Physician-Assisted Death

We recognize that perceptions can be swayed by how a topic is framed and by the terminology used. In this, as with everything else in this guide, our goal is to be fair and accurate.

Guide Name

There is no widely accepted, neutral term for this guide’s topic:

• Supporters tend toward terms like “medical aid in dying.” Supporters usually don’t mention “suicide,” arguing it carries associations with mental illness and impulsive behavior that do not reflect end-of-life decisions under terminal illness. They also use terms like “death with dignity,” “right to die,” and “end-of-life choice,” but these are not meant to be neutral descriptions.

• Opponents tend toward terms that include “suicide,” most prominently “physician-assisted suicide.” They argue it is appropriately descriptive, and that terms like “aid in dying” are euphemistic and could just as well refer to late-stage palliative care.

In the absence of a consensus on neutral terminology, we followed the National Academies of Sciences, Engineering, and Medicine’s choice for “physician-assisted death” as the term to use.²⁷ However, we made clear in the subtitle and elsewhere in the guide that opponents consider it assisted suicide.

“Physician”

We use the term “physician” rather than “doctor” because “physician” more precisely refers to clinicians licensed to practice medicine; “doctor” can also refer to people with non-medical doctoral degrees.

In some states, it is legal for an advanced registered nurse practitioner or physician assistant to evaluate and prescribe in PAD cases.²⁸ These are licensed clinicians who can see patients and prescribe medications within their legal scope of practice. But they are not physicians: They do not complete the same level of medical training as MDs (Doctors of Medicine) and DOs (Doctors of Osteopathic Medicine).

The fact that non-physicians can sometimes evaluate patients for PAD and prescribe the medication complicates the term “physician-assisted death.” We chose to still use it because of the reasons mentioned in Guide Name, and because there is no prominent alternative that captures the role of the authorized clinician. (“Authorized clinician” might be more technically accurate, but it is not a commonly used term in the PAD debate.)

Overall Framing

In the United States, the debate about physician-assisted death has a central question: Should mentally capable adults with a terminal illness be allowed to obtain medical assistance to end their own lives?

Accordingly, we chose this as the main framing for the guide. Because all existing state laws have the same general characteristics, modeled after Oregon’s first-in-the-nation law, we focused on those characteristics rather than minor variations across states.

Euthanasia

Some opponents see the American version of PAD—which limits the physician’s role to prescribing the medication, not administering it—as mostly a political tactic to avoid association with euthanasia. They argue this is misleading because, in their view, the key moral aspect is the same: The physician intentionally helps the patient end their life. They note other prominent countries with PAD, like the Netherlands and Canada, consider euthanasia to be part of PAD. Thus, some opponents may conclude this guide perpetuates supporters’ agenda by accepting the non-euthanasia framing.

Our thinking: This guide is about the debate in the United States, which is about the non-euthanasia version of PAD. So the natural framing is the non-euthanasia framing. In the Slippery Slope factor, we included opponents’ concerns that current U.S. PAD laws are a wedge for later expanding to euthanasia.

Factor Choices

In debates about physician-assisted death, the arguments that most often shape people’s views tend to fall into three types of questions:

• Moral principle: For some situations, is physician-assisted death a morally permissible—or even a morally required—response to suffering? This includes questions about whether it can be understood as an act of mercy, whether it respects or violates human dignity, and whether assisting death is meaningfully different from allowing death through the refusal of treatment.

• Practical risks and uncertainty: Even if PAD may be justified in some cases, how confident can we be that it will be applied safely and as intended? This includes concerns about imperfect prognoses, coercion, limits of safeguards, and whether legal boundaries can remain stable over time.

• Social meaning and institutional effects: What broader message does legalizing PAD send, and how does it reshape the roles of key institutions like medicine? This includes questions about whether PAD changes how society values certain lives, and whether it alters the ethical identity and responsibilities of physicians.

These three types of questions are reflected across the Factors to Consider. The factors provide a structure in which the different sides’ arguments can meet head-on. For a fair-minded reader, this is more helpful than simply seeing a list of each side’s talking points, which usually talk past each other.

For more on Fairmind guides’ structure and authoring principles, see Fairmind Format.

Labels for Supporters and Opponents

We used the terms “PAD supporters” and “PAD opponents” because they are descriptive and avoid advocate-defined terms like “assisted suicide” or “right to die.”

