Opinion ID: 818004
Heading Depth: 4
Heading Rank: 1

Heading: Freedom of intimate association

Text: Decisions to enter into and maintain certain intimate human relationships “must be secured against undue intrusion by the State because of the role of such relationships in safeguarding the individual freedom that is central to our constitutional scheme. In this respect, freedom of association receives protection as a fundamental element of personal liberty.” Roberts v. U.S. Jaycees, 468 U.S. 609, 617–18 (1984). The types of personal relationships that qualify for constitutional protection “attend the creation and sustenance of a family” including marriage, childbirth, raising and educating children, and cohabitation with relatives. Id. at 619; Johnson v. City of Cincinnati, 310 F.3d 484, Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 11 499 (6th Cir. 2002). In addition, courts have extended protection to personal friendships and non-marital romantic relationships. Anderson v. City of LaVergne, 371 F.3d 879, 882 (6th Cir. 2004). These kinds of personal relationships are characterized by “such attributes as relative smallness, a high degree of selectivity in decisions to begin and maintain the affiliation, and seclusion from others in critical aspects of the relationship.” Roberts, 468 U.S. at 620. Only similar relationships “with these sorts of qualities are likely to reflect the considerations that have led to an understanding of freedom of association as an intrinsic element of personal liberty.” Id. On the other hand, an association with a large business enterprise lacks these qualities necessary for constitutional protection. Id. And in between these two points “lies a broad range of human relationships that may make greater or lesser claims to constitutional protection from particular incursions by the State.” Id. To evaluate whether constitutional protection extends to a particular association, the relationship’s objective characteristics must be assessed to determine where the relationship lies “on the spectrum from the most intimate to the most attenuated of personal attachments.” Id. Factors relevant to this analysis include “size, purpose, policies, selectivity, and congeniality.” Id. We have described the right to intimate association as protecting “those relationships . . . that presuppose deep attachments and commitments to the necessarily few other individuals with whom one shares not only a special community of thoughts, experiences, and beliefs but also distinctly personal aspects of one’s life.” Anderson, 371 F.3d at 881–82 (internal quotation marks omitted). We have also recognized that medical patients typically do not share “deep attachments and commitments” with physicians, nor do patients and physicians typically share “a special community of thoughts, experiences, and beliefs.” See id. Plaintiffs contend that their relationships with their physicians satisfy certain aspects of intimate association: relative smallness (a relationship between two individuals), a high degree of selectivity (the choice of a doctor is significant and selective), and seclusion from others in critical aspects (doctor-patient confidentiality protects the disclosure of private health information). Citing Andrews v. Ballard, Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 12 498 F. Supp. 1038, 1047 (S.D. Tex. 1980), plaintiffs suggest that the right to intimate association extends to their doctor–patient relationships. In Andrews, the district court addressed a claim that a patient’s decision to obtain acupuncture treatment is a constitutional right encompassed within the right of privacy, and that Texas regulations limiting the practice of acupuncture to licensed physicians imposed a significant burden on the patient’s decision and were not narrowly drawn to achieve a compelling state interest. Id. Andrews is inapposite. There the court was concerned with an alleged Fourteenth Amendment right to privacy, not the First Amendment right to intimate association. Id. at 1045. The case is also distinguishable because the statute at issue imposed a direct limitation on the ability of physicians to practice, whereas the individual mandate does not impose any similar limitations on the rights of physicians. At most, Andrews is authority from a lower court in another circuit that may be persuasive. It does not compel us to hold that plaintiffs’ doctor–patient relationships are protected by the freedom of intimate association. Even if the factors of smallness, selectivity, and seclusion of others exist to some degree in plaintiffs’ relationships with their doctors, those factors are not sufficient to establish a right to intimate association that should receive heightened scrutiny. See Flaskamp v. Dearborn Pub. Sch., 385 F.3d 935, 942 (6th Cir. 2004). The Ninth Circuit has concluded that the relationship between a psychoanalyst and a patient was not the type of bond that qualified for intimate association, see e.g. Nat’l Ass’n for Advancement of Psychoanalysis v. Cal. Bd. of Psychology, 228 F.3d 1043, 1050 (9th Cir. 2000), because these kinds of ties have not “played a critical role in the culture and traditions of the Nation by cultivating and transmitting shared ideals and beliefs,” nor have they acted “as critical buffers between the individual and the power of the State.” Roberts, 468 U.S. at 618–19. Moreover, “most federal courts have held that a patient does not have a constitutional right to obtain a particular type of treatment or to obtain treatment from a particular provider if the government has reasonably prohibited that type of treatment or provider.” Mitchell v. Clayton, 995 F.3d 772, 775 (7th Cir. 1993) (citing Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 13 cases); Carnohan v. United States, 616 F.2d 1120, 1122 (6th Cir. 1980) (“Constitutional rights of privacy and personal liberty do not give individuals the right to obtain laetrile free of the lawful exercise of governmental police power.”). In addition, relationships with large business enterprises like health insurance companies do not qualify as intimate associations warranting constitutional protection. Roberts, 468 U.S. at 620. We conclude that the individual plaintiffs, Thompson and Grapek, failed to show that they possess a right of intimate association with physicians that is infringed by the individual mandate. USCA’s claim also fails as it does not explain how its size, purpose, policies, selectivity, and congeniality establish that it has a protected right to intimate association. See id. at 620–21 (holding that Jaycees chapters lack the distinctive characteristics that might afford constitutional protection). Plaintiffs’ claim that PPACA violates their freedom of intimate association fails for another reason. Nothing in the individual mandate precludes plaintiffs from establishing relationships with the medical professionals of their choice, nor does the individual mandate require them to associate with particular medical professionals. The individual mandate simply requires most Americans to maintain a minimum level of health insurance coverage or make the shared responsibility payment. Nat’l Fed’n of Indep. Bus., 132 S. Ct. at 2580, 2595–96. The district court properly dismissed this claim.