2 Eugenics and Sterilization 2 Eugenics and Sterilization

At present, arguably the dominant mode of state control of reproduction mandates pregnancy and birth, but it wasn't that way. In this unit, we will study the rise and transformation of eugenics, as well as its ongoing relevance today.

2.1 Buck v. Bell 2.1 Buck v. Bell

BUCK v. BELL, SUPERINTENDENT.

No. 292.

Argued April 22, 1927.

Decided May 2, 1927.

*201 Mr. I. P. Whitehead for plaintiff in error.

*203 Mr. Aubrey E. Strode for defendant in error.

*205Mr. Justice Holmes

delivered the opinion of the Court.

This is a writ of error to review a judgment of the Supreme Court of Appeals of the State of Virginia, affirming a judgment of the Circuit Court of Amherst County, by which the defendant in error, the superintendent of the State Colony for Epileptics and Feeble Minded, was ordered to perform the operation of salpingectomy upon Carrie Buck, the plaintiff in error, for the purpose of making her sterile. 143 Va. 310. The case comes here upon the contention that the statute authorizing the judgment is void under the Fourteenth Amendment as denying to the plaintiff in error due process of law and the equal protection of the laws.

Carrie Buck is a feeble minded white woman who was committed to the State Colony above mentioned in due form. She is the daughter of a feeble minded mother in the same institution, and the mother of an illegitimate feeble minded child. She was eighteen years old at the time of the trial of her case in the Circuit Court, in the latter part of 1924. An Act of Virginia, approved March 20, 1924, recites that the health of the patient and the welfare of society may be promoted in certain cases by the sterilization of mental defectives, under careful safeguard, &c.; that the sterilization may be effected in males by vasectomy and in females by salpingectomy, without serious pain or substantial danger to life; that the Commonwealth is supporting in various institutions many defective persons who if now discharged would become *206a menace but if incapable of procreating, might be discharged with safety and become self-supporting with benefit to themselves and to society;.and that experience has shown that heredity plays an important part, in the transmission of insanity, imbecility, &c. The statute then enacts that whenever the superintendent of certain institutions including the above named State Colony shall be of opinion that it is for the best interests of the patients and of society that an inmate under his care should be sexually sterilized, he may have the operation performed upon any patient afflicted with hereditary forms of insanity, imbecility, &c., on complying with the very careful provisions by which the act protects the patients from possible abuse.

The superintendent first presents a petition to the special board of directors of his hospital or colony, stating the facts and the grounds for his opinion, verified by affidavit. Notice of the petition and of the time and place of the hearing in the institution is to be served upon the inmate, and also upon his guardian, and if there is no guardian the superintendent is to apply to the Circuit Court of the County to appoint one. If the inmate is a minor notice also is to be given to his parents if any with a copy of the petition. The board is to see to it that the inmate may attend the hearings if desired by him or his guardian. The evidence is all to be reduced to writing, and after the board has made its order for or against the operation, the superintendent, or the inmate, or his guardian, may appeal to the Circuit Court of the County. The Circuit Court may consider the record of the board and the evidence before it and such other admissible evidence as may be offered, and may affirm, revise, or reverse the order of the board and enter such order as it deems just. Finally any party may apply to.the Supreme Court of Appeals, which, if it grants the appeal, is to hear the case upon the record of the trial *207in the Circuit Court and may enter such order as it thinks the Circuit Court should have entered. There can be no doubt that so far as procedure is concerned the rights of the patient are most carefully considered, and as every step in this case was taken in scrupulous compliance with the statute and after months of observation, there is no doubt that in that respect the plaintiff in error has had due process of law.

The attack is not upon the procedure but upon the substantive law. It seems to be contended that in no circumstances could such an order be justified. It certainly is contended that the order cannot be justified upon the existing grounds. The judgment finds the facts that have been recited and that Carrie Buck “ is the probable potential parent of socially inadequate offspring, likewise afflicted, that she may be sexually sterilized without detriment to her general health and that her welfare and that of society will be promoted by her sterilization,” and thereupon makes the order. In view of the general declarations of the legislature and the specific findings of the Court, obviously we cannot say as matter of law that the grounds do not exist, and if they exist they justify the result. We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices, often not felt to be such by those concerned, in order to prevent our being swamped with incompetence. It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Jacobson v. Massachusetts, 197 U. S. 11. Three generations of imbeciles are enough.

*208But, it is said, however it might be if this reasoning were applied generally, it fails when it is confined to the small number who are in the institutions named and is not applied to the multitudes outside. It is the usual last resort of constitutional arguments to point out shortcomings of this sort. But the answer is that the law does all that is needed when it does all that it can, indicates a policy, applies it to all within the lines, and seeks to bring within the lines all similarly situated so far and so fast as its means allow. Of course so far as the operations enable those who otherwise must be kept confined to be returned to the world, and thus open the asylum to others, the equality aimed at will be more nearly reached.

Judgment affirmed.

Mr. Justice Butler dissents.

2.2 Skinner v. Oklahoma ex rel. Williamson 2.2 Skinner v. Oklahoma ex rel. Williamson

SKINNER v. OKLAHOMA ex rel. WILLIAMSON, ATTORNEY GENERAL.

No. 782.

Argued May 6, 1942.

Decided June 1, 1942.

*536 Messrs. W. J. Hulsey,, H. I. Aston, and Guy L. Andrews submitted for petitioner.

Mr. Mac Q. Williamson, Attorney General of Oklahoma, for respondent.

Mr. Justice Douglas

delivered the opinion of the Court.

This case touches a sensitive and important area of human rights. Oklahoma deprives certain individuals of a right which is basic to the perpetuation of a race—the right to have offspring. Oklahoma has decreed the enforcement of its law against petitioner, overruling his claim that it violated the Fourteenth Amendment. Because that decision raised grave and substantial constitutional questions, we granted the petition for certiorari.

The statute involved is Oklahoma’s Habitual Criminal Sterilization Act. Okla. Stat. Ann. Tit. 57, § § 171, et seq.; L. 1935, pp. 94 et seq. That Act defines an “habitual criminal” as a person who, having been convicted two or more times for crimes “amounting to felonies involving moral turpitude,” either in an Oklahoma court or in a court of any other State, is thereafter convicted of such a felony in Oklahoma and is sentenced to a term of imprisonment in an Oklahoma penal institution. § 173. Machinery is provided for the institution by the Attorney General of a proceeding against such a person in the Oklahoma courts for a judgment that such person shall be rendered sexually sterile. §§ 176, 177. Notice, an opportunity to be heard, and the right to a jury trial are provided. § § 177-181. The issues triable in such a proceeding are narrow and con*537fined. If the court or jury finds that the defendant is an “habitual criminal” and that he “may be rendered sexually sterile without deteriment to his or her general health,” then the court “shall render judgment to the effect that said defendant be rendered sexually sterile” (§ 182) by the operation of vasectomy in case of a male, and of salpingectomy in case of a female. § 174. Only one other provision of the Act is material here, and that is § 195, which provides that “offenses arising out of the violation of the prohibitory laws, revenue acts, embezzlement, or political offenses, shall not come or be considered within the terms of this Act.”

Petitioner was convicted in 1926 of the crime of stealing chickens, and was sentenced to the Oklahoma State Reformatory. In 1929 he was convicted of the crime of robbery with firearms, and was sentenced to the reformatory. In 1934 he was convicted again of robbery with firearms, and was sentenced to the penitentiary. He was confined there in 1935 when the Act was passed. In 1936 the Attorney General instituted proceedings against him. Petitioner in his answer challenged the Act as unconstitutional by reason of the Fourteenth Amendment. A jury trial was had. The court instructed the jury that the crimes of which petitioner had been convicted were felonies involving moral turpitude, and that the only question for the jury was whether the operation of vasectomy could be performed on petitioner without detriment to his general health. The jury found that it could be. A judgment directing that the operation of vasectomy be performed on petitioner was affirmed by the Supreme Court of Oklahoma by a five to four decision. 189 Okla. 235, 115 P. 2d 123.

Several objections to the constitutionality of the Act have been pressed upon us. It is urged that the Act cannot be sustained as an exercise of the police power, in view *538of the state of scientific authorities respecting inheritability of criminal traits.1 It is argued that due process is lacking because, under this Act, unlike the Act2 upheld in Buck v. Bell, 274 U. S. 200, the defendant is given no opportunity to be heard on the issue as to whether he is the probable potential parent of socially undesirable offspring. See Davis v. Berry, 216 F. 413; Williams v. Smith, 190 Ind. 526, 131 N. E. 2. It is also suggested that the Act is penal in character and that the sterilization provided for is cruel and unusual punishment and violative of the Fourteenth Amendment. See Davis v. Berry, supra. Cf. State v. Feilen, 70 Wash. 65, 126 P. 75; Mickle v. Henrichs, 262 F. 687. We pass those points without intimating an opinion on them, for there is a feature of the Act which clearly condemns it. That is, its failure to meet the requirements of the equal protection clause of the Fourteenth Amendment.

We do not stop to point out all of the inequalities in this Act. A few examples will suffice. In Oklahoma, grand larceny is a felony. Okla. Stats. Ann. Tit. 21, §§ 1705, 5. Larceny is grand larceny when the property taken exceeds $20 in value. Id. § 1704. Embezzlement is punishable “in the manner prescribed for feloniously stealing property of the value of that embezzled.” Id. § 1462. Hence, he who embezzles property worth more than $20 is guilty of a felony. A clerk who appropriates over $20 from his employer’s till (id. § 1456) and a stranger who steals the same *539amount are thus both guilty of felonies. If the latter repeats his act and is convicted three times, he may be sterilized. But the clerk is not subject to the pains and penalties of the Act no matter how large his embezzlements nor how frequent his convictions. A person who enters a chicken coop and steals chickens commits a felony (id. § 1719); and he may be sterilized if he is thrice convicted. If, however, he is a bailee of the property and fraudulently appropriates it, he is an embezzler. Id. § 1455. Hence, no matter how habitual his proclivities for embezzlement are and no matter how often his conviction, he may not be sterilized. Thus, the nature of the two crimes is intrinsically the same and they are punishable in the same manner. Furthermore, the line between them follows close distinctions—distinctions comparable to those highly technical ones which shaped the common law as to “trespass” or “taking.” Bishop, Criminal Law (9th ed.) Vol. 2, §§ 760, 799, et seq. There may be larceny by fraud rather than embezzlement even where the owner of the personal property delivers it to the defendant, if the latter has at that time “a fraudulent intention to make use of the possession as a means of converting such property to his own use, and does so convert it.” Bivens v. State, 6 Okla. Cr. 521, 529, 120 P. 1033, 1036. If the fraudulent intent occurs later and the defendant converts the property, he is guilty of embezzlement. Bivens v. State, supra; Flohr v. Territory, 14 Okla. 477, 78 P. 565. Whether a particular act is larceny by fraud or embezzlement thus turns not on the intrinsic quality of the act but on when the felonious intent arose— a question for the jury under appropriate instructions. Bivens v. State, supra; Riley v. State, 64 Okla. Cr. 183, 78 P. 2d 712.

It was stated in Buck v. Bell, supra, that the claim that state legislation violates the equal protection clause of the Fourteenth Amendment is “the usual last resort of constitutional arguments.” 274 U. S. p. 208. Under our con*540stitutional system the States in determining the reach and scope of particular legislation need not provide “abstract symmetry.” Patsone v. Pennsylvania, 232 U. S. 138, 144. They may mark and set apart the classes and types of problems according to the needs and as dictated or suggested by experience. See Bryant v. Zimmerman, 278 U. S. 63, and cases cited. It was in that connection that Mr. Justice Holmes, speaking for the Court in Bain Peanut Co. v. Pinson, 282 U. S. 499, 501, stated, “We must remember that the machinery of government would not work if it were not allowed a little play in its joints.” Only recently we reaffirmed the view that the equal protection clause does not prevent the legislature from recognizing “degrees of evil” (Truax v. Raich, 239 U. S. 33, 43) by our ruling in Tigner v. Texas, 310 U. S. 141, 147, that “the Constitution does not require things which are different in fact or opinion tobe treated in law as though they were the same.” And see Nashville, C. & St. L. Ry. v. Browning, 310 U. S. 362. Thus, if we had here only a question as to a State’s classification of crimes, such as embezzlement or larceny, no substantial federal question would be raised. See Moore v. Missouri, 159 U. S. 673; Hawker v. New York, 170 U. S. 189; Finley v. California, 222 U. S. 28; Patsone v. Pennsylvania, supra. For a State is not constrained in the exercise of its police power to ignore experience which marks a class of offenders or a family of offenses for special treatment. Nor is it prevented by the equal protection clause from confining “its restrictions to those classes of cases where the need is deemed to be clearest.” Miller v. Wilson, 236 U. S. 373, 384. And see McLean v. Arkansas, 211 U. S. 539. As stated in Buck v. Bell, supra, p. 208, “. . . the law does all that is needed when it does all that it can, indicates a policy, applies it to all within the lines, and seeks to bring within the lines all similarly situated so far and so fast as its means allow.”

*541But the instant legislation runs afoul of the equal protection clause, though we give Oklahoma that large deference which the rule of the foregoing cases requires. We are dealing here with legislation which involves one of the basic civil rights of man. Marriage and procreation are fundamental to the very existence and survival of the race. The power to sterilize, if exercised, may have subtle, far-reaching and devastating effects. In evil or reckless hands it can cause races or types which are inimical to the dominant group to wither and disappear. There is no redemption for the individual whom the law touches. Any experiment which the State conducts is to his irreparable injury. He is forever deprived of a basic liberty. We mention these matters not to reexamine the scope of the police power of the States. We advert to them merely in emphasis of our view that strict scrutiny of the classification which a State makes in a sterilization law is essential, lest unwittingly, or otherwise, invidious discriminations are made against groups or types of individuals in violation of the constitutional guaranty of just and equal laws. The guaranty of “equal protection of the laws is a pledge of the protection of equal laws.” Yick Wo v. Hopkins, 118 U. S. 356, 369. When the law lays an unequal hand on those who have committed intrinsically the same quality of offense and sterilizes one and not the other, it has made as invidious a discrimination as if it had selected a particular race or nationality for oppressive treatment. Yick Wo v. Hopkins, supra; Gaines v. Canada, 305 U. S. 337. Sterilization of those who have thrice committed grand larceny, with immunity for those who are embezzlers, is a clear, pointed, unmistakable discrimination. Oklahoma makes no attempt to say that he who commits larceny by trespass or trick or fraud has biologically inheritable traits which he who commits embezzlement lacks. Oklahoma’s line between larceny by fraud and embezzlement is determined, as we have noted, “with reference to the time when the *542fraudulent intent to convert the property to the taker's own use” arises. Riley v. State, supra, 64 Okla. Cr. at p. 189, 78 P. 2d p. 715. We have not the slightest basis for inferring that that line has any significance in eugenics, nor that the inheritability of criminal traits follows the neat legal distinctions which the law has marked between those two offenses. In terms of fines and imprisonment, the crimes of larceny and embezzlement rate the same under the Oklahoma code. Only when it comes to sterilization are the pains and penalties of the law different. The equal protection clause would indeed be a formula of empty words if such conspicuously artificial lines could be drawn. See Smith v. Wayne Probate Judge, 231 Mich. 409, 420-421, 204 N. W. 40. In Buck v. Bell, supra, the Virginia statute was upheld though it applied only to feeble-minded persons in institutions of the State. But it was pointed out that “so far as the operations enable those who otherwise must be kept confined to be returned to the world, and thus open the asylum to others, the equality aimed at will be more nearly reached.” 274 U. S. p. 208. Here there is no such saving feature. Embezzlers are forever free. Those who steal or take in other ways are not. If such a classification were permitted, the technical common law concept of a “trespass” (Bishop, Criminal Law, 9th ed., vol. 1, §§ 566, 567) based on distinctions which are “very largely dependent upon history for explanation” (Holmes, The Common Law, p. 73) could readily become a rule of human genetics.

It is true that the Act has a broad severability clause.3 But we will not endeavor to determine whether its applica*543tion would solve the equal protection difficulty. The Supreme Court of Oklahoma sustained the Act without reference to the severability clause. We have therefore a situation where the Act as construed and applied to petitioner is allowed to perpetuate the discrimination which we have found to be fatal. Whether the severability clause would be so applied as to remove this particular constitutional objection is a question which may be more appropriately left for adjudication by the Oklahoma court. Dorchy v. Kansas, 264 U. S. 286. That is reemphasized here by our uncertainty as to what excision, if any, would be made as a matter of Oklahoma law. Cf. Smith v. Cahoon, 283 U. S. 553. It is by no means clear whether, if an excision were made, this particular constitutional difficulty might be solved by enlarging on the one hand or contracting on the other (cf. Mr. Justice Brandeis dissenting, National Life Ins. Co. v. United States, 277 U. S. 508, 534-535) the class of criminals who might be sterilized.

Reversed.

Mr. Chief Justice Stone,

concurring:

I concur in the result, but I am not persuaded that we are aided in reaching it by recourse to the equal protection clause.

If Oklahoma may resort generally to the sterilization of criminals on the assumption that their propensities are transmissible to future generations by inheritance, I seriously doubt that the equal protection clause requires it to apply the measure to all criminals in the first instance, or to none. See Rosenthal v. New York, 226 U. S. 260, 271; *544 Keokee Coke Co. v. Taylor, 234 U. S. 224, 227; Patsone v. Pennsylvania, 232 U. S. 138, 144.

Moreover, if we must presume that the legislature knows—what science has been unable to ascertain—that the criminal tendencies of any class of habitual offenders are transmissible regardless of the varying mental characteristics of its individuals, I should suppose that we must likewise presume that the legislature, in its wisdom, knows that the criminal tendencies of some classes of offenders are more likely to be transmitted than those of others. And so I think the real question we have to consider is not one of equal protection, but whether the wholesale condemnation of a class to such an invasion of personal liberty, without opportunity to any individual to show that his is not the type of case which would justify resort to it, satisfies the demands of due process.

There are limits to the extent to which the presumption of constitutionality can be pressed, especially where the liberty of the person is concerned (see United States v. Carolene Products Co., 304 U. S. 144, 152, n. 4) and where the presumption is resorted to only to dispense with a procedure which the ordinary dictates of prudence would seem to demand for the protection of the individual from arbitrary action. Although petitioner here was given a hearing to ascertain whether sterilization would be detrimental to his health, he was given none to discover whether his criminal tendencies are of an inheritable type. Undoubtedly a state may, after appropriate inquiry, constitutionally interfere with the personal liberty of the individual to prevent the transmission by inheritance of his socially injurious tendencies. Buck v. Bell, 274 U. S. 200. But until now we have not been called upon to say that it may do so without giving him a hearing and opportunity to challenge the existence as to him of the only facts which could justify so drastic a measure.

*545Science has found and the law has recognized that there are certain types of mental deficiency associated with delinquency which are inheritable. But the State does not contend—nor can there be any pretense—that either common knowledge or experience, or scientific investigation,1"'1' has given assurance that the criminal tendencies of any class of habitual offenders are universally or even generally inheritable. In such circumstances, inquiry whether such is the fact in the case of any particular individual cannot rightly be dispensed with. Whether the procedure by which a statute carries its mandate into execution satisfies due process is a matter of j udicial cognizance. A law which condemns, without hearing, all the individuals of a class to so harsh a measure as the present because some or even many merit condemnation, is lacking in the first principles of due process. Morrison v. California, 291 U. S. 82, 90, and cases cited; Taylor v. Georgia, 315 U. S. 25. And so, while the state may protect itself from the demonstrably inheritable tendencies of the individual which are injurious to society, the most elementary notions of due process would seem to require it to take appropriate steps to safeguard the liberty of the individual by affording him, before he is condemned to an irreparable injury in his person, some opportunity to show that he is without such inheritable tendencies. The state is called on to sacrifice no permissible end when it is required to reach its objective by a reasonable and just procedure adequate to safeguard rights of the individual which concededly the Constitution protects.

*546Mr. Justice Jackson

concurring:

I join the Chief Justice in holding that the hearings provided are too limited in the context of the present Act to afford due process of law. I also agree with the opinion of Mr. Justice Douglas that the scheme of classification set forth in the Act denies equal protection of the law. I disagree with the opinion of each in so far as it rejects or minimizes the grounds taken by the other.

Perhaps to employ a broad and loose scheme of classification would be permissible if accompanied by the individual hearings indicated by the Chief Justice. On the other hand, narrow classification with reference to the end to be accomplished by the Act might justify limiting individual hearings to the issue whether the individual belonged to a class so defined. Since this Act does not present these questions, I reserve judgment on them.

I also think the present plan to sterilize the individual in pursuit of a eugenic plan to eliminate from the race characteristics that are only vaguely identified and which in our present state of knowledge are uncertain as to transmissibility presents other constitutional questions of gravity. This Court has sustained such an experiment with respect to an imbecile, a person with definite and observable characteristics, where the condition had persisted through three generations and afforded grounds for the belief that it was transmissible and would continue to manifest itself in generations to come. Buck v. Bell, 274 U. S. 200.

