Court Opinion

ID: 8408838
Source: CourtListenerOpinion
Date Created: 2022-11-02 16:48:30.400553+00
Date Added: 2024-06-11T16:47:37.128839
License: Public Domain

WALLACE, Senior Circuit Judge,
dissenting:
As my colleagues in the majority suggest, this case is not about the ethics or public policy implications of physician-assisted suicide. We need not decide whether the federal government or the states is better equipped to regulate physician-assisted suicide. Setting aside the public policy aspects of physician-assisted suicide that evoke passionate feelings, this case involves a single legal question: is the Attorney General’s interpretation of 21 C.F.R. § 1306.04(a) entitled to deference? Because our past decisions command deference to the Attorney General’s interpre-five rule, I would deny the petition for review on the merits.
I.
The Oregon Death with Dignity Act (Oregon Act) provides that a capable adult who “has been determined by the attending physician and consulting physician to be suffering from a terminal disease, and who has voluntarily expressed his or her wish to die, may make a written request for medication for the purpose of ending his or her life in a humane and dignified manner.” OR. REV. STAT. § 127.805(1). Once various safeguards have been satisfied, the attending physician may “writ[e] a prescription for medication to enable a qualified patient to end his or her life,” id. § 127.815(l)(k), and the attending physician, the pharmacist, or a third person may dispense the medication to the patient, id. § 127.815(1)(L). To date, Oregon is the only state that has passed legislation expressly legalizing physician-assisted suicide.
By authorizing physicians to prescribe and dispense controlled substances for the purpose of assisting suicide, the Oregon Act arguably draws Oregon law into tension with the federal Controlled Substances Act, 21 U.S.C. §§ 801-971. “Except as authorized by [the Controlled Substances Act],” it is unlawful for any person — including physicians — to “manufacture, distribute, or dispense” a controlled substance. 21 U.S.C. § 841. The Controlled Substances Act permits physicians to dispense controlled substances *1132only if they have previously registered with the Attorney General. Id. §§ 822(a)(2), 823(f). Even registered phy-' sicians may not distribute controlled substances, however, without first issuing a “prescription,” id. § 829(a), which, “to be effective[,] must be issued for a legitimate medical purpose,” 21 C.F.R. § 1306.04(a). The Attorney General may revoke or suspend a physician’s registration if the registrant has been convicted of violating the Controlled Substances Act, 21 U.S.C. § 824(a)(2), or has committed acts “inconsistent with the public interest,” id. §§ 823(f), 824(a)(4).
Whether physician-assisted suicide is “a legitimate medical purpose” and “consistent with the public interest” has been the subject of considerable public debate. In a letter dated November 5, 1997, Drug Enforcement Administration (DEA) Administrator Thomas A. Constantine opined that assisting suicide is not a “legitimate medical purpose” under the Controlled Substances Act. Letter from Constantine, DEA Administrator, to Henry J. Hyde, Congressman (Nov. 5, 1997), available at http://www.house.gov/judiciary/ constan-tine.htm. Seven months later, however, then-Attorney General Janet Reno rejected the DEA Administrator’s opinion letter, concluding that “the [Controlled Substances Act] does not authorize DEA to prosecute, or to revoke the DEA registration of, a physician who has assisted in a suicide in compliance with Oregon law.” Statement of Attorney General Reno on Oregon’s Death with Dignity Act (June 5, 1998), available at http://www.usdoj. gov/opa/pr/1998/June/259ag.htm.html. General Reno’s interpretation of the Controlled Substances Act prompted a stern letter from several Senators-including then Missouri Senator John Ashcroft:
[T]here is agreement among all three branches of the Federal government that assisted suicide is not a legitimate medical practice. The DEA is therefore on solid ground in concluding that “delivering, dispensing or prescribing a controlled substance with the intent of assisting a suicide would not be under any current definition a ‘legitimate medical purpose,’ ” and that such a misuse of drugs warrants the revocation of a physician’s license to dispense controlled substances.
Letter from John Ashcroft et ah, U.S. Senators, to Janet Reno, Attorney General (Dec. 19,1997).
Following his appointment to head the Department of Justice, General Ashcroft issued an interpretive rule on November 9, 2001, reversing his predecessor’s earlier position regarding physician-assisted suicide. Dispensing of Controlled Substances To Assist Suicide (Ashcroft Directive), 66 Fed.Reg. 56,607 (Nov. 9, 2001) (to be codified at 21 C.F.R. pt. 1306). The Ashcroft Directive states that “assisting suicide is not a ‘legitimate medical purpose’ within the meaning of 21 C.F.R. § 1306.04 (2001)” and that a physician who prescribes controlled substances to assist suicide “may’ render his registration ... inconsistent with the public interest’ ” and thereby risk suspension or revocation of his registration under 21 U.S.C. § 824(a)(4). Id. at 56,608. General Ashcroft directed “the DEA, effective upon publication of this memorandum in the Federal Register, to enforce and apply this determination, notwithstanding anything to the contrary in the June 5, 1998, Attorney General’s letter.” Id.
Before the Department of Justice took action to enforce the Ashcroft Directive, a group of physicians, patients, and the state of Oregon (collectively Petitioners) brought this action in federal district court, seeking declaratory and injunctive relief. Although the district court lacked jurisdiction to consider the petition for review, see Pac. Power & Light Co. v. *1133Bonneville Power Admin., 795 F.2d 810, 814-16 (9th Cir.1986); UMC Indus., Inc. v. Seaborg, 439 F.2d 953, 955 (9th Cir.1971) (per curiam), this court has jurisdiction pursuant to 28 U.S.C. § 1631 and 21 U.S.C. § 877.
II.
The Petitioners do not dispute that the Controlled Substances Act prohibits physicians from dispensing and prescribing controlled substances except for legitimate medical purposes. See 21 C.F.R. § 1306.04(a) (“A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose— ”); United States v. Moore, 423 U.S. 122, 124, 96 S.Ct. 335, 46 L.Ed.2d 333 (1975) (holding that physicians violate the Controlled Substances Act “when their activities fall outside the usual course of professional practice”); United States v. Kaplan, 895 F.2d 618, 619 (9th Cir.1990) (stating that the Controlled Substances Act prohibits “prescribing controlled substances for reasons other than legitimate medical purposes”); United States v. Rosenberg, 515 F.2d 190, 193 (9th Cir.1975) (interpreting the Controlled Substances Act “to mean that a doctor who acts [outside] the course of professional practice is not a practitioner under the Act and is therefore not authorized to prescribe controlled substances”). Instead, they argue that the Ashcroft Directive is not a valid agency rule — and thus is not entitled to deference — for the following four reasons: (1) the Attorney General did not promulgate the Ashcroft Directive pursuant to the Administrative Procedure Act’s (APA) notice-and-comment rulemak-ing procedures; (2) the Ashcroft Directive violates the Controlled Substances Act’s non-preemption provision; (3) the Ashcroft Directive exceeds the scope of the Attorney General’s authority under the Controlled Substances Act; and (4) the Ashcroft Directive is an arbitrary and capricious agency action. As will be seen, none of these creative challenges to the Ashcroft Directive withstands close scrutiny or justifies the majority’s departure from our customary canons of deference to agency action.
A.
Petitioners argue first that deference to the Ashcroft Directive is not warranted because the Attorney General did not satisfy the APA’s notice-and-comment rule-making procedures. See 5 U.S.C. § 553 (requiring that agencies give “interested persons” notice of proposed rules and “an opportunity to participate in the rule making through submission of written data, views, or arguments with or without opportunity for oral presentation”). The United States counters that the APA does not require notice and comment here, because the Ashcroft Directive is an interpretive rule, not a legislative rule. See id. § 553(b)(3)(A) (stating the APA’s notice- and-comment procedures do not ordinarily apply to interpretive rules). If the Ashcroft Directive is “genuinely an interpretive rule, it is valid despite the absence of notice and comment procedures.” Hemp Indus. Ass’n v. DEA 333 F.3d 1082, 1087 (9th Cir.2003).
We distinguish interpretive and legislative rules by asking (1) whether, absent the rule, there would be an inadequate legislative basis for an enforcement action; (2) whether the agency “explicitly invoked its general legislative authority”; and (3) whether “the rule effectively amends a prior legislative rule.” Id. “If the answer to any of these questions is affirmative, we have a legislative, not an interpretive rule.” Sweet v. Sheahan, 235 F.3d 80, 91 (2d Cir.2000), quoting Am. Mining Cong. v. Mine Safety & Health Admin., 995 F.2d 1106, 1112 (D.C.Cir.1993).
*1134The Ashcroft Directive does not bear any of these three hallmarks of a legislative rule. First, even absent the Ashcroft Directive, the Attorney General could bring an enforcement action because the Controlled Substances Act itself prohibits distributing a controlled substance without a prescription, 21 U.S.C. § 829(a), and preexisting Department of Justice regulations declare that “[a] prescription for a controlled substance to be effective must be issued for a legitimate medical purpose,” 21 C.F.R. § 1306.04(a). Second, the Attorney General did not expressly invoke his statutory authority to “promulgate ... any [legislative rules] ... which he may deem necessary and appropriate for the efficient execution of his functions under” the Controlled Substances Act. 21 U.S.C. § 871(b). Third, although the Ashcroft Directive contradicts former Attorney General Reno’s 1998 statement, the Ashcroft Directive is not inconsistent with any legislative rule. See Chief Prob. Officers of Cal. v. Shalala, 118 F.3d 1327, 1337 (9th Cir.1997) (holding that an interpretive rule can amend an interpretive rule); Richard J. Pierce, Jr., Distinguishing Legislative Rules from Interpretative Rules, 52 ADMIN. L. REV. 547, 566-73 (2000) (discussing this principle).
The Ashcroft Directive does not purport to “create rights, impose obligations, or effect a change in existing law pursuant to authority delegated by Congress.” Hemp, 333 F.3d at 1087. Instead, like other interpretive rules, the Ashcroft Directive is “essentially hortatory and instructional,” clarifying what the Controlled Substances Act means when applied to a narrowly defined situation. Alcaraz v. Block, 746 F.2d 593, 613 (9th Cir.1984); see also Hemp, 333 F.3d at 1087 (explaining that interpretive rules “explain, but do not add to, the substantive law that already exists in the form of a statute or legislative rule”). Thus, General Ashcroft’s failure to give Petitioners advance notice and an opportunity to comment does not invalidate the Ashcroft Directive.
B.
The Petitioners next contend that the Ashcroft Directive violates 21 U.S.C. § 903, the Controlled Substances Act’s non-preemption clause. Section 903 reads:
No provision of this subchapter shall be construed as indicating an intent on the part of the Congress to occupy the field in which that provision operates ... to the exclusion of any State law on the same subject matter which would otherwise be within the authority of the State, unless there is a positive conflict between that provision of this subchapter and that State law so that the two cannot consistently stand together.
21 U.S.C. § 903. The Petitioners argue that the Ashcroft Directive construes the Controlled Substances Act to preempt the Oregon Act and that this result violates 21 U.S.C. § 903 because there is no “positive conflict” between the Controlled Substances Act’s text and the Oregon Act.
Petitioners are wrong; the Ashcroft Directive is consistent with section 903 because it does not utterly exclude state regulation of medical practice or even state regulation of physician-assisted suicide. The Ashcroft Directive does not effect a “positive conflict” with state law because it does not make “the federal role ... so pervasive that no room is left for the states to supplement it.” Sayles Hydro Assocs. v. Maughan, 985 F.2d 451, 455 (9th Cir.1993). States may supplement the Ashcroft Directive by expanding the Controlled Substances Act’s prohibitions, providing additional civil or criminal sanctions against physicians who assist suicide, or permitting conduct that the Ashcroft Directive does not prohibit.
More relevant for present purposes, the Ashcroft Directive proscribes only one *1135method of assisting suicide: prescription, dispensation, and administration of controlled substances. The majority vastly exaggerates the Ashcroft Directive’s scope by intimating that it “ban[s] physician-assisted suicide outright.” A closer examination of the Ashcroft Directive’s text reveals that “[assisting] suicide is not a ‘legitimate medical purpose’ ” only “within the meaning of 21 C.F.R. § 1306.CH” (prescription of controlled substances). Ashcroft Directive, 66 Fed.Reg. at 56,608 (emphasis added). The Ashcroft Directive avoids the sweeping prohibition claimed by the majority by assiduously limiting its reach to controlled substances; under its plain terms, only applications involving controlled substances may “render [a physician’s] registration ... inconsistent with the public interest” and therefore subject to revocation. Id., quoting 21 U.S.C. § 824(a)(4). Oregon physicians may continue to assist suicide by other means without risking suspension or revocation of their registration to prescribe controlled substances. See George J. Annas, The “Right To Die” in America: Sloganeering from Quinlan and Cruzan to Quill and Kevorkian, 34 DUQ. L. REV. 875, 891 (1996) (discussing carbon monoxide as an alternative to controlled substances); Jeffrey G. Sherman, Mercy Killing and the Right To Inherit, 61 U. Cin. L.Rev. 803, 834 (1993) (same). The Ashcroft Directive does not, therefore, “occupy the field” of physician-assisted suicide in violation of section 903. See United States v. Leal, 75 F.3d 219, 227 (6th Cir.1996) (holding that “there is no such conflict” between 21 C.F.R. § 1306.04 and state law).
C.
Petitioners maintain — -and the majority agrees — that the Ashcroft Directive is not entitled to deference because the Attorney General promulgated it “in excess of statutory jurisdiction, authority, or limitations, or short of statutory right.” 5 U.S.C. § 706(2)(C).
1.
The Ashcroft Directive is not entitled to deference, the majority contends, because “Congress intended to limit federal authority under the [Controlled Substances Act] to the field of drug abuse” while preserving states’ discretion to authorize other life-threatening applications of controlled substances. By what * authority? True, the Controlled Substances Act’s preamble arguably manifests Congress’s intent “to strengthen existing law enforcement authority in the field of drug abuse,” Comprehensive Drug Abuse Prevention and Control Act of 1970, Pub.L. No. 91-513, pmbl., 84 Stat. 1236, 1236, but it does not “expressly limit[ ] federal authority under the Act” to mainstream drug abuse, as the majority argues. Moreover, there is simply no textual support for the majority’s conclusory assertion that “the field of drug abuse,” as discussed in the Controlled Substances Act, does not encompass drug-induced, physician-assisted suicide.
The Controlled Substances Act’s text furnishes ample evidence that Congress was concerned not only with street-variety drug trafficking and abuse but also with any other improper drug use that might have a “detrimental effect on the health and general welfare of the American people.” 21 U.S.C. § 801(2). The Act targets all “improper use of controlled substances,” id., and gives the Attorney General discretion to decide whether registering a physician to dispense drugs is “consistent with the public health and safety,” id. § 823(b)(5). Reasonable minds might disagree as to whether physician-assisted suicide constitutes an “improper use” of a controlled substance, but nothing in the Controlled Substances *1136Act’s text precludes its application to physician-assisted suicide.
Lacking a textual hook for its position, the majority attempts to patch the holes in its argument with inconclusive fragments of legislative history. Discerning congressional intent from legislative history is a speculative enterprise under the best of circumstances, and the risk of error is compounded in a case such as this when legislators’ published statements do not squarely address the question presented-i.e., whether Congress intended to exclude drug-induced, physician-assisted suicide from regulation under the Controlled Substances Act. See Chisom v. Roemer, 501 U.S. 380, 406, 111 S.Ct. 2354, 115 L.Ed.2d 348 (1991) (Scalia, J., dissenting) (“We are here to apply the statute, not legislative history, and certainly not the absence of legislative history.”).
The Controlled Substances Act’s legislative history suggests that some members of Congress envisioned the physician-registration provisions primarily as a mechanism to stem the flow of controlled substances into illicit channels, Moore, 423 U.S. at 135, 96 S.Ct. 335, but the record also specifically identifies “suicides and attempted suicides” as a”[m]isuse of a drug.” H.R. REP. NO. 91-1444 (1970), reprinted in 1970 U.S.C.C.A.N. 4566, 4572; see also Dangerous Drug Diversion Control Act of 1984-: Hearing on H.R. 5656 Before the House Subcomm. on Health and the Env’t, 98th Cong. 365 (1984) (statement of Rep. Henry A. Waxman, Chairman, House Sub-comm. on Health and the Env’t) (expressing concern that “[d]rugs legally manufactured for use in medicine are responsible for a substantial majority of drug-related deaths”); 130 CONG. REC. 25,851 (statement of Rep. Rodino) (1984) (reporting that “diversion” of prescription drugs “is responsible for 70 percent of the deaths and injuries due to all drug abuse”). Viewed holistically, the record “does not demonstrate a clear and certain congressional intent” to preclude physician-assisted suicide from regulation under sections 823 and 824. Rust v. Sullivan, 500 U.S. 173, 190, 111 S.Ct. 1759, 114 L.Ed.2d 233 (1991). Controlling precedent thus compels the conclusion that the Controlled Substances Act’s “legislative history ... cannot form the basis for enjoining [the Attorney General’s] regulation[ ].” Id.; see also Student Loan Fund of Idaho, Inc. v. U.S. Dept. of Educ., 272 F.3d 1155, 1165 (9th Cir.2001) (applying this principle in an analogous setting).
2.
The majority asserts that the Attorney General lacks authority to decide whether physician-assisted suicide is consistent with “the public interest” and a “legitimate medical practice” under the Controlled Substances Act and its implementing regulations because Congress intended to preserve the states’ traditional authority to make these determinations. This argument ignores the Controlled Substances Act’s text and controlling Supreme Court decisions.
It is axiomatic that the meaning of federal law is a federal question. See Reconstr. Fin. Corp. v. Beaver County, 328 U.S. 204, 208, 66 S.Ct. 992, 90 L.Ed. 1172 (1946) (“What meaning Congress intended is a federal question we must determine.”). Although federal law occasionally incorporates state-law definitions by reference, see, e.g., De Sylva v. Ballentine, 351 U.S. 570, 580-82, 76 S.Ct. 974, 100 L.Ed. 1415 (1956) (defining the word “children” in a federal statute according to state law), recourse to state law is the exception rather than the norm. “[I]n the absence of a plain indication to the contrary, ... Congress when it enacts a statute [does] not mak[e] the application of the federal act dependent on state law.” Miss. Band of *1137Choctaw Indians v. Holyfield, 490 U.S. 30, 43, 109 S.Ct. 1597, 104 L.Ed.2d 29 (1989) (quoting Jerome v. United States, 318 U.S. 101, 104, 63 S.Ct. 483, 87 L.Ed. 640 (1943)); Kahn v. INS, 36 F.3d 1412, 1414 (9th Cir.1994) (per curiam) (same).
State law may be relevant to certain provisions of the Controlled Substances Act, see, e.g., 21 U.S.C. § 823(f) (instructing the Attorney General to consider state-law violations when deciding whether a physician’s registration would be contrary to the public interest), but nothing in the Controlled Substances Act plainly evinces a congressional intent to define “the public interest” solely according to state law. On the contrary, section 823 instructs the Attorney General to identify acts “inconsistent with the public interest” by reference to a variety of sources, including a physician’s federal conviction record, compliance with “Federal ... laws relating to controlled substances,” and “other conduct which may threaten public health and safety.” Id. The majority’s contention that the Attorney General cannot suspend or revoke a physician’s registration without state authorization ignores Mississippi Band’s “plain indication” rule and contravenes Congress’s clearly expressed intent.
The majority also cites Washington v. Glucksberg, 521 U.S. 702, 735, 737, 117 S.Ct. 2258, 138 L.Ed.2d 772 (1997) (O’Con-nor, J., concurring), for the position that the Attorney General must defer to the Oregon Act because “[pjhysician-assisted suicide is an unrelated, general medical practice to be regulated by the States in the first instance.” Glucksberg, however, addressed states’ authority to prohibit physician-assisted suicide in the absence of federal regulation; the case did not answer the question whether Congress may exercise its Commerce Clause power to deny physicians access to controlled substances for physician-assisted suicide. Rather than place federalism limitations on the federal government’s authority to restrict physician-assisted suicide, Justice O’Connor’s concurring opinion stressed that “[tjhere is no reason to think the democratic process will not strike the proper balance between the interests of terminally ill ... individuals ... and the State’s interests in protecting those who might seek to end life mistakenly or under pressure.” Id. at 737, 117 S.Ct. 2258. Simply put, courts should defer to the political process instead of interposing hasty constitutional constraints.
Glucksberg does not require the Attorney General to interpret the Controlled Substances Act and its implementing regulations according to state standards of professional conduct. Rather, the Supreme Court’s decision stands for the broader proposition that federal courts generally should keep their distance, allowing the political process to decide whether and how to regulate physician-assisted suicide. The majority’s shortsighted decision to declare the Ashcroft Directive invalid has precisely the opposite effect.
3.
As an alternative, the majority contends that the Secretary of Health and Human Services (Secretary) — not the Attorney General — should decide whether medical practices are “legitimate” and consistent with the “public interest” under the Controlled Substances Act and its implementing regulations. The Controlled Substances Act’s text directly contradicts this argument: “The Attorney General may deny an application for ... registration [of a practitioner to dispense drugs] if he determines that the issuance of such registration would be inconsistent with the public interest.” 21 U.S.C. § 823(f) (emphasis added). Congress could not have stated more plainly that the Attorney General, not the Secretary, has authority to deter*1138mine whether a physician’s registration is consistent with the public interest.
The majority’s reading of section 823 is a particularly astonishing exercise in statutory construction because the Controlled Substances Act specifically provides for the Secretary’s participation in other discretionary judgments. See, e.g., 21 U.S.C. § 811(b) (providing that the Secretary’s determination with respect to the classification of controlled substances “shall be binding on the Attorney General”); id. § 823(f) (authorizing the Secretary to evaluate a practitioner’s “qualifications and competency” to perform “research with controlled substances”); id. (stating that the Secretary “shall consult with the Attorney General as to effective procedures to adequately safeguard against diversion of ... controlled substances from legitimate medical or scientific use”); id. § 823(g)(2)(H)® (empowering the Secretary to “issue regulations ... or issue practice guidelines” for the approval of “additional credentialing bodies”). When Congress wished to entrust a discretionary judgment to the Secretary it said so explicitly. The Controlled Substances Act conspicuously omits any reference to the Secretary, however, when discussing the Attorney General’s authority to assess “the public interest” for purposes of ordinary physician registrations. Id. § 823(f). The explanation for this omission is perfectly clear: section 823 authorizes the Attorney General' — not the Secretary — to decide whether a physician’s registration is consistent with the public interest.
The majority asserts that under the Controlled Substance Act all standards of legitimate professional conduct are set by the Secretary, not by the Attorney General. The majority’s argument relies on a section of the Act entitled “Medical Treatment of Narcotic Addiction,” which is located in a different title of the legislation. This section provides that the Secretary, “after consultation with the Attorney General ..., shall determine the appropriate methods of professional practice in the medical treatment of ... narcotic addiction.” 42 U.S.C. § 290bb 2a (emphasis added). Obviously, this is irrelevant to the issue before us. Yet from this narrow provision, the majority draws the sweeping, untenable conclusion that the Attorney General cannot enforce the Controlled Substances Act against a physician unless the Secretary first concludes that the prescription did not issue for a “legitimate medical purpose.”
The Supreme Court rejected a similar challenge to the Attorney General’s interpretive authority in Moore. The Court explained that Congress designed subsection 290bb 2a to function only as a limited safe-harbor for physicians who prescribe controlled substances to drug addicts; as long as physicians employ the treatment methods outlined in the Secretary’s published standards of professional practice, the Attorney General may not prosecute them under the Controlled Substances Act. Moore, 423 U.S. at 144, 96 S.Ct. 335. The Court recognized, however, that “[t]he negative implication [of this provision] is that physicians who go beyond approved practice remain subject to serious criminal penalties.” Id. In other words, section 290bb-2a prevents the Attorney General from enforcing the Controlled Substances Act and its implementing regulations only when the Secretary declares that a specific narcotic addiction treatment serves a “legitimate medical purpose.”
We confirmed Moore’s reading of subsection 290bb 2a in Rosenberg, holding that the Attorney General may enforce the Controlled Substances Act against physicians whose practices do not qualify for protection under the Secretary’s specific safe-harbor guidelines. We explained that the Secretary’s authority to
*1139determine the appropriate method of professional practice in the medical treatment of narcotic addiction ... was adopted in light of Congress’ awareness that there had been criminal prosecution of physicians whose methods of prescribing narcotic drugs have not conformed to the opinions of Federal prosecutors. The committee evidenced no intention to restrict such prosecutions. Indeed[,] they seemed to think [these prosecutions] would continue, but that some standards of professional practice should be established so that ... physicians who comply with the recommendations made by the Secretary will no longer jeopardize their professional careers by accepting narcotic addicts as patients.
515 F.2d at 194-95 (emphasis added) (internal quotations omitted), citing H.R. REP. NO. 91-1444, reprinted in 1970 U.S.C.C.A.N. at 4581 (observing that “for the last 50 years” federal officials have “determine[d] the appropriate method of the practice of medicine ... through ... criminal prosecution[s]” and suggesting that these prosecutions should continue subject to the Secretary’s limited guidelines for treatment of narcotic addiction); see also H.R. REP. NO. 93-884 (1974), reprinted in 1974 U.S.C.C.A.N. 3029, 3034 (recognizing that “[t]he registration required under [the section of the Controlled Substances governing treatment of narcotic addiction] is separate and distinct from regular registration under the Controlled Substances Act,” which is administered by the Attorney General (emphasis added)).
Here the Petitioners have not shown and do not contend that the Secretary’s guidelines approve physician-assisted suicide as an “appropriate method[] of professional practice in the medical treatment of ... narcotic addiction.” 42 U.S.C. § 290bb 2a (emphasis added). As such, subsection 290bb 2a’s safe-harbor rule does not apply, and the Attorney General was not required to consult the Secretary prior to issuing his determination that physician-assisted suicide does not constitute a “legitimate medical purpose” under 21 C.F.R. § 1306.04(a).
4.
The majority maintains that even if the Controlled Substances Act authorizes the Attorney General to ascertain whether physician-assisted suicide is “inconsistent with the public interest,” General Ashcroft abused his discretion in this case by failing to consider all five factors outlined in 21 U.S.C. § 823(f). Subsection (f) provides in part that “[i]n determining the public interest, the following factors shall be considered”:
(1) The recommendation of the appropriate State licensing board or professional disciplinary authority.
(2) The applicant’s experience in dispensing, or conducting research with respect to controlled substances.
(3) The applicant’s conviction record under Federal or State laws relating to the manufacture, distribution, or dispensing of controlled substances.
(4) Compliance with applicable State, Federal, or local laws relating to controlled substances.
(5) Such other conduct which may threaten the public health and safety.
28 U.S.C. § 823(f). The Ashcroft Directive is invalid, the majority argues, because General Ashcroft “made no effort to solicit input from the State of Oregon before issuing” the interpretive rule.
Contrary to the majority’s assertion, the Ashcroft Directive does not sidestep subsection 823(f)’s five-factor inquiry. The Justice Department has yet to initiate an enforcement action against any individual physician pursuant to section 824, so the hour has not arrived for the Attorney General to consider subsections 823(f)(l)-(4) *1140(i.e., the state licensing board’s recommendation and physicians’ relevant experience and criminal record). The Ashcroft Directive merely cautions that a physician who prescribes controlled substances to assist suicide “may ‘render his registration ... inconsistent with the public interest,’ ” Ashcroft Directive, 66 Fed.Reg. at 56,608 (emphasis added); it does not declare that assisting suicide shall render a physician’s registration inconsistent with the public interest. This word choice is significant, because it conclusively refutes the majority’s contention that assisting suicide automatically renders a physician’s registration “inconsistent with the public interest” under the Ashcroft Directive. Even if “assisting suicide is not a ‘legitimate medical purpose’ within the meaning of 21 C.F.R. § 1306.04 (2001),” the Attorney General remains free to consult all of section 823’s five factors' — including the recommendation of Oregon’s licensing board or disciplinary authority — before making a final decision whether to suspend or revoke a particular physician’s registration.
Significantly, the Ashcroft Directive’s warning that assisting suicide could prompt Controlled Substances Act enforcement actions comports with fundamental administrative law principles:
When a governmental official is given the power to make discretionary decisions under a broad statutory standard [e.g., “the public interest”], case-by-case decisionmaking may not be the best way to assure fairness. Here the [Attorney General] ... sought to define the statutory standard ... by the use of his rulemaking authority. The decision to use objective rules in this case provides [physicians] with more precise notice of what conduct will be sanctioned and promotes equality of treatment among similarly situated [individuals].
Dixon v. Love, 431 U.S. 105, 115, 97 S.Ct. 1723, 52 L.Ed.2d 172 (1977). The Controlled Substances Act facilitates adherence to these principles by expressly authorizing the Attorney General to “promulgate and enforce any rules, regulations, and procedures which he may deem necessary and appropriate for the efficient execution of his functions under this subchapter.” 21 U.S.C. § 871. Thus, General Ashcroft acted well within the scope of his statutory authority in declaring that assisting suicide does not serve a “legitimate medical purpose” under 21 C.F.R. § 1306.04(a) and that this practice “may ‘render [a physician’s] registration ... inconsistent with the public interest’ and therefore subject to possible suspension or revocation under [section] 824.” Ashcroft Directive, 66 Fed.Reg. at 56,608.
5.
Finally, the majority argues that the Ashcroft Directive exceeds the Attorney General’s statutory authority because Congress has not clearly authorized the Attorney General to upset the delicate balance between federal regulation of controlled substances and state control of medical practices. As support for this conclusion, the majority invokes the Supreme Court’s recent analysis in Solid Waste Agency of Northern Cook County v. U.S. Army Corps of Engineers, 531 U.S. 159, 121 S.Ct. 675, 148 L.Ed.2d 576 (2001):
Where an administrative interpretation of a statute invokes the outer limits of Congress’ power, we expect a clear indication that Congress intended that result. This requirement stems from our prudential desire not to needlessly reach constitutional issues and our assumption that Congress does not casually authorize administrative agencies to interpret a statute to push the limit of congressional authority. This concern is heightened where the administrative interpretation alters the federal-state framework by *1141permitting federal encroachment upon a traditional state power.
Id. at 172-73, 121 S.Ct. 675 (internal citations omitted), citing Edward J. DeBartalo Corp. v. Fla. Gulf Coast Bldg. & Constr. Trades Council, 485 U.S. 568, 575, 108 S.Ct. 1392, 99 L.Ed.2d 645 (1988). See generally id. at 172-74, 108 S.Ct. 1392 (refusing to afford deference to an agency-regulation that raised a serious constitutional issue where there was no indication in the statute that Congress intended to encroach on traditional state powers over land and water use). Although the Court addressed the validity of “an administrative interpretation of a statute,” id. at 172, 121 S.Ct. 675 (emphasis added), its reasoning should apply equally to an administrative interpretation of an agency regulation.
Solid Waste’s clear statement rule is based upon understandable and significant federalism concerns, the importance of which I do not doubt. The question we must ask ourselves, however, is whether this canon of statutory interpretation applies to the case before us.
Not every colorable constitutional question triggers Solid Waste’s clear statement rule. Our past decisions dictate that we must “scrutinize constitutional objections to[the] agency interpretation skeptically. Only if the agency’s proffered interpretation raises serious constitutional concerns may [we] refuse to defer.... ” Williams v. Babbitt, 115 F.3d 657, 662 (9th Cir.1997), citing Republican Nat’l Comm. v. Fed. Election Comm’n, 76 F.3d 400, 409 (D.C.Cir.1996). As such, the proper approach here is to proceed directly to the merits of Petitioners’ constitutional challenge, deciding whether the agency interpretation “raise[s] the sort of grave and doubtful constitutional questions” that could lead us to “invalidate the regulations in order to save the statute from unconstitutionality.” Rust, 500 U.S. at 191, 111 S.Ct. 1759 (internal quotation marks omitted); see also United States v. Deaton, 332 F.3d 698, 704-08 (4th Cir.2003) (construing the Solid Waste canon in light of Rust and deciding the disputed constitutional question to determine if it is serious enough to warrant requiring a clear statement). Only if the Attorney General’s proposed interpretation would likely render the statute unconstitutional do we apply Solid Waste’s clear statement canon. See Williams, 115 F.3d at 663 (“Rust ... limits this intrusion on agency power to situations where it’s absolutely necessary.”). Applying these principles, we should not require a clear statement in this case because controlling precedent compels the conclusion that the Attorney General’s interpretation did not invoke “the outer limits” of Congress’s Commerce Clause power. Solid Waste, 531 U.S. at 172, 121 S.Ct. 675; see also Republican Nat’l Comm., 76 F.3d at 409 (“Because we can easily resolve the [constitutional] challenges through the application of controlling precedent ..., we do not face the sort of serious constitutional questions ‘that would lead us to assume Congress did not intend to authorize the [regulation’s] issuance.’ ” (quoting Rust, 500 U.S. at 191, 111 S.Ct. 1759)).
The Commerce Clause empowers Congress to regulate (1) “the use of the channels of interstate commerce”; (2) “the in-strumentalities of interstate commerce, or persons or things in interstate commerce”; and (3) “those activities that substantially affect interstate commerce.” United States v. Lopez, 514 U.S. 549, 558-59, 115 S.Ct. 1624, 131 L.Ed.2d 626 (1995). Our court has long recognized that “the Commerce Clause empowers the federal government to regulate prescription drugs,” In re Grand Jury Proceedings, 801 F.2d 1164, 1169 (9th Cir.1986) (per curiam); accord Rosenberg, 515 F.2d at 198. We have steadfastly upheld the Controlled Substances Act against Commerce Clause *1142challenges, even in cases involving wholly intrastate activity. See, e.g., United States v. Tisor, 96 F.3d 370, 375 (9th Cir.1996); United States v. Kim, 94 F.3d 1247, 1250 (9th Cir.1996). But see Raich v. Ashcroft, 352 F.3d 1222, 1227-28 (9th Cir.2003) (stating that the Controlled Substances Act, as applied to “the intrastate, noncommercial cultivation and possession of cannabis for personal medical purposes as recommended by a patient’s physician pursuant to a valid California state law,” likely exceeded Congress’s Commerce Clause power).
Turning to the specific issue raised here — whether the prescription or dispensation of controlled substances to assist suicide substantially affects interstate commerce — we base our assessment on four factors:
1) whether the statute in question regulates commerce or any sort of economic enterprise; 2) whether the statute contains any express jurisdictional element which might limit its reach to a discrete set of cases; 3) whether the statute or its legislative history contains express congressional findings that the regulated activity affects interstate commerce; and 4) whether the link between the regulated activity and a substantial effect on interstate commerce is attenuated.
United States v. McCoy, 323 F.3d 1114, 1119 (9th Cir.2003) (internal quotation marks omitted). Of these four factors, the first and last are most important. Id.
The Ashcroft Directive clearly satisfies McCoy’s first and the last criteria. The Ashcroft Directive regulates economic transactions: physicians generally prescribe and dispense controlled substances for a fee. There is no indication here, as there was in Raich with regards to medicinal marijuana, that drug-induced physician-assisted suicide “does not involve [the] sale, exchange, or distribution” of controlled substances. Raich, 352 F.3d at 1229. The link between these transactions and their effect on interstate commerce is not attenuated simply because relatively few Oregonians use controlled substances for assisted suicide. We evaluate whether an activity’s link to interstate commerce is attenuated by assessing whether its effect on interstate commerce is sufficiently direct, Solid Waste, 531 U.S. at 195, 121 S.Ct. 675; McCoy, 323 F.3d at 1123-24, and we assess individual provisions as “part[s] of a wider regulatory scheme” (i.e., the Controlled Substances Act), which regulates a field of drug-related activity that has “a ‘substantial affect’ on interstate commerce,” Tisor, 96 F.3d at 375. Here Congress naturally and directly reduces the amount of a controlled substance that flows through the interstate channels when it prohibits the substance’s distribution for a particular use. Thus, the link between drug prescriptions and interstate commerce is sufficiently direct and substantial even if the drugs ultimately are used in intrastate activities such as physician-assisted suicide and the activities’ disaggregated effect on interstate commerce is small.
Because the Ashcroft Directive satisfies McCoy’s first and last factors, we need not consider whether it meets the other, less important ones. See McCoy, 323 F.3d at 1119 (explaining that the second and third factors may “aid” the court’s analysis, but “are ordinarily not, in themselves, disposi-tive”); id. at 1126-27 (observing that legislative history is “neither necessary nor conclusive” in Commerce Clause analysis). Under McCoy, Congress’ Commerce Clause power to prohibit physicians from prescribing controlled substances to assist suicide is not open to serious question. That ends the matter in this circuit and, of course, for this case.
*1143The majority cannot have it otherwise. Their argument that “direct control of medical practice in the states is beyond the power of the federal government” misses the point. Linder v. United States, 268 U.S. 5, 18, 45 S.Ct. 446, 69 L.Ed. 819 (1925) (emphasis added). Unless and until the Supreme Court directs us differently, our opinions and other binding precedent compel the conclusion that Congress acts comfortably within its Commerce Clause power when it regulates the prescription and dispensation of controlled substances. See Minor v. United States, 396 U.S. 87, 98 n. 13, 90 S.Ct. 284, 24 L.Ed.2d 283 (1969) (stating that “a flat ban on certain [drug transactions] ... is sustainable under the powers granted Congress” by the Commerce Clause); Reina v. United States, 364 U.S. 507, 511, 81 S.Ct. 260, 5 L.Ed.2d 249 (1960) (referring to Congress’s “undoubted power to enact the narcotics laws”); Tisor, 96 F.3d at 375 (“[D]rug trafficking is a commercial activity which substantially affects interstate commerce.”); Kim, 94 F.3d at 1250 n. 4 (recognizing that Congress may regulate controlled substances pursuant to the Commerce Clause even when legislation “intrudes into an area traditionally regulated by states”); Rosenberg, 515 F.2d at 198 (dubbing an analogous constitutional challenge “singularly unpersuasive”). General Ashcroft’s interpretation of 21 C.F.R. § 1306.04(a) does not, therefore, “invoke[ ] the outer limits of Congress’ power,” Solid Waste, 531 U.S. at 172, 121 S.Ct. 675, the clear statement rule does not apply, and we must evaluate the Ashcroft Directive according to ordinary standards of deference.
D.
The Petitioners contend that the Ashcroft Directive constitutes an arbitrary and capricious interpretation of section 1306.04(a)’s “legitimate medical practice” requirement. General Ashcroft’s determination is arbitrary and capricious, they argue, because he failed to examine the “wealth” of substantive data documenting the Oregon Act’s effect on public health and safety. They point to a collection of studies which indicate that the Oregon Act’s procedures have not been used disproportionately by the poor, uneducated, or uninsured. “Normally, an agency rule would be arbitrary and capricious if the agency ... entirely failed to consider an important aspect of the problem.” Motor Vehicle Mfrs. Ass’n v. State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 43, 103 S.Ct. 2856, 77 L.Ed.2d 443 (1983).
Although these empirical studies might be socially important, their findings were not an “important aspect of the problem” confronted by the Attorney General. General Ashcroft had before him a single question: whether physician-assisted suicide is a “legitimate medical purpose” as defined in existing case law, federal policy, general state law, and medical opinion. Evidence that Oregon physicians used the Oregon Act’s procedures disproportionally against the poor, uneducated, or uninsured could have strengthened his conclusion that physician-assisted suicide is not a “legitimate medical purpose,” but it does not follow that the absence of such evidence means physician-assisted suicide is a “legitimate medical practice.” Thus, whether the Oregon Act provided adequate safeguards for vulnerable groups was not a sufficiently important aspect of the Attorney General’s inquiry to render the Ashcroft Directive an arbitrary and capricious agency action.
Furthermore, Petitioners’ assertion that General Ashcroft “entirely failed to consider” Oregon’s position on the social benefits of physician-assisted suicide is plainly false. The Attorney General based his decision on a memorandum from the Office of Legal Counsel, which considered, but rejected, Oregon’s position in favor of ex*1144isting case law, federal policies and practices, the majority state position, and the dominant views of the American medical and nursing professions. See Memorandum from Shelden Bradshaw, Deputy Assistant Attorney General, and Robert J. Delahunty, Special Counsel, Memorandum for the Attorney General: Whether Physician-Assisted Suicide Serves a “Legitimate Medical Purpose” Under the Drug Enforcement Administration’s Regulations Implementing the Controlled Substances Act (Memorandum) 5-14 (June 27, 2001). Thus, Petitioners have not shown that General Ashcroft’s decision to reject the Oregon Act’s permissive approach to physician-assisted suicide was “arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law.” 5 U.S.C. § 706(2)(a).
III.
Having demonstrated the fallacies of the foregoing challenges to the Ashcroft Directive, I now consider what standard of review this court should apply when assessing the Ashcroft Directive’s validity. The degree of deference we accord an interpretive rule depends upon whether the rule construes a statute or an agency regulation.
If the Ashcroft Directive represents a statutory interpretation, it enjoys deference as defined in Skidmore v. Swift & Co., 323 U.S. 134, 65 S.Ct. 161, 89 L.Ed. 124 (1944). Omohundro v. United States, 300 F.3d 1065, 1067-68 (9th Cir.2002). Under Skidmore, “[t]he weight of such a judgment in a particular case will depend upon the thoroughness evident in its consideration, the validity of its reasoning, its consistency with earlier and later pronouncements, and all those factors which give it power to persuade, if lacking power to control.” Skidmore, 323 U.S. at 140, 65 S.Ct. 161. Especially relevant under Skidmore is the fact that the Ashcroft Directive reverses the agency’s earlier interpretation. See Cmty. Hosp. of the Monterey Peninsula v. Thompson, 323 F.3d 782, 792 (9th Cir.2003) (“An agency interpretation ... which conflicts with the agency’s earlier interpretation is entitled to considerably less deference than a consistently held agency view.” (internal brackets, quotation marks, and citation omitted)). The agency “is not disqualified from changing its mind,” however, “and when it does, the courts still sit in review of the administrative decision and should not approach the statutory construction issue de novo and without regard to the administrative understanding of the statutes.” NLRB v. Local Union No. 103, Int’l Ass’n of Bridge, Structural & Ornamental Iron Workers, 434 U.S. 335, 351, 98 S.Ct. 651, 54 L.Ed.2d 586 (1978).
If the Ashcroft Directive interprets an agency regulation, rather than the Controlled Substances Act itself, we must accord it “substantial deference.” Thomas Jefferson Univ. v. Shalala, 512 U.S. 504, 512, 114 S.Ct. 2381, 129 L.Ed.2d 405 (1994). Under this highly deferential standard,
[o]ur task is not to decide which among several competing interpretations best serves the regulatory purpose. Rather, the agency’s interpretation must be given controlling weight unless it is plainly erroneous or inconsistent with the regulation. In other words, we must defer to the Secretary’s interpretation unless an alternative reading is compelled by the regulation’s plain language or by other indications of the Secretary’s intent at the time of the regulation’s promulgation.
Id. (internal citations and quotation marks omitted). Agency interpretations of regulations enjoy substantial deference even if they are inconsistent with the agency’s prior interpretations. As the Supreme Court explained in Thomas Jefferson, an agency “is not estopped from changing a *1145view[it] believes to have been grounded upon a mistaken legal interpretation.” Id. at 517, 114 S.Ct. 2381 (internal quotation marks and citation omitted). “[WJhere the agency’s interpretation of [its regulation] is at least as plausible as competing ones, there is little, if any, reason not to defer to its construction.” Id. (internal quotation marks and citation omitted) (second brackets in original).
In my view, the Ashcroft Directive constitutes an interpretation of a regulation rather than a statutory interpretation. The Ashcroft Directive’s single interpretive act is to “determine that assisting suicide is not a ‘legitimate medical purpose’ within the meaning of 21 C.F.R. § 1306.04 (2001).” Ashcroft Directive, 66 Fed.Reg. at 56,608. The Petitioners point to General Ashcroft’s warning that prescribing a controlled substance to assist suicide may render a physician’s registration subject to suspension or revocation under section 824(a)(4). This statement was not an interpretation of the Controlled Substances Act, however, but an explanation of the logical consequences flowing from General Ashcroft’s interpretation of 21 C.F.R. § 1306.04. If assisting suicide is not a “legitimate medical purpose,” the direct result is that a physician cannot prescribe controlled substances for this purpose without violating Controlled Substances Act section 829 and thereby risking suspension or revocation of their registration under sections 823 and 824. See 21 U.S.C. § 823(f)(4) (stating that a physician’s violation of federal law is relevant to determine if his registration is inconsistent with the public interest); id. § 824(a)(4) (providing that a physician’s registration may be revoked for acts inconsistent with the public interest under section 823). Petitioners’ contention that General Ashcroft was interpreting the word “practitioner” under 21 U.S.C. § 829 is likewise wrong. Nothing in the Ashcroft Directive turns upon the definition of “practitioner.” Thus, the Ashcroft Directive qualifies for Thomas Jefferson’s highly deferential standard of review.
Applying the Thomas Jefferson standard, I have no trouble upholding the Ashcroft Directive from Petitioners’ attack. As the Office of Legal Counsel concluded:
[TJhe overwhelming weight of authority in judicial decisions, the past and present policies of nearly all of the States and of the Federal Government, and the clear, firm and unequivocal views of the leading associations within the American medical and nursing professions, establish that assisting in suicide is not an activity undertaken in the course of professional medical practice and is not a legitimate medical purpose. Indeed, we think it fair to say that physician-assisted suicide should not be considered a medical procedure at all.... It is plainly a fallacy to assume that a procedure must be “medical” because it is performed by a physician rather than, say, by a family member, or because it involves the use of a drug that a physician has prescribed.
Memorandum at 13-14; see also Ashcroft Directive, 66 Fed.Reg. at 56,608 (stating that the Memorandum “sets forth the legal basis for my decision”). ’ In Glucksberg, the Supreme Court offered a similar assessment: “opposition to and condemnation of suicide — and, therefore, of assisting suicide — are consistent and enduring themes of our philosophical, legal, and cultural heritages. More specifically, for over 700 years, the Anglo American common-law tradition has punished or otherwise disapproved of both suicide and assisting suicide.” Glucksberg, 521 U.S. at 711, 117 S.Ct. 2258 (internal citations omitted). Given this overwhelming historical, legal, and medical consensus that physician-assisted suicide is not a legitimate medical purpose, the Ashcroft Directive clearly satisfies Thomas Jefferson. Therefore, I *1146would defer to the Ashcroft Directive’s conclusion that physician-assisted suicide is not a “legitimate medical practice” under 21 C.F.R. § 1306.04(a).
IV.
Although I concur with the majority’s brief discussion on justiciability and its conclusion as to our jurisdiction, I write separately to address the latter, as it is contested by the parties and resolved improperly by the district court, yet given scant attention by the majority. The majority suggests that Hemp Industries Association v. DEA, 333 F.3d 1082 (9th Cir.2003), is dispositive, but Hemp Industries declined to answer the precise question at issue here; that is, we left open “whether we would have original jurisdiction over an interpretive rule.” Id. at 1085. A more thorough analysis is therefore needed to determine whether the Ashcroft Directive, which by its terms is an interpretive rule, is a “final determination” within the meaning of 21 U.S.C. § 877 over which we would have jurisdiction.
Section 877 provides that “[a]11 final determinations, findings, and conclusions of the Attorney General under this subchap-ter shall be final and conclusive decisions of the matters involved.” 21 U.S.C. § 871. The section provides us original jurisdiction where “any person aggrieved by a final decision of the Attorney General” seeks “review of the decision.” Id. Significantly, the Ashcroft Directive echoes the language of this provision by “advis[ing] ... that the original DEA determination is reinstated and should be implemented.” Ashcroft Directive, 66 Fed.Reg. 56,608 (emphasis added); see also, e.g., id. (“I hereby determine that assisting suicide is not a ‘legitimate medical purpose’ within the meaning of 21 C.F.R. § 1306.04 (2001) .... ” (emphasis added)); id. (“I hereby direct the DEA ... to enforce and apply this determination .... ” (emphasis added)). Although helpful, the Attorney General’s choice of words does not necessarily mean his “determination” is “final.”
The district court held that the Ashcroft Directive is not “final” because General Ashcroft kept his own counsel, gave no notice or opportunity for comment, took no evidence, and did not produce an administrative record. As the district court observed, there is a paucity of appellate court decisions analyzing section 877’s requirements for review. In order to respond to the district court’s argument, therefore, I must reason by analogy and look to general principles of administrative law formulated under the APA. See U.S. West Communications, Inc. v. Hamilton, 224 F.3d 1049, 1054-55 (9th Cir.2000) (using the AJPA’s definition of “final” to interpret “final orders” under the Hobbs Act). For an agency action to be final under the APA, the agency need not obtain outside advice. It need not give notice and an opportunity to comment. Guadamuz v. Bowen, 859 F.2d 762, 771 (9th Cir.1988). Absent a contrary command under the governing statute, the agency need not produce an administrative record, especially for review of purely legal questions such as those in the case before us.
As the Supreme Court held in Bennett v. Spear, 520 U.S. 154, 117 S.Ct. 1154, 137 L.Ed.2d 281 (1997), an agency action is “final” under the APA if it satisfies two criteria: (1) “the action must mark the consummation of the agency’s decision making process — it must not be of a merely tentative or interlocutory nature”; and (2) “the action must be one by which rights or obligations have been determined, or from which legal consequences will flow.” Id. at 177-78, 117 S.Ct. 1154 (internal citations and quotation marks omitted). In evaluating whether an agency action meets these conditions, relevant considerations include: (a) whether the action is a “definitive statement of an agency’s position,” (b) whether it has a “direct and immediate *1147effect on the complaining parties,” (c) whether it “has the status of law,” and (d) whether it “requires immediate compliance.” Assn. of Am. Med. Colls. v. United States, 217 F.3d 770, 780 (9th Cir.2000).
As an interpretive rule, the Ashcroft Directive does not have the “force of law.” Hemp Indus. Ass’n, 333 F.3d at 1087. Nevertheless, this does not necessarily preclude the Ashcroft Directive from constituting a “final determination.” In Abbott Laboratories v. Gardner, 387 U.S. 136, 87 S.Ct. 1507, 18 L.Ed.2d 681 (1967), overruled on other grounds, Califano v. Sanders, 430 U.S. 99, 97 S.Ct. 980, 51 L.Ed.2d 192 (1977), the Supreme Court announced that finality is to be interpreted “in a pragmatic way,” meaning that even pre-enforcement regulations that merely state an agency’s intentions may be final for review. Id. at 149-50, 87 S.Ct. 1507; see also Alaska v. EPA 244 F.3d 748, 750 (9th Cir.2001) (order) (holding that the EPA’s pre-enforcement order to invalidate a permit was final). Because an interpretive rule can be a final order, and because “final orders” are analytically equivalent to “final agency actions,” U.S. West Communications, 224 F.3d at 1055, it follows that interpretive rules can constitute final agency actions under the APA. Thus, the Ashcroft Directive may qualify as a final agency action notwithstanding the fact that it has not been enforced and does not have the force of law.
Turning to the first Bennett requirement, the Ashcroft Directive clearly marks the consummation of the Attorney General’s decision making process even though it is a nonbinding, pre-enforcement, interpretive rule. The Ashcroft Directive reflects internal agency deliberation, on a matter of public importance, and commands immediate implementation. Eschewing tentative or equivocal words, it speaks in the immediate and imperative language of final agency action. See Ashcroft Directive, 66 Fed.Reg. at 56,608 (“I hereby direct the DEA ... to enforce and apply this determination .... ”); accord Nat’l Automatic Laundry & Cleaning Council v. Shultz, 443 F.2d 689, 702 (D.C.Cir.1971) (holding that “when [an agency’s] interpretation is not labeled as tentative or otherwise qualified by arrangement for reconsideration” there is “no basis” for concluding that the “ ‘agency action’ is ‘not final’ for purposes of the APA and judicial review”). The Ashcroft Directive purports to be the Attorney General’s interpretation, not the interpretation of an underling whose view may be overruled. Accord Nat’l Automatic Laundry, 443 F.2d at 701 (reasoning that “with the authoritative interpretative ruling by the [agency head,] the agency’s interpretative action has come to an end, and there is no fair basis for saying this process will be disrupted by judicial review”). In addition, the Attorney General’s decision to publish the Ashcroft Directive in the Federal Register, rather than simply issue a press release or send an opinion letter to a private party, indicates that the Ashcroft Directive represents the consummation of his decision-making process. For these reasons, the Ashcroft Directive clearly satisfies the first Bennett inquiry.
The next question under Bennett is whether legal consequences flow from the agency action. 520 U.S. at 178, 117 S.Ct. 1154. Relevant factors include whether the agency action has a “direct and immediate . effect” on the complaining parties and requires their “immediate compliance.” Am. Med. Colls., 217 F.3d at 780. As explained previously, an interpretive rule may be a final agency action even though it is not legally binding.
The Ashcroft Directive satisfies this second requirement as well. Although it may not have the force of law, the Ashcroft Directive significantly and immediately alters the legal landscape for Oregon physi*1148cians. See Bennett, 520 U.S. at 178, 117 S.Ct. 1154 (holding that an agency action met this requirement because it had similar “direct and appreciable legal consequences”); Abbott Labs., 387 U.S. at 152-53, 87 S.Ct. 1507 (holding that where plaintiffs must either comply with unfavorable regulations immediately or “risk serious criminal and civil penalties,” the agency action satisfies this requirement). The Ashcroft Directive “directfs] the DEA, effective upon publication of this memorandum in the Federal Register, to enforce and apply” the Attorney General’s interpretation of 21 C.F.R. § 1306.04(a). This instruction created direct and immediate consequences for physicians who wish to prescribe controlled substances for assisted suicide.
It is of no moment that physicians will not experience the Ashcroft Directive’s concrete legal effects unless they actually choose to prescribe controlled substances for assisted suicide. An agency action can be final even if its concrete legal effects are contingent upon a future event. City of Fremont v. FERC, 336 F.3d 910, 914 (9th Cir.2003) (concluding that agency orders that attach legal consequences to future proceedings are final for judicial review). The Ashcroft Directive requires the physicians’ immediate compliance. Thus, it satisfies Bennett’s second requirement for finality.
Because the Ashcroft Directive constitutes a final agency action under Bennett, the instant petition for review falls squarely within this court’s original jurisdiction. I therefore concur in the majority’s assessment that, the district court was without jurisdiction and the petition should be considered transferred to this court under 28 U.S.C. § 1631.
V.
Although I am convinced of the merits of my legal argument, I admit that even if I persuaded one of my colleagues to join me, my opinion would not be a final chapter. Those who are uneasy with my position (as I assume Petitioners will be) should see its limited grasp. The Ashcroft Directive constitutes a final agency action, but it surely will not be the last word on physician-assisted suicide. The Ashcroft Directive does not spell the end of the public’s “earnest and profound debate about the morality, legality, and practicality of physician-assisted suicide,” Glucksberg, 521 U.S. at 735, 117 S.Ct. 2258, nor does it halt states’ “extensive and serious evaluation of physician-assisted suicide and other related issues,” Glucksberg, 521 U.S. at 736, 737, 117 S.Ct. 2258 (O’Connor, J., concurring). State legislators may supplement the Ashcroft Directive’s sanctions, and they may authorize alternative methods for assisting suicide that do not involve the prescription of controlled substances.
More to my point, the Ashcroft Directive is not even an immutable expression of federal policy. A change in presidential administrations or a shift in the current President or Attorney General’s perspective might precipitate the Ashcroft Directive’s rescission. Certainly, Congress is free to enact legislation limiting or counteracting the Ashcroft Directive’s effects. Although opinions differ over the propriety of assisted suicide, I fully subscribe to Justice O’Connor’s canny observation that there is simply “no reason to think that 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 [government’s interests in protecting those who might seek to end life mistakenly or under pressure.” Id. In short, we should trust the democratic process.
Thus, the discrete question before this court is a narrow one: is the Attorney *1149General’s interpretation of 21 C.F.R. § 1306.04 entitled to deference? Nothing in the Controlled Substances Act’s text or legislative history authorizes the majority to deny deference to the Ashcroft Directive. As an interpretive rule, the Ashcroft Directive is not subject to the APA’s notice-and-comment rulemaking procedures. It does not violate the Controlled Substances Act’s nonpreemption provision. It neither exceeds the Attorney General’s statutory authority under the Controlled Substances Act nor “push[es] the limit of congressional authority” under the Commerce Clause. Solid Waste, 531 U.S. at 173, 121 S.Ct. 675. Petitioners have not demonstrated that the Ashcroft Directive’s interpretation of section 1306.04 is arbitrary and capricious. For these reasons, firmly established principles of administrative law formulated by the Supreme Court and our court command us to defer to the Attorney General’s interpretation of section 1306.04.
Therefore, I dissent.