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SJC-12472

SJC-12473

AMANDA S. OBERLIES & others1 vs. ATTORNEY GENERAL & another.2

DONNA KELLY WILLIAMS & others3 vs. ATTORNEY GENERAL & another.4

Suffolk. April 3, 2018. - June 18, 2018.

Present: Gants, C.J., Lenk, Gaziano, Lowy, Budd, Cypher,

& Kafker, JJ.

Initiative. Constitutional Law, Initiative petition. Attorney 

General. Nurse.

Civil action commenced in the Supreme Judicial Court for 

the county of Suffolk on January 19, 2018.

The case was reported by Gaziano, J.

Civil action commenced in the Supreme Judicial Court for 

the county of Suffolk on September 8, 2017.

 

1 Sharon Gale, Patricia M. Noga, and Timothy Quigley.

2 Secretary of the Commonwealth.

3 Karen A. Coughlin, Susan Wright Thomas, Mary Elizabeth 

Amsler, Daniel R. Rec, Nora A. Watts, Linda Barton, Ellen Smith, 

Paula Ryan, and Harley W. Keisch.

4 Secretary of the Commonwealth.
2

The case was reported by Gaziano, J.

Edward V. Colbert, III (David Koha & Carmen F. Francella, 

III, also present) for Donna Kelly Williams & others.

Juliana deHaan Rice, Assistant Attorney General (Michael B. 

MacKenzie, Assistant Attorney General, also present) for the

Attorney General.

Andrew N. Nathanson (Elissa Flynn-Poppey & Mathilda McGeeTubb also present) for Amanda S. Oberlies & others.

The following submitted briefs for amici curiae:

Thaddeus A. Heuer, Andrew M. London, & Rachel C. Hutchinson

for Steward Health Care System LLC.

Edward V. Colbert, III, David Koha, & Carmen F. Francella, 

III, for Massachusetts Nurses Association.

Carol Igoe, of California, & David Hadas for National 

Nurses United & another.

Thomas R. Kiley, Carol Valvo, & Meredith Fierro for 

American Nurses Association Massachusetts, Inc.

Elissa Flynn-Poppey, Andrew N. Nathanson, & Mathilda S. 

McGee-Tubb for Massachusetts Health & Hospital Association & 

others.

LENK, J. We are asked to determine whether two initiative 

petitions satisfy the requirements of art. 48 of the Amendments 

to the Massachusetts Constitution. The first, Initiative 

Petition 17-07, would limit the number of patients who may be 

assigned to a registered nurse in Massachusetts health care 

facilities, and would prohibit facilities from accommodating 

those limits by reducing certain other health care staff. The 

second, Initiative Petition 17-08, contains the same provisions 

as the first petition, with an additional section that would 

require publicly funded hospitals to make annual public 

disclosures of their financial assets. The Attorney General 

certified that Initiative Petition 17-07 meets the requirements 
3

of art. 48, but declined to certify Initiative Petition 17-08, 

after concluding that the mandate for financial disclosure was 

not sufficiently related to or mutually dependent upon the other 

provisions in the petition. The opponents of Initiative 

Petition 17-07, and the proponents of Initiative Petition 17-08, 

sought relief before a single justice in the county court.

On the request of all parties, the single justice reserved 

and reported both cases to this court. In the first case, the 

plaintiffs challenge the Attorney General's decision to certify 

Initiative Petition 17-07; they contend that the nurse-topatient ratios are not sufficiently related to or dependent upon

the requirement that, in implementing those ratios, covered 

facilities are prohibited from reductions in other health care 

staff. Because the restriction on staff reduction pertains to

implementation of the nurse-to-patient ratios, we conclude that 

these two elements of the proposal form "a unified statement of 

public policy," Carney v. Attorney Gen., 447 Mass. 218, 231 

(2006) (Carney I), and therefore are related "within the meaning 

of art. 48." See Hensley v. Attorney Gen., 474 Mass. 651, 672 

(2016). The plaintiffs challenging Initiative Petition 17-07 

also argue that it is not in the form required by art. 48 for 

presentation to the voters, on a number of grounds, which we 

determine are unsupported. As a result, we conclude that the 
4

Attorney General's decision to certify Initiative Petition 17-07 

was correct.

In the second case, the plaintiffs challenge the Attorney 

General's decision not to certify Initiative Petition 17-08; 

they argue that the financial disclosure provision is 

sufficiently related to the nurse-to-patient ratios, because it 

will shed light on facilities' capacity to meet new staffing 

needs. We conclude that the Attorney General was correct in 

declining to certify Initiative Petition 17-08 on the ground 

that the financial asset disclosure requirement and the 

limitations on nurse-patient staffing ratios are not 

sufficiently related or mutually dependent, as required by 

art. 48. See Massachusetts Teachers Ass'n v. Secretary of the 

Commonwealth, 384 Mass. 209, 219-220 (1981).5

1. Background. In August, 2017, two petitions, each 

signed by ten registered voters in the Commonwealth, were 

submitted to the Attorney General for certification. The 

Attorney General numbered them Initiative Petition 17-07 and 

 

5 We acknowledge the amicus briefs submitted by the 

Massachusetts Nurses Association, Steward Health Care System 

LLC, and National Nurses United and the California Nurses 

Association in Oberlies's case. We also acknowledge the amicus 

briefs submitted by the Massachusetts Health & Hospital 

Association, Massachusetts Council of Community Hospitals, 

Conference of Boston Teaching Hospitals, and Massachusetts 

Association of Behavioral Health Systems; Steward Health Care 

System LLC; and the American Nurses Association Massachusetts, 

Inc., in Williams's case.
5

Initiative Petition 17-08. Although both are entitled 

"Initiative Petition For A Law Relative To Patient Safety And 

Hospital Transparency," the petitions differ with respect to one 

section.