There are limits to the extent to which a legislatively represented majority may conduct biological experiments at the expense of the dignity and personality and natural powers of a minority—even those who have been guilty of what the majority define as crimes. But this Act falls down before reaching this problem, which I mention only to *547avoid the implication that such a question may not exist because not discussed. On it I would also reserve judgment.

2.3 Doe ex rel. Tarlow v District of Columbia, 489 F.3d 376 (D.C. 2007) 2.3 Doe ex rel. Tarlow v District of Columbia, 489 F.3d 376 (D.C. 2007)

489 F.3d 376 (2007)

Jane DOE, I, by her next friend Linda J. TARLOW, et al., Appellees
v.
DISTRICT OF COLUMBIA and Mental Retardation and Developmental Disabilities Administration, Appellants.

No. 05-7190.

United States Court of Appeals, District of Columbia Circuit.

Argued February 6, 2007.
Decided June 12, 2007.

377*377 Mary T. Connelly, Assistant Attorney General, Office of Attorney General for the District of Columbia, argued the cause for appellants. With her on the brief were Robert J. Spagnoletti, Attorney General at the time the brief was filed, Todd S. Kim, Solicitor General, and Edward E. Schwab, Deputy Solicitor General.

Robert A. Dybing, pro hac vice, argued the cause for appellees. With him on the brief was Harvey S. Williams.

Before: GRIFFITH and KAVANAUGH, Circuit Judges, and WILLIAMS, Senior Circuit Judge.

Opinion for the Court filed by Circuit Judge KAVANAUGH.

KAVANAUGH, Circuit Judge:

This case involves the District of Columbia's 2003 policy for authorizing surgeries for intellectually disabled persons who are in the District's care and have never had the mental capacity to make medical decisions for themselves. The District of Columbia authorizes surgeries for such persons when: (i) two physicians have certified that the proposed surgery is "clinically indicated to maintain the health" of the patient; (ii) D.C. caregivers have made efforts to discuss the surgery with the patient at the level of patient comprehension; and (iii) no guardian, family member, or other close relative, friend, or associate is available to otherwise consent or withhold consent. Plaintiffs argue that the 2003 policy is inconsistent with D.C. statutes and the Due Process Clause of the Fifth Amendment. We disagree and therefore reverse the judgment of the District Court.

 

I

 

1. Jane Doe I, Jane Doe II, and Jane Doe III live in District of Columbia facilities for the intellectually disabled. They are plaintiffs here, and they represent a class certified by the District Court of 378*378 intellectually disabled persons who live in District of Columbia facilities and receive medical services from the District of Columbia. These individuals have never had the mental capacity to make medical decisions for themselves. (Some District of Columbia statutes and cases use the term "mentally retarded"; we will use the more common term "intellectually disabled.")

The District of Columbia Mental Retardation and Developmental Disabilities Administration (commonly referred to as the MRDDA although the official name has now changed to the Department of Disability Services) ensures that those intellectually disabled individuals receive necessary medical services, including necessary surgeries. Many of the surgeries MRDDA authorizes are relatively routine; MRDDA also authorizes more significant surgeries when medically necessary.

The District of Columbia's Health Care Decisions Act provides that any individual, including persons who have been determined to be intellectually disabled, "shall be presumed capable of making health-care decisions unless certified otherwise" in accordance with D.C. law. D.C.Code § 21-2203. Of course, some individuals may not have the mental capacity to make healthcare decisions for themselves. The D.C.Code sets out a procedure to make the mental incapacity determination. The Code provides: "Mental incapacity to make a health-care decision shall be certified by 2 physicians who are licensed to practice in the District and qualified to make a determination of mental incapacity." Id. § 21-2204(a). At least one of the two certifying physicians must be a psychiatrist, and at least one must have examined the individual in question within one day of the certification of incapacity. Id. The physicians must apply the following standard: A person lacks mental capacity to make healthcare decisions if he or she "lacks sufficient mental capacity to appreciate the nature and implications of a health-care decision, make a choice regarding the alternatives presented or communicate that choice in an unambiguous manner." Id. § 21-2202(5). "All professional findings and opinions forming the basis of [the] certification ... shall be expressed in writing ... and provide clear evidence that the person is incapable of understanding the health-care choice, making a decision concerning the particular treatment or services in question, or communicating a decision even if capable of making it." Id. § 21-2204(b).

Mental incapacity to make a healthcare decision "shall not be inferred from the fact that an individual ... [i]s mentally retarded." Id. § 21-2203(2). In other words, under D.C. law, not all intellectually disabled persons lack the mental capacity to make healthcare decisions. The two inquiries are separate. Plaintiffs' counsel here agrees, however, that all of the class members in this case lack the mental capacity to make healthcare decisions. See Tr. of Oral Arg. at 21, 27; see also Does I Through III v. District of Columbia, 232 F.R.D. 18, 32 (D.D.C.2005).

D.C. law creates a hierarchy of individuals authorized to make healthcare decisions for persons who have been certified under § 21-2204 as lacking mental capacity. See D.C.Code § 21-2210(a), (d), (f). That list includes, in order of priority: a court-appointed guardian or conservator; a spouse or domestic partner; an adult child; a parent; an adult sibling; a religious superior, if applicable; a close friend; or the nearest living relative. Id. § 21-2210(a). The MRDDA Administrator makes healthcare decisions for an incapacitated patient only if none of the above individuals is available and willing to do so. See In re Estate of Gillis, 849 A.2d 1015, 1018-19 (D.C.2004) (providing overview of 379*379 MRDDA's statutory authority to make healthcare decisions for intellectually disabled patients). The D.C.Code also explicitly provides that abortions, sterilizations, and psycho-surgeries may not be authorized, at least absent a court order. D.C.Code § 21-2211.

