Title: Kligler v. Attorney General
Citation: N/A
Docket Number: SJC-13194
State: Massachusetts
Issuer: Massachusetts Supreme Court
Date: December 19, 2022

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
volumes of the Official Reports.  If you find a typographical 
error or other formal error, please notify the Reporter of 
Decisions, Supreme Judicial Court, John Adams Courthouse, 1 
Pemberton Square, Suite 2500, Boston, MA, 02108-1750; (617) 557-
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SJC-13194 
 
ROGER M. KLIGLER & another1  vs.  ATTORNEY GENERAL & another.2 
 
 
 
Suffolk.     March 9, 2022. - December 19, 2022. 
 
Present:  Budd, C.J., Gaziano, Lowy, Cypher, Wendlandt, 
& Georges, JJ. 
 
 
Physician-Assisted Suicide.  Doctor, Doctor-patient 
relationship, Prescription.  Declaratory Relief.  
Injunction.  Practice, Civil, Declaratory proceeding, 
Injunctive relief, Standing.  Jurisdiction, Justiciable 
question, Declaratory relief, Injunction against criminal 
prosecution.  Supreme Judicial Court, Justiciable question, 
Jurisdiction.  Constitutional Law, Equal protection of 
laws, Freedom of speech and press, Standing.  Due Process 
of Law.  Homicide.  Practice, Civil, Summary judgment. 
 
 
 
Civil action commenced in the Superior Court Department on 
October 24, 2016. 
 
The case was heard by Mary K. Ames, J., on motions for 
summary judgment. 
 
The Supreme Judicial Court on its own initiative 
transferred the case from the Appeals Court. 
 
 
 
1 Alan Steinbach. 
 
2 District attorney for the Cape and Islands district. 
2 
 
John Kappos, of California (Meng Xu, of California, Kevin 
Díaz, of Oregon, & Jonathan M. Albano also present) for the 
plaintiffs. 
Maria Granik, Assistant Attorney General (Julie E. Green & 
James A. Sweeney, Assistant Attorneys General, also present) for 
the defendants. 
Christopher P. Schandevel, of Virginia, for Euthanasia 
Prevention Coalition USA. 
The following submitted briefs for amici curiae: 
Konstantin Tretyakov, pro se. 
Dwight G. Duncan for Massachusetts Citizens for Life, Inc. 
Michelle M. Uzeta, of California, for Disability Rights 
Education and Defense Fund & others. 
Catherine Glenn Foster, Steven H. Aden, Katie Glenn, & 
Natalie M. Hejran, of the District of Columbia, Carolyn 
McDonnell, of Wisconsin, & Andrew Beckwith for Christian Medical 
& Dental Associations. 
Kevin Yuill, pro se. 
Brandon Jiha, of the District of Columbia, Robert A. 
Skinner, Thanithia Billings, & Douglas Hallward-Driemeier for 
Massachusetts Medical Society & another. 
Andrés J. Gallegos, of Illinois, for National Council on 
Disability. 
Michael J. Kerrigan for four Roman Catholic Bishops of the 
Dioceses of Massachusetts. 
 
 
 
GAZIANO, J.  In this case, we are faced with the solemn 
task of determining whether the Massachusetts Declaration of 
Rights provides a substantive due process right to physician-
assisted suicide.  The plaintiffs, a doctor who wishes to 
provide physician-assisted suicide and a patient who has been 
diagnosed with an incurable cancer, contend that terminally ill 
patients with six months or less to live have a constitutional 
right to receive a prescription for lethal medication in order 
to bring about death at a time and in a manner of their 
choosing. 
3 
 
 
Although we recognize the paramount importance and profound 
significance of all end-of-life decisions, after careful 
consideration, we conclude that the Massachusetts Declaration of 
Rights does not reach so far as to protect physician-assisted 
suicide.3  We conclude as well that the law of manslaughter may 
prohibit physician-assisted suicide, and does so, without 
offending constitutional protections. 
 
Background.  We summarize the facts based on the summary 
judgment record on the parties' cross motions for summary 
judgment.  "In a case like this one where both parties have 
moved for summary judgment, the evidence is viewed in the light 
most favorable to the party against whom judgment [has 
entered]."  Boazova v. Safety Ins. Co., 462 Mass. 346, 350 
(2012). 
 
1.  Physician-assisted suicide.  Physician-assisted 
suicide, also known as medical aid in dying, is a term of art 
that refers to the practice of providing a terminally ill, 
competent patient who has a short time left to live with a 
 
3 We acknowledge the amicus briefs submitted by Konstantin 
Tretyakov; Massachusetts Citizens for Life, Inc.; Disability 
Rights Education and Defense Fund and eighteen other 
organizations; Christian Medical and Dental Associations; 
Euthanasia Prevention Coalition USA; Kevin Yuill; Massachusetts 
Medical Society and Hospice and Palliative Care Federation of 
Massachusetts; and four Roman Catholic Bishops of the Dioceses 
of Massachusetts; as well as the amicus letter submitted by the 
National Council on Disability. 
4 
 
prescription for medication that the patient may ingest to bring 
about a quick and painless death.4  See Morris v. Brandenburg, 
2016-NMSC-027, ¶ 5; Myers v. Schneiderman, 30 N.Y.3d 1, 10 
(2017).  See also Pope, Medical Aid in Dying:  Key Variations 
Among U.S. State Laws, J. Health & Life Sci. L., vol. 14, Oct. 
2020, at 32.  The prescription generally is for barbiturates and 
includes instructions on the manner in which to administer the 
medication in a way that will cause death. 
After obtaining the prescription, the patient may choose to 
self-administer the medication and die painlessly at a time and 
place of his or her choosing.  For some terminally ill 
individuals, obtaining such a prescription may alleviate anxiety 
related to the process of dying by serving as reassurance that 
the individual will have the option to end his or her own 
suffering. 
Physician-assisted suicide has been legalized in ten States 
and the District of Columbia.5  Attempts to legalize the practice 
 
 
4 While the plaintiffs use the term "medical aid in dying," 
in 2018, the American Medical Association's Council on Judicial 
and Ethical Affairs again asserted its belief that "ethical 
deliberation and debate is best served" by using the term 
"physician-assisted suicide" rather than the more ambiguous "aid 
in dying."  The vast majority of cases and statutes to have 
addressed the issue to date in other jurisdictions also use the 
phrase "physician-assisted suicide." 
 
5 See Cal. Health & Safety Code §§ 443 et seq.; Colo. Rev. 
Stat. §§ 25-48-101 et seq.; D.C. Code §§ 7-661.01 et seq.; Haw. 
Rev. Stat. §§ 327L-1 et seq.; Me. Rev. Stat. tit. 22, § 2140; 
5 
 
in Massachusetts, however, have been unsuccessful.  In 2012, 
voters rejected a proposed ballot initiative that would have 
allowed a physician to provide a competent, terminally ill 
patient with medication to end the patient's life.  See 
Secretary of the Commonwealth, Statewide Ballot Questions -- 
Statistics by Year:  1919-2018.6  See also Secretary of the 
Commonwealth, Massachusetts Information for Voters:  2012 Ballot 
Questions 7-8.7  Additionally, although lawmakers have introduced 
over a dozen bills to legalize physician-assisted suicide in the 
Commonwealth, none has advanced to a vote.8  To the contrary, the 
Legislature has adopted a stance against physician-assisted 
suicide.  See G. L. c. 111, § 227 (c) (health care providers are 
 
N.J. Stat. Ann. §§ 26:16-1 et seq.; N.M. Stat. Ann. §§ 24-7c-1 
et seq.; Or. Rev. Stat. §§ 127.800 et seq.; Vt. Stat. Ann. tit. 
18, §§ 5281 et seq.; Wash. Rev. Code §§ 70.245.010 et seq.; 
Baxter v. State, 2009 MT 449, ¶¶ 49-50 (terminally ill patient's 
consent to physician-assisted suicide constitutes statutory 
defense to charge of homicide). 
 
6 Available at https://www.sec.state.ma.us/ele/elebalm 
/balmresults.html [https://perma.cc/ZE73-J2MF]. 
 
7 Available at https://www.sec.state.ma.us/ele/elepdf/IFV-
2012.pdf [https://perma.cc/J3X7-G32K]. 
 
8 See House Bill No. 2381 (Feb. 8, 2021); Senate Bill No. 
1384 (Feb. 8, 2021); House Bill No. 4782 (May 29, 2020); Senate 
Bill No. 2745 (May 29, 2020); House Bill No. 1926 (Jan. 8, 
2019); Senate Bill No. 1208 (Jan. 14, 2019); Senate Bill No. 
1225 (Jan. 18, 2017); House Bill No. 1194 (Jan. 18, 2017); House 
Bill No. 2233 (Jan. 21, 2011); House Bill No. 1468 (Jan. 14, 
2009); House Bill No. 3195 (Jan. 2003); House Bill No. 1543 
(Jan. 1997); House Bill No. 3173 (Jan. 1995). 
6 
 
not permitted to "offer to provide information about assisted 
suicide or the prescribing of medication to end life"); G. L. 
c. 201D, § 12 ("Nothing in this chapter shall be construed to 
constitute, condone, authorize, or approve suicide or mercy 
killing, or to permit any affirmative or deliberate act to end 
one's own life other than the permit the natural process of 
dying"). 
2.  Parties.  Plaintiff Roger Kligler is a retired 
physician who has been diagnosed with metastatic prostate 
cancer.  His cancer is categorized as stage 4, which is the most 
advanced form of cancer.  In May 2018, Kligler's treating 
physician estimated that there was a fifty percent chance that 
Kligler would die within five years. 
Nonetheless, Kligler has not yet received a six-month 
prognosis; indeed, his cancer currently has been contained, and 
his physician asserts that it would not be surprising if Kligler 
were alive ten years from now.  Kligler asserts, however, that 
if he were to receive a six-month prognosis, he would wish to 
pursue physician-assisted suicide.  In Kligler's view, the 
possibility of physician-assisted suicide "would allow [him] to 
live out the rest of [his] days knowing that, if [his] suffering 
becomes too great, [he] would have the option of ending [his] 
suffering."  Given the uncertain legal status of physician-
7 
 
assisted suicide, Kligler has been unable to find a doctor in 
Massachusetts willing to provide such assistance. 
Plaintiff Alan Steinbach is a licensed physician and 
currently practices as an urgent care provider in Falmouth.  
Although Steinbach is not Kligler's doctor, Steinbach treats 
other patients who are nearing the end of life and who wish to 
discuss various end-of-life options, including physician-
assisted suicide.  Steinbach asserts that he would like to 
provide physician-assisted suicide, but that he does not do so 
out of fear of prosecution. 
The Attorney General and the district attorney for the Cape 
and Islands district (district attorney) are named as defendants 
in their official capacities.  They are both elected officials 
empowered to prosecute those who violate State criminal laws.  
Although the defendants have not expressed an affirmative 
intention to prosecute Kligler or Steinbach, they have declined 
to commit not to prosecute those who engage in physician-
assisted suicide based on their conclusion that such a practice 
is "not immune from prosecution in Massachusetts." 
3.  Prior proceedings.  In October of 2016, the plaintiffs 
commenced a civil action in the Superior Court, seeking 
declaratory and injunctive relief.  Specifically, they sought a 
declaration that "physicians do not violate the criminal laws of 
the Commonwealth of Massachusetts when they follow a medical 
8 
 
standard of care and prescribe Medical Aid in Dying medications 
for self-administration by the patient . . . or alternatively, 
that application of criminal laws of the Commonwealth of 
Massachusetts to physicians providing such care is 
unconstitutional under the Massachusetts [C]onstitution."  The 
plaintiffs also sought an injunction to enjoin the defendants 
from "prosecuting physicians for . . . prescribing medication 
for Medical Aid in Dying to such patients upon request."  The 
complaint asserted that such relief was warranted for several 
reasons.  In the plaintiffs' view, physician-assisted suicide 
could not satisfy the required elements of manslaughter as a 
matter of law.  To the extent that the law of manslaughter does 
apply to physician-assisted suicide, the complaint asserted that 
the law is unconstitutionally vague and, moreover, interferes 
with the plaintiffs' constitutional rights to equal protection 
and substantive due process.  Finally, the complaint asserted 
that a physician's right to freedom of speech precludes the 
prosecution of doctors for discussing physician-assisted suicide 
with a terminally ill patient. 
The defendants moved to dismiss on the ground that the 
complaint failed to state a claim for declaratory relief because 
the allegations did not give rise to an actual controversy.  A 
Superior Court judge concluded that the plaintiffs had presented 
9 
 
an actual controversy and were eligible to seek declaratory 
relief.  The judge therefore denied the motion to dismiss. 
The plaintiffs subsequently moved for partial summary 
judgment on their equal protection and free speech claims, and 
the defendants filed a cross motion for summary judgment on all 
claims.  The same Superior Court judge granted the plaintiffs' 
motion for partial summary judgment as to the free speech claim, 
but granted the defendants' motion for summary judgment on the 
other claims.  The judge concluded that "providing advice and 
information about [medical aid in dying] is permitted in the 
Commonwealth," a determination from which the defendants did not 
appeal.  The judge also concluded that physician-assisted 
suicide could constitute involuntary manslaughter and that the 
law of manslaughter was not unconstitutionally vague when 
applied in such a way.  The judge determined that the 
criminalization of physician-assisted suicide did not offend the 
plaintiffs' rights to equal protection and due process.  In so 
holding, the judge reasoned that the Massachusetts Declaration 
of Rights did not protect a fundamental right to physician-
assisted suicide and that the criminalization of physician-
assisted suicide is supported by a rational basis.  The 
plaintiffs appealed from the order allowing the defendants' 
motion for summary judgment, and we transferred the case to this 
court on our own motion. 
10 
 
Discussion.  We review a grant of summary judgment, 
including the judge's legal conclusions, de novo.  Roman v. 
Trustees of Tufts College, 461 Mass. 707, 711 (2012). 
The plaintiffs contend that the judge erred in allowing the 
defendants' motion for summary judgment for a number of reasons.  
They argue that the Massachusetts Declaration of Rights protects 
a fundamental right to physician-assisted suicide and that 
therefore the practice may not be criminalized; they assert that 
any prosecution for physician-assisted suicide would be 
unconstitutional.  They also argue that physician-assisted 
suicide is not wanton or reckless, and is not the proximate 
cause of a patient's death, and therefore it cannot satisfy the 
required elements of involuntary manslaughter.  The plaintiffs 
maintain that, in any event, physician-assisted suicide cannot 
be prosecuted because the law of manslaughter is 
unconstitutionally vague as applied.  In addition, in their 
view, the criminalization of physician-assisted suicide violates 
their rights to equal protection under the law by 
differentiating between terminally ill individuals who wish to 
pursue physician-assisted suicide and those who wish to hasten 
death through other means. 
We first consider whether we have jurisdiction over the 
matter, and we then proceed to the merits of the plaintiffs' 
claims. 
11 
 
1.  Jurisdiction.  The declaratory judgment act, G. L. 
c. 231A, § 1, authorizes courts to make "binding declarations of 
right, duty, status and other legal relations" where the parties 
present an "actual controversy."  Such relief is appropriate 
only if a plaintiff can demonstrate the existence of an actual 
controversy, as well as "the requisite legal standing to secure 
its resolution" (citation omitted).  Entergy Nuclear Generation 
Co. v. Department of Envtl. Protection, 459 Mass. 319, 326 
(2011). 
An actual controversy is 
"a real dispute caused by the assertion by one party of a 
legal relation, status or right in which he has a definite 
interest, and the denial of such assertion by another party 
also having a definite interest in the subject matter, 
where the circumstances attending the dispute plainly 
indicate that unless the matter is adjusted such 
antagonistic claims will almost immediately and inevitably 
lead to litigation." 
 
Gay & Lesbian Advocates & Defenders v. Attorney Gen., 436 Mass. 
132, 134-135 (2002) (GLAD), quoting Bunker Hill Distrib., Inc. 
v. District Attorney for the Suffolk Dist., 376 Mass. 142, 144 
(1978).  "A party has standing when it can allege an injury 
within the area of concern of the statute, regulatory scheme, or 
constitutional guarantee under which the injurious action has 
occurred."  Doe No. 1 v. Secretary of Educ., 479 Mass. 375, 386 
(2018). 
12 
 
"The purpose of both the actual controversy and the 
standing requirements is to ensure the effectuation of the 
statutory purpose of G. L. c. 231A, which is to enable a court 
'to afford relief from . . . uncertainty and insecurity with 
respect to rights, duties, status and other legal relations'" 
(alteration in original).  Massachusetts Ass'n of Indep. Ins. 
Agents & Brokers v. Commissioner of Ins., 373 Mass. 290, 292 
(1977), quoting G. L. c. 231A, § 9.  "In declaratory judgment 
actions, both requirements are liberally construed" so as to 
effectuate the statute's broad, remedial purpose.  Doe No. 1, 
479 Mass. at 384-385. 
 
a.  Actual controversy.  Kligler's interest in and ability 
to pursue physician-assisted suicide under the fundamental right 
as he asserts it is contingent upon his receipt of a six-month 
prognosis.  We previously have recognized that a plaintiff may 
present an actual controversy even if his or her exercise of a 
right is contingent upon the occurrence of some other event.  
See, e.g., Oxford v. Oxford Water Co., 391 Mass. 581, 584 (1984) 
("It is not necessary that the parties be irrevocably bound to a 
course of action before a court can afford declaratory relief"); 
Southbridge v. Southbridge Water Supply Co., 371 Mass. 209, 213-
214 (1976), S.C., 411 Mass. 675 (1992) (exercise of right at 
stake was contingent upon outcome of town meeting vote).  See 
also American Mach. & Metals v. De Bothezat Impeller Co., 166 
13 
 
F.2d 535, 536 (2d. Cir. 1948) ("Where there is an actual 
controversy over contingent rights, a declaratory judgment may 
nevertheless be granted").  For example, in Southbridge Water 
Supply Co., supra at 212-214, we concluded that a town could 
receive a declaratory judgment regarding what it would have to 
pay to purchase a corporation, even though the town's ability to 
purchase the corporation was contingent upon a town vote.  We 
recognized that the town could decide against purchasing the 
corporation and that, even if the town chose to attempt to 
complete the purchase, it might not receive the votes to do so.  
Id. at 214.  Nonetheless, we granted declaratory relief in part 
because doing so would inform the town's decision whether to 
pursue the purchase of the corporation.  Id. at 214-215. 
 
This case, however, is distinguishable because Kligler does 
not currently possess the option of pursuing physician-assisted 
suicide, as the plaintiffs define the right, given that he has 
not yet received a six-month prognosis.  Nor is it apparent that 
he will soon receive such a prognosis and therefore meet the 
stated qualifications for physician-assisted suicide.  Kligler's 
doctor opined that "[Kligler's] cancer is under good control 
with the treatment that he has had," and that he has a "good 
prognosis."  The doctor also noted that "[s]ome patients can 
live for many years" with Kligler's particular type of cancer.  
Should Kligler's cancer become more aggressive, the doctor 
14 
 
indicated there are at least five treatment options that might 
be able to control the cancer, and thus delay a six-month 
prognosis.  Accordingly, Kligler's doctor stated that he would 
not "be surprised if [Kligler] is alive in ten years' time." 
Because Kligler is not currently in the position that the 
plaintiffs assert is necessary to be entitled to pursue 
physician-assisted suicide, issuing a declaratory judgment would 
have no immediate impact on Kligler or his decision-making, and 
therefore would not fulfill the purposes of the declaratory 
judgment act.  See Massachusetts Ass'n of Indep. Ins. Agents & 
Brokers, 373 Mass. at 292 ("the declaration issued is intended 
to have an immediate impact on the rights of the parties").  
Accordingly, Kligler's complaint for declaratory relief should 
have been dismissed. 
Steinbach's claims, on the other hand, present a different 
question.  Steinbach asserts that he would engage in assisting 
patients who were seeking physician-assisted suicide were it not 
for the risk of prosecution for manslaughter.  Thus, he argues, 
an actual controversy exists because he faces a credible threat 
of prosecution should he carry out his intention to provide 
physician-assisted suicide.  "When contesting the 
constitutionality of a criminal statute, 'it is not necessary 
that [the plaintiff] first expose himself to actual arrest or 
prosecution'" in order to present an actual controversy.  
15 
 
Babbitt v. United Farm Workers Nat'l Union, 442 U.S. 289, 298 
(1979), quoting Steffel v. Thompson, 415 U.S. 452, 459 (1974).  
See, e.g., Commonwealth v. Baird, 355 Mass. 746, 755 (1969), 
cert. denied, 396 U.S. 1029 (1970).  Rather, "[a] plaintiff who 
challenges a statute must demonstrate a realistic danger of 
sustaining a direct injury as a result of the statute's 
operation or enforcement."  Babbitt, supra, quoting O'Shea v. 
Littleton, 414 U.S. 488, 494 (1974).  An actual controversy 
exists where the plaintiff demonstrates (1) "an intention to 
engage in a course of conduct arguably affected with a 
constitutional interest, but [arguably] proscribed by a 
statute," and (2) "a credible threat of prosecution thereunder."  
Babbitt, supra. 
Here, Steinbach asserts that he intends to provide 
physician-assisted suicide for qualifying patients if he can do 
so lawfully.  Thus, an actual controversy exists.  Compare 
Sturgis v. Attorney Gen., 358 Mass. 37, 38 (1970) (actual 
controversy existed where doctors who challenged statute that 
prohibited unmarried persons from obtaining contraceptives 
stated that "[i]t has been, is, and will be [their] desire in 
the course of [their] medical practice . . . to administer to, 
and prescribe for, certain unmarried patients drugs or articles 
intended for the prevention of pregnancy"). 
16 
 
Whether Steinbach has demonstrated "a credible threat of 
prosecution," however, presents a much closer question.  See 
Babbitt, 442 U.S. at 298.  The motion judge concluded that 
Steinbach faced a credible threat based on statements to the 
media made by the district attorney indicating his belief that 
physician-assisted suicide is a prosecutable offense under 
current law. 
We occasionally have recognized the presence of an actual 
controversy where a prosecuting official expresses an opinion 
that a plaintiff's intended course of action violates the law.  
For example, in Essex Theatre Corp. v. Police Comm'r of Boston, 
365 Mass. 183, 184 (1974), we held that a controversy existed 
where the plaintiff sought publicly to display a film admittedly 
depicting "explicit sexual congress," and the defendant 
"indicated that any film which showed explicit sexual congress 
was obscene and a showing of it would violate [the law]."  
Similarly, in Benefit v. Cambridge, 424 Mass. 918, 922 (1997), 
we concluded that the plaintiff faced "a continuing threat . . . 
of prosecution" where the district attorney, who previously had 
brought charges against the plaintiff for engaging in a form of 
speech prohibited by statute, refused to commit to "refrain[ing] 
from enforcing [the challenged statute] against the plaintiff." 
The asserted threats in this case, however, are somewhat 
atypical.  The statements were not addressed to Steinbach 
17 
 
specifically and were discussing conduct that Steinbach has yet 
to attempt.  Compare Benefit, 424 Mass. at 919-920.  Moreover, 
the defendants have never prosecuted anyone for physician-
assisted suicide.  Compare Essex Theatre Corp., 365 Mass. 
at 184.  This calls into question whether Steinbach faces a 
threat of prosecution sufficient to support an actual 
controversy.  The United States Supreme Court occasionally has 
concluded that a true threat, and therefore an actual 
controversy, existed even where no threat of prosecution was 
made by a prosecuting official.  See, e.g., Steffel, 415 U.S. at 
459 (actual controversy existed where plaintiff twice had been 
warned to stop "handbilling" at shopping center, which was 
prohibited by statute he argued was unconstitutional, and where 
plaintiff was told he likely would be prosecuted if he did so 
again).  See also Holder v. Humanitarian Law Project, 561 U.S. 
1, 8-13, 15 (2010) (actual controversy existed where plaintiffs 
wanted to violate statute prohibiting knowingly providing 
material support to foreign terrorist organization, of which 
plaintiffs had been members before it was designated as 
terrorist group, but did not do so out of fear of prosecution).  
In light of the current state of the law on manslaughter, which 
we review in some detail infra, we conclude that, even apart 
from any consideration of specific media reports concerning 
statements attributed to the district attorney, Steinbach does 
18 
 
face a true threat of prosecution, and thus an actual 
controversy exists. 
i.  Law of manslaughter.  "Involuntary manslaughter is an 
unintentional, unlawful killing caused by wanton or reckless 
conduct."  Commonwealth v. Earle, 458 Mass. 341, 347 (2010).  To 
sustain a conviction of involuntary manslaughter, the 
Commonwealth bears the burden of proving "that the defendant's 
conduct (1) was intentional; (2) was wanton or reckless; and 
(3) caused the victim's death" (footnote omitted).9  See 
Commonwealth v. Carter, 474 Mass. 624, 632 (2016) (Carter I), 
S.C., 481 Mass. 352 (2019) (Carter II), cert. denied, 140 S. Ct. 
910 (2020). 
To satisfy the first element, the Commonwealth need only 
establish general intent, that is, that a defendant intended to 
"perform the act that causes death."  See Commonwealth v. Life 
Care Ctrs. of Am., Inc., 456 Mass. 826, 832 (2010).  It is 
irrelevant whether the defendant intended the resulting harm.  
See Commonwealth v. Welansky, 316 Mass. 383, 398 (1944). 
As to the second element, wanton or reckless conduct is 
that which a defendant knew or should have known created a 
substantial risk of death or serious bodily injury.  See 
 
9 "There is no statutory definition of manslaughter in 
Massachusetts; its elements are derived from common law."  
Commonwealth v. Catalina, 407 Mass. 779, 783 (1990). 
19 
 
Commonwealth v. Carrillo, 483 Mass. 269, 275 (2019).  See also 
Model Jury Instructions on Homicide 88-89 (2018).  "The risk of 
harm must be more than a possible or unreasonable risk; it must 
reach a 'high degree of likelihood.'"  Carrillo, supra at 276, 
quoting Welansky, 316 Mass. at 399.  "[A] defendant's subjective 
awareness of the reckless nature of his conduct is sufficient, 
but not necessary, to convict him of involuntary manslaughter.  
Conduct which a reasonable person, in similar circumstances, 
would recognize as reckless will suffice as well."  Commonwealth 
v. Catalina, 407 Mass. 779, 789 (1990). 
With respect to the third element, to prove that a 
defendant caused the victim's death, the Commonwealth must 
demonstrate that the defendant's actions were the proximate 
cause of death.  See Commonwealth v. Cunningham, 405 Mass. 646, 
659 (1989).  "[P]roximate cause is a cause which in the natural 
and continuous sequence produces death and without which the 
death would not have occurred" (citation omitted).  Commonwealth 
v. Askew, 404 Mass. 532, 534 (1989).  "If a series of events 
occur between the [wanton or reckless] conduct and the ultimate 
harm, the court must determine whether those intervening events 
have . . . extinguished the element of proximate cause and 
become a superseding cause of the harm."  Kent v. Commonwealth, 
437 Mass. 312, 321 (2002).  Intervening conduct extinguishes 
20 
 
proximate cause only if it was not reasonably foreseeable.  See 
Catalina, 407 Mass. at 791. 
Steinbach argues that the law of involuntary manslaughter 
is per se inapplicable to physician-assisted suicide because a 
doctor's participation in physician-assisted suicide is not 
wanton, reckless, or the proximate cause of death.  Steinbach 
maintains that the determination whether a doctor acted wantonly 
or recklessly turns on genuine issues of material fact regarding 
the doctor's decision-making process.  In Steinbach's view, a 
doctor who follows general medical standards in prescribing 
lethal medication for the purpose of physician-assisted suicide 
is not acting wantonly or recklessly; rather, he or she is 
making an informed and deliberate medical judgment calculated 
"to help a terminally ill patient obtain peace of mind, rather 
than causing harm or death of the patient." 
As Steinbach asserts, whether a doctor facing a charge of 
involuntary manslaughter acted wantonly or recklessly in 
prescribing medication that resulted in a patient's death 
ordinarily is a question of fact for a fact finder.  See 
Commonwealth v. Levesque, 436 Mass. 443, 452 (2002) ("Whether 
certain behavior is properly categorized as reckless or 
negligent is ordinarily left for the jury").  But for purposes 
of Steinbach's motion for summary judgment, the question we must 
decide is whether he is entitled to a judgment declaring that 
21 
 
"manslaughter charges are not applicable to physicians who 
follow a medical standard of care" in providing physician-
assisted suicide.  Thus, we need only decide whether a charge of 
involuntary manslaughter would be foreclosed as a matter of law 
in any case of physician-assisted suicide, and we need not wade 
through a factual determination whether any particular exercise 
of physician-assisted suicide is wanton or reckless.  See 
Piantedosi v. Bassett, 279 Mass. 337, 339 (1932) (determining 
that certain conduct cannot be considered negligent as matter of 
law). 
As the motion judge concluded, physician-assisted suicide 
could constitute wanton or reckless conduct.  Our case law 
demonstrates that knowingly providing someone who has expressed 
an interest in ending his or her life with the means to do so 
may be considered wanton or reckless behavior.  See, e.g., 
Persampieri v. Commonwealth, 343 Mass. 19, 23 (1961) (husband 
acted recklessly or wantonly in providing his wife, who was 
emotionally distraught and threatening to commit suicide, with 
loaded weapon and instructions on how she could use it to kill 
herself).  That a doctor's intent in providing the lethal 
medication was to alleviate a patient's suffering is irrelevant, 
as conduct may be wanton or reckless even where the actor "meant 
no harm to the victim."  See Commonwealth v. Walker, 442 Mass. 
185, 193 n.16 (2004), quoting Commonwealth v. Depradine, 42 
22 
 
Mass. App. Ct. 401, 407 (1997).  See Commonwealth v. Pugh, 462 
Mass. 482, 495 n.21 (2012) (motive is irrelevant to crime of 
manslaughter). 
Steinbach further contends that a doctor who provides a 
lethal prescription pursuant to the practice of physician-
assisted suicide cannot be considered the proximate cause of a 
patient's suicide under this court's reasoning in Carter I, 474 
Mass. at 635-636, and Carter II, 481 Mass. at 368.  In Carter I, 
supra, and Carter II, supra at 354, we concluded that a 
defendant who verbally pressured her boyfriend into committing 
suicide could be liable for involuntary manslaughter.  The 
boyfriend had planned to kill himself by filling his truck with 
carbon monoxide, a plan which he previously had discussed with 
the defendant.  Carter II, supra.  The defendant and the victim 
remained in contact via telephone as the victim began to carry 
out his plan.  Id. at 358.  At some point, the victim suspended 
his suicide attempt by getting out of the truck and telling the 
defendant that he was afraid the carbon monoxide was working.  
Id. at 359.  The defendant then instructed him to get back into 
the truck, knowing that it had become a toxic environment.  Id.  
The victim complied, and eventually he succumbed to the carbon 
monoxide.  Id.  We concluded that, although the victim 
ultimately died by his own hand, the defendant nonetheless was 
the proximate cause of his death because she "overpowered" his 
23 
 
will to live by coercing and pressuring him to complete his 
suicide attempt, while aware that he was in a "weakened state."  
Id. at 363. 
With respect to the third element of involuntary 
manslaughter, causation, Steinbach maintains that Carter I, 474 
Mass. at 635-636, and Carter II, 481 Mass. at 368, stand for the 
proposition that a defendant is not the proximate cause of 
another's suicide unless the defendant uses coercion to 
"overpower[] that person's will to live."  Carter II, supra.  
Because doctors who provide physician-assisted suicide in 
accordance with medical standards do not coerce or pressure 
victims to ingest the lethal medication, Steinbach asserts that 
they cannot be the proximate cause of a patient's suicide. 
This argument misconstrues our reasoning in Carter I, 474 
Mass. at 635-636, and Carter II, 481 Mass. at 361-362.  Those 
cases did not create a new standard of causation where a victim 
dies by suicide, but, rather, they applied our ordinary 
standards of causation in a novel context.  Although the 
coercion in those cases was sufficient to establish causation, 
it does not follow that coercion is always necessary to 
establish causation in cases of suicide.  See Carter II, supra 
at 363 ("legal causation in the context of suicide is an 
incredibly complex inquiry" that depends on facts of each case).  
Indeed, we previously have concluded that a defendant caused a 
24 
 
victim's suicide even where the defendant's actions were not so 
coercive as to overpower the victim's will to live.  See, e.g., 
Commonwealth v. Atencio, 345 Mass. 627, 629-630 (1963) 
(defendants who played game of "Russian roulette" with victim 
caused victim's self-inflicted death, even though they did not 
"force the deceased to play or suggest that he play"). 
Steinbach argues that, regardless, doctors who provide 
physician-assisted suicide cannot be the proximate cause of a 
patient's death because the patient's decision to ingest the 
medication is a superseding event that extinguishes proximate 
cause.  We do not agree.  It is entirely foreseeable that a 
terminally ill patient who requests medication intended to bring 
about death may use the medication for such a purpose.  See 
Catalina, 407 Mass. at 791 ("Intervening conduct that is 
reasonably foreseeable will not relieve the defendant of 
criminal responsibility").  Indeed, the majority of patients who 
receive a prescription for lethal medication pursuant to 
physician-assisted suicide ultimately die by ingesting the 
medication.10 
 
10 Based on data from reports of States where physician-
assisted suicide is legal, approximately sixty-seven percent of 
patients who received a prescription for lethal medication died 
from ingesting the medication.  See California Department of 
Public Health, California End of Life Option Act:  2020 Data 
Report (July 2021); District of Columbia Department of Health, 
District of Columbia Death with Dignity Act:  2018 Data Summary; 
Hawaii Department of Health, Report to the Thirty-first 
25 
 
Of course, as Steinbach notes, there is always a 
possibility that a patient ultimately will decide against 
ingesting the medication, as the outcomes suggest about one-
third of patients do.  See note 10, supra.  But that conduct is 
not inevitable does not mean that it is not foreseeable.  See, 
e.g., Catalina, 407 Mass. at 791 (defendant who provides heroin 
to another may be liable for user's death because "the act of 
the [user] in injecting [him- or her]self is not necessarily so 
unexpected, unforeseeable or remote as to insulate the 
[defendant] from criminal responsibility," even though user may 
decide against injecting provided heroin).  The act of ingesting 
the lethal medication therefore is foreseeable and does not 
destroy proximate causation.  See Askew, 404 Mass. at 534. 
In sum, under our existing law, doctors who engage in 
physician-assisted suicide may risk liability for involuntary 
 
Legislature:  2021 (July 1, 2021); Hawaii Department of Health, 
Report to the Thirtieth Legislature:  2020 (July 1, 2020); Maine 
Department of Health and Human Services, Patient-Directed Care:  
2020 Annual Report (Mar. 1, 2020); Maine Department of Health 
and Human Services, Patient-Directed Care at End of Life:  
Annual Report (Apr. 28, 2020); Oregon Health Authority, Oregon 
Death with Dignity Act:  2020 Data Summary (Feb. 26, 2021); 
Vermont Department of Health, Report to the Vermont Legislature:  
Report Concerning Patient Choice at the End of Life (Jan. 15, 
2018); Washington Department of Health, 2020 Death with Dignity 
Act Report (Oct. 21, 2021); Washington Department of Health, 
2019 Death with Dignity Act Report (Aug. 16, 2021); Washington 
Department of Health, 2018 Death with Dignity Act Report (July 
2019); Washington Department of Health, Death with Dignity Act 
Report (Mar. 2018). 
26 
 
manslaughter.  We turn to consider whether this potential risk 
is sufficient to demonstrate that Steinbach has established an 
actual controversy. 
ii.  Possibility that Steinbach will be prosecuted for 
manslaughter.  The line between an abstract question and an 
actual controversy is not always clear cut, but, rather, 
"necessarily one of degree."  See Maryland Cas. Co. v. Pacific 
Coal & Oil Co., 312 U.S. 270, 273 (1941).  In borderline cases, 
such as this one, "[a] judge enjoys some discretion in deciding 
whether a case is appropriate for declaratory relief."  Pazolt 
v. Director of the Div. of Marine Fisheries, 417 Mass. 565, 569 
(1994).  Although "[i]n different circumstances we might 
conclude that that some of the questions presented were not 
proper subjects for a declaratory decree," here we exercise our 
discretion in determining that Steinbach presents an actual 
controversy.  See Southbridge Water Supply Co., 371 Mass. 
at 215, quoting Cohasset Water Co. v. Cohasset, 321 Mass. 137, 
149 (1947). 
Were we to decline to consider the merits today, "the 
rights of the parties may never be set to rest," as it seems 
unlikely that a more suitable case would arise.  See Ciszewski 
v. Industrial Acc. Bd., 367 Mass. 135, 139 (1975).  Given the 
current state of the law on manslaughter, and the significant 
penalties a conviction carries, it is doubtful that any doctor 
27 
 
would be willing openly to practice physician-assisted suicide.  
See G. L. c. 265, § 13 (manslaughter is punishable by up to 
twenty years in prison).  It similarly is unlikely that a 
prosecutor definitively would commit to prosecuting any 
particular individual should he or she engage in physician-
assisted suicide, because prosecutors "cannot be compelled to 
render advisory opinions, at the behest of private citizens."  
Bunker Hill Distrib., Inc., 376 Mass. at 147. 
Moreover, the case at hand "involve[s] questions of 
pressing public importance" that reach far beyond Steinbach's 
immediate interest.  See School Comm. of Boston v. Board of 
Educ., 352 Mass. 693, 697 (1967).  Without resolution of the 
questions presented by this case, terminally ill patients will 
face uncertainty about their options, which may have an impact 
on their end-of-life decisions.  See District Attorney for the 
Suffolk Dist. v. Watson, 381 Mass. 648, 660 (1980) (issuance of 
declaratory judgment on constitutionality of death penalty was 
warranted where it would afford "relief from present 
uncertainties which in turn, to say the least, will affect major 
decisions" in plaintiffs' ongoing criminal prosecutions). 
Therefore, addressing the request for declaratory relief in 
the instant case would "remove, and . . . afford relief from, 
uncertainty and insecurity in the applicability of [laws]," and 
thus would serve the remedial purpose of the declaratory 
28 
 
judgment act.  See Massachusetts Ass'n of Tobacco Distrib. v. 
State Tax Comm'n, 354 Mass. 85, 88-89 (1968).  Accordingly, we 
"exercise[] our discretion very broadly in this case in favor of 
declaratory relief for the reason that a decision of all these 
matters seems important to enable parties to deal intelligently 
with the situation before them . . . and to reduce as much as 
possible the area of future litigation."  See Southbridge Water 
Supply Co., 371 Mass. at 214-215, quoting Cohasset Water Co., 
321 Mass. at 149. 
b.  Standing.  We turn to the question whether Steinbach 
had standing to bring a claim for declaratory and injunctive 
relief.  As a general rule, a plaintiff does not have standing 
"'to vindicate the constitutional rights of some third party,' 
because '[o]nly one whose rights are impaired by a statute can 
raise the question of its constitutionality, and he can object 
to the statute only as applied to him" (citation omitted).  See 
McCarty's Case, 445 Mass. 361, 367 (2005), quoting Blixt v. 
Blixt, 437 Mass. 649, 661 (2002), cert. denied, 537 U.S. 1189 
(2003).  Nonetheless, a plaintiff may have standing to assert 
the rights of a third party under jus tertii standing.  See 
Planned Parenthood League of Mass., Inc. v. Bell, 424 Mass. 573, 
578 (Bell), cert. denied, 522 U.S. 819 (1997).  Although "jus 
tertii standing is infrequently granted," it nonetheless is 
appropriate where (1) "the relationship of the litigant to the 
29 
 
third party whose right the litigant seeks to assert [is] such 
that 'the enjoyment of the right is inextricably bound up with 
the activity the litigant wishes to pursue'" and (2) there is 
"some genuine obstacle that renders the third party unable to 
assert the allegedly affected right on his or her own behalf."  
See id., quoting Singleton v. Wulff, 428 U.S. 106, 114-116 
(1976).  Relying on jus tertii standing, we previously have 
determined that physicians may assert their patients' 
constitutional right to choose to terminate a pregnancy.  See 
Bell, supra at 579.  See also Singleton, supra at 118 ("it 
generally is appropriate to allow a physician to assert the 
rights of women patients as against governmental interference 
with the abortion decision"). 
Jus tertii standing is appropriate here for similar 
reasons.  Physician-assisted suicide, much like abortion, 
necessarily requires the involvement of a medical provider.  See 
Akron v. Akron Ctr. for Reproductive Health, Inc., 462 U.S. 416, 
427 (1983) ("because abortion is a medical procedure, . . . the 
full vindication of the woman's fundamental right necessarily 
requires" physician's exercise of medical judgment).  Moreover, 
a terminally ill patient claiming a constitutional right to 
physician-assisted suicide would face the significant obstacle 
of "imminent mootness," because, by definition, the patient 
would be likely to pass away within six months.  See Singleton, 
30 
 
428 U.S. at 117 (women seeking abortion face obstacle of 
"imminent mootness," as their pregnancy likely would conclude 
prior to resolution of litigation).  Thus, Steinbach has 
standing not only to challenge the application of the law of 
manslaughter to physicians who practice physician-assisted 
suicide, but also to litigate the constitutional rights of 
terminally ill patients seeking physician-assisted suicide. 
2.  Substantive due process.  The Fourteenth Amendment to 
the United States Constitution and arts. 1, 10, and 12 of the 
Massachusetts Declaration of Rights guarantee individuals due 
process of law.  See Klein v. Catalano, 386 Mass. 701, 707 n.6 
(1982).  This guarantee has two aspects, one procedural and one 
substantive.  See Vasquez v. Commonwealth, 481 Mass. 747, 757 
(2019).  "[P]rocedural due process mandates that deprivations of 
life, liberty, or property be 'implemented in a fair manner.'"  
Commonwealth v. Preston P., 483 Mass. 759, 766-767 (2020), 
quoting Brangan v. Commonwealth, 477 Mass. 691, 703 (2017).  
Substantive due process, on the other hand, protects individual 
liberty against "certain government actions regardless of the 
fairness of the procedures used to implement them."  Daniels v. 
Williams, 474 U.S. 327, 331 (1986).  Substantive due process 
thus prohibits governmental actions that unduly interfere with 
rights that are deemed fundamental.  See Commonwealth v. 
Simmons, 448 Mass. 687, 695 (2007). 
31 
 
 
"Fundamental rights are those rights that are 'explicitly 
or implicitly guaranteed by the Constitution.'"  Chelsea 
Collaborative Inc. v. Secretary of the Commonwealth, 480 Mass. 
27, 32 n.16 (2018), quoting Watson, 381 Mass. at 663.  Statutes 
that have an impact on fundamental rights are subject to strict 
scrutiny, an exacting form of judicial review requiring that the 
statute be "narrowly tailored to further a compelling and 
legitimate government interest."  See LeSage, petitioner, 488 
Mass. 175, 181 (2021).  Statutes that do not have an impact on 
fundamental rights, by contrast, are subject to rational basis 
review, "a less exacting standard of review whereby a challenged 
[law] will pass constitutional muster . . . if it 'bears a 
reasonable relation to a permissible legislative objective.'"  
See Aime v. Commonwealth, 414 Mass. 667, 673 (1993), quoting 
Rushworth v. Registrar of Motor Vehicles, 413 Mass. 265, 268 
(1992).  "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 v. Department of Pub. Health, 440 
Mass. 309, 330 (2003), quoting Coffee-Rich, Inc. v. Commissioner 
of Pub. Health, 348 Mass. 414, 422 (1965).  The fit between the 
challenged statute and the asserted government interest need 
only be reasonable; the government is not required to tailor the 
statute precisely to further its interest, Murphy v. Department 
32 
 
of Correction, 429 Mass. 736, 742 (1999), nor is the government 
"bound to choose the best or gentlest of methods" to advance 
this interest, see Spence v. Gormley, 387 Mass. 258, 271 (1982). 
"In determining which rights are fundamental, judges are 
not left at large to decide cases in light of their personal and 
private notions."  Griswold v. Connecticut, 381 U.S. 479, 493 
(1965) (Goldberg, J., concurring).  To the contrary, because 
identifying a right as fundamental generally "place[s] the 
matter outside the arena of public debate and legislative 
action," courts must proceed with the "'utmost care' . . . lest 
the [rights] protected by [due process] be subtly transformed 
into the policy preferences" of the court.  See Washington v. 
Glucksberg, 521 U.S. 702, 720 (1997), quoting Collins v. Harker 
Heights, 503 U.S. 115, 125 (1992).  "This principle of judicial 
restraint includes recognition of the inability and 
undesirability of the judiciary substituting its notions of 
correct policy for that of a popularly elected Legislature."  
Zayre Corp. v. Attorney Gen., 372 Mass. 423, 433 (1977).  
Perhaps especially where such matters are hotly debated by those 
representatives, judges must not forget that "[o]ur obligation 
is to define the liberty of all, not to mandate our own moral 
code."  Goodridge, 440 Mass. at 312, quoting Lawrence v. Texas, 
539 U.S. 558, 571 (2003). 
33 
 
To discipline the substantive due process inquiry, the 
United States Supreme Court has articulated two standards for 
identifying fundamental rights under the Federal Constitution.  
As a matter of Federal law, a fundamental right may be 
determined either through a narrow view of this nation's history 
and traditions, see Glucksberg, 521 U.S. at 720-721, or through 
a more comprehensive approach, which uses "reasoned judgment" to 
determine whether a right is fundamental, even if it has not 
been recognized explicitly in the past, guided by history and 
precedent, see Obergefell v. Hodges, 576 U.S. 644, 664 (2015). 
 
The narrow approach to identifying a fundamental right 
involves two discrete steps.  First, the court "careful[ly] 
describ[es]" the fundamental liberty interest at issue (citation 
omitted).  Glucksberg, 521 U.S. at 721.  In so doing, the 
asserted right cannot be generalized to vague precepts, such as 
personal autonomy; rather, it must be phrased with narrow 
precision to reflect the specific activity at issue.  See id. at 
722-723.  Second, the court considers whether the right is 
"deeply rooted in this [n]ation's history and tradition, and 
implicit in the concept of ordered liberty, such that neither 
liberty nor justice would exist if they were sacrificed" 
(quotations and citations omitted).  Id. at 720-721.  Emphasis 
on the nation's history and legal traditions is essential, 
because "guideposts for responsible decisionmaking in [the area 
34 
 
of substantive due process] are scarce and open-ended."  
Collins, 503 U.S. at 125. 
 
For example, in Glucksberg, 521 U.S. at 720-721, the United 
States Supreme Court considered whether a law prohibiting 
physician-assisted suicide unduly burdened an individual's 
fundamental rights.  Rejecting the plaintiffs' framing of the 
liberty interest as the right to "choose how to die," or to 
"determin[e] the time and manner of one's death," the Court 
first defined the right at issue as the right to commit suicide 
with the assistance of another.  Id. at 722-723.  Then, the 
Court surveyed the common-law tradition, as revealed by 
contemporaneous legal treatises.  See id. at 712, quoting 4 W. 
Blackstone, Commentaries *189 ("the law has . . . ranked 
[suicide] among the highest crimes" [alteration in original]); 
Glucksberg, supra at 714, quoting Blackwood v. Jones, 111 Fla. 
528, 532 (1933) ("No sophistry is tolerated . . . which seek[s] 
to justify self-destruction as commendable or even a matter of 
personal right"). 
 
The Court also examined, citing judicial precedent and 
statutes, the historical condemnation of suicide from the time 
of the early American colonies to the modern era.  Glucksberg, 
521 U.S. at 712-718.  The Court observed that "a consistent and 
almost universal tradition [exists] that has rejected the 
asserted right, and continues explicitly to reject it today, 
35 
 
even for terminally ill, mentally competent adults."  Id. 
at 723.  Accordingly, the Court concluded that there was no 
fundamental right to physician-assisted suicide and allowed the 
"earnest and profound debate about the morality, legality, and 
practicality of physician-assisted suicide . . . to continue, as 
it should in a democratic society."  Id. at 728, 735. 
 
The Court also has articulated another, more comprehensive 
standard of substantive due process.  This standard is based on 
its observation that identifying and protecting fundamental 
rights "is an enduring part . . . of the judicial duty to 
interpret the Constitution," which "requires courts to exercise 
reasoned judgment in identifying interests of the person so 
fundamental that the State must accord them its respect."  See 
Obergefell, 576 U.S. at 663-664. 
 
The exercise of reasoned judgment cannot be reduced to a 
mechanical formula.  See Obergefell, 576 U.S. at 671.  Reasoned 
judgment may counsel against an overly narrow description of a 
right, where such a framing would perpetuate or otherwise 
reflect invidious discrimination.  See id.  See also Goodridge, 
440 Mass. at 328.  Thus, the right at issue may be stated at a 
higher level of generalization where the asserted liberty 
interest converges with an equality interest.  See Obergefell, 
supra.  When phrased at a higher level of generalization, the 
right is stripped of the particulars of who is exercising it, 
36 
 
and how, in an effort to avoid invidious discrimination.  For 
example, in Lawrence, 539 U.S. at 562-563, a challenge to a 
statute that prohibited sexual acts between two men, the right 
at issue was framed as the right to enter into consensual, 
intimate relationships, rather than as the right to engage in 
same-sex sodomy.  After all, "[i]f rights were defined by who 
exercised them in the past, then received practices could serve 
as their own continued justification and new groups could not 
invoke rights once denied."  Obergefell, supra.  Using the 
proper framing, a reviewing court then may examine modern 
precedent -- in addition to history -- to determine whether the 
right is fundamental.  See id. at 664-665.  "History and 
tradition guide and discipline this inquiry but do not set its 
outer boundaries. . . .  That method respects our history and 
learns from it without allowing the past alone to rule the 
present."  Id. at 664, citing Lawrence, supra at 572. 
"The nature of injustice is that we may not always see it 
in our times.  The generations that wrote and ratified the 
Bill of Rights and the Fourteenth Amendment did not presume 
to know the extent of freedom in all of its dimensions, and 
so they entrusted to future generations a charter 
protecting the right of all persons to enjoy liberty as we 
learn its meaning.  When new insight reveals discord 
between the Constitution's central protections and a 
received legal stricture, a claim to liberty must be 
addressed." 
 
Obergefell, supra.  Reformulating the analysis in this way, 
constitutional tradition "gains content from the long sweep of 
37 
 
our history and from successive judicial precedents -- each 
looking to the last and each seeking to apply the Constitution's 
most fundamental commitments to new conditions."  See Dobbs v. 
Jackson Women's Health Org., 142 S. Ct. 2228, 2326 (2022) 
(Breyer, Sotomayor, & Kagan, JJ., dissenting). 
 
For example, in Obergefell, 576 U.S. at 675, the Court 
considered whether same-sex couples had a fundamental right to 
marry.  Rather than framing the asserted right as the "right to 
same-sex marriage," the Court explained that the true right at 
issue was the "right to marry," and concluded that this framing 
"capture[d] the essence of the right in a more accurate and 
comprehensive way."  Id. at 670-672.  The Court then undertook a 
survey of the ancient history of marriage, as well as modern 
judicial precedent recognizing the right to marry as a 
fundamental right.  The Court began its analysis by emphasizing 
that "[f]rom their beginning to their most recent page, the 
annals of human history reveal the transcendent importance of 
marriage."  Id. at 656.  But the Court also carefully examined 
nearly fifty years of settled judicial precedent, which 
expressly recognized the "right to marry" as a fundamental 
right.  Id. at 664, 671, citing Turner v. Safley, 482 U.S. 78, 
95 (1987), Zablocki v. Redhail, 434 U.S. 374, 384 (1978), and 
Loving v. Virginia, 388 U.S. 1, 12 (1967).  Deferring to 
judicial precedent, as well as to the long-standing veneration 
38 
 
of marriage, the Court held that same-sex couples had a 
fundamental right to marry.  See Obergefell, supra at 675. 
 
Although Obergefell, 576 U.S. at 675, and other cases 
applying the comprehensive approach remain good law, the United 
States Supreme Court appears to have abandoned the comprehensive 
approach and to have settled on the narrow approach as the 
definitive test for identifying fundamental rights protected by 
the Fourteenth Amendment.  See Dobbs, 142 S. Ct. at 2242-2243. 
 
"Fundamental to the vigor of our [F]ederal system of 
government is that '[S]tate courts are absolutely free to 
interpret [S]tate constitutional provisions to accord greater 
protection to individual rights than do similar provisions of 
the United States Constitution.'"  Goodridge, 440 Mass. at 328, 
quoting Arizona v. Evans, 514 U.S. 1, 8 (1995).  See Brennan, 
State Constitutions and the Protection of Individual Rights, 90 
Harv. L. Rev. 489, 491 (1977) ("State constitutions, too, are a 
font of individual liberties, their protections often extending 
beyond those required by the Supreme Court's interpretation of 
[F]ederal law"). 
 
We previously have observed that "our treatment of due 
process challenges adheres to the same standards followed in 
Federal due process analysis."  Gillespie v. Northampton, 460 
Mass. 148, 153 n.12 (2011), quoting Goodridge, 440 Mass. at 353 
(Spina, J., dissenting).  See Commonwealth v. Ellis, 429 Mass. 
39 
 
362, 371 (1999).  We also have recognized, however, that the 
Massachusetts Declaration of Rights "may demand broader 
protection for fundamental rights" than the Federal 
Constitution.  See Goodridge, supra at 313.  See also Gillespie, 
supra.  Accordingly, we part ways with previously adopted 
Federal standards if they do not provide the degree of 
protection required by our State Constitution.  See Commonwealth 
v. Clarke, 461 Mass. 336, 346 n.8 (2012) ("Where we have deemed 
Federal law inadequate to protect rights guaranteed under 
art. 12, we have not shied away from the promulgation of 
separate State law rules . . ."); Stornanti v. Commonwealth, 389 
Mass. 518, 526 (1983) (Federal standards should only be applied 
if they are "consonant with our Constitution"). 
For the reasons that follow, we conclude that the narrow 
approach adopted by the United States Supreme Court in 
Glucksberg, 521 U.S. at 720-723, does not adequately protect the 
rights guaranteed by the Massachusetts Declaration of Rights.  
Accordingly, the proper analysis for identifying fundamental 
rights under the Massachusetts Declaration of Rights is the 
comprehensive approach. 
By precluding this court from recognizing as fundamental 
those rights that may not have enjoyed legal protection 
throughout history, a rigid application of the narrow approach 
would "freeze for all time the original view of what 
40 
 
[constitutional] rights guarantee, [and] how they apply."  See 
Dobbs, 142 S. Ct. at 2326 (Breyer, Sotomayor, & Kagan, JJ., 
dissenting).  Such a result is incompatible with our State 
constitutional provisions, which "are, and must be, adaptable to 
changing circumstances and new societal phenomena."  See 
Goodridge, 440 Mass. at 350 n.6 (Greaney, J., concurring).  See 
also Commonwealth v. Horton, 365 Mass. 164, 177 (1974) 
("Certainly constitutional interpretation must respond to social 
change . . .").  The comprehensive approach, unlike the narrow 
approach, allows us to interpret constitutional protections "in 
the light of our whole experience and not merely in that of what 
we said a hundred years ago," and therefore is more consonant 
with our State Constitution (citation omitted).  See McDuffy v. 
Secretary of the Executive Office of Educ., 415 Mass. 545, 620 
(1993).  See, e.g., John Donnelly & Sons, Inc. v. Outdoor 
Advertising Bd., 369 Mass. 206, 218 (1975), quoting Euclid v. 
Ambler Realty Co., 272 U.S. 365, 387 (1926) ("'[W]hile the 
meaning of constitutional guaranties never varies, the scope of 
their application must expand or contract to meet the new and 
different conditions which are constantly coming within the 
field of their operation.'  What was deemed unreasonable in the 
past may now be reasonable due to changing community values" 
[citation omitted]); Merit Oil Co. v. Director of the Div. on 
the Necessaries of Life, 319 Mass. 301, 305 (1946) (State's 
41 
 
constitutionally conferred regulatory authority adjusts "with 
the changing needs of society"). 
Moreover, the narrow approach risks perpetuating the 
discrimination and subordination of the past in a way that is 
odious to our Constitution.  See Goodridge, 440 Mass. at 312 
("The Massachusetts Constitution affirms the dignity and 
equality of all individuals.  It forbids the creation of second-
class citizens").  By definition, marginalized groups have not 
possessed the full panoply of rights enjoyed by others 
throughout our nation's history and therefore, under the narrow 
approach, may be unable to prove that their rights are "deeply 
rooted."  See id. at 339, quoting United States v. Virginia, 518 
U.S. 515, 557 (1996) ("The history of constitutional law 'is the 
story of the extension of constitutional rights and protections 
to people once ignored or excluded'").  By phrasing the right 
more broadly, and considering modern precedent alongside 
history, we are able to cleanse our substantive due process 
analysis of the bigotry that too often haunts our history, and 
to ensure that those who were denied rights in the past due to 
outmoded prejudices are not denied those rights in the future.  
"The Massachusetts Constitution was never meant to create dogma 
that adopts inflexible views of one time to deny lawful rights 
to those who live in another."  Goodridge, supra at 350 n.6 
(Greaney, J., concurring). 
42 
 
 
In addition, the comprehensive approach is more consistent 
with our jurisprudence on substantive due process.  For example, 
in our prior cases, we have not mechanically applied the precise 
framing required by the narrow approach, but, rather, 
occasionally have employed a more generalized framing of the 
right at issue.  See, e.g., Commonwealth v. Weston W., 455 Mass. 
24, 25, 32-33 (2009) (in case challenging ordinance that imposed 
curfew on minors, concluding that there is "[a] fundamental 
right to move freely within the Commonwealth").  Additionally, 
although we have viewed history as instructive, we have declined 
to treat it as determinative.  See, e.g., Goodridge, 440 Mass. 
at 328 ("history must yield to a more fully developed 
understanding of the invidious quality of the discrimination").  
Indeed, we regularly augment history with modern precedent, 
which may reveal new insights about the realm of liberty 
protected by substantive due process.  See, e.g., id. at 339-340 
(discussing modern precedent reflecting marriage as "an evolving 
paradigm"); Superintendent of Belchertown State Sch. v. 
Saikewicz, 373 Mass. 728, 739 (1977) (basing right to refuse 
medical treatment in part on recent case law recognizing 
constitutional regard for privacy). 
 
By parting ways with the recent Federal analysis of 
substantive due process, discussed supra, and instead adopting 
the comprehensive approach to substantive due process, we ensure 
43 
 
that the rights protected by the Massachusetts Declaration of 
Rights are not inappropriately limited by an unduly restrictive 
reading of history or tradition.  In this way, we allow our 
State Constitution to respond effectively to our changing world, 
and to "define a liberty that remains urgent in our own era."  
See Obergefell, 576 U.S. at 672. 
 
3.  Application to Steinbach's assertion of a fundamental 
right.  We turn to Steinbach's contention that the application 
of the law of manslaughter to physician-assisted suicide 
infringes upon fundamental rights protected by the Massachusetts 
Declaration of Rights.11  As noted, an asserted right should be 
stated at a higher level of generality where the right 
intersects with an equality interest.  Here, there is no 
allegation that the asserted right at issue is tainted by a 
history of invidious discrimination.  Cf. Dobbs, 142 S. Ct. 
at 2324-2325 (Breyer, Sotomayor, & Kagan, JJ., dissenting) 
(discussing how colonial-era abortion restrictions reflected 
historical disregard for rights of women).  Nor does Steinbach 
represent a class seeking equal access to a right presently 
 
11 Steinbach contends that the criminalization of physician-
assisted suicide violates terminally ill patients' "privacy 
rights," as well as their rights to "personal autonomy and 
liberty."  Nonetheless, as the motion judge observed, "[b]oth 
the Commonwealth and [Steinbach] appear to treat these [c]ounts 
as asserting substantive due process claims."  Accordingly, we 
do not distinguish between the two claims. 
44 
 
enjoyed by others.  Cf. Goodridge, 440 Mass. at 328 (considering 
whether same-sex couples enjoyed same right to marry as 
heterosexual couples).  Because the right at stake does not 
implicate any equality concerns, it need not be generalized.  
Accordingly, the question we must consider is whether physician-
assisted suicide ranks among those fundamental rights protected 
by the Massachusetts Declaration of Rights. 
a.  Historical treatment of suicide.  There is little 
question that, throughout history, American society has not 
regarded suicide, in any form, as an individual right.  To the 
contrary, both the Commonwealth and the nation at large have 
long treated suicide as a social problem to be prevented and 
remedied. 
English common law ranked suicide as "among the highest 
crimes" one could commit, and punished it accordingly.  See 4 W. 
Blackstone, Commentaries *189.  The early colonies, including 
Massachusetts, appear to have adopted a similar view, 
universally condemning and punishing suicide as "self-murder."  
See generally Marzen, O'Dowd, Crone, & Balch, Suicide:  A 
Constitutional Right?, 24 Duq. L. Rev. 1, 64-65 (1985) (Marzen).  
See, e.g., The General Laws and Liberties of the Massachusetts 
Colony (1672), reprinted in 2 The Laws and Liberties of 
Massachusetts 1641-1691, 363 (J.D. Cushing ed., 1976) (General 
Laws and Liberties); The Earliest Acts and Laws of the Colony of 
45 
 
Rhode Island and Providence Plantations 1647-1719, at 19 (J.D. 
Cushing ed., 1977); A.P. Scott, Criminal Law in Colonial 
Virginia 108 & n.193, 198 & n.15 (1930).  For instance, in 
Massachusetts, the Colony Act provided that a person who 
committed suicide was to be "Buried in some Common High-
way . . . [with] a Cart-load of Stones laid upon the Grave."  
General Laws and Liberties, supra. 
States, including Massachusetts, eventually repealed laws 
intended to punish suicide, see, e.g., St. 1824, c. 143; 
Glucksberg, 521 U.S. at 713, "not because suicide itself was 
viewed as a lesser evil or as a human right, but because the 
penalties punished the innocent family of the suicide, without 
in any way reaching the real perpetrator of the act" (emphasis 
in original), Marzen, supra at 69.  See Commonwealth v. Mink, 
123 Mass. 422, 428-429 (1877) (repeal of State law punishing 
suicide "may well have had its origin in consideration for the 
feelings of innocent surviving relatives," but did not render 
suicide lawful).  See also Glucksberg, supra ("the movement away 
from the common law's harsh sanctions did not represent an 
acceptance of suicide; rather . . . this change reflected the 
growing consensus that it was unfair to punish the suicide's 
family for his wrongdoing"). 
Even if suicide was not technically a crime, courts 
continued to consider it a "grave public wrong."  See Hundert v. 
46 
 
Commercial Travelers' Mut. Acc. Ass'n of Am., 244 A.D. 459, 460 
(N.Y. 1935).  See also Glucksberg, 521 U.S. at 714.  For 
example, in Mink, 123 Mass. at 426, we noted that suicide was 
"considered malum in se, and a felony," notwithstanding the 
repeal of the Colony Act.  This view was not unique, but rather 
was shared by other State courts across the country.  See State 
v. Willis, 255 N.C. 473, 475 (1961) ("Nearly all [State courts] 
agree that suicide is malum in se").  To this day, courts regard 
suicide as a serious social ill that the State has a strong 
interest in preventing.  See Guardianship of Doe, 411 Mass. 512, 
521, cert. denied, 503 U.S. 950 (1992) (recognizing "the 
prevention of suicide" as an "important State interest[]").  
See, e.g., Krischer v. McIver, 697 So. 2d 97, 103 (Fla. 1997) 
(State "has a compelling interest in preventing suicide"); State 
v. Melchert-Dinkel, 844 N.W.2d 13, 22 & n.4 (Minn. 2014) (State 
has "compelling interest in preserving human life by preventing 
suicide"); McNabb v. Department of Corrections, 163 Wash. 2d 
393, 403 (2008) (recognizing compelling State interest in "the 
prevention of suicide"). 
Perhaps for this reason, assisting another to commit 
suicide largely has been, and continues to be, regarded as a 
serious crime.  See Carter I, 474 Mass. at 635-636 (defendant 
who pressured individual to commit suicide may be prosecuted for 
involuntary manslaughter); Commonwealth v. Bowen, 13 Mass. 356, 
47 
 
358 (1816) ("those who are counselling, hiring, and procuring 
the suicide to be committed are principal felons").  See also 
Glucksberg, 521 U.S. at 716 ("voters and legislators continue 
for the most part to reaffirm their States' prohibitions on 
assisting suicide"); Cruzan v. Director, Mo. Dep't of Health, 
497 U.S. 261, 280 (1990) ("the majority of States in this 
country have laws imposing criminal penalties on one who assists 
another to commit suicide"); Model Penal Code § 210.5 ("A person 
who purposely aids or solicits another to commit suicide is 
guilty of a felony in the second degree . . .").  Generally, it 
is no defense that the decedent may have requested the 
perpetrator's assistance.  See Marzen, supra at 78 (Twentieth 
Century courts have "held that consent is no defense to a charge 
of homicide"); Model Penal Code § 210.5 comment 5 ("the 
interests in the sanctity of life that are represented by the 
criminal homicide laws are threatened by one who expresses a 
willingness to participate in taking the life of another, even 
though the act may be accomplished with the consent, or at the 
request, of the suicide victim").  But see Baxter v. State, 2009 
MT 449, ¶¶ 40-42 (statutory consent defense may apply to 
physicians who provide physician-assisted suicide). 
Nor is it legally relevant that the decedent was close to 
death.  See Glucksberg, 521 U.S. at 714 ("the prohibitions 
against assisting suicide never contained exceptions for those 
48 
 
who were near death").  See also Blackburn v. State, 23 Ohio St. 
146, 163 (1872) ("The life of those to whom life has become a 
burden -- of those who are hopelessly diseased or fatally 
wounded -- . . . are under the protection of the law, equally as 
the lives of those who are in the full tide of life's enjoyment, 
and anxious to continue to live").  For example, in Bowen, 13 
Mass. at 360, we upheld the conviction of a defendant who 
encouraged a fellow prisoner to commit suicide, even though the 
prisoner's execution was imminent.  We stated that the 
defendant's offense was no less severe simply because only "a 
small portion of [the decedent's] earthly existence could, in 
any event, remain to him."  Id. 
 
While our nation's stance against suicide writ large is 
clear and virtually unanimous, physician-assisted suicide 
specifically has engendered more controversy.  Far from being a 
contemporary dilemma, "[t]he question of whether severely ill 
suffering patients are entitled to a physician's help to end 
their suffering by ending their lives has been debated since 
antiquity."  See Quill & Sussman, The Hastings Center, 
Physician-Assisted Death (Sept. 23, 2015).12 
 
12 Available at https://www.thehastingscenter.org 
/briefingbook/physician-assisted-death/ [https://perma.cc/43CN-
BHSN]. 
49 
 
 
Throughout history, physicians have assisted patients in 
hastening death, most often in secret.  See Macleod, Wilson, & 
Malpas, Assisted or Hastened Death:  The Healthcare 
Practitioner's Dilemma, 4 Global J. Health Sci. 87, 90 (2012).  
The practice, however, has never enjoyed broad social acceptance 
and has "remained a concept that the medical profession as a 
whole condemn[s]."  See Ebbott, A "Good Death" Defined by Law:  
Comparing the Legality of Aid-in-Dying Around the World, 37 Wm. 
Mitchell L. Rev. 170, 177-178 & n.62 (2010).  Indeed, no medical 
professional society in the United States has adopted an 
official stance in favor of physician-assisted suicide.  See 
Barsness, Regnier, Hook, & Mueller, U.S. Medical and Surgical 
Society Position Statements on Physician-Assisted Suicide and 
Euthanasia:  A Review, BMC Medical Ethics 4 (2020).13 
Only recently has physician-assisted suicide come to enjoy 
any form of legal protection.  See Dugdale, Lerner, & Callahan, 
Pros and Cons of Physician Aid in Dying, 92 Yale J. of Biology & 
Med. 747, 748 (2019).  Ten States and the District of Columbia 
currently have statutory protections for physician-assisted 
suicide, but "[n]o appellate court has held that there is a 
 
13 Available at https://bmcmedethics.biomedcentral.com 
/track/pdf/10.1186/s12910-020-00556-5.pdf [https://perma.cc 
/HVA7-A9SG]. 
50 
 
constitutional right to physician aid in dying."  See Morris, 
2016-NMSC-027, ¶ 5. 
 
In sum, the history of suicide in general, and physician-
assisted suicide in particular, provides no support for the 
conclusion that physician-assisted suicide is an individual 
right protected by the Massachusetts Declaration of Rights. 
 
b.  Modern precedent.  Of course, that something may have 
been unprotected, or even prohibited, throughout history is not 
determinative, as our Constitution evolves alongside newly 
discovered insights about the nature of liberty.  See McDuffy, 
415 Mass. at 620 (constitutional protections "necessarily will 
evolve together with our society").  See, e.g., Loving, 388 U.S. 
at 12 (determining that there is fundamental right to 
interracial marriage, notwithstanding historical prohibitions 
against it).  We therefore look to the arc of precedent to 
discern whether our tradition has evolved so as to encompass a 
right to physician-assisted suicide.  See Goodridge, 440 Mass. 
at 327-328 (considering ways in which protections for marriage 
have evolved over time by evaluating recent precedent). 
In Steinbach's view, the right to physician-assisted 
suicide is a natural outgrowth of the right to refuse medical 
treatment recognized in Saikewicz, 373 Mass. at 736, and Brophy 
v. New England Sinai Hosp., 398 Mass. 417, 419 (1986).  In 
Saikewicz, supra, we considered the right of an individual to 
51 
 
decline potentially life-prolonging treatment, and ultimately 
concluded that there was a protected right to refuse medical 
treatment.  Id. at 739-740.  Such a right is derived from two 
related sources.  Id.  First, "a person has a strong interest in 
being free from nonconsensual invasion of his [or her] bodily 
integrity."  Id. at 739.  This interest is reflected in the 
common-law doctrine of informed consent, which protects "the 
inviolability of [an individual's] person" from unwanted 
intrusion (citation omitted).  Id.  See Feeley v. Baer, 424 
Mass. 875, 880 (1997) (O'Connor, J., concurring) ("doctrine of 
informed consent has its foundation in the law of battery").  
Second, we determined that the unwritten constitutional right to 
privacy "encompasses the right of a patient to preserve his or 
her right to privacy against unwanted infringements of bodily 
integrity in appropriate circumstances."  Saikewicz, supra. 
 
Subsequently, in Brophy, 398 Mass. at 419, we again 
examined the right to refuse medical treatment in deciding 
whether to honor the previously expressed desire of a person, 
then in a persistent vegetative state, to discontinue life-
sustaining nutrition and hydration.  We once again concluded 
that a patient has a right to refuse medical treatment based on 
the common law of informed consent and "the unwritten and 
penumbral constitutional right to privacy."  Id. at 430.  "A 
significant aspect of this right of privacy is the right to be 
52 
 
free of nonconsensual invasion of one's bodily integrity," which 
reflects the historical regard for "self-determination and 
individual autonomy."  Id. at 430-432. 
 
The reasoning in Brophy, 398 Mass. at 430-432, and 
Saikewicz, 373 Mass. at 739-740, however, does not extend so far 
as to encompass physician-assisted suicide, which implicates 
neither the common-law right to be "free of nonconsensual 
invasion of one's bodily integrity" nor the right to privacy.  
With respect to the common-law tradition against unwanted 
physical intrusions, the patients in Brophy, supra, and 
Saikewicz, supra, were subjected to forced medical procedures.  
The same cannot be said of terminally ill patients who seek 
physician-assisted suicide.  The common-law right to be free 
from unwanted bodily invasions therefore is not relevant to the 
analysis here. 
As to the right to privacy, our prior cases have described 
the right as safeguarding an individual's ability to "mak[e] 
certain decisions that fundamentally affect his or her person 
'free from unwarranted governmental intrusion.'"  See 
Commonwealth v. Stowell, 389 Mass. 171, 173 (1983), quoting 
Eisenstadt v. Baird, 405 U.S. 438, 453 (1972).  While the 
specific contours of this right elude precise definition, it is 
clear that the right does not extend to every ostensibly private 
activity or decision.  See, e.g., Marcoux v. Attorney Gen., 375 
53 
 
Mass. 63, 66 (1978) (right to privacy does not encompass drug 
possession and use in one's home).  See also Commonwealth v. 
Walter, 388 Mass. 460, 464 (1983) (right to privacy does not 
protect commercial sexual activity in private areas); Stowell, 
supra at 174 (right to privacy does not include right to engage 
in adulterous relationships). 
Steinbach asserts that if the right to privacy includes the 
right to refuse unwanted medical care, it also necessarily must 
include the right to physician-assisted suicide, because there 
is no meaningful distinction between the two.  We do not agree, 
but, rather, recognize an important distinction between the 
refusal of medical treatment and physician-assisted suicide, 
which lies in fundamental legal principles of cause and effect; 
whereas withdrawing or withholding medical care is not the 
primary cause of a patient's death, physician-assisted suicide 
is. 
These principles are not new; to the contrary, they have 
been invoked explicitly in the very cases upon which Steinbach 
relies.  For instance, in Saikewicz, 373 Mass. at 743 n.11, we 
noted that 
"[i]n the case of the competent adult's refusing medical 
treatment such an act does not necessarily constitute 
suicide since (1) 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." 
54 
 
 
Indeed, we deemed the distinction between withholding life-
prolonging treatment and suicide to be so obvious and 
incontrovertible that it "require[d] little if any discussion."  
Id. 
Similarly, in Brophy, 398 Mass. at 439, we concluded that 
honoring the patient's desire to withdraw life-sustaining 
medical treatment did not implicate the State's interest in the 
prevention of suicide.  In distinguishing between ceasing 
treatment and suicide, we observed that 
"[the patient] suffers an affliction which makes him 
incapable of swallowing.  The discontinuance of [artificial 
nutrition and hydration] 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.  Declining 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."  (Quotations, 
citations, alterations, and footnote omitted.) 
 
Id.  We relied on this distinction to state that "the law does 
not permit suicide" and therefore "does not permit unlimited 
self-determination, nor give unqualified free choice over life."  
Id. at 434 n.29. 
The distinction between medical intervention that causes 
death and that which does not is not arbitrary, but, rather, is 
55 
 
"widely recognized and endorsed in the medical profession and in 
our legal traditions" (footnote omitted).  See Vacco v. Quill, 
521 U.S. 793, 800-801 (1997).  In medical ethics, "the right of 
competent, informed patients to refuse life-prolonging 
interventions . . . is firmly established," whereas the right to 
physician-assisted suicide is a matter of "ethical . . . 
controversy."  See, e.g., Quill, Lo, & Brock, Palliative Options 
of Last Resort:  A Comparison of Voluntarily Stopping Eating and 
Drinking, Terminal Sedation, Physician-Assisted Suicide, and 
Voluntary Active Euthanasia, 278 JAMA 2099, 2099-2100 (1997). 
The American Medical Association has opined, for example, 
that although physicians should "honor patients' informed 
decisions to refuse life-sustaining treatment," physician-
assisted suicide "is fundamentally incompatible with the 
physician's role as healer."  See American Medical Association, 
Code of Medical Ethics c. 5, at 8-9.14  See also Lagay, 
Physician-Assisted Suicide:  The Law and Professional Ethics, 5 
AMA J. Ethics 21, 21 (2003), quoting Scott, Assisted-Suicide 
Foes, AMA, Defeat Maine Ballot Initiative, Physician's Weekly, 
Dec. 4, 2000 ("physician-assisted suicide goes against 2,000 
years of medical ethics").  Similarly, the American College of 
 
14 Available at https://www.ama-assn.org/system/files/2019-
06/code-of-medical-ethics-chapter-5.pdf [https://perma.cc/V9SZ-
PUQR]. 
56 
 
Physicians "does not support the legalization of physician-
assisted suicide," which it believes "raises ethical, clinical, 
and other concerns."  See Sulmasy & Mueller, Ethics and the 
Legalization of Physician-Assisted Suicide:  An American College 
of Physicians Position Paper, Annals of Internal Medicine 3 
(Sept. 19, 2017).15  The medical community's differing treatment 
is justified by the fact that the withdrawal of medical 
treatment does not cause death, whereas physician-assisted 
suicide does.  See id. at 3-5; Glasson, Report of the Council on 
Ethical and Judicial Affairs, Physician-Assisted Suicide of the 
American Medical Association, 10 Issues L. & Med. 91, 93 (1994) 
("When a life-sustaining treatment is declined, the patient dies 
primarily because of an underlying disease"). 
Courts likewise frequently have distinguished between 
actions that cause death and those that do not.  See Vacco, 521 
U.S. at 804 n.8, and cases cited.  The United States Supreme 
Court, and State courts in every State, have relied on this 
distinction unanimously to conclude that broader protections for 
individual privacy do not extend so far as to include physician-
assisted suicide.  See, e.g., Glucksberg, 521 U.S. at 725 (right 
to end life-sustaining treatment does not support right to 
 
15 Available at https://www.acponline.org/system/files 
/documents/clinical_information/ethics-professionalism/ethics-
and-the-legalization-of-physician-assisted-suicide-2017.pdf 
[https://perma.cc/P6ZR-MJ7T]. 
57 
 
physician-assisted suicide); Sampson v. State, 31 P.3d 88, 94 
(Alaska 2001) (rights to personal autonomy implicit in State 
Constitution do not "remotely hint[] at" right to physician-
assisted suicide); Donorovich-Odonnell v. Harris, 241 Cal. App. 
4th 1118, 1139 (2015) (rejecting argument that terminally ill 
patients have privacy interest in assisted suicide); People v. 
Kevorkian, 447 Mich. 436, 464 (1994), cert. denied, 514 U.S. 
1083 (1995) (no fundamental right to assisted suicide "grounded 
in the notion of personal autonomy and springing from common-law 
concepts of bodily integrity and informed consent"). 
Accordingly, although courts in other jurisdictions widely 
protect the right to refuse medical treatment, none has 
concluded that physician-assisted suicide constitutes a 
fundamental right.  See, e.g., Krischer, 697 So. 2d at 102-103 
(discussing "significant difference" between protected privacy 
right to refuse medical treatment and physician-assisted 
suicide); Morris, 2016-NMSC-027, ¶ 52 (no part of protected 
State right to medical autonomy supports finding physician-
assisted suicide to be fundamental right); Myers, 30 N.Y.3d at 
14 (noting "well-established distinction between refusing life-
sustaining treatment and assisted suicide"). 
In sum, given our long-standing opposition to suicide in 
all its forms, and the absence of modern precedent supporting an 
affirmative right to medical intervention that causes death, we 
58 
 
cannot conclude that physician-assisted suicide ranks among 
those fundamental rights protected by the Massachusetts 
Declaration of Rights.  Thus, application of the law of 
manslaughter to physician-assisted suicide would not impinge on 
an individual's right to substantive due process. 
 
4.  Vagueness.  Steinbach contends as well that the law of 
manslaughter is unconstitutionally vague as applied to 
physician-assisted suicide.  He notes that we have not 
previously directly addressed whether physician-assisted suicide 
constitutes involuntary manslaughter, yet implied in Carter I, 
474 Mass. at 636, that it did not. 
 
"A law is unconstitutionally vague and denies 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 (1986).  "The . . . 
principle is that no man shall be held criminally responsible 
for conduct which he could not reasonably understand to be 
proscribed."  Bouie v. Columbia, 378 U.S. 347, 351 (1964), 
quoting United States v. Harriss, 347 U.S. 612, 617 (1954). 
 
Our previous cases make clear that someone who causes 
another's suicide through wanton or reckless behavior may be 
liable for involuntary manslaughter.  See Carter II, 481 Mass. 
at 365; Atencio, 345 Mass. at 628-629; Persampieri, 343 Mass. 
59 
 
at 22-23.  Although physician-assisted suicide is, in some ways, 
factually distinct from these cases, the distinctions are not 
legally significant.  For example, it is irrelevant that the 
decedent may have been close to death.  See Bowen, 13 Mass. 
at 360 (defendant who encouraged prisoner to commit suicide was 
liable for murder, even though prisoner was to be executed 
imminently).  It similarly is not relevant that the physician 
acted out of care for the patient.  See Pugh, 462 Mass. at 495 
n.21 (motive is irrelevant in prosecution for manslaughter). 
 
Because our prior cases indicate that physician-assisted 
suicide may constitute involuntary manslaughter, it is of not 
moment that we have not yet applied the law of manslaughter to 
physician-assisted suicide.  See United States v. Lanier, 520 
U.S. 259, 271 (1997) ("general statements of the law are not 
inherently incapable of giving fair and clear warning").  A law 
is not impermissibly vague simply because "the very action in 
question has [not] previously been held unlawful" (alteration in 
original).  Krupien v. Ritcey, 94 Mass. App. Ct. 131, 135 
(2018), quoting Lanier, supra.  See Carter I, 474 Mass. at 631 
n.11, 633 (concluding that law of manslaughter was not 
unconstitutionally vague as applied, even though court had never 
previously "had occasion to consider [an indictment for 
involuntary manslaughter] against a defendant on the basis of 
words alone"). 
60 
 
 
Steinbach argues that Carter I, 474 Mass. at 636, 
nonetheless renders the law of manslaughter impermissibly vague 
as applied to physician-assisted suicide.  In Carter I, supra, 
we stated that "a person offering support, comfort, and even 
assistance to a mature adult who, confronted with [terminal 
illness,] has decided to end his or her life" was "easily 
distinguishable" from the facts of that case. 
 
Of course, the statement undoubtedly was dictum and 
therefore is not a controlling statement of law.  See Crocker v. 
Justices of the Superior Court, 208 Mass. 162, 173 (1911) 
(although dicta "are entitled to respect, they are not of 
binding authority, and . . . not to be regarded as of 
controlling significance").  In any event, when viewed in 
context, the dictum did not imply that providing a terminally 
ill patient with a lethal prescription could not be considered 
involuntary manslaughter.  Our decision in Carter I, 474 Mass. 
at 633, determined whether an indictment for involuntary 
manslaughter for assisting in a suicide could stand "on the 
basis of words alone."  Our passing mention of a physician who 
offers "assistance" to a terminally ill patient did not address 
the issues we confront in this case.  See id. at 636.  This 
understanding was further emphasized in Carter II, 481 Mass. 
at 368.  There, we stated that, "[a]s we explained in Carter I, 
[supra], and reemphasize today, this case does not involve the 
61 
 
prosecution of end-of-life discussions between a doctor . . . 
and a mature, terminally ill adult" (emphasis added).  
Carter II, supra.  Thus, the application of the law of 
manslaughter to physician-assisted suicide is clearly 
foreshadowed by our precedent and is not rendered 
unconstitutionally vague by our passing mention in Carter I, 
supra. 
5.  Equal protection.  Steinbach also argues that the 
application of common-law manslaughter to physician-assisted 
suicide violates the right to equal protection of the law by 
treating terminally ill adults who wish to pursue physician-
assisted suicide differently from other terminally ill adults. 
Articles 1 and 10 of the Massachusetts Declaration of 
Rights guarantee equal protection under the law.  Commonwealth 
v. Long, 485 Mass. 711, 715 (2020).  This guarantee "is 
essentially a direction that all persons similarly situated 
should be treated alike."  Moore v. Executive Office of the 
Trial Court, 487 Mass. 839, 848 (2021), quoting Doe v. Acton-
Boxborough Regional Sch. Dist., 468 Mass. 64, 75 (2014).  
Accordingly, in order to prove a violation of equal protection, 
plaintiffs must "identify and relate specific instances where 
persons situated similarly in all relevant aspects were treated 
differently" (quotation and citation omitted).  Cote-Whitacre v. 
Department of Pub. Health, 446 Mass. 350, 376 (2006).  See 
62 
 
Matter of Corliss, 424 Mass. 1005, 1006 (1997) ("One 
indispensable element of a valid equal protection claim is that 
individuals who are similarly situated have been treated 
differently"). 
Steinbach argues that, by criminalizing physician-assisted 
suicide, the Commonwealth treats terminally ill adults who wish 
to avail themselves of the practice differently from those who 
wish to hasten death through other means, such as voluntarily 
stopping eating or drinking, withdrawing life support, or 
palliative sedation.16  This argument, however, cannot succeed 
because application of the law of manslaughter to physician-
assisted suicide does not treat any person differently from any 
other.  See Doe, 468 Mass. at 75 (differential treatment is 
"essential component[] of any equal protection claim").  Under 
 
16 "With [voluntarily stopping eating and drinking], a 
patient who is otherwise physically capable of taking 
nourishment makes an active decision to discontinue all oral 
intake and then is gradually 'allowed to die,' primarily of 
dehydration or some intervening complication."  See Quill, Lo, & 
Brock, Palliative Options of Last Resort:  A Comparison of 
Voluntarily Stopping Eating and Drinking, Terminal Sedation, 
Physician-Assisted Suicide, and Voluntary Active Euthanasia, 278 
JAMA 2099, 2099 (1997).  Palliative sedation is a "last-resort 
option" if a "patient finds severe physical symptoms intolerable 
despite state-of-the-art palliative care, and continuing 
consciousness under the circumstances is unacceptable."  See 
Quill, Lo, Brock, & Meisel, Last-Resort Options for Palliative 
Sedation, 151 Annals Internal Med. 421, 422 (2009).  In 
palliative sedation, "sedation is rapidly increased over minutes 
to a few hours until the patient is unresponsive," and medical 
treatments, including artificial nutrition and hydration, 
generally are withdrawn until death occurs.  See id. 
63 
 
our current law, competent adults who are terminally ill may 
elect to stop eating or drinking, may agree to the withdrawal of 
life support, or may choose to pursue palliative sedation, but 
none is entitled to physician-assisted suicide.  See Brophy, 398 
Mass. at 430 & 434 n.29.  Accordingly, because Steinbach has not 
identified any form of differential treatment, he does not state 
a violation of the equal protection of the laws. 
Application of the law of manslaughter to physician-
assisted suicide passes constitutional muster because the law is 
reasonably related to the State's legitimate interests in 
preserving life; preventing suicide; protecting the integrity of 
the medical profession; ensuring that all end-of-life decisions 
are informed, voluntary, and rational; and "protecting 
vulnerable people from indifference, prejudice, and 
psychological and financial pressure to end their lives."  
Vacco, 521 U.S. at 808-809.  See Glucksberg, 521 U.S. at 728-
733; Myers, 30 N.Y.3d at 16.  We respect the immense magnitude 
of all end-of-life decisions and acknowledge the overwhelming 
importance of the desire to conclude one's life in a way that is 
painless, peaceful, and consistent with one's values.  Our 
decision today does not diminish the critical nature of these 
interests, but rather recognizes the limits of our Constitution, 
and the proper role of the judiciary in a functioning democracy.  
The desirability and practicality of physician-assisted suicide 
64 
 
raises not only weighty philosophical questions about the nature 
of life and death, but also difficult technical questions about 
the regulation of the medical field.  These questions are best 
left to the democratic process, where their resolution can be 
informed by robust public debate and thoughtful research by 
experts in the field. 
 
Conclusion.  Because Kligler does not present an actual 
controversy, the case is remanded to the Superior Court for 
entry of an order dismissing Kligler as a party.  We otherwise 
affirm the Superior Court judge's order on summary judgment as 
it pertains to Steinbach. 
 
 
 
 
 
 
 
So ordered. 
 
 
CYPHER, J. (concurring).  In this appeal, the plaintiffs 
seek a declaration that the Massachusetts Constitution protects 
a fundamental right to physician-assisted suicide, thereby 
immunizing the practice from criminal prosecution.  I agree with 
the court that the proposed right, as defined by the plaintiffs,1 
finds no support in the relevant provisions of our State 
Constitution.  See Moe v. Secretary of Admin. & Fin., 382 Mass. 
629, 633 n.4 (1981) ("We have historically taken the view that 
the principles of due process of law in our State Constitution 
are embodied in arts. 1, 10, and 12 of the Declaration of Rights 
and in Part II, c. 1, of the Constitution"). 
I write separately, however, to probe the court's position 
that, in every circumstance, the Commonwealth's interests 
 
1 I.e., that a terminally ill patient, determined by 
appropriate medical professionals to be (1) mentally competent 
and (2) possessing six months or less to live, can receive a 
prescription for lethal medication, which they then can elect to 
self-administer at their chosen time and place.  Sanctioning 
such a complex and ethically fraught medical protocol by 
judicial fiat, "with its implicit assessment of the 
effectiveness of alternative means, raises an unacceptable 
danger of this court's substituting its judgment for that of the 
Legislature," "absent a constitutional mandate to do so."  Blue 
Hills Cemetery, Inc. v. Board of Registration in Embalming & 
Funeral Directing, 379 Mass. 368, 375 (1979).  See Pope, Medical 
Aid in Dying:  Key Variations Among U.S. State Laws, 14 J. 
Health & Life Sci. L. 25, 32 (2020) (detailing eligibility 
requirements and procedural safeguards in eleven United States 
jurisdictions that allow physician-assisted suicide).  Indeed, 
such a decision likely would conflict with the separation of 
powers provision of our Constitution.  See art. 30 of the 
Massachusetts Declaration of Rights. 
2 
 
outweigh those of terminally ill patients seeking physician-
assisted suicide.  In doing so, I call attention to those 
patients presently experiencing the objective limitations of 
late-stage palliative care, a group faced "not with the choice 
of whether to live, only of how to die."  Washington v. 
Glucksberg, 521 U.S. 702, 746 (1997) (Stevens, J., concurring).  
For that group of patients, our case law addressing the right to 
refuse medical treatment -- in tandem with certain end-of-life 
practices already in use in the Commonwealth -- provides a 
constitutional zone of liberty and bodily autonomy that, while 
narrow, should not be subject to the State's reach. 
 
It is undisputed that patients in Massachusetts have 
certain fundamental rights when it comes to accepting or 
rejecting medical treatment.  See Lane v. Candura, 6 Mass. App. 
Ct. 377, 383 (1978) ("The law protects [a person's] right to 
make [his or her] own decision to accept or reject treatment, 
whether that decision is wise or unwise").  These rights 
"arise[] both from the common law and the unwritten and 
penumbral . . . right to privacy" afforded by the Massachusetts 
Constitution.  Brophy v. New England Sinai Hosp., Inc., 398 
Mass. 417, 430 (1986).  See Superintendent of Belchertown State 
Sch. v. Saikewicz, 373 Mass. 728, 738-739 (1977) ("There is 
implicit recognition in the law of the Commonwealth, as 
elsewhere, that a person has a strong interest in being free 
3 
 
from nonconsensual invasion of his bodily integrity").  See also 
Harnish v. Children's Hosp. Med. Ctr., 387 Mass. 152, 154 
(1982); Matter of Spring, 380 Mass. 629, 634 (1980); 
Commissioner of Correction v. Myers, 379 Mass. 255, 261 (1979). 
In Saikewicz, 373 Mass. at 729-730, 742, which concerned a 
patient's choice to decline life-prolonging chemotherapy for his 
leukemia, we first recognized a "substantial distinction" in the 
State's interests in the preservation of human life "where the 
affliction is curable, as opposed to" where "the issue is not 
whether but when, for how long, and at what cost to the 
individual that life may be briefly extended."  As such, we 
concluded that it was "not inconsistent" with the State's 
interest in promoting life "to recognize a right to decline 
medical treatment in a situation of incurable illness."  Id. at 
742 ("The constitutional right to privacy . . . is an expression 
of the sanctity of individual free choice and self-determination 
as fundamental constituents of life").  Equally as important as 
recognizing a patient's right to make certain end-of-life 
decisions, however, Saikewicz signaled a shift by reviewing 
courts "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."  
Brophy, 398 Mass. at 430-431. 
4 
 
This shift readily is apparent in Brophy, 398 Mass. at 423, 
decided a decade after Saikewicz, where we were asked to 
consider the previously expressed wishes of a patient in a 
vegetative state that he not be kept alive through artificial 
means.  The patient in Brophy was situated in a qualitatively 
different position from the one in Saikewicz, however, as the 
former was neither "terminally ill nor in danger of imminent 
death" from an underlying illness.  Id. at 434.  Rather, the 
patient in Brophy relied on a noninvasive plastic tube for 
nourishment and hydration, but otherwise was stable in a medical 
sense.  See id. at 425 & n.16 ("Brophy breathes on his own, 
without a respirator . . . .  All of his other major organs 
function normally and without mechanical assistance").  
Nevertheless, we reasoned that the "duty of the State to 
preserve life must encompass a recognition of an individual's 
right to avoid circumstances in which the individual himself 
would feel that efforts to sustain life demean or degrade his 
humanity."  Id. at 434.  We therefore concluded that it was 
"antithetical to our scheme of ordered liberty and to our 
respect for the autonomy of the individual for the State [rather 
than the patient] to make decisions regarding the individual's 
quality of life" and, as a practical consequence, ruled that the 
maintenance of the feeding tube "for [an indefinite] period of 
5 
 
several years" constituted "intrusive treatment as a matter of 
law."  Id. at 434-435. 
Two propositions can be derived from our reasoning in 
Saikewicz and Brophy.  The first is that the paternalism of the 
State in matters involving health care must yield, on occasion, 
to the personal autonomy of patients facing outcomes that vary 
only in their respective degrees of bleakness.  The second is 
that the State recognizes that certain medical scenarios permit 
the deeply personal decision to hasten death, sometimes 
drastically so.  See Cruzan v. Director, Mo. Dep't of Health, 
497 U.S. 261, 279 (1990) (due process clause of Fourteenth 
Amendment to United States Constitution grants competent persons 
constitutionally protected right to refuse both lifesaving and 
life-sustaining hydration and nutrition); Brophy, 398 Mass. at 
434-435.  In short, the State can, and has, conceived of a life 
that may no longer be worth living.  See Brophy, supra.  
Contrast Cruzan, supra at 335 n.8 (Stevens, J., dissenting) 
(Missouri argued in Cruzan that all life is "worthy of 
preservation without regard to its quality"). 
As far as determining whether a patient has a right to 
physician-assisted suicide, I can find no meaningful distinction 
between a mentally competent adult in a semicomatose –- but 
otherwise painless –- state, see Brophy, 398 Mass. at 434-435, 
and a terminally ill patient, who faces certain, imminent, and 
6 
 
excruciating death effectuating his or her own death, see id. at 
447 (Lynch, J., dissenting in part) ("If nutrition and hydration 
are terminated, it is not the illness which causes the death but 
the decision [and act in accordance therewith] that the illness 
makes life not worth living.  There is no rational distinction 
between suicide by deprivation of hydration or nutrition in or 
out of a medical setting -- both are suicide" [footnote 
omitted]).2 
To justify this incongruity, the court in this matter 
relies on (1) the well-established right of patients to be free 
from "forced medical procedures" (i.e., the doctrine of informed 
consent) as well as (2) a cause-and-effect analysis, in which 
the underlying affliction is presumed to "cause," in a legal 
sense, the medical death of the patient rather than the actions 
or omissions of the medical provider or patient.  See ante 
at    .  Both lines of argument are unconvincing in a 
jurisdiction where Brophy remains good law. 
The patient's feeding apparatus in Brophy was a tube that 
was powered by gravity.  See Brophy, 398 Mass. at 425-426.  It 
did not deliver unnatural medical interventions to the patient, 
such as chemotherapy or synthesized opioids.  See id.  Rather, 
 
2 I recognize that the consequences for the physician, 
however, are quite different. 
7 
 
the tube delivered to the patient only those essential units of 
life:  water and calories.  See id. at 426. 
This mechanism does not appear to me to be what is meant by 
"forced medical intervention."  To claim that the affirmative 
withdrawal of the tube was not the proximate cause of the 
patient's death ignores logic.  See id. at 444 (Lynch, J., 
dissenting in part) ("the cause of death would not be some 
underlying physical disability like kidney failure or the 
withdrawal of some highly invasive medical treatment, but the 
unnatural cessation of feeding and hydration which, like 
breathing, are part of the responsibilities we assume toward our 
bodies routinely"). 
Moreover, the fact that this court cites to the court's 
opinion in Brophy –- which rationalized the patient's inability 
to swallow as the actual "death producing agent" that would 
"caus[e] his own death" -- should have some legal import for the 
thousands of Commonwealth families with loved ones suffering 
from advanced Alzheimer's disease, Parkinson's disease, 
amyotrophic lateral sclerosis, or other terminal illness that 
interferes with swallowing.  Id. at 439.  See Bolser, A Serious 
and Often Overlooked Issue for Patients with Brain Diseases:  
Swallowing, The Conversation (Mar. 16, 2017), https: 
//theconversation.com/a-serious-and-often-overlooked-issue-for-
patients-with-brain-diseases-swallowing-67042 [https://perma.cc 
8 
 
/G6NM-326B] (millions of Americans with brain diseases, 
including those with Alzheimer's, Parkinson's, amyotrophic 
lateral sclerosis disease, stroke, multiple sclerosis, and 
traumatic brain injury, suffer from some form of dysphagia). 
I think that Saikewicz and Brophy were decided correctly.  
But, in keeping with the comprehensive approach we always have 
used to identify fundamental rights under the Massachusetts 
Constitution, I seek to highlight the degree to which our 
precedent has arced vitally close toward encompassing a right to 
physician-assisted suicide.  See Goodridge v. Department of Pub. 
Health, 440 Mass. 309, 327-328 (2003) (invoking modern cases to 
reveal evolving insights about marriage in contemporary 
context). 
By vindicating the interest of the patient in Brophy to 
refuse hydration and nourishment, this court already has 
"authorized affirmative conduct" that would not only hasten 
death but also would guarantee that outcome.  Glucksberg, 521 
U.S. at 743 (Stevens, J., concurring).  If a constitutionally 
cognizable liberty interest outweighing the respective interests 
of the State were found for a patient who was neither terminally 
ill nor in obvious pain, then logic dictates that that same 
interest should be able to be invoked by patients suffering 
through late-stage palliative care -- patients straddling the 
periphery between life and death. 
9 
 
 
Of course, the removal of life-sustaining nourishment is 
just one of several ways medical personnel are (legally) able to 
hasten a patient's death in Massachusetts.  Other deliberate 
efforts include the removal of breathing tubes, the turning off 
of ventilators, and the discontinuing of intravenous life-
sustaining medications.  Notably, none of "[t]hese measures are 
. . . passive."  Myers v. Schneiderman, 30 N.Y.3d 1, 24 (2017) 
(Rivera, J., concurring). 
 
Apart from these more traditional actions to hasten death 
for the terminally ill, the State also permits physicians to 
practice palliative sedation to unconsciousness,3 commonly known 
as terminal sedation.4  Terminal sedation is used when a 
 
3 In its Code of Medical Ethics, the American Medical 
Association sanctions the use of sedation to unconsciousness as 
"an intervention of last resort."  American Medical Association, 
Code of Medical Ethics, c. 5.6, at 7, https://www.ama-assn.org 
/system/files/2019-06/code-of-medical-ethics-chapter-5.pdf 
[https://perma.cc/V9SZ-PUQR].  Pursuant to the code, terminal 
sedation should be practiced only in those rare instances 
"[w]hen a terminally ill patient experiences severe pain or 
other distressing clinical symptoms that do not respond to 
aggressive, symptom-specific palliation."  Id. 
 
4 For relevant statutes addressing palliative care, see 
G. L. c. 6D, § 14 (certification standards for patient-centered 
medical homes); G. L. c. 6D, § 15 (certification standards for 
accountable care organizations); G. L. c. 12C, § 20 (public 
information regarding palliative care); G. L. c. 94C, § 19D 
(exception to seven-day supply limitation on opioids for 
palliative care); G. L. c. 111, § 24K (pediatric palliative care 
program); G. L. c. 111, § 57D (hospice programs providing 
palliative care); G. L. c. 111, § 227 (disclosures regarding 
palliative care); G. L. c. 111, § 233 (palliative care and 
quality of life interdisciplinary advisory council); G. L. 
10 
 
terminally ill patient's pain cannot otherwise be relieved with 
medication and the patient's death clinically is imminent.  See 
Quill, Lo, Brock, & Meisel, Last-Resort Options for Palliative 
Sedation, 151 Annals Internal Med. 421, 421 (2009) (Quill, Last-
Resort Options); Quill, Lo, & Brock, Palliative Options of Last 
Resort:  A Comparison of Voluntarily Stopping Eating and 
Drinking, Terminal Sedation, Physician-Assisted Suicide, and 
Voluntary Active Euthanasia, 278 JAMA 2099, 2100 (1997) (Quill, 
Comparisons). 
The goal of palliative sedation to unconsciousness is to 
make the patient unconscious to provide complete relief.  See 
Quill, Last-Resort Options, supra at 421; Quill, Comparisons, 
supra at 2100.  In this method, "sedation is rapidly increased 
over minutes to a few hours until the patient is unresponsive," 
artificial nutrition and hydration typically are not provided, 
and the patient remains in this state until death occurs.  
Quill, Last-Resort Options, supra at 422.  See Quill, 
Comparisons, supra at 2100 ("Although death is inevitable, it 
usually does not take place for days or even weeks").  
Palliative sedation to unconsciousness is the last-resort 
clinical response to spare terminally ill patients with no 
 
c. 111, § 234 (palliative care consumer and professional 
information and education program); G. L. c. 111O, § 4 (members 
of mobile integrated health advisory council to be drawn from 
fields including palliative care). 
11 
 
likely prospect of recovery from otherwise unrelievable physical 
suffering.  Quill, Last-Resort Options, supra at 422.  As with 
all forms of palliative care, palliative sedation to 
unconsciousness is undertaken only with the consent of the 
patient or a surrogate, with the patient's treatment goals and 
priorities in mind.  See L. Forrow & H.S. Smith, Pain Management 
in End of Life:  Palliative Care, in Principles and Practice of 
Pain Medicine 492, 494 (C.A. Warfield & Z.H. Bajwa, eds., 2d ed. 
2004). 
For this subgroup of terminally ill patients, the State 
recognizes palliative sedation to unconsciousness as a lawful 
means to end life.  The difference, however, "between injecting 
a drug that sedates a patient while simultaneously quickening 
death and prescribing lethal medication is not meaningful in the 
constitutional sense."  Myers, 30 N.Y.3d at 27 (Rivera, J., 
concurring).  In undertaking both practices, "the purpose of the 
physician's act and the patient's goal . . . is to expedite the 
dying process and avoid the severe pain, suffering, and 
indignity associated with the last stage of a terminal illness."  
Id. 
I would go so far as to argue that, from a legal 
standpoint, terminal sedation requires more direct action on the 
part of the attending physician to facilitate patient death than 
does physician-assisted suicide.  See Quill, Last-Resort 
12 
 
Options, supra at 422 ("With [terminal sedation], sedation is 
rapidly increased over minutes to a few hours until the patient 
is unresponsive . . .").  See also Glucksberg, 521 U.S. at 736-
737 (O'Connor, J., concurring) ("a patient who is suffering from 
a terminal illness and who is experiencing great pain has no 
legal barriers to obtaining medication, from qualified 
physicians, to alleviate that suffering, even to the point of 
causing unconsciousness and hastening death").  In the former 
method, a doctor places the patient into a chemically induced 
torpor from which he or she loses all agency to struggle against 
death, at which point the anesthetizing drugs, the removal of 
supplemental hydration, and, of course, the underlying 
condition(s) each become the potential legal cause of 
expiration.  See Orentlicher, The Supreme Court and Terminal 
Sedation:  Rejecting Assisted Suicide, Embracing Euthanasia, 24 
Hastings Const. L.Q. 947, 957 (1997).  By contrast, with 
physician-assisted suicide, the doctor's involvement ends after 
prescribing lethal drugs to the competent patient.  The decision 
whether to consume the drugs –- much less whether to fill the 
prescription –- remains at all times with the patient.5 
 
5 As one amicus points out, data from these jurisdictions 
shows that, of the total number of patients who have requested 
and received the necessary prescription for lethal medication, 
between one-quarter and one-half of them never take the final 
step of self-administering the medication.  The available data 
shows that, in California, 63.54 percent of patients who have 
13 
 
The court attempts to draw a bright line between those 
medical interventions "that cause death and those that do not."  
Ante at    .  See id. at     (finding meaningful distinction 
between right to refuse unwanted medical care and practice of 
physician-assisted suicide vis-à-vis classic legal principles of 
cause and effect).  What the State-sanctioned practice of 
terminal sedation makes clear, however, is that no one can 
really say just where that line is.6 
 
Given that terminally ill patients in the Commonwealth, who 
are in severe pain resistant to palliation, may invoke their 
liberty interests and opt to be terminally sedated, the State 
appears to have no rational interest in denying patients 
 
received a prescription for lethal medication as part of 
physician-assisted suicide have taken it; in the District of 
Columbia, fifty percent; in Maine, 60.78 percent; and in Oregon, 
65.8 percent.  See California Department of Health, California 
End of Life Option Act:  2020 Data Report 3 (July 2021); 
District of Columbia Department of Health, District of Columbia 
Death with Dignity Act:  2018 Data Summary 2; Maine Department 
of Health and Human Services, Patient-Directed Care:  Annual 
Report 5 (Mar. 1, 2021); Maine Department of Health and Human 
Services, Patient-Directed Care at End of Life:  Annual Report 4 
(Apr. 28, 2020); Oregon Health Authority, Oregon Death with 
Dignity Act:  2020 Data Summary 14 (Feb. 26, 2021). 
 
6 See Glucksberg, 521 U.S. at 751 (Stevens, J., concurring) 
("The illusory character of any differences in intent or 
causation [between physician-assisted suicide and terminal 
sedation] is confirmed by the fact that the American Medical 
Association unequivocally endorses the practice of terminal 
sedation -- the administration of sufficient dosages of pain-
killing medication to terminally ill patients to protect them 
from excruciating pain even when it is clear that the time of 
death will be advanced"). 
14 
 
similarly situated the "choice of a less intrusive option . . . 
which may better comport with [that] patient's autonomy and 
dignity."  Myers, 30 N.Y.3d at 29 (Rivera, J., concurring).  
Rather, this subgroup of patients possesses what the late 
Justice Stevens deemed a "constitutionally protected [liberty] 
interest" that "differs from, and is stronger than, both the 
common-law right to refuse medical treatment and the unbridled 
interest in deciding whether to live or die."  Glucksberg, 521 
U.S. at 745 (Stevens, J., concurring).  The usual reasons used 
to deny these patients access to physician-assisted suicide 
(e.g., reverence for life, archaic proscriptions against 
suicide, incorrect prognoses) do not carry the same weight when 
the patient's choices are limited to either inadequate pain 
management or terminal sedation, a practice that differs from 
physician-assisted suicide in degree and not in kind. 
"The duty of the State to preserve life must encompass a 
recognition of an individual's right to avoid circumstances in 
which the individual himself would feel that efforts to sustain 
life demean or degrade his humanity."  Brophy, 398 Mass. at 434.  
This court authored those poignant words some three and one-half 
decades ago when it honored the previously expressed wishes of 
an adult patient not to be left to subsist in a vegetative 
state.  In doing so, we broadened our conception of a patient's 
autonomy to encompass the liberty to forgo basic life-sustaining 
15 
 
care even if that patient were neither "terminally ill nor in 
danger of imminent death from any underlying physical illness."  
Id.  Since that time, the United States Supreme Court has 
recognized the same individual liberty interest under the 
Federal Constitution and has concluded that competent adults in 
a persistent vegetative state have the "right to die."  Cruzan, 
497 U.S. at 277. 
I concur with the court that the plaintiffs' proposed 
physician-assisted suicide schema is, as a matter of right, too 
procedurally complex for us to adopt whole cloth.  See note 1, 
supra.  In addition, I fully support the court's thoughtful and 
timely primer on substantive due process, which preserves the 
comprehensive approach as the proper test for identifying 
fundamental rights under our State Constitution.  See ante at     
("For the reasons that follow, we conclude that the narrow 
approach [for identifying fundamental rights protected by the 
Fourteenth Amendment] adopted by the Supreme Court [in Dobbs v. 
Jackson Women's Health Org., 142 S. Ct. 2228, 2242-2243 (2022),] 
does not adequately protect the rights guaranteed by [arts. 1, 
10, and 12] of the Massachusetts Declaration of Rights.  
Accordingly, the proper test for identifying fundamental rights 
16 
 
under the Massachusetts Declaration of Rights is the 
comprehensive approach").7  I therefore concur in the judgment. 
However, based on the strength of our existing case law 
concerning end-of-life patient autonomy, in conjunction with 
current palliative treatments that are commensurate with 
physician-assisted suicide, I do "not foreclose the possibility 
that some applications" of our criminal statutes "may impose an 
intolerable intrusion on" patient freedom.  Glucksberg, 521 U.S. 
at 751-752 (Stevens, J., concurring).  When that appropriate 
challenge (or challenger) does come forward, we must be ready to 
extend our State constitutional protections to terminally ill 
patients seeking to exercise what remains of their bodily 
autonomy. 
 
7 See J.E. Fleming, Construing Basic Liberties:  A Defense 
of Substantive Due Process 226 (2022) ("Instead of looking 
exclusively to the [F]ederal Constitution, [liberal reformers] 
should be looking primarily to [S]tate [C]onstitutions, 
especially for the next generation"); Kafker, State 
Constitutional Law Declares Its Independence:  Double Protecting 
Rights During a Time of Federal Constitutional Upheaval, 49 
Hastings Const. L.Q. 115, 116 (2022) ("there is nothing in the 
design of the [F]ederal Constitution, or its original 
understanding, requiring [S]tates to adopt the Supreme Court's 
interpretation of analogous provisions in the [F]ederal 
Constitution as the default or lockstep setting for interpreting 
parallel provisions in [S]tate [C]onstitutions.  State courts 
are fully empowered and expected to interpret independently 
analogous provisions in their [S]tate [C]onstitutions and 
thereby provide greater protections of individual rights, if 
they so conclude . . ."). 
 
 
WENDLANDT, J. (concurring in part and dissenting in part, 
with whom Budd, C.J., joins with regard to parts 2 and 3).  The 
plaintiff, Roger M. Kligler, a terminally ill, mentally 
competent patient with incurable stage 4 prostate cancer, has 
presented an "actual controversy" for purposes of the 
declaratory judgment act, G. L. c. 231A, § 1 (act).  While 
Kligler's death is not looming, he, like the patients of the 
plaintiff, Alan Steinbach, presents more than a potential future 
conflict.  Kligler need not spend the last six months of his 
life embroiled in a legal battle; he, no less than Steinbach, 
deserves his day in court.  Accordingly, I dissent from the 
portion of the court's decision dismissing Kligler's claims. 
Because I agree with the court that there is no fundamental 
right to prescribe, or to receive a prescription for, medication 
to assist a terminally ill, mentally competent patient's suicide 
(physician-assisted suicide), I concur in the judgment as it 
concerns Steinbach.  I also agree with the court that 
application of the criminal laws to physician-assisted suicide 
generally survives rational basis review.  I write separately 
because, when a terminally ill, mentally competent patient 
approaches the final stage of the dying process, the 
Commonwealth's interest in criminalizing physician-assisted 
suicide reduces to a nullity, such that even under rational 
basis review, the State Constitution protects the nonfundamental 
2 
 
right to physician-assisted suicide from application of the 
State's criminal laws. 
 
1.  Actual controversy requirement.  Kligler is mentally 
competent and terminally ill.  He has stage 4 prostate cancer, 
and his diagnosis includes his treating physicians' best 
estimates as to his remaining life span.  When he commenced this 
litigation, he had a fifty percent chance of dying within the 
next five years.  Thankfully, those estimates do not yet put 
Kligler at death's door; in my view, however, they provide 
sufficient interest in the sought declaration to hurdle the 
minimal bar for an "actual controversy" set by the act.  See 
Massachusetts Ass'n of Indep. Ins. Agents & Brokers, Inc. v. 
Commissioner of Ins., 373 Mass. 290, 293 (1977) ("the 'actual 
controversy' . . . requirement[] should be liberally 
construed").  Contrary to the court's conclusion, he does not 
allege merely a "potential future conflict[]."  Cf. Penal 
Instits. Comm'r for Suffolk County v. Commissioner of 
Correction, 382 Mass. 527, 531 (1981). 
To be sure, the plaintiffs have pleaded a right to 
physician-assisted suicide that they assert is triggered at the 
point when a patient has received an estimate of a six-month 
remaining life span, which is designed apparently to cabin the 
sought right to follow the best practices of medicine in those 
States that permit it.  The court uses this pleading to conclude 
3 
 
that Kligler does not present an actual controversy because 
Kligler's own estimated remaining life span does not yet fall 
within the six-month window. 
However, anyone who has received, or has had a loved one 
receive, an estimate as to the patient's remaining life span 
knows that by necessity (indeed, by definition) such an estimate 
lacks mathematical precision even though it is based on the 
collective experiences of similarly situated patients.  
Indubitably, Steinbach's patients' estimates also lack the rigor 
of a precise mathematical formula, yet that imprecision does not 
dissuade the court from addressing his claim. 
Given that litigation challenging the constitutionality of 
State action often (and nearly always) lasts more than six 
months, the court ought to exercise its discretion to reach the 
merits of Kligler's claim consistent with its treatment of 
Steinbach's claim;1 it is, after all, Kligler (the terminally ill 
patient) who is the principal to whom the right at issue here is 
 
1 Under the court's view, to meet the "actual controversy" 
requirements of the act, Kligler must spend the last six months 
of his life embroiled in litigation the end to which he will not 
likely witness because he will die.  Such a miserly view of the 
act is inconsistent with our charge to liberally construe it.  
Massachusetts Ass'n of Indep. Ins. Agents & Brokers, Inc., 373 
Mass. at 293. 
 
4 
 
most critical.2  Accordingly, I dissent from the court's 
dismissal of Kligler's claims -- a decision that does nothing to 
further our interests either in conserving judicial resources or 
in avoiding prematurely deciding constitutional issues in view 
of the court's decision to address the merits of Steinbach's 
claims. 
2.  No fundamental right to physician-assisted suicide.  I 
agree with the court that there is no fundamental right to 
physician-assisted suicide; as the court reasons, such a right 
finds no support in our history, in our evolving traditions and 
understandings of equality and fairness, or in our judicial 
precedent.3  It is worth emphasizing that this lack of consensus 
 
2 Indeed, as the court recognizes, Steinbach's standing to 
bring this action relies on the standing of his patients, who, 
like Kligler, have received a diagnosis of a terminal illness. 
 
 
3 Society's evolving traditions and better-informed 
understandings of the liberty interests protected by substantive 
due process may or may not be reflected in judicial precedent.  
Thus, while I agree with the court that judicial precedent may 
reflect new insights about the realm of liberty protected by 
substantive due process, see ante at    , the insights 
themselves are what guide our analysis of the evolving 
understanding whether an asserted right is implicit in the 
concept of ordered liberty.  If our recognition of new insights 
and societal understandings was limited to those found in 
judicial precedents, we would risk either ossifying our 
understanding or transforming the rights protected by due 
process into the policy preferences of the majority of the 
court.  See Goodridge v. Department of Pub. Health, 440 Mass. 
309, 312 (2003), quoting Lawrence v. Texas, 539 U.S. 558, 571 
(2003) ("Our obligation is to define the liberty of all, not to 
mandate our own moral code").  Cf. Zayre Corp. v. Attorney Gen., 
372 Mass. 423, 433 (1977) ("This principle of judicial restraint 
5 
 
is particularly salient to our substantive due process analysis 
of the presently asserted right because physician-assisted 
suicide does not implicate principles of equality.  See 
Goodridge v. Department of Pub. Health, 440 Mass. 309, 320-321 
(2003), quoting Lawrence v. Texas, 539 U.S. 558, 575 (2003) 
("Equality of treatment and the due process right to demand 
respect for conduct protected by the substantive guarantee of 
liberty are linked in important respects . . ."); Goodridge, 
supra at 328 n.17 (Federal and State Constitutions "prohibit[] a 
State from wielding its formidable power to regulate conduct in 
a manner that demeans basic human dignity, even though that 
statutory discrimination may enjoy broad public support"). 
In connection with physician-assisted suicide, we do not 
write against a backdrop of bias, invidious discrimination, or 
animus that made the affected group's ability to participate in 
the legislative process to advocate for a given right more 
difficult as a practical matter.  Compare Obergefell v. Hodges, 
576 U.S. 644, 664-665 (2015) (right to marry someone of same 
sex); Lawrence, 539 U.S. at 564 (right to engage in same-sex 
sexual conduct); Loving v. Virginia, 388 U.S. 1, 12 (1967) 
(right to marry persons of different race).  The argument 
 
includes recognition of the inability and undesirability of the 
judiciary substituting its notions of correct policy for that of 
a popularly elected Legislature"). 
6 
 
presented is not part of "the story of the extension of 
constitutional rights and protections to people once ignored or 
excluded."  Goodridge, 440 Mass. at 339, quoting United States 
v. Virginia, 518 U.S. 515, 557 (1996). 
To the contrary, dying is something we all will face in 
time; it is something nearly all of us will have our closest 
loved ones experience.  There is no disenfranchised group that 
needs constitutional protection by this court, or who cannot 
advocate zealously and fairly for the ability to die as they 
please.  Rather, every one of us is free to vote and encourage 
our legislators to enact laws, and to craft appropriate 
procedural safeguards, with respect to one of the only human 
experiences that will affect us all.  As such, the asserted 
right ought to be left to the democratic process.  See 
Glucksberg, 521 U.S. 702, 737 (1997) (O'Connor, J., concurring) 
("There is no reason to think the democratic process will not 
strike the proper balance between the interests of terminally 
ill, mentally competent individuals who would seek to end their 
suffering and the State's interests in protecting those who 
might seek to end life mistakenly or under pressure"). 
"Because the controversy surrounding physician-assisted 
suicide is so firmly rooted in questions of social policy, 
rather than constitutional tradition, it is a quintessentially 
legislative matter."  Sampson v. State, 31 P.3d 88, 98 (Alaska 
7 
 
2001).  See Morris v. Brandenburg, 2016-NMSC-027, ¶ 2 ("It is 
not easy to define who would qualify to be a terminally ill 
patient, or what would be the criteria for assuring a patient is 
competent to make an end-of-life decision, or what medical 
practices are acceptable to aid a patient in dying, or what 
constitutes a safe medication"). 
3.  Rational basis review.  Because there is no fundamental 
right to physician-assisted suicide, we employ rational basis 
review to evaluate whether criminalization of physician-assisted 
suicide through application of our criminal laws comports with 
due process.  See Doe, Sex Offender Registry Bd. No. 339940 v. 
Sex Offender Registry Bd., 488 Mass. 15, 20 (2021).  As a 
general matter, I agree with the court that the Commonwealth has 
identified several public safety and welfare interests, each of 
which is reasonably related to applying criminal laws to 
physician-assisted suicide. 
I write separately because the application of criminal laws 
to physician-assisted suicide will not always pass 
constitutional muster even under the relatively meager bar of 
rational basis review.  In particular, when a terminally ill, 
mentally competent patient approaches the final stage of the 
dying process, accompanied by unbearable pain that cannot be 
alleviated by palliative care short of sedation to 
unconsciousness, the rational basis calculus necessarily 
8 
 
changes.  In such a situation, the Commonwealth's interests 
reduce to a nullity,4 as the individual's liberty interest in 
choosing a peaceful death that comports with the individual's 
values and dignity, specifically through physician-assisted 
suicide, strengthens to its zenith; death is looming and 
inevitable, and the question is no longer "whether to live, only 
of how to die."  Glucksberg, 521 U.S. at 746 (Stevens, J., 
concurring).  See Myers v. Schneiderman, 30 N.Y.3d 1, 18 (2017) 
(Rivera, J., concurring) (as patient's life draws to inevitable 
end, State's interests diminish and "do not outweigh either the 
individual's right to self-determination or the freedom to 
choose a death that comports with the individual's values and 
sense of dignity").  "For this subgroup of patients, healing, as 
understood as a restoration of bodily health, is no longer a 
possibility."  Id. at 33. 
At such a moment, there is no meaningful distinction 
between physician-assisted suicide and palliative sedation to 
unconsciousness followed by withdrawal of nutrients so as to 
cause dehydration and starvation.  Where the State permits the 
latter procedure, it "has no compelling rationale, or even a 
 
 
4 Our decision in Bowen is not to the contrary.  There, we 
upheld the conviction of a prisoner who encouraged a death row 
inmate to commit suicide on the basis that there was a public 
interest in the public execution of criminals.  Commonwealth v. 
Bowen, 13 Mass. 356, 360 (1816).  No comparable interest exists 
in the context contemplated here. 
9 
 
rational interest, in refusing a mentally-competent, terminally-
ill patient who is in the final stage of life the choice of a 
less intrusive option -- access to [physician-assisted suicide] 
-- which may better comport with the patient's autonomy and 
dignity."  Id. at 29.  In this scenario, depriving the patient 
of a legal path to bring about a death in line with his or her 
wishes also injures surviving family members, who must watch 
helplessly as their loved one suffers through the final moments 
of his or her life.  Id. at 30.  Allowing this subset of 
patients to choose to die with dignity as their final act while 
death is looming and inevitable would not result in harm to the 
public welfare.  In such a case, application of the criminal 
laws to the nonfundamental right to physician-assisted suicide 
would be irrational and thus proscribed by substantive due 
process. 
4.  Conclusion.  For the foregoing reasons, I dissent in 
part and concur in part.