Review under the rational basis standard " ... is the most relaxed and tolerant form of judicial scrutiny under the Equal Protection Clause." Dallas v. Stanglin, 490 U.S. 19, 26 (1989). In discussing the rational basis standard in McGowan v. Maryland, the Court stated that:

        "Although no precise formula has been developed,

        the Court has held that the Fourteenth Amendment 

        permits the States a wide scope of discretion in 

        enacting laws which affect some groups of citizens

        differently than others. The constitutional safeguard 

        is offended only if the classification rests on grounds

        wholly irrelevant to the achievement of the State's

        objective. State legislatures are presumed to have

        acted within their constitutional power despite the 

        fact that, in practice, their laws result in some 

        inequality. A statutory discrimination will not be set

        aside if any state of facts reasonably may be con-

        cieved to justify it." McGowan v. Maryland, 366

        U.S. 420, 425-426 (1961). See also Dandridge v. 

        Williams, 397 U.S. 471, 485 (1970).

As Justice Stewart observed in his concurring opinion in San Antonio School District v. Rodriguez, 411 U.S. 1, 60 (1973), "[t]his doctrine is no more than a specific application of one of the first principles of constitutional adjudication - the basic presumption of constitutional validity of a duly inacted state or federal law. [citation omitted]" Thus, under the rational basis standard, legislation is first presumed valid and then, shielded by that presumption, tested to determine if the classification it creates is rationally related to a legitimate state interest.(9)

In discussing this presumption in Quill, however, the Second Circuit stated "[t]ht general rule ... is that state legislation carries a presumption of validity if the statutory classification is 'rationally related to a legitimate state interest.' [citation omitted]" Quill, supra, 80 F.3d at 725 (emphasis added). This is incorrect. The existence of the presumption of validity is not conditioned upon a subsequent finding of rational relationship; rather, the presumption precedes application of the standard itself. The Second Circuit's apparent failure to accord New York's statutes the presumption of validity to which they are entitled may provide at least some explanation why the Court utilized such a strict, skeptical, means-end analysis to review the challenged statutes.

While the Second Circuit did identify several important state interests implicated by New York's prohibition of assisted suicide, it went on to conclude that:

               The New York stautes prohibiting assisted sui-

        cide, which are similar to the Washington statute, do

        not serve any of the state interests noted, in view of

        the statutory and common law schemes allowing

        suicide through the withdrawal of life-sustaining

        treatment." Quill, supra, 80 F.3d at 730 (italics

        added).

This holding, like its misidentification of a similarly situated class, is based on the Second Circuit's failure to differentiate between the withdrawal of life-sustaining treatment and the act of suicide. Once this recurrent error is removed from the analysis, however, it immediately becomes clear that New York's prohibition of assisted suicide directly furthers, and thus is rationally related to, several important state interests. Those interests include, but are not limited to: (1) the protection and preservation of human life;(10) (2) the prevention of suicide;(11) (3) preventing the fraud, errors and abuse which would accompany acceptance of suicide and assisted suicide;(12) (4) maintaining the ethical integrity of the medical profession;(13) (5) protecting the poor and minorities from exploitation;(14) (6) protecting handicapped persons from societal indifference;(15) (7) protecting innocent third parties.(16)

The Second Circuit's application of the rational basis standard was further flawed by its improper insertion of quality-of-life considerations into its analysis which it used to discount the State's important interest in the protection and preservation of human life. Quill, supra, 80 F.3d at 729-730. Such quality-of-life considerations are directly contrary to this Court's holding in Cruzan that:

        "[W]e think a State may properly decline to make

        judgements about the 'quality' of life that a particu-

        lar individual may enjoy, and simply assert an

        unqualified interest in the preservation of human 

        life to be weighed against the constitutionally pro-

        tected interests of the individual." Cruzan v. Direc-

        tor, Missouri Dept. of Public Health, 497 U.S. 261, 

        282 (1990).

The dangers inherent in using such quality-of-life considerations are well-recognized. "Were quality of life at issue, persons with all manner of handicaps might find the state seeking to terminate their lives." Cruzan v. Harmon, 760 S.W.2d 408, 420 (Mo. banc 1988), aff'd sub nom. Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261 (1990). Such an analysis also disregards the irrefutable principle that all lives, from beginning to end and irrespective of physical or mental condition, are under the full protection of the law.

        "The life of those to whom life has become a 

        burden - of those who are hopelessly diseased or

        fatally wounded - nay, even the lives of criminals

        condemmed to death, are under the protection of the 

        law, equally as the lives of those who are in full

        tide of life's enjoyment, and anxious to continue to

        live." Cruzan v. Director, Missouri Dept. of Health,

        497 U.S. 261, 295 (1990) (Scalia, J., concurring),

        citing Blackburn v. State, 23 Ohio St. 146, 163

        (1873).

In discounting the State's important interests in the protection and preservation of human life, the Second Circuit also cited this Court's opinion in Planned Parenthood v. Casey, 505 U.S. 833 (1992). That citation was particularly surprising in that Casey itself reaffirms the States' "...legitimate interests from the outset of the pregnancy in protecting the health of the woman and the life of the fetus that may become a child." Casey, supra, 505 U.S. at 846. Nevertheless, the Second Circuit relied on Casey when posing the following rhetorical question:

        "What concern prompts the state to interfere with a 

        mentally competent patient's 'right to define [his]

        own concept of existence, of meaning, of the uni-

        verse, and of the mystery of human life,' Planned 

        Parenthood v. Casey, 505 U.S. 833, 851, 112 S.Ct.

        2791, 2807, 120 L.Ed.2d. 674 (1992), when the 

        patient seeks to have drugs prescribed to end life

        during the final stages of a terminal illness? The

        greatly reduced interest of the state is preserving

        life compels the answer to these questions: 'None.'"

        Quill, supra, 80 F.3d at 730.

There are at least two fundamental flaws in the Second Circuit's reliance on Casey for this proposition. First, it is well-settled that "[i]t is not the province of this Court to create substantive constitutional rights in the name of guaranteeing equal protection of the laws." San Antonio School District v. Rodriguez, 411 U.S. 1, 33 (1973). That, however, was precisely what the Second Circuit did in this case. Within the liberty interest descibed by this Court in Casey, the Second Circuit has created a new right "to have drugs prescribed to end life during the final stages of a terminal illness." Quill, supra, 80 F.3d at 730. Second, this is precisely the sort of "unlimited right to do with one's body as one pleases" which this Court has consistently and soundly rejected. See Roe v. Wade, 410 U.S. 113, 154 (1973); Bowers v. Hardwick, 478 U.S. 186, 191 (1986); and Paris Adult Theatre I v. Slaton, 413 U.S. 48, 68 (1973), citing, inter alia, constitutionally unchallenged laws against suicide.

Finally, in Quill, the Second Circuit suggested that New York could achieve its objective of avoiding undue influence on the elderly and infirm to choose death by "... establish[ing] rules and procedures to assure that all choices [to commit assisted suicide] are free of such pressures." Quill, supra, 80 F.3d at 730 (inserts added). With respect to the definition of "terminal illness", the Second Circuit suggested:

 

        "Again, New York may define the stage of illness

        with greater particularity, require the opinion of

        more than one physician or impose any other obliga-

        tion upon patients and physicians who collaborate

        in hastening death.[footnote omitted]" Quill, supra,

        80 F.3d at 731.

In the footnote which accompanies the quoted text, the Second Circuit went on to suggest numerous other ways in which the State of New York could achieve its objectives but still allow assisted suicide. Quill, supra, 80 F.3d at 734 n. 4. However, this same argument was rejected by the Court in Dallas v. Stanglin, 490 U.S. 19 (1989), and, as in that case, demonstrates a " ... missapprehen[sion] of the nature of rational-basis scrutiny, which is the most relaxed and tolerant form of judicial scrutiny under the Equal Protection Clause." Dallas, supra, 490 U.S. at 26-27. The fact that a state may, if it chooses, seek to achieve its legitimate objectives through other means does not, in any way, establish that the means actually selected are either irrational or arbitrary. Indeed, as this Court observed with respect to the problems of financing and managing a statewide public school system:

        "The very complexity of the problems ... suggests

        that there will be more than one constitutionally

        permissible method of solving them, and that,

        within the limits of rationality, the legislature's

        efforts to tackle the problems should be entitled to 

        respect." San Antonio School District v. Rodriguez,

        411 U.S. 1, 42 (1973) (internal quotes and citation 

        omitted).

9.) See City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 440 (1985) ('The general rule is that legislation is presumed to be valid and will be sustained if the classification drawn by the statute is rationally related to a legitimate state interest. [citations omitted]").
10.) Cruzan v. Director, Missouri Dept. of Public Health, 497 U.S. 261, 280 (1990).
11.) "Suicide is the eighth leading cause of death in the United States." New York State Task Force Report, When Death is Sought - Assisted Suicide and Euthanasia in the Medical Context (May 1994), at 9 (footnote omitted). "Studies that examine the psychological background of individuals who kill themselves show that 95 percent have a diagnosable mental disorder at the time of death." Id., at 11. Furthermore, "[l]ike other suicidal individuals, patients who desire suicide or an early death during a terminal illness are usually suffering from a treatable mental illness, most commonly depression." Id., at 13 (footnote omitted).
12.) Cruzan, supra, 497 U.S. at 281 ("[E]ven where family members are present, [t]here will, of course, be some unfortunate situations in which family members will not act to protect a patient. A State is entitled to guard against potential abuses in such situations. [citation omitted, internal quotes omitted]"). See also Donaldson v. Lungren, 2 Cal.App.4th 1614, 1623, 4 Cal.Rptr. 59, 64 (1992) (The state's interest must prevail over the individual because of the difficulty, if not the impossibility, of evaluating the motives of the assister or determining the presence of undue influence."), and Donaldson, supra, 2 Cal.App.4th at 1624 ("Third parties, even family members, do not always act to protect the person whose life will end.").
13.) Cf. Middlesex Ethics Committee v. Garden State Bar Association, 457 U.S. 423, 434 (1982) (important state interest in "maintaining and assuring the professional conduct of professional attorneys it licenses"). See also Donaldson v. Lungren, 2 Cal.App.4th 1614, 1620, 4 Cal.Rptr.2d 59, 62 (1992) (recognizing state interest in maintaining the ethical integrity of the medical profession). In reaffirming its long-standing opposition to physician assited suicide, the American Medical Association has declared that physician assisted suicide "... threatens the very core of the medical profession's ethical integrity" and is"... fundamentally inconsistent with the physician's professional role." American Medical Association, Council on Ethical and Judicial Affairs, Code of Medical Ethics Reports, Vol. V. No. 2 (July 1994), Report 59, Physician Assisted Suicide, 269 and 274, respectively.
14.) Quill, supra, 80 F.3d at 730, citing Compassion in Dying v. State of Washington, 49 F.3d 586, 592-593 (9th Cir. 1995), superseded by 79 F.3d 790 (9th Cir. 1996).
15.) Quill, supra, 80 F.3d at 730, citing Compassion in Dying v. State of Washington, 49 F.3d 586, 592-593 (9th Cir. 1995), superseded by 79 F.3d 790 (9th Cir. 1996).
16.) Application of President & Directors of Georgetown College, Inc., 118 U.S.App.D.C. 80, 331 F2d 1000, 1008 (1964), cert. denied, 377 U.S. 978 (1964). See also Bartling v. Superior Court, 163 Cal.App.3d 186, 195 n. 6, 209 Cal.Rptr. 220, 225 n. 6 (1984).