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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 j[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 Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM

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Page 1: OPENING BRIEF OF APPELLANTS MORGAN, LEWIS & BOCKIUS LLP

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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),

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

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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)

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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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41

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

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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

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43

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

47

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).

ADDENDUM 47

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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

ADDENDUM 48

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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

3

ADDENDUM 49

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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.

4

ADDENDUM 50

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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.

5

ADDENDUM 51

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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.

6

ADDENDUM 52

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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

ADDENDUM 53

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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.

8

ADDENDUM 54

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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.

9

ADDENDUM 55

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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

10

ADDENDUM 56

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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

11

ADDENDUM 57

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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 119

Massachusetts Appeals Court Case: 2021-P-0156 Filed: 5/10/2021 4:44 PM