Assessing the Constitutionality of Death-with-DignityAssessing the Constitutionality of Death-with-Dignity
By Noah Killeen ‘27
The Constitution is often praised as protecting Americans’ freedoms—granting citizens various liberties and guarding individual autonomy from governmental control. However, by nature, the document is finite and the rights enumerated within it are broad and subject to interpretation. In the ever-evolving landscape of constitutional rights and ethical debates, the discourse surrounding the constitutionality of death with dignity stands as a poignant test of the limits of constitutional protection. By refraining from legalizing physician-assisted death (PAD) at the federal level, the government infringes upon the individual liberties that it is constitutionally obliged to protect.
PAD provides terminally ill patients with the option to take a lethal dose of medication, allowing them to dictate the terms of their final days. This choice is typically reserved for individuals facing unbearable suffering that cannot be relieved through palliative care and who have been given a prognosis of six months or less to live. If an individual is deemed eligible for PAD they must subsequently fulfill a series of requirements, including affirming their desire for PAD in front of witnesses and undergoing evaluations of their cognitive capacity and mental health. PAD is currently legal in ten states as well as in the District of Columbia. (1) Common features across these jurisdictions include mandatory waiting periods between a patient's requests for PAD, multiple affirmations of the patient's desire, and safeguards against undue influence or coercion.
However, despite the fact that PAD functions as an expression of individual autonomy, arguably crucial to the idea of "liberty," the Supreme Court has deemed that PAD is not protected by the Constitution. Thus, the Court has referred the issue to the states essentially decentralizing the regulation of the practice and allowing its restriction and even criminalization in some states. However, the sanctioning of physician-assisted suicide by certain states serves as a direct infringement on the enumerated right to “liberty,” as it involves an excessive level of government intervention in a private matter.
The history of the right to privacy in the United States is deeply rooted in the history of constitutional interpretation. Though not explicitly articulated in the Constitution, the right to privacy has been recognized and elaborated upon through significant legal landmarks including Griswold v. Connecticut and Roe v. Wade. Griswold v. Connecticut, a seminal case in 1965, initially addressed the privacy rights in regards to married couples seeking access to contraceptives. (2) Here, the Supreme Court established a precedent that the Due Process Clause of the 14th Amendment safeguards certain unenumerated rights. This decision was based on recognizing a fundamental right to privacy implicit in the penumbras of the Bill of Rights. The implied protection of privacy, integral to American law, finds written expression in several amendments, including the First Amendment's protection of freedom of religion and speech, which inherently involves privacy of beliefs and expression; the Third Amendment's prohibition against quartering of soldiers, reflecting privacy within the home; and the Fifth Amendment's safeguarding against self-incrimination, implying protection of personal information and autonomy. (3) However, it wasn't until Roe v. Wade in 1973 that the right to privacy was explicitly invoked in the context of reproductive rights, establishing privacy as a substantive constitutional right. In Roe v. Wade, the Court ruled that a woman's decision to terminate a pregnancy falls within the ambit of the right to privacy under the Due Process Clause. (4) This landmark decision solidified the right to privacy as a fundamental aspect of individual autonomy, shaping subsequent legal interpretations and protections in areas such as access to abortion, sexual conduct, and same-sex marriage.
While some rights are protected under the Due Process Clause, the Court imposes a somewhat ill-defined threshold for assessing the rights that can be ensured under the clause. Specifically, the Supreme Court rejected the individual freedom of patients to make their own medical decisions in Washington v. Glucksberg. Dr. Harold Glucksberg appealed Washington’s ban on physician-assisted death by asserting that the state’s law violated the "liberty" ensured to individuals through the due process clause by preventing terminally ill patients with full capacity from making their own decisions regarding end-of-life care. Glucksberg claimed that such restrictions not only undermined the autonomy guaranteed by the Due Process Clause but also overlooked the fundamental right to privacy inherent in medical decision-making. (5) Nevertheless, the court ruled in favor of Washington, citing that the state had provided a “compelling reason” for protecting medical ethics and privacy, meaning if citizens are given the option of death, they might be more convinced of their desire for death despite not needing it. The Court further justified Washington’s policy by citing the precedent of Oregon’s Death with Dignity Act which was adopted in 1997, granting access to life-ending medication for those meeting specific terminally ill criteria. (6) The Court suggests that because Oregon was granted the right to determine the legality of PAD, Washington also holds a similar right. These two outcomes resulted in the Court setting the precedent that PAD is not a constitutional right, and thus the federal government can not limit states from legalizing the treatment.
The Court's decision to defer to states regarding the legality of PAD in turn creates a stark discrepancy in access across state borders. For instance, since Oregon implemented its Death with Dignity law in 1997, approximately 750 individuals have taken advantage of this option. (7) Conversely, in states where PAD remains illegal, terminally ill patients are left with no medical recourse, resigning them to a decline in cognitive and physical capabilities. Individuals seeking PAD services and living in such states would have to relocate, hindering the ability of many, particularly those in lower-class communities, to receive the treatment. This discrepancy underscores the urgent need for a more uniform approach to end-of-life care across state lines, ensuring that all terminally ill individuals can exercise their right to autonomy and dignity in their final moments.
Furthermore, by labeling PAD as an issue of state jurisdiction, the court opens a large inconsistency in medical services offered across state lines, leading to disparate access to care. This discrepancy disproportionately impacts low-income individuals, as only the affluent can afford to travel across state borders for PAD. The Supreme Court must recognize that access to end-of-life options shouldn't be determined by geographic location or financial means. By federally granting PAD as a right under the Due Process Clause, the Court would mitigate the inequality in access to care and ensure that all individuals, regardless of socioeconomic status, have equal access to a dignified end-of-life choice.