Initiative Petition 17-07 seeks to create a new statute, 

entitled "The Patient Safety Act" (act or proposed act) that 

would amend c. 111 of the General Laws. The act would create 

"patient assignment limits" for registered nurses working in 

"facilities" in Massachusetts. The proposed act defines the 

term "[f]acility" as "a hospital licensed under [G. L. c. 111, 

§ 51], the teaching hospital of the University of Massachusetts 

medical school, any licensed private or [S]tate-owned and 

[S]tate-operated general acute care hospital, an acute 

psychiatric hospital, an acute care specialty hospital, or any 

acute care unit within a [S]tate[-]operated healthcare 

facility." "[R]ehabilitation facilities" and "long-term care 

facilities" are explicitly excluded.

The act proposed by Initiative Petition 17-07 would set

limits on the number of patients who could be assigned to a 

registered nurse in any given facility, based on the unit where 

the nurse works and the condition of the patients. For example, 

in any emergency services department, a registered nurse would 

be assigned only one critical care or intensive care patient; in 

pediatric units, up to four pediatric patients could be assigned 
6

to one registered nurse. In any unit not specifically listed in 

the proposed act, the patient assignment ratio would be four 

patients per registered nurse. The patient assignment limits 

would be in effect at all times except "during a [S]tate or 

nationally declared public health emergency."

The proposed act provides, "Each facility shall implement 

the patient assignment limits established by [G. L. c. 111, 

§] 231C [the nurse-patient limit provision of the proposed act]. 

However, implementation of these limits shall not result in a 

reduction in the staffing levels of the health care workforce."

We refer to this requirement as the "workforce reduction 

restriction." The "health care workforce" is defined by the 

proposed act as all "personnel employed by or contracted to work 

at a facility that have an effect upon the delivery of quality 

care to patients, including but not limited to registered 

nurses, licensed practical nurses, unlicensed assistive 

personnel, service, maintenance, clerical, professional and 

technical workers, and all other health care workers." The 

proposed act would require each facility to submit a written 

plan to the Health Policy Commission (HPC),6 certifying that the 

 

6 The Health Policy Commission was created in 2012 to 

"monitor the reform of the health care delivery and payment 

system in the [C]ommonwealth." See St. 2012, c. 224, § 15; 

G. L. c. 6D, §§ 2, 5.
7

facility will implement the patient assignment limits without 

diminishing its health care workforce.

The act proposed by Initiative Petition 17-07 also would 

authorize the HPC to promulgate regulations governing 

implementation and operation of the act. These regulations 

would include, but not be limited to, "regulations setting forth 

the contents and implementation of: (a) certification plans 

each facility must prepare for implementing the patient 

assignment limits enumerated in [§] 231C, including the facility 

obligation that implementation of limits shall not result in a 

reduction in the staffing level of the health care workforce 

assigned to such patients; and (b) written compliance plans that 

shall be required for each facility out of compliance with the 

patient assignment limits." The HPC would not be authorized to 

promulgate any regulation that directly or indirectly delays, 

waives, or modifies the patient assignment limits, or the 

requirement that those limits be implemented without resulting 

reductions in a facility's health care workforce.

Under the terms of the proposed act, the HPC "may conduct 

inspections of facilities to ensure compliance with the terms of 

this act. A facility's failure to adhere to the patient 

assignment limits," as adjusted per the act's requirements,

"shall be reported by the [HPC] to the Attorney General for 

enforcement." The Attorney General would be able to sue a
8

facility found to be in violation of the act in the Superior 

Court for injunctive relief and civil penalties up to $25,000

per violation.

The other initiative petition at issue in this case, 

Initiative Petition 17-08, seeks to enact the "Patient Safety 

and Hospital Transparency Act." Initiative Petition 17-08 is 

essentially identical to Initiative Petition 17-07, but with one

additional provision. General Laws c. 111, § 231K, would

require that "[e]ach facility that accepts funds from the 

Commonwealth . . . report annually to the [HPC] all financial 

assets owned by the facility, along with assets of any holding 

company and any and all parent, subsidiary, or affiliated 

companies." Under Initiative Petition 17-08, the HPC would be 

required to make this information public within seven days of 

its receipt, unless doing so otherwise is prohibited by law.

In September, 2017, the Attorney General certified that

Initiative Petition 17-07 is in proper form for submission to 

the people; that it is not substantially the same as any measure 

qualified for submission to the people at either of the two 

preceding biennial State elections; and that it contains only 

matters that are related or mutually dependent and not excluded 

from the initiative process under art. 48. By December 6, 2017, 

the petition's proponents had gathered and filed sufficient 

voter signatures to require the Secretary of the Commonwealth 
9

(Secretary) to transmit the petition to the Legislature. The 

Secretary did so in January, 2018. If the Legislature does not 

adopt the measure, and if the proponents submit sufficient 

additional signatures by July 3, 2018, the Secretary intends to 

include the proposed law in the Information for Voters guide 

that will be printed in the summer of 2018. See art. 48, The 

Initiative, V, § 1, of the Amendments to the Massachusetts 

Constitution, as amended by art. 81, § 2, of the Amendments.

In January, 2018, four registered voters commenced an 

action in the county court, challenging the Attorney General's 

decision to certify Initiative Petition 17-07. These 

plaintiffs, whom we will call the Oberlies plaintiffs, sought 

writs of mandamus and certiorari and a declaratory judgment, and 

asked the court to declare that Initiative Petition 17-07 is 

invalid, to quash the Attorney General's certification of the 

petition, and to enjoin the Secretary of the Commonwealth from 

placing the petition on the 2018 Statewide ballot. On the 

parties' joint motion and an agreed-upon statement of facts, the 

single justice reserved and reported the case to the full court.

At the same time that she certified Initiative Petition 17-

07, the Attorney General declined to certify Initiative Petition 

17-08, after having concluded that the financial disclosure 

requirement was not sufficiently related to or mutually 

dependent upon the patient assignment limits to satisfy the 
10

requirements of art. 48. Shortly thereafter, ten registered 

voters filed a complaint in the county court, seeking an order 

of mandamus reversing that decision.7 We refer to these 

plaintiffs as the Williams plaintiffs.

The single justice allowed the parties' joint motion to 

enter a preliminary order that, without passing on the 

likelihood that the Williams plaintiffs would succeed, required

the Attorney General to release a summary of the petition to the 

Secretary of the Commonwealth. This order also directed the 

Secretary to prepare blank signature forms so that signatures 

could be gathered while the challenge to the Attorney General's 

decision was pending. In December, 2017, upon the joint request 

of the parties, the order was amended to require the Secretary 

to advance the petition to the Legislature, if the proponents 

collected sufficient signatures prior to December 6, 2017. Also 

that month, on the parties' joint motion and an agreed statement 

of facts, the single justice reserved and reported the case to 

the full court.

2. Discussion. When a new law is proposed by initiative 

petition, before it can be presented to the Legislature and then 

to the voters for their consideration, the Attorney General must 

 

7 The original Williams plaintiffs moved, with the assent of 

the defendants, to substitute ten different registered voters as 

the Williams plaintiffs. The single justice allowed this 

motion.
11

review it and certify that it meets the requirements of art. 48. 

See art. 48, The Initiative, II, § 3, as amended by art. 74. We 

review the Attorney General's decision regarding whether to 

certify a ballot petition de novo, bearing in mind "the firmly 

established principle that art. 48 is to be construed to support 

the people's prerogative to initiate and adopt laws." Abdow v. 

Attorney Gen., 468 Mass. 478, 487 (2014), quoting Carney v. 

Attorney Gen., 451 Mass. 803, 814 (2008).

The primary question at issue with respect to both 

Initiative Petitions 17-07 and 17-08 is whether the subjects

addressed in each petition are related or mutually dependent. 

See art. 48, The Initiative, II, § 3, as amended by art. 74. 

The opposition to Initiative Petition 17-07 also raises an 

additional question whether it is in a proper form for 

submission to the voters as required by art. 48. See Nigro v. 

Attorney Gen., 402 Mass. 438, 443 (1988). We address each issue 

in turn.

a. Whether subjects are related or mutually dependent. 

Under art. 48, if a petition addresses multiple subjects, those

subjects must be "related or . . . mutually dependent." 

Art. 48, The Initiative, II, § 3, as amended by art. 74. See 

Albano v. Attorney Gen., 437 Mass. 156, 161 (2002). We have 

held that two provisions that "exist independently" of each 

other are not mutually dependent. See Gray v. Attorney Gen., 
12

474 Mass. 638, 648 (2016). No "bright-line" test exists for 

determining whether two subjects are related. See Dunn v. 

Attorney Gen., 474 Mass. 675, 680 (2016); Abdow, 468 Mass. at 

499. "The decisions of this court illustrate how we have 

endeavored to construe the related subjects requirement in a 

balanced manner that fairly accommodates both the interests of 

initiative petitioners and the interests of those who would 

ultimately vote on the petition. On the one hand, the 

requirement must not be construed so narrowly as to frustrate 

the ability of voters to use the popular initiative as 'the 

people's process' to bring important matters of concern directly 

to the electorate." Abdow, supra. On the other hand, while 

art. 48 does not demand that an initiative concern only one

subject, "relatedness cannot be defined so broadly that it 

allows the inclusion in a single petition of two or more 

subjects that have only a marginal relationship to one another." 

Id. Otherwise, a petition "might confuse or mislead voters, 

or . . . place them in the untenable position of casting a 

single vote on two or more dissimilar subjects." Id.

Indeed, the drafters of art. 48 were concerned that 

initiatives could confuse voters, or could be used for 

"logrolling." See Dunn, 474 Mass. at 679-680; Carney I, 447 

Mass. at 226-228. "Logrolling" refers to the bundling of 

multiple provisions such that they all gain approval, even if 
13

one or more of them would, standing alone, be rejected. Carney 

I, supra at 219 n.4. Logrolling is of particular concern when 

an unpopular provision could be hidden or made less apparent by 

a more attractive proposal that catches voters' attention. See 

id. at 229.

We accordingly have held that the related subjects

requirement is satisfied where "one can identify a common 

purpose to which each subject of an initiative petition can 

reasonably be said to be germane." Massachusetts Teachers 

Ass'n, 384 Mass. at 219-220. "We have not construed this 

requirement narrowly nor demanded that popular initiatives be 

drafted with strict internal consistency." Mazzone v. Attorney 

Gen., 432 Mass. 515, 528-529 (2000). "But we have also 

cautioned that '[a]t some high level of abstraction, any two 

laws may be said to share a "common purpose."'" Dunn, 474 Mass. 

at 680, quoting Abdow, 468 Mass. at 500.

"[W]e have posed two questions to be considered in 

addressing the related subjects requirement." Dunn, 474 Mass. 

at 680. First, "[d]o the similarities of an initiative's 

provisions dominate what each segment provides separately so 

that the petition is sufficiently coherent to be voted on 'yes' 

or 'no' by the voters?" Abdow, 468 Mass. at 500, quoting 

Carney I, 447 Mass. at 226. Second, does the initiative 

petition "express an operational relatedness among its 
14

substantive parts that would permit a reasonable voter to affirm 

or reject the entire petition as a unified statement of public 

policy?" Abdow, supra at 501, quoting Carney I, supra at 230-

231.

The Oberlies plaintiffs challenge the Attorney General's 

determination that Initiative Petition 17-07 contains subjects 

that are related or mutually dependent. The Williams plaintiffs 

assert that the Attorney General erred in determining that 

Initiative Petition 17-08 fails this test. For the reasons 

discussed infra, we conclude that the Attorney General was 

correct in reaching both of these determinations.

i. Initiative Petition 17-07. The common purpose of the 

provisions in Initiative Petition 17-07 is to establish and 

enforce nurse-to-patient ratios in facilities in the 

Commonwealth.8 This common purpose is not "so broad as to render 

the 'related subjects' limitation meaningless." Massachusetts 

Teachers Ass'n, 384 Mass. at 219. The patient assignment limits

 

8 The Oberlies plaintiffs contend that Initiative 

Petition 17-07's purpose is "patient safety," based on the title 

of the proposed act, references to patient safety in the 

petition's text, and a memorandum submitted by its proponents to 

the Attorney General. The court agrees with the Attorney 

General's characterization of the proposal's purpose, which is 

to achieve patient safety specifically through the 

"establishment of patient-to-nurse assignment limits in 

hospitals and other specified health care facilities." See 

Opinion of the Justices, 422 Mass. 1212, 1220-1221 (1996) 

(rejecting initiative drafters' asserted purpose, and accepting 

purpose advanced by brief of counsel to House of 

Representatives).
15

"can reasonably be said to be germane" to the petition's common 

purpose, because they implement the nurse-to-patient ratios that 

the petition seeks to achieve. Id. at 219-220. Notwithstanding 

the Oberlies plaintiffs' claims to the contrary, the workforce 

reduction restriction also advances the petition's common 

purpose.

First, "the similarities of [the] initiative's provisions 

dominate what each segment provides separately so that the 

petition is sufficiently coherent to be voted on 'yes' or 'no' 

by the voters." Abdow, 468 Mass. at 500, quoting Carney I, 447 

Mass. at 226. The workforce reduction restriction only 

prohibits reduction in a facility's health care workforce that 

results from putting in place the patient assignment limits.9 In 

other words, the restriction on workforce reduction is triggered 

by the implementation of these limits. It does not prohibit 

reduction of the health care workforce for any other reason, 

but, rather, dictates how nurse-to-patient ratios may be 

maintained: in a manner such that there be no reductions in 

staff among other members of the health care workforce. Because 

the patient assignment limits and the workforce reduction 

 

9 Initiative Petition 17-07 provides, "Each facility shall 

implement the patient assignment limits established by [G. L. 

c. 111, §] 231C [the nurse-patient limit provision of the 

proposed act]. However, implementation of these limits shall 

not result in a reduction in the staffing levels of the health 

care workforce."
16

restriction both determine how nurse-patient staffing ratios 

will be implemented, their similarity "dominate[s] what each 

segment provides separately." See Abdow, supra, quoting 

Carney I, supra.

Second, Initiative Petition 17-07 "express[es] an 

operational relatedness among its substantive parts that would 

permit a reasonable voter to affirm or reject the entire 

petition as a unified statement of public policy." Abdow, 468 

Mass. at 501, quoting Carney I, 447 Mass. at 230-231. Because 

it anticipates and addresses a potential consequence of the 

nurse-patient staffing ratios, the workforce reduction 

restriction is "simply one piece of the proposed integrated 

scheme." See Hensley, 474 Mass. at 659. If hospitals were 

economically burdened by hiring more registered nurses, they 

might attempt to compensate by reducing the numbers of other

staff. Indeed, when California implemented nurse-to-patient 

ratios, the health care industry protested that hospitals would 

be forced to lay off personnel to pay for additional nurses. 

See California Nurses Ass'n vs. Schwarzenegger, Cal. Super Ct.,

No.04CS01725, slip op. (Sacramento County May 27, 2005). 

"Neither the Attorney General nor this court is required to 

check common sense at the door when assessing the question of 

relatedness." Carney I, 447 Mass. at 232. Because the 

workforce reduction restriction would shape the impact of the 
17

patient assignment limits, it forms part of the proposal's

"unified statement of public policy." See id. at 230-231.

In this sense, the situation at bar is similar to that in

Dunn. In that case, we considered a petition seeking to 

prohibit confinement of specified farm animals in a cruel manner

(farm provision), and also banned the sale, within the 

Commonwealth, of certain products produced from animals so 

confined (sales provision). Dunn, 474 Mass. at 676. We 

concluded that the provisions were related within the meaning of 

art. 48, because the sales provision "protects Massachusetts 

farmers who comply with the law by preventing Massachusetts 

businesses from selling eggs, veal, and pork obtained from outof-State farmers who confine their animals in a cruel manner and 

who, by doing so, may be able to underprice their Massachusetts 

competitors." Id. at 681, 682. In other words, the sales 

provision anticipated and mitigated private actors' foreseeable 

reactions to the farm provision.

Similarly, here, the workforce reduction restriction seeks 

to address facilities' potential responses to the nurse-patient

staffing ratio requirement. Indeed, because the workforce 

reduction restriction regulates the same facilities as those 

affected by the patient assignment limits, the two requirements 

are more closely related than the farm provision and the sales 

provision we considered in Dunn, supra; the farm provision 
18

governed farms that produced certain goods, while the sales 

provision constrained businesses that purchased those goods. 

Id. at 676.

"The 'unified statement of public policy' called for by 

Carney I, 447 Mass. at 230-231, does not require that an 

initiative petition be a comprehensive piece of legislation that 

would entirely cover its field. It requires that the portion of 

the field covered by the petition be presented in a way that 

permits a reasonable voter to make an intelligent up or down 

choice." Abdow, 468 Mass. at 503. A voter who approves of the 

registered nurse-patient staffing ratio requirement, but 

believes health care facilities should be able to accommodate 

this requirement by eliminating other members of the health care 

workforce, "is free to vote 'no' . . . , but the proposed act 

does not place anyone 'in the untenable position of casting a 

single vote on two or more dissimilar subjects'" (emphasis in 

original). Hensley, 474 Mass. at 659, quoting Abdow, supra at 

499.

The argument that Initiative Petition 17-07 violates the 

related subjects requirement because it might impose a financial 

burden on facilities is unavailing. The Oberlies plaintiffs 

point to Gray, 474 Mass. at 647, where, in concluding that the

proposal did not satisfy the relatedness test, we noted the 

costs associated with one of the initiative's provisions. That 
19

case concerned a proposal that would have altered the 

educational curriculum of publicly funded elementary and 

secondary schools, and would have required the release of 

certain test information included in the prior year's 

comprehensive assessment tests mandated for those schools. See 

id. at 638-639, 648. We concluded that those two subjects were 

not sufficiently related, because educational curricula and

school transparency represented "two separate public policy 

issues." Id. at 649. Although we observed that there could be 

a high "price tag" associated with the "test items" disclosure 

requirement, this observation was not dispositive of our 

conclusion. See id. at 647-649. The Oberlies plaintiffs' 

reliance on Gray is misplaced.

The Oberlies plaintiffs also suggest that the workforce 

reduction restriction is simply an attempt to make Initiative 

Petition 17-07 more politically palatable, by providing job 

security to health care workers. The proposed act, however, 

would prohibit only health care workforce reductions resulting 

from the implementation of nurse-patient assignment limits; it 

is not an outright ban on reducing staffing levels at covered 

facilities. Even if Initiative Petition 17-07 might be 

appealing to some hospital employees because they believed that 

they would stand to gain job security if it were enacted, the 

enjoyment, by some, of an "ancillary benefit" does not render 
20

the proposal's provisions unrelated. See Dunn, 474 Mass. at 

682. "Nor is it necessary that all of an initiative's 

supporters share the same motivations" in order for the 

initiative to satisfy the relatedness test. See Abdow, 468 

Mass. at 503.10

The Oberlies plaintiffs also contend that voters will not 

understand the potential impact of the workforce reduction 

restriction. Based on their expansive reading of the definition 

of "health care workforce," the Oberlies plaintiffs maintain 

that Initiative Petition 17-07 "mandates the retention of 

virtually every employee or contractor who works for or at a 

hospital."11 They argue that even the petition's proponents do

not appreciate the possible sweeping consequences of the 

workforce reduction restriction. Additionally, the parties 

dispute whether a separate section in the petition limits the 

definition of the "health care workforce," thereby narrowing the 

 

10 Additionally, the Oberlies plaintiffs have not alleged 

that the electorate previously rejected an initiative proposing 

solely patient assignment limits, without any associated 

workforce reduction provision. Cf. Carney v. Attorney Gen., 447 

Mass. 218, 222, 232 (2006) (voters' earlier rejection of one 

provision of proposed petition was relevant to relatedness 

analysis).

11 Initiative Petition 17-07 defines "health care workforce" 

to include those "personnel employed by or contracted to work at 

a facility that have an effect upon the delivery of quality care 

to patients, including but not limited to registered nurses, 

licensed practical nurses, unlicensed assistive personnel, 

service, maintenance, clerical, professional and technical 

workers, and all other health care workers."
21

scope of the workforce reduction restriction. This section 

requires that facilities' certification plans, which must be 

submitted to HPC, address "the facility obligation that 

implementation of limits shall not result in a reduction of the 

staffing level of the health care workforce assigned to such 

patients" (emphasis supplied). The parties disagree with 

respect to whether, pursuant to this language, only those 

employees who are assigned to individual patients would be 

considered part of the health care workforce.

When determining whether an initiative meets the 

requirements of art. 48, we exercise "restraint in deciding 

whether a measure would or would not have the legal effect 

intended," and restrict such considerations to the extent 

necessary to determine whether a proposal satisfies the 

requirements of art. 48. See Abdow, 468 Mass. at 507. "In 

circumstances like these, the proper time for deciding 

definitively whether the measure has the desired legal effect 

will come if and when the measure is passed." Id. at 508. We 

need not, at this juncture, construe the definition of "health

care workforce" or decide whether this definition could have 

consequences that its drafters did not intend. Nor do we need 

to determine how to reconcile this definition with the proposed 

act's reference, in a separate section, to "the facility 

obligation that implementation of limits shall not result in a 
22

reduction in the staffing level of the health care workforce 

assigned to such patients" (emphasis supplied). The proper

interpretation of these provisions is not dispositive of the 

question of relatedness. Under any reading, the workforce 

reduction restriction merely constrains how nurse-patient

staffing ratios may be implemented. As a result, we conclude 

that Initiative Petition 17-07 "contains only subjects that are 

related or are mutually dependent. It is therefore fair to ask 

the people of the Commonwealth to vote 'yes' or 'no' on" the 

petition. Dunn, 474 Mass. at 682.

ii. Initiative Petition 17-08. As stated, the text of 

Initiative Petition 17-08 is virtually identical to that of 

Initiative Petition 17-07, with the addition of one section. 

That section, the financial disclosure requirement, would 

require hospitals that accept funds from the Commonwealth to 

file annual reports of their financial assets with the HPC. The 

HPC, in turn, would be required to make this information public 

within seven calendar days of its receipt, unless doing so is 

otherwise prohibited by law.

In determining whether the financial disclosure requirement

is sufficiently related to the remainder of Initiative Petition 

17-08, we look for "a common purpose to which each subject of 

[the] initiative petition can reasonably be said to be germane." 

Massachusetts Teachers Ass'n, 384 Mass. at 219-220. The 
23

Williams plaintiffs contend that the common purpose unifying 

Initiative Petition 17-08 is patient safety. They assert that 

the financial disclosure requirement furthers this goal by 

shining a light on hospitals' economic capacity to hire new 

staff, as might be required by the nurse-patient assignment 

limits.

These issues might be connected, in some sense, if 

hospitals' financial assets reflect their ability to pay the 

salaries of additional registered nurses. The patient 

assignment limits, however, are mandatory and inflexible, and

are not tied to a hospital's financial condition; under the 

terms of Initiative Petition 17-08, an inability to pay is no 

defense for a failure to comply. Nor does the proposal provide 

a mechanism to increase funding to hospitals that would bear an 

economic hardship if forced to hire additional registered 

nurses. The financial disclosure requirement, therefore, has 

"only a marginal relationship" to the nurse-patient staffing 

ratios. See Abdow, 468 Mass. at 499. Moreover, the initiative 

cannot be saved by assertion of a more general common purpose, 

such as regulation of hospitals. "At some high level of 

abstraction, any two laws may be said to share a 'common 

purpose,'" Carney I, 447 Mass. at 226, but a petition's asserted 

common purpose cannot be "so broad as to render the relatedness 
24

limitation 'meaningless,'" id. at 225, quoting Massachusetts 

Teachers Ass'n, 384 Mass. at 219.

Initiative Petition 17-08 recalls Opinion of the Justices, 

422 Mass. 1212, 1220-1221 (1996), in which the Justices 

concluded that the goal of making "Massachusetts government more 

accountable to the people" was "unacceptably broad" as a 

"general purpose" for an initiative petition. The petition at 

issue in that case primarily sought to regulate legislators' 

compensation, but contained one provision that would have 

permitted the Inspector General to request and summon records 

held by the commissioner of veterans' services. Id. at 1213-

1214. The Justices determined that the proposal's true common 

purpose was more narrow, specifically to improve legislative 

accountability. Id. at 1220-1221. The initiative failed the 

related subjects requirement because "permitting the Inspector 

General access to the records of the commissioner of veterans' 

services does not relate in any meaningful way to improving 

legislative accountability." Id. at 1221. Similarly, here, the 

financial asset disclosure requirement "does not relate in any 

meaningful way" to patient safety through the establishment of 

nurse-patient staffing ratios.12 See id.

 

12 The Williams plaintiffs alternatively assert that the 

common purpose of Initiative Petition 17-08 is "the safety of 

patients through adequate staffing and hospital transparency in 

disclosing their means and methods of staffing." By its terms, 
25

The subjects are unrelated because they concern "two 

separate public policy issues." Gray, 474 Mass. at 649. This 

becomes clear when one reads the section of Initiative Petition 

17-08 that would impose the financial disclosure requirement. 

That section provides, "It is in the public interest to have 

access to a transparent, detailed, and comprehensive record of 

the financial health of each facility that accepts funds from 

the Commonwealth to provide healthcare to its residents." The 

stated policy goal of this section -- public access to 

hospitals' financial records -- has no apparent connection to 

the petition's purported purpose of ensuring patient safety by 

virtue of creating nurse-to-patient staffing ratios. "The 

combination of these two issues in one initiative petition does 

not offer the voters a 'unified statement of public policy"

(emphasis in original). Id. at 649, quoting Carney I, 447 Mass. 

at 231. "Rather, because the issues combined in the petition 

are substantively distinct, it is more likely that the voters 

would be in the 'untenable position of casting a single vote on 

two or more dissimilar subjects.'" Gray, supra, quoting Abdow, 

468 Mass. at 499. These subjects therefore lack "sufficient 

 

however, this "common purpose" purports to tackle "two separate 

public policy issues": adequate hospital staffing and hospital 

transparency. See Gray v. Attorney Gen., 474 Mass. 638, 649 

(2016).
26

operational connection . . . to be 'related' within the meaning 

of art. 48." Gray, supra at 648.

As a result, we conclude that Initiative Petition 17-08 

fails the two-part relatedness test. First, the similarities 

between the financial disclosure requirement and the remainder 

of the initiative petition do not "dominate what each segment 

provides separately." Carney I, 447 Mass. at 226. While both

elements of the proposal pertain to hospitals, even this 

commonality is limited; the financial disclosure requirement 

would be imposed only on State-funded hospitals, while the 

remainder of the initiative would apply to all facilities. 

Second, and more crucially, because they represent "two separate 

public policy issues," Gray, 474 Mass. at 649, there is no 

"operational relatedness" between the two requirements. See 

Carney I, supra at 230-231.

Additionally, "[t]he two subjects in this petition are 

clearly not 'mutually dependent.' In fact, the opposite seems 

true." Gray, 474 Mass. at 648, quoting Art. 48, The Initiative, 

II, § 3, as amended by art. 74. In Gray, we held that 

terminating public schools' use of the national common core 

curriculum was not "mutually dependent" on the requirement that 

schools release certain testing information because, "whether 

the diagnostic assessment tests are based on the common core 

standards or some previous set of academic standards . . . will 
27

not affect in any way the . . . obligation" to release the 

required test information. Id. Because these two subjects 

would "exist independently," they were not "mutually dependent." 

Id. Similarly, here, a facility's implementation of, or failure 

to implement, the required nurse-to-patient ratios would "not 

affect in any way" its obligation to disclose its financial 

assets, and the two requirements would therefore "exist 

independently." Id. The provisions of Initiative Petition 17-

08 are thus not "mutually dependent." See id.

In sum, the nurse-patient staffing ratios and the financial 

disclosure requirement are neither mutually dependent nor 

related subjects. The Attorney General was correct in declining 

to certify that Initiative Petition 17-08 satisfies the demands 

of art. 48.

b. Proper form requirement. Only laws and constitutional 

amendments may be presented through the initiative process under 

art. 48. See art. 48, The Initiative, I ("the popular 

initiative" allows specified number of voters "to submit 

constitutional amendments and laws to the people"). "[A]n 

initiative petition that proposes neither a law nor a 

constitutional amendment is not 'in proper form for submission 

to the people.'" Dunn, 474 Mass. at 682, quoting art. 48, The 

Initiative, II, § 3, as amended by art. 74. Although we have 

declined to "construe the word 'form' in a narrow and technical 
28

sense," our analysis of whether a petition has the proper form 

has focused on the question "whether a law is proposed." 

Paisner v. Attorney Gen., 390 Mass. 593, 598 (1983). In other 

words, we examine whether the petition presents a measure that 

has a binding effect, and "govern[s] conduct external to the 

legislative body." Id. at 600. The Oberlies plaintiffs 

contend, on five different grounds, that Initiative Petition 

17-07 does not take the proper form required by art. 48. For 

the reasons discussed infra, we conclude that these claims are 

unavailing.13

The Oberlies plaintiffs first argue that the title of 

Initiative Petition 17-07 -- "Initiative Petition For A Law 

Relative To Patient Safety And Hospital Transparency" -- is 

misleading, because, unlike the rejected Initiative Petition 17-

08, it contains no provision requiring hospitals to disclose 

their financial assets. In this view, the title's reference to 

 

13 The Oberlies plaintiffs properly do not contend that 

Initiative Petition 17-07, if approved, would not constitute a 

law. We observe that, under Initiative Petition 17-07, "[e]ach 

facility shall implement the patient assignment limits," and 

"implementation of these limits shall not result in a reduction 

in the staffing levels of the health care workforce" (emphasis 

supplied). It is well established that use of the word "shall" 

indicates a mandatory duty. See Galenski v. Erving, 471 Mass. 