Of relevance to this case, D.C. law distinguishes between two categories of persons who lack mental capacity: (i) those who once possessed mental capacity, such as those in a coma or who have lost their mental capacity due to age, disease, or an accident; and (ii) those who have always lacked mental capacity, such as certain intellectually disabled persons. For patients who once had mental capacity, the decision must be based on the "known wishes of the patient" if those wishes can be "ascertained" — for example, as expressed in a durable power of attorney. Id. § 21-2210(b); see also id. §§ 21-2206(c)(1), 21-2207. For those who have never had the mental capacity, the decision must be based on "a good faith belief as to the best interests of the patient." Id.

In 2003, MRDDA adopted a new policy for medical care of intellectually disabled persons in order to meet — and exceed — the statutory requirements. The policy, entitled "Procedures for Securing Medical and Dental Care for MRDDA Consumers," provides that those intellectually disabled patients who are "deemed competent to make informed decisions" are "allowed to refuse examination/treatment." Joint Appendix at 196-97.

For intellectually disabled patients who do not have the mental capacity to make medical decisions, the 2003 policy allows the MRDDA Administrator to authorize medical treatment only when, among other requirements, the patient has been "certified as an incapacitated individual" and "two (2) licensed physicians have certified, in writing, that the health care service, treatment, or procedure is clinically indicated to maintain the health of the [patient]." Id. at 204. The policy further provides that "[e]fforts should be made to provide information and explanations at the level of [patient] comprehension." Id. at 203. In other words, MRDDA must discuss the proposed treatment with the intellectually disabled patient. The policy also states that family members and guardians should receive notice of recommended medical treatment and be "given an opportunity to grant consent." Id. at 204. If "there is no family member[] or other person available or willing to provide consent," however, the MRDDA Administrator may authorize the surgery. Id.

2. Plaintiffs filed suit and alleged that MRDDA violated District of Columbia law, as well as their due process rights under the Fifth Amendment, by authorizing surgeries on them without considering their wishes. It is undisputed that plaintiffs have always lacked "sufficient mental capacity to appreciate the nature and implications of a health-care decision, make a choice regarding the alternatives presented or communicate that choice in an unambiguous manner." D.C.Code § 21-2202(5); see also Does I Through III, 232 F.R.D. at 32; Tr. of Oral Arg. at 21, 27. The District of Columbia has argued that it legally and logically cannot consider the wishes of patients who lack — and always have lacked — mental capacity to make independent medical decisions because "there is no information about what they would want if they were not incapacitated." Does v. District of Columbia, 374 F.Supp.2d 107, 115 (D.D.C.2005) (internal quotation marks omitted) (emphasis in original). The District of Columbia points out that consideration of the wishes of a patient who lacks mental capacity to make healthcare decisions could lead to denial of essential medical care to a patient who purportedly did 380*380 not want it — even though the patient by law has always lacked the mental capacity to make such a decision.

The District Court concluded that "[e]ven a legally incompetent, mentally retarded individual may be capable of expressing or manifesting a choice or preference regarding medical treatment." Id. (internal quotation marks omitted). The court thus held that the District of Columbia's 2003 policy — which is based on the statutory "best interests" standard rather than the "known wishes" standard — is inconsistent with D.C. statutory law, "violates plaintiffs' and the class members' liberty interest to accept or refuse medical treatment and is therefore an unconstitutional infringement of the substantive and procedural due process rights of plaintiffs and their fellow class members." Does I Through III, 232 F.R.D. at 34. The District Court permanently enjoined the District of Columbia from authorizing elective surgeries for MRDDA patients under its present policy, ruling that MRDDA must follow the "known wishes of the patient" standard in determining whether to authorize surgeries on MRDDA patients. Id. The court ordered the District of Columbia to make "documented reasonable efforts to communicate" with patients "regarding [their] wishes." Id. If a patient's wishes still remain unknown after such inquiry, however, the court held that the District of Columbia should determine the patient's "best interests" by considering the "totality of [the] circumstances." Id.

On appeal, the District of Columbia argues that neither (i) D.C. statutory law nor (ii) the Due Process Clause of the Fifth Amendment requires MRDDA to consider the healthcare wishes of intellectually disabled patients (such as the plaintiffs here) who have always lacked mental capacity to make healthcare decisions for themselves. We exercise de novo review over those legal questions. Arrington v. United States, 473 F.3d 329, 333 (D.C.Cir.2006).

 

II

 

We first consider whether the 2003 policy is consistent with D.C. statutory law. Under the 2003 D.C. policy, the MRDDA Administrator may authorize medical treatment for an intellectually disabled patient who has always lacked the mental capacity to make medical decisions only if: (i) two physicians have certified that the proposed surgery is "clinically indicated to maintain the health" of the patient; (ii) D.C. caregivers have made efforts to discuss the surgery with the patient at the level of patient comprehension; and (iii) no guardian, family member, or other close relative, friend, or associate is available to otherwise consent or withhold consent. When those conditions are met, the Administrator's practice is to authorize the surgery, because the surgery is deemed in the patient's "best interests" under D.C. law.

The class representatives argue that D.C. statutory law requires more, however, and that MRDDA must consider the wishes even of persons who have always lacked mental capacity to make medical decisions, such as the class members here. In other words, plaintiffs argue that the "known wishes" standard of the D.C.Code applies rather than the "best interests" standard. The District of Columbia responds that D.C. statutes do not (and logically could not) require MRDDA to consider the wishes of those intellectually disabled patients who have always lacked the mental capacity to make medical decisions for themselves. See D.C.Code § 21-2204(b) (providing that determination of incapacity requires certifying physicians to provide in writing "clear evidence that the person is incapable of understanding the health-care choice, 381*381 making a decision concerning the particular treatment or services in question, or communicating a decision even if capable of making it"). Moreover, the District of Columbia points out that considering the wishes of a patient who has always lacked mental capacity could result in the incorrect denial of medical treatment, cause the death or serious injury of patients, and trigger a host of ethical and legal problems.

We agree with the District of Columbia that the "best interests" standard — not the "known wishes" standard — applies to medical decisions for intellectually disabled individuals who have always lacked the mental capacity to make those decisions for themselves. The D.C.Code provides that a "decision to grant, refuse or withdraw consent" on behalf of a patient who lacks the mental capacity to make medical decisions "shall be based on the known wishes of the patient" if those wishes are ascertainable. Id. § 21-2210(b) (emphasis added). But "if the wishes of the patient are unknown and cannot be ascertained," the decision "shall be based on ... a good faith belief as to the best interests of the patient." Id. (emphasis added). It is undisputed here that plaintiffs have always lacked "sufficient mental capacity to appreciate the nature and implications of a health-care decision, make a choice regarding the alternatives presented or communicate that choice in an unambiguous manner." Id. § 21-2202(5); see also Does I Through III v. District of Columbia, 232 F.R.D. 18, 32 (D.D.C.2005); Tr. of Oral Arg. at 21, 27. Because plaintiffs have never been able to make informed choices regarding their medical treatment, their true wishes with respect to a recommended surgery "are unknown and cannot be ascertained" for purposes of § 21-2210(b). Therefore, the District of Columbia is correct that the "best interests" standard applies to the class of plaintiffs in this case.

D.C. case law confirms our reading of the statutory text. As the D.C. Court of Appeals has stated, those statutes were "designed to address situations in which doctors, family members, and the courts may be required to make treatment decisions for a patient who has become unable to decide such matters for himself or herself." Khiem v. United States, 612 A.2d 160, 169 (D.C.1992) (emphasis added). As that court has explained, an incompetent patient can fall into one of two categories: (i) those who were once competent to make healthcare decisions for themselves; and (ii) those who have never been competent. The distinction is critical because the competent person's pre-existing wishes (as best they can be determined) must be followed "in cases of adults who at one time were competent but later became incompetent." In re K.I., 735 A.2d 448, 455 (D.C.1999). By contrast, if a patient has never been competent to make medical decisions, D.C. courts have concluded that D.C. statutes require the decision be made by assessing the patient's "best interests," particularly their medical needs as determined by medical doctors. In In re K.I., the court thus affirmed the trial judge's determination that "the best interests of the child rather than the substituted judgment standard applied `in cases involving minor respondents who have lacked, and will forever lack, the ability to express a preference regarding their course of medical treatment.'" Id. at 452, 456.

The class representatives rely on the decision of the D.C. Court of Appeals in In re A.C. But that case involved a patient who had once been competent to make healthcare decisions on her own. See 573 A.2d 1235, 1249 (D.C.1990). The decision in In re A.C. therefore does not support the conclusion that MRDDA must somehow try to ascertain the wishes of patients who have never had the mental capacity to 382*382 make decisions for themselves. See id. at 1246 ("incompetent patients ... have just as much right as competent patients to have their decisions made while competent respected") (emphasis added); id. at 1243 (observing "the tenet common to all medical treatment cases: that any person has the right to make an informed choice, if competent to do so, to accept or [forgo] medical treatment") (emphasis added). Indeed, as explained above, the D.C. Court of Appeals has noted that the standard set forth in In re A.C. applies "in cases of adults who at one time were competent but later become incompetent." In re K.I., 735 A.2d at 455. Contrary to plaintiffs' suggestion, therefore, nothing in the In re A.C. decision supports the conclusion that the wishes of a patient who has never been competent must be considered by a person charged with making medical decisions on his or her behalf.

It bears mention that the approach of plaintiffs' counsel has the potential for grave consequences. Their position would require MRDDA to give effect, at least in some cases, to the medical wishes of patients who by definition lack "sufficient mental capacity to appreciate the nature and implications" of the preference expressed. D.C.Code § 21-2202(5). As a result, MRDDA could be required to deny essential medical care to a patient who purportedly did not want it — even though the patient by law lacked the mental capacity to make that decision. The result could be serious injury or death to the patient, and great potential for abuse and confusion. Not surprisingly, so far as we are aware, no state applies the rule suggested by plaintiffs.

In sum, we hold that the 2003 policy complies with D.C. law.

 

III

 

Plaintiffs also contend that the District of Columbia's 2003 policy is inconsistent with what they describe as their procedural and substantive due process rights.

To reiterate, under the 2003 policy at issue here, the MRDDA Administrator authorizes surgery for an intellectually disabled patient who has always lacked mental capacity to make medical decisions only if: (i) two physicians have certified that the proposed surgery is "clinically indicated to maintain the health" of the patient; (ii) D.C. caregivers have made efforts to discuss the surgery with the patient at the level of patient comprehension; and (iii) no guardian, family member, or other close relative, friend, or associate is available to otherwise consent or withhold consent.

Plaintiffs argue that this policy violates their right to due process because it does not require the MRDDA Administrator to consider an intellectually disabled patient's wishes in deciding whether to authorize surgery. But as we explained above, accepting the wishes of patients who lack (and have always lacked) the mental capacity to make medical decisions does not make logical sense and would cause erroneous medical decisions — with harmful or even deadly consequences to intellectually disabled persons. Consideration of the wishes of patients who are not and have never been competent is therefore not required by the Supreme Court's procedural due process cases. Cf. Washington v. Harper, 494 U.S. 210, 226, 110 S.Ct. 1028, 108 L.Ed.2d 178 (1990) (upholding state policy allowing prison to administer medication to mentally ill prisoners); see also Heller v. Doe, 509 U.S. 312, 332, 113 S.Ct. 2637, 125 L.Ed.2d 257 (1993) ("At least to the extent protected by the Due Process Clause, the interest of a person subject to governmental action is in the accurate determination of the matters before the court ....").

383*383 Plaintiffs also try to make out a substantive due process claim (as distinct from their procedural due process claim). Even assuming their complaint about procedures used by MRDDA can be properly shoehorned into a substantive due process claim, plaintiffs have not shown that consideration of the wishes of a never-competent patient is "deeply rooted in this Nation's history and tradition" and "implicit in the concept of ordered liberty," such that "neither liberty nor justice would exist if [the asserted right] were sacrificed." Washington v. Glucksberg, 521 U.S. 702, 720-21, 117 S.Ct. 2258, 138 L.Ed.2d 772 (1997) (internal citations and quotation marks omitted).

Plaintiffs rely on Cruzan v. Dir., Mo. Dep't of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990), which held that the Due Process Clause permits a state to require clear and convincing evidence of an incompetent patient's wishes — articulated when she was competent — as to the withdrawal of life-sustaining treatment. Id. at 284, 110 S.Ct. 2841. As the Second Circuit has correctly explained, however, nothing in Cruzan supports the view that a person who has never had the capacity "to make an informed and voluntary choice" with respect to medical treatment has a constitutional right under the Due Process Clause to have his or her wishes considered. Id. at 280, 110 S.Ct. 2841; see Blouin v. Spitzer, 356 F.3d 348, 360 (2d Cir.2004) ("Cruzan ... rests solely on the patient's capacity to express her intention regarding the course of her medical treatment; a capacity that Nancy Cruzan once possessed but that Sheila Pouliot [the plaintiff] never did.").

Finally, we note that the breadth of plaintiffs' constitutional claims is extraordinary because no state of which we are aware applies the rule suggested by plaintiffs. Plaintiffs apparently are arguing, therefore, that all states' laws and practices with respect to medical treatment for intellectually disabled individuals who have never been competent are inconsistent with the Constitution. Cf., e.g., In re Christopher, 106 Cal.App.4th 533, 549, 131 Cal.Rptr.2d 122 (2003) (test based on the presumed wishes of the patient "assumes some understanding of the patient's wants, desires, feelings, and previous mental and physical states," and "is therefore an inappropriate tool for making medical decisions for patients ... who [have] never been competent to make [their] own decisions or express [their] emotions and feelings on the subject"); Guardianship of Doe, 411 Mass. 512, 583 N.E.2d 1263, 1268 (1992) (requirement that state determine what incompetent patient would have wanted if competent is a "legal fiction" as applied to a never-competent person); In re Storar, 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64, 72 (1981) ("it is unrealistic to attempt to determine whether [a patient suffering from cancer] would want to continue potentially life prolonging treatment if he were competent" if patient has been profoundly intellectually disabled for most of his life); see also Norman L. Cantor, The Relation Between Autonomy-Based Rights and Profoundly Mentally Disabled Persons, 13 ANNALS HEALTH L. 37, 42 (2004) (surrogate "cannot protect a never-competent patient's right of self-determination" because a "profoundly disabled person has never been able to make autonomous choices"); John A. Robertson, Cruzan and the Constitutional Status of Nontreatment Decisions for Incompetent Patients, 25 GA. L. REV. 1139, 1194 (1991) (best interests test "has wide support when the patient never was previously competent but a decision must be made, as occurs with pediatric patients and patients who have always been retarded"); American Association on Mental Retardation/Association for Retarded Citizens 384*384 Position Statement on Health Care for the Intellectually Disabled, available at http://www.aamr.org/Policies/pos_health-care.shtml ("decision to accept or refuse treatment requires informed consent," which means that "the individual decision-maker or surrogate decision-maker" must have "the legal capacity to give consent"; decisionmaking in those circumstances "must always be consistent with the best interests of the individual").

In sum, plaintiffs' constitutional claims are meritless.

 

IV

 

We conclude that, to the extent challenged in this case, the 2003 policy is consistent with D.C. statutory law and the Due Process Clause of the Fifth Amendment. We therefore reverse the District Court's grant of summary judgment, vacate the District Court's injunction, and direct the entry of judgment for defendants with respect to plaintiffs' claims for declaratory and injunctive relief. Pending before the District Court are also individual damages claims brought by Jane Doe I, Jane Doe II, and Jane Doe III based on alleged incidents that occurred more than a decade ago, before adoption of the 2003 policy. The damages claims are not before us, and we therefore do not address them.

So ordered.