“Dignity”

In the public discourse about PAD, the word “dignity” is used in different ways, which can be confusing:

• PAD supporters use the term “death with dignity” to mean a patient can choose the timing and manner of their death, avoiding physical or cognitive decline they would find degrading.

• PAD opponents use the term “dignity” to refer to the inherent worth of a person, which does not depend on condition or capability. They believe this should be respected by caring for the person rather than intentionally ending their life.

In describing the debate, we used those terms as advocates use them, in their respective contexts, in distinct parts of the guide.

Our preference is to cite data and analyses from neutral sources. But in some cases, we sourced data from organizations connected with advocates on one side or the other of the debate. We did so because they had the best data for the information we wanted to convey. For example:

• Under “Facts,” there’s a map of states that do and don’t allow PAD. The data came from Death with Dignity, an advocacy organization for PAD.

• Under “Facts,” the footnote about states that have not authorized PAD is based on data from the Charlotte Lozier Institute, a PAD opponent.

In all cases when we used data from an advocate-aligned source, we verified its accuracy and checked that it was presented fairly by comparing it with other sources.

The U.S. Supreme Court has addressed physician-assisted death, most notably in Washington v. Glucksberg and Vacco v. Quill, both unanimous decisions from 1997.²⁹ In those cases, the Court held that there is no constitutional right to physician-assisted death, leaving the issue to the states.³⁰ Since then, PAD has developed through state legislation modeled on Oregon's 1997 statute rather than through further Supreme Court cases.

Although the 1997 cases are often mentioned in the PAD debate, we did not mention them in the main content because they did not resolve the ethical and policy debate this guide addresses. What they did establish is that PAD must be won or lost in state legislatures, not federal courts. This explains why the policy landscape today is a patchwork of state laws, and why the debate is typically framed in terms of competing policy considerations rather than constitutional rights.

Opponents sometimes argue that the availability of PAD will cause insurers or health systems to push patients toward it as a way to minimize costs. They sometimes cite individual cases where an insurance company denied an expensive treatment but was willing to pay for PAD.

In researching this aspect of the debate, we found that the cases cited always had circumstances that complicated the point. For example, in 2008 Barbara Wagner was a 64-year-old woman with recurrent lung cancer. Her physician recommended a chemotherapy drug costing several thousand dollars per month. The Oregon Health Plan declined to cover the drug. In a letter, the plan stated it would cover palliative care and, if she chose it, medication under Oregon’s PAD law.

In media reports, Wagner took the message to be “we’ll pay for you to die, but not pay for you to live.” The Oregon Health Services Commission responded that the letter to Wagner was poorly worded, but the coverage decision reflected Oregon’s standard Medicaid policy of prioritizing treatments. That policy does not normally cover expensive drugs with limited expected benefit. They emphasized that this was independent of PAD and noted that the letter also offered normal palliative care.³¹

In our view, a more relevant scenario would be if an insurer offered to pay for PAD to end a patient’s life immediately but not for palliative care that would let death occur naturally over a period of time. We found no evidence of this scenario occurring.

More generally, PAD does not appear capable of meaningfully altering the economic incentives of insurers or health-care providers. This is for a combination of reasons:

• Few patients: In Oregon, PAD cases number in only the hundreds per year. That figure could double or triple, and it would still be a tiny number relative to all end-of-life medical cases in a year—which in turn is a tiny fraction of all Oregonians covered by insurance.

• Limited time: Patients are only eligible for PAD when they have less than six months to live. Most take it with only days or weeks remaining in their prognosis. So there just isn’t that much time (and thus potential costs of care) saved.

• Limited cost: In Oregon, 92% of PAD users were in hospice care, often at home.³² At that stage, expensive disease-directed treatments have typically ended, and care focuses on comfort. The remaining costs are generally lower than earlier phases of treatment.

Taken together, these are not circumstances that cause large additional expenditures for an insurer or health system.³³ As a result, there is less at stake economically for insurers and healthcare providers than people might think—far less than the reputational costs that would come from having a policy channeling patients to PAD over palliative care.

For this reason, we did not include cost savings for insurers or health systems in the guide’s main content.

