aff., J.A. Ex. 39, at ,r 6; Green Disclosure, J.A. Ex. 16, at ,r,r 1, 10. The doctor's
role, particularly in VSED, is to ensure that the patient's symptoms are controlled. Forrow Aff.,
J.A. Ex. 39, at ,r 6; Green Disclosure, J.A. Ex. 16, at 10. The Commonwealth also introduced
expert testimony that palliative sedation is different from MAID because it does not necessarily
involve an intent to shorten life nor does it necessarily cause or hasten death. See Forrow Aff.,
14 The Court notes that the Vermont Legislature included a regulatory sunset provision in the statute that authorized MAID, 2013 Vt. Acts 39, but then repealed that sunset provision. See 2015 Vt. Acts 27.22. This provides further evidence that a general standard of care is not appropriate for MAID.
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J.A. Ex. 39, at 1 8; Greene Depo., J.A. Ex. 7, at 92-95; Greene Aff., J.A. Ex. 40, at 18. Rather,
palliative sedation may be conducted in such a fashion as to ensure that the underlying disease,
not the sedation is the cause of death. Greene Aff., J.A. Ex. 40, 18; Forrow Aff., J.A. Ex. 39, at
19. Finally, the Commonwealth produced expert testimony that the permissible end-of-life
alternatives potentially involve far less risk than MAID because they occur in hospitals or other
institutions devoted to medical treatment and involve numerous physician and staff personnel,
which together provide an environment that lends itself to oversight and responsibility. Forrow
Aff. 118, 16; Green Aff., J.A. Ex. 40, 15. MAID, on the other hand, potentially takes place in
an uncontrolled environment, without assurance that the patient will administer the medication
when close to death, and without physician oversight.
In light of these legitimate public interests that are served by prohibiting MAID, the
Court concludes that the plaintiffs failed to demonstrate a violation of their due process or equal
protection rights. 15
E. Conclusion
In concluding that MAID is not authorized under Massachusetts law, the Court notes that
there appears to be a broad consensus that this issue is not best addressed by the judiciary. See,
e.g., Morris, 376 P. 3d at 838 (indicating that legality of MAID is an issue for the political
branches); Myers, 31 N.Y.S. 3d at 64-65 (same); Donorovich-Odonnell, 241 Cal. App. 4th at
1124c1125, 1140 (same); Sampson, 31 P. 3d at 98 (same); Krischer, 697 So. 2d at 104 (same).
MAID raises difficult moral, societal, and governmental questions, the resolution of which
require the type of robust public debate the courts are ill-suited to accommodate. Although
15 The Court acknowledges the countervailing expert testimony provided by the plaintiffs. However, this testimony merely indicates that the plaintiffs' views on MAID are reasonable not that the state's decision to prohibit MAID is without rational basis.
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plaintiffs have presented several strong arguments for making MAID a legal option for those
suffering from terminal illness, there are equally strong arguments for prohibiting MAID or
ensuring that MAID occurs in an environment in which clear, thoughtful, and mandatory
standards are in place to protect terminally ill patients who wish to make an irreversible decision.
The Legislature, not the Court, is ideally positioned to weigh these arguments and determine
whether and if so, under what restrictions, MAID should be legally authorized.
ORDER
For the forgoing reasons:
1. The defendants' motion for summary judgment is ALLOWED as to Counts I, II, III, IV
and VI, but DENIED IN PART as to Count V;
2. The plaintiffs' motion for partial summary judgment is ALLOWED IN PART as to
Count V but otherwise DENIED. The Court declines to issue injunctive relief.
It is further ORDERED, ADJUDGED, and DECLARED that: None of the arguments
advanced in this action preclude the defendants from prosecuting physicians who prescribe lethal
medication for purposes of Medical Aid in Dying; this, however, does not apply to physicians
who provide information and advice on Medical Aid in Dying to terminally ill, competent adults.
~L~~ . · 'K.Ames Justice of the Superior Court
Dated: December 31, 2019
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WESTLAW ADDENDUM 74
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WESTLAW ADDENDUM 78
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Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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WESTLAW ADDENDUM 91
Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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WESTlAW ADDENDUM 95
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WESTLAW ADDENDUM 97
Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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WESTLAW ADDENDUM 111
Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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WESTLAW ADDENDUM 113
Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM
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WESTLAW ADDENDUM 119
Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM