(Boise, Idaho) A federal court today issued a landmark ruling in a lawsuit challenging the constitutionality of an Idaho law provision that the State interpreted to require pregnant individuals to receive life-sustaining treatment, even if it violated the person's advance directive. The court ruled that the provision invalidating a pregnant individual’s advance directive, which the State previously had said was mandatory for over 15 years, actually is voluntary.

The court further ruled that the State’s erroneous interpretation of the law was unconstitutional and violated Plaintiffs’ First, Fifth, and Fourteenth amendment rights.

As a result of this ruling, Idaho women can refuse to include the pregnancy exclusion in their advance directives about their end-of-life care preferences and decide what care they want, and what care they don’t want, if they become incapacitated while pregnant.

The provision contained within Idaho’s 2005 advance directive statute states that if an individual has been diagnosed as pregnant, their advance directive “shall have no force during the course of pregnancy.”

The lawsuit, Almerico et al. v. State of Idaho et al, filed in 2018 on behalf of four Idaho women of child-bearing age, asserts that the law violates their constitutional rights to free speech, medical decision-making, procedural due process, and equal protection.  More than 300,000 Idaho women were estimated to be of childbearing age (ages 15-44) in 2016.

The four women are represented in the lawsuit by Compassion & Choices, Legal Voice, If/When/How: Lawyering for Reproductive Justice, and Perkins Coie, LLP. The State changed its position in a January 2021 pleading, when it said: “its ‘pregnancy exclusion’ language is voluntary.” However, the State had still not taken any affirmative steps to publicize its change in position.

The court ruling today recognized the pregnancy exclusion represented “an unprecedented and extraordinary step beyond abortion restrictions.” The court held that Idaho’s law violated an individual’s constitutional right to refuse unwanted medical treatment, as the U.S. Supreme Court first recognized in Cruzan v. Director, Missouri Department of Health, stating: “Women do not lose these rights because they are pregnant when they fall into a coma…” The court further ruled that: “[t]he pregnancy exclusion also violates the First Amendment, which prevents the Government from compelling individuals to express certain views, just as it prohibits impermissible Government censorship of speech.”

The ruling could have repercussions for pregnancy exclusions in over 30 states, including 10 states with severe restrictions: Alabama, Indiana, Kansas, Kentucky, Michigan, Missouri, South Carolina, Texas, Utah, and Wisconsin.

The issue of pregnancy exclusions in advance directive statutes garnered national attention in 2013. The case involved Marlise Muñoz, a Texas woman who was approximately 14 weeks pregnant when she suffered a pulmonary embolism, and two days later doctors declared her brain-dead. Knowing Marlise’s end-of-life wishes, her husband, Erick Muñoz, asked her doctors to withdraw or withhold any “life-sustaining” medical treatment from his brain-dead wife. The hospital refused, citing a Texas statute, the Advance Directive Act, that automatically invalidates a woman’s advance directive in the event she is pregnant. Two months later, the trial court held that the Texas statute does not apply to a woman who is legally dead and pregnant and ordered the hospital to remove all life-sustaining treatment from her body.

“This decision is a victory for tens of thousands of women of child-bearing age in Idaho,” said plaintiff Hannah Sharp, who was pregnant when the lawsuit was filed in May 2018, but since has given birth and lives in Boise. “I am so thankful to now have the peace of mind that my directive will be valid and enforceable, despite lacking the pregnancy exclusion language.”

The other three plaintiffs are Chelsea Gaona-Lincoln of Caldwell, and Boise residents Anna Almerico and Micaela de Loyola-Carkin.

“For Plaintiffs, and for people throughout the nation,  the need for a legally enforceable directive is even more critical now, given the risks posed by COVID-19,” says the plaintiffs’ motion for summary judgment filed in the U.S. District Court for the District of Idaho by the Boise office of Perkins Coie LLP. “Patients with COVID-19 are at an increased risk of invasive interventions, such as mechanical ventilation, that limit or eliminate their ability to communicate.”

“We are relieved that the court concluded the pregnancy exclusion is voluntary because pregnant people also are at increased risk for death or severe illness from COVID-19,” said Kevin Díaz, chief legal advocacy officer for Compassion & Choices. “The likelihood of having severe illness that may lead to invasive interventions is higher for people with certain medical conditions, including asthma, which Ms. Sharp has.”

“Under the pregnancy exclusion, a pregnant woman who was about to die and whose advance directive dictated the withdrawal of all life support, would nevertheless have life support forced upon her until her baby was delivered,” said Jessica Pezley, staff attorney for Compassion & Choices. “The court found the pregnancy exclusion violates the constitutional right of a competent person to refuse unwanted, life-saving medical treatment.”

Compassion & Choices is committed to empowering people to get the care they want during a serious illness or at the end of life. Anyone can access our free end-of-life care planning tools, including advance directives and a COVID-19 toolkit at CompassionAndChoices.org/End-of-Life-Planning/

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