Although PAD’s potential cost savings appear to be a nearly negligible share of insurers’ and healthcare providers’ spending, PAD could represent a meaningful cost difference versus ongoing care for an uninsured individual and family. In this view, the concern is not that institutions will steer patients toward PAD, but that some patients may steer themselves toward PAD: A terminally ill patient might weigh not only their own suffering but also the financial impact of continued care on their family—such as medical bills, caregiving burdens, or depletion of savings. Critics argue that in such situations, the option of PAD could function less as a freely chosen alternative and more as a response to economic pressure, raising questions about how voluntary such decisions truly are. Some conclude that PAD should not be legalized in a state that does not have universal healthcare insurance.³⁴

We did not include this angle in the main content for three reasons:

• Limited Evidence of Impact: In Oregon’s 2025 reporting about PAD patients, only 6% of cases cited “Financial implications of treatment” as a concern related to their PAD decision.³⁵ The most commonly cited concerns related to loss of autonomy and the inability to engage in meaningful activities.

• Applies to Other End-of-Life Decisions: Many end-of-life decisions already take place within the same financial and social constraints—for example, when a patient decides to “give up” on active interventions or to refuse treatment.

• Prominence. It’s not a prominent argument in the discourse. If mentioned, it’s usually in passing—for example, as the observation that it is ironic for a state to allow PAD while lacking universal healthcare.

PAD supporters often cite public-opinion research, which has long shown a majority of Americans supporting PAD. As of 2024, Gallup found 66% support for PAD.³⁶ This figure comes from a question that uses the word “suicide”—relevant because Gallup’s historical data shows support runs 5–10 points higher when questions describe the intervention as “ending a patient’s life by painless means” instead of mentioning “suicide.” Nevertheless, both framings have shown majority support for decades.

We did not include a public-opinion argument in the main content for two reasons:

• Public opinion does not determine advocates’ positions. Advocates use polling when it suits their purpose; otherwise they ignore or attack it. If the polling flipped, advocates wouldn’t change their views on PAD. They’d simply change their views on the relevance of the polling.

• Public opinion shouldn’t be a primary reason for your own decision. The purpose of a Fairmind guide is to help you think through the substance of an issue for yourself. Letting public opinion decide for you is the opposite of that.

Also, it’s worth noting that most polls on the topic are national, whereas PAD laws are decided state by state. Each state’s public opinion will differ from national opinion, making the national results less relevant than they might initially seem.

Opponents sometimes argue that rather than legalizing PAD, society should invest in making excellent palliative care universally available. In this view, PAD is a response to a failure of care, and the right answer is to fix the care.

We did not include this in the main content for two reasons:

• Plausibility: The best evidence does not support the idea that palliative care, even at its most effective, can fully relieve suffering for all or even most patients. It can meaningfully reduce physical pain, but its effects on non-physical suffering are considerably less consistent.³⁷ And there are clearly scenarios that palliative care cannot directly address, such as people losing control of bodily movement.

• Timing: Even if it was possible to improve palliative care’s quality and availability to the point that no one would rationally choose PAD instead, achieving this would take time. Meanwhile, the question remains whether PAD should be legal now, for patients whose suffering is not being adequately addressed.

Ultimately, we saw “fix palliative care first” not as a rebuttal to the case for PAD but as a call for a separate initiative running alongside it.

Some participants in the debate argue that legalized PAD could affect suicide rates more broadly, though they disagree which way.

Opponents sometimes argue that PAD could contribute to a “suicide contagion” effect. This draws on well-established research showing that suicide rates can be influenced by social messaging and publicized cases. In this view, normalizing PAD might affect how some at-risk individuals think about suicide more generally.

In contrast, some researchers have explored whether PAD could have a substitution or harm-reduction effect. They raise scenarios like: (1) a terminally ill patient who might otherwise die by conventional suicide instead enters the PAD process; (2) due to the process’ safeguards—medical evaluations, waiting periods, and explanations of alternatives—the patient decides against ending life through PAD or conventional suicide.

We did not include a “Suicide Contagion” standalone factor because the empirical evidence is limited and inconclusive. A small number of studies have examined whether jurisdictions with PAD laws experience changes in non-assisted suicide rates, with mixed results and significant methodological constraints. These studies do not establish a causal relationship, and they do not isolate mechanisms such as contagion or substitution.³⁸

That said, the arguments reflect broader, well-supported ideas: that social norms can influence behavior, and that policy can shape how people respond to difficult circumstances. The Social Effects factor alludes to this.

PAD opponents often invoke the Hippocratic Oath as a reason to reject PAD. Traditionally attributed to the ancient Greek Hippocrates, the Oath is a set of ