News|Articles|October 22, 2026

Panelists Weigh Legal, Ethical Limits of Medical Aid in Dying

Legal and clinical experts examined the US medical aid in dying framework, its limits, and ethical debates.

Nearly a third of patients who obtain a prescription for medical aid in dying (MAID) in Oregon never take it, a pattern that legal and clinical experts say reflects the medication's quiet psychological value: simply having the option can ease a dying patient's fear of future suffering.

That finding anchored a wide-ranging discussion of the US framework for MAID during a webinar held October 21 by The American Journal of Managed Care^®and Pharmacy Times^® that was moderated by Dominic Sisti, PhD, associate professor in the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Sisti was joined by Brent Kious, MD, PhD, associate professor of psychiatry at the University of Utah, who also works as a bioethicist in the university's Center for Health Ethics, Arts, and Humanities, and Kevin Diaz, JD, president and CEO of Compassion and Choices and a former legal director of the American Civil Liberties Union (ACLU) of Oregon. The panel covered the legal landscape governing MAID across the US, the ethical objections clinicians raise, and unresolved questions about extending the practice to patients with psychiatric illness.

Statutory Model Ties Eligibility to a 6-Month Prognosis

MAID is currently authorized in 14 jurisdictions: 13 states and Washington, DC.¹ Diaz traced the framework to Oregon's 1994 ballot initiative, the country's first safe-harbor law; most jurisdictions have since followed through legislatures, although 3 came via ballot initiative and 1 via a state supreme court ruling.

Eligibility criteria are similar across nearly every jurisdiction, Diaz said. An adult with a terminal illness and a prognosis of 6 months or less who retains decision-making capacity must make a voluntary, formal request, typically assessed by 2 independent clinicians who must also discuss feasible alternatives, including hospice and pain control, so patients receive gold-standard end-of-life care, with waiting periods that can be waived when death is imminent. Oregon, Montana, and Vermont do not require patients to be state residents, although practical barriers still limit access for people traveling from elsewhere. Because the medication must pass through the gastrointestinal tract, patients unable to swallow may still qualify via a feeding tube or rectal catheter, but those unable to self-ingest by any route cannot use the statutory process. Kious noted that a few newer state laws explicitly prohibit intravenous administration, distinguishing the US approach from Canada and the European countries where clinician-administered voluntary euthanasia is legal and the more common choice.

Oregon's data, the longest-running in the country, show why access to a prescription does not guarantee its use. In 2025, 100 of 637 (16%) people who received a prescription had not ingested the medication as of the state's reporting cutoff and later died of other causes.² Cumulatively since 1998, only 3691 of the state's 5520 prescriptions, about 67%, are known to have ended in death from ingestion, leaving roughly a third unused or of unknown status. Diaz said merely holding the prescription can relieve a patient's fear of unbearable suffering and let them focus on their remaining time. Most Oregon patients who use the law have cancer, 61.3% in 2025, followed by heart or circulatory disease (11.3%) and amyotrophic lateral sclerosis (14%).

Conscientious Objection Raises Questions About Records and Referrals

Kious said the most common objections to MAID center on the belief that medical killing of any kind is wrong, often rooted in the Hippocratic oath, alongside concern that patients could be coerced by family members, clinicians, or health systems. Some critics, he said, argue that aid in dying could be ethically defensible if removed from medicine altogether and handled by dedicated, nonmedical thanatologists.

The more troubling pattern, Diaz said, is not physicians declining to prescribe but institutions and clinicians refusing to share medical records or facilitate a transfer to a willing clinician. Medical records are legally the patient's property, he said, which is part of why such disputes have drawn litigation, including pending cases in Illinois and New York over whether institutions can restrict a clinician's ability to prescribe or participate in MAID.

“That just doesn’t seem like very good care,” Diaz said of clinicians who decline to even discuss a patient's request.

“It is probably antithetical to good medicine and, frankly, good bedside manner to refuse to engage with your patient when they bring up the issue,” Kious agreed, although he remains sympathetic to conscientious-objection concerns in states that require clinicians to facilitate a records transfer.

Progressive Disease, Lost Capacity Complicate Access

The panel also addressed a gap raised by audience questions. Kious said patients with progressive neurodegenerative conditions, such as Huntington disease or early-stage Alzheimer disease, often cannot access MAID because by the time they are expected to die within 6 months, they have frequently already lost the capacity to make the request. A health care surrogate or power of attorney cannot request MAID on an incapacitated patient's behalf, Sisti noted; only the patient can make that request, in writing, on video, or orally.

Kious said some clinicians and scholars have proposed voluntary stopping of eating and drinking (VSED) as a bridge: a person who is not yet terminal can lawfully stop eating and drinking, and if sustained, that choice can itself produce a terminal condition, such as kidney failure, that then qualifies them for MAID. He called the approach controversial and said he would not be surprised by future legal challenges. Diaz urged clinicians considering that path to seek jurisdiction-specific legal advice, noting VSED is lawful on its own and skips the waiting periods MAID statutes impose.

Psychiatric MAID Remains Unsettled, as Canada Pulls Back

MAID for a primary psychiatric illness is practiced primarily in Luxembourg, Belgium, the Netherlands, and Switzerland, Kious said, typically justified as voluntary euthanasia for severe, unremitting suffering unresponsive to treatment. The US statutory model requires terminal illness, which psychiatric conditions generally do not meet, although Kious noted debate over whether diagnoses such as anorexia nervosa could, in rare cases, be considered terminal.

Canada had planned to extend MAID eligibility to people whose sole underlying condition is mental illness. On October 7, Justice Minister Sean Fraser announced the government would indefinitely exclude that population from the program instead.³ Diaz said Compassion and Choices does not advocate for psychiatric MAID and questioned whether such cases could meet the legal standard that a condition be both irreversible and irremediable. Kious said the deeper challenge is distinguishing an authentic, autonomous request from a symptom of the illness itself. He cited research indicating that patients with serious psychiatric illness, including schizophrenia, often retain surprising capacity for complex health care decisions, while conditions marked by persistent suicidal ideation, such as major depressive disorder, raise harder questions about whose values a request reflects.

Panelists Expect Continued Expansion, Point to Advocacy Resources

Asked how nonphysicians might participate, Kious said MAID should stay within the house of medicine so that someone who knows the patient assesses eligibility. Diaz agreed, noting a few states have extended prescribing authority to other clinicians and that death doulas can offer valuable, nonmedical support to patients and families.

Diaz pointed listeners toward compassionandchoices.org, where volunteers can get involved in state-level advocacy efforts. Both panelists expect MAID jurisdictions to keep growing, alongside continued legal challenges over who controls the process.

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