305, 309 (2015), citing Hashimi v. Kalil, 388 Mass. 607, 609 

(1983). The proposed act thus would have a "binding" effect on 

facilities, thereby regulating "conduct external to the 

legislative body." Paisner v. Attorney Gen., 390 Mass. 593, 600 

(1983). The initiative petition therefore meets the requirement 

of art. 48 that it propose either a law or a constitutional 

amendment. See id.
29

"hospital transparency" is "incongruous." The Oberlies 

plaintiffs further contend that the title should include a 

reference to the workforce reduction restriction.

"Nowhere is it provided that the title of a proposed law 

shall be descriptive of it to any particular degree, or wholly 

accurate so far as it is descriptive." Nigro, 402 Mass. at 445, 

quoting Bowe v. Secretary of the Commonwealth, 320 Mass. 230, 

240-241 (1946). "The legislative history and structure of 

art. 48 demonstrate that the 'proper form' requirement is not 

intended to require a title to give fair notice of the scope and 

essential nature of the underlying measure." Nigro, supra. 

Rather, the Attorney General's summary serves the purpose of 

explaining the proposal's contents, and "any harm caused by a 

misleading title can be corrected by an accurate summary."14 Id. 

at 447, citing Opinion of the Justices, 309 Mass. 631, 640-641 

(1941). Even if the title were inaccurate, therefore, and we do 

not conclude that the title here is, that alone would not render 

the form of an initiative petition invalid.

The Oberlies plaintiffs' remaining challenges to the form 

of Initiative Petition 17-07 are related to its contents. They 

contend that the terms "facilities" and "health care workforce," 

as used in the text, are internally inconsistent or open to 

 

14 The Oberlies plaintiffs have not challenged the Attorney 

General's summary of Initiative Petition 17-07.
30

multiple interpretations. They thereby ask us to conduct "an 

[impermissible] inquiry into substance." See Nigro, 402 Mass. 

at 445-446 ("The debate concerning the original adoption of the 

'proper form' requirement reveals that the framers of art. 48 

were primarily concerned with avoiding errors of draftmanship," 

and did not intend that it "become an inquiry into substance").

In Mazzone, 432 Mass. at 530, we rejected a similar 

challenge to the form of an initiative petition in which the 

plaintiffs claimed that the definition of a key term was 

"circular" and "mystifying." We explained that "[n]either the 

petitioners' skill at legislative drafting, the potential 

constitutional infirmities of an arbitrary or vague statute, nor 

the potential effects of a measure on current law are reviewable 

matters under art. 48." Id. "[T]he pros and cons of the 

measure, including its possible legal flaws," Abdow, 468 Mass. 

at 508, are not before us at this time.

The Oberlies plaintiffs also challenge an exception 

included in Initiative Petition 17-07 that provides that "[t]he 

requirements of this act, and its enforcement, shall be 

suspended during a [S]tate or nationally declared public health 

emergency." They argue that voters will misread this section, 

and believe that the proposed act's requirements will be 

suspended under any situation that commonly might be described 

as an emergency, such as food poisoning at a popular restaurant
31

or a multivehicle accident on the expressway, rather than only

under the limited circumstances of a State or nationally

declared public health emergency. The proposal's language, 

however, plainly states that its requirements would be suspended 

only during a State or nationally declared public health 

emergency. This claim does not assert any "errors of 

draftmanship," see Nigro, 402 Mass. at 446, but, rather, appears 

to challenge the narrow scope of the proposed exception. "The 

plaintiffs' disagreements with the petition's purpose, the 

methods chosen to achieve that purpose and the possible effects" 

are not grounds upon which to reject an initiative petition. 

See Mazzone, 432 Mass. at 529.

Finally, the Oberlies plaintiffs argue that Initiative 

Petition 17-07 is fatally flawed because it does not adequately 

set forth how the workforce reduction restriction will be 

enforced, or the grounds for determining whether a violation has 

occurred. They assert that the proposal's failure to answer 

these questions will make the proposed act difficult to 

implement, and "deprive voters of the ability to make an 

informed electoral choice." The proposal, however, if approved, 

would empower the HPC to "promulgate regulations governing and 

ensuring the implementation and operation of th[e] act." A

petition does not lack the proper form solely because, at this 

stage, the details of its administration are unclear. See 
32

Mazzone, 432 Mass. at 530 ("The plaintiffs' argument that 'a 

statutory scheme that demands arbitrary enforcement by providing 

no guidance to those who must administer it states no law'

misconstrues the constitutional requirements for the enactment 

of legislation by the people or the Legislature"). "[T]he 

proper time for deciding definitively whether the measure has 

the desired legal effect will come if and when the measure is 

passed." Abdow, 468 Mass. at 508. That the full consequences 

of the proposed act would be fleshed out after its passage does 

not render its form improper. See id. at 509-510.

As a result, the Attorney General was correct in 

determining that Initiative Petition 17-07 is in a proper form 

for submission to the voters, pursuant to art. 48.

3. Conclusion. We remand the matter to the county court 

for entry of a judgment declaring that the Attorney General's 

decisions to certify Initiative Petition 17-07, and declining to 

certify Initiative Petition 17-08, were in compliance with the 

requirements of art. 48.

So ordered.