In the past, the justice system has ruled in favor of competent adults being able to refuse life-sustaining treatment, making it unclear why they wouldn’t hold the same view for PAD. In Bouvia vs. Superior Court in 1986, the court was tasked with determining the constitutionality of capable adults’ decision to refuse life-sustaining treatment. In this case, the court ruled that such a refusal was protected under the constitutional right to privacy and autonomy, as guaranteed by the Due Process Clause of the Fourteenth Amendment. Elizabeth Bouvia who suffered from cerebral palsy and arthritis, making it difficult to perform everyday functions, actively refused nutrition from medical personnel. The hospital began force-feeding Bouvia using tubes, despite her pleas to withdraw from treatment. The conflict was ultimately brought to the Superior Court where the justices ruled that if the patient had their full mental capacity, the right to die was the patient's choice. (8) Such a decision logically extends to individuals facing terminal illnesses. In the case of Bouvia vs Superior Court, a patient requested the right to die, in the case of PAD, patients are also requesting the right to die. Given the parallel nature of these situations, they should be subject to the same legal rules and regulations. However, such reasoning is not universally accepted.
A large concern for those who critique PAD is that the treatment runs the risk of rampant medical malpractice. Though the concern has merit, it ignores the fact that states can implement numerous safeguards to regulate and prevent malpractice. For instance, after passing the End of Life Option Act, California necessitated the creation of a report detailing the use and reasoning behind the use of end-of-life treatment. (9) By requiring documentation, the state accurately records the reason and date for which the medication is prescribed. Additionally, citizens must meet specific criteria to be eligible for the care including the following: having a terminal illness that will kill them in 6 months, no mental impairments that would prevent them from making the decision themself and being able to self-administer the drug. (10) By following a strict protocol, the state avoids the risk of people receiving the treatment despite not needing it.
PAD also faces criticism from both religious and disability advocate groups, who argue that the law could disproportionately impact individuals with disabilities and perpetuate the stigma surrounding suicide, particularly within religious communities where suicide is often viewed as a sin. (11) In regards to opposition from disability advocates, there is concern that physicians may be more likely to suggest PAD to individuals with disabilities under the assumption that their quality of life is inherently diminished. This fear stems from the worry that physicians may perceive disabilities as intrinsically undesirable and may therefore be more inclined to recommend PAD as a solution, even though the individual's quality of life may not necessarily be compromised. Meanwhile, religious groups claim that PAD is a form of suicide as the lethal injection is voluntary by the person. They find that the law permits people not to let “God to run the course of death,” which could classify this form of dying as suicide. As a result, critics argue that PAD may not be a suitable means of addressing the needs of individuals facing terminal illnesses, particularly within the context of disability rights and religious beliefs.
While religious and disability advocacy groups express legitimate concerns regarding PAD, it's crucial to recognize that legalized physician-assisted death doesn't undermine the value of life or perpetuate discrimination against individuals with disabilities. Instead, it offers a compassionate option for terminally ill patients who are suffering intolerably. Legal safeguards, such as stringent eligibility criteria and thorough evaluation processes, ensure that medical aid in dying is only accessible to competent individuals facing imminent death and intolerable suffering, rather than being based on societal perceptions of quality of life. Additionally, legalizing PAD empowers individuals to make autonomous decisions about their own end-of-life care, which is consistent with principles of individual autonomy and bodily integrity. Framing PAD as “suicide” is a misinterpretation that perceives PAD as giving up on life rather than the real reason, which is the individual’s acceptance of death. It is also arguably inappropriate given the fact that such patients are terminal and thus cannot be characterized as willingly succumbing to their illness.
Furthermore, by labeling PAD as an issue of state jurisdiction, the court opens a large inconsistency in medical services offered across state lines, leading to disparate access to care. This discrepancy disproportionately impacts low-income individuals, as only the affluent can afford to travel across state borders for PAD. The Supreme Court must recognize that access to end-of-life options shouldn't be determined by geographic location or financial means. By federally granting PAD as a right under the Due Process Clause, the Court would mitigate the inequality in access to care and ensure that all individuals, regardless of socioeconomic status, have equal access to a dignified end-of-life choice.
Other countries, like Canada, exemplify the successful implementation of legislation that grants all citizens the right to physician-assisted death. They have made headlines with liberal policies towards Medical Assistance in Dying (MAiD), specifically a provision in the Criminal Code of Canada that permits those with chronic and terminal illnesses to receive lethal medication. The treatment has grown in popularity in Canada with 13,102 people in 2022 choosing to exercise their right to die through MAiD. (12) Besides certain eligibility criteria differing slightly, MAiD shares many similarities with how PAD operates in the US. The largest exception between the two cases is that Canada recognizes that all citizens must have the right to physician-assisted death, whereas the US does not. Canada’s policies highlight how the United States could amend its laws to constitutionalize PAD.
The US guarantees its citizens the right to “Life, Liberty, and the Pursuit of Happiness,” but it becomes a gray area when affording individuals the right to death. However, it is the right of citizens under the principle of “liberty” to exercise their autonomy in dictating the terms of their lives and consequently their deaths. When death is imminent, the government should not prevent individuals from pursuing it if it is the best decision for their happiness. Legalizing PAD on the federal level avoids interstate discrepancies and places the control into the individual’s hands to define their end-of-life care. Ultimately, such legislation would promote fairness, compassion, and respect for human dignity in the face of terminal illness.
Endnotes
(1) CNN, 2014
(2) Griswold v. Connecticut
(3) Bill of Rights
(4) The New York Times Learning Network, 2014
(5) CNN, 2014
(6) CNN, 2014
(7) The New York Times Learning Network, 2014
(8) Casebriefs
(9) New York Times
(10) Kaiser Permante
(11) Verywell Health
(12) Leyland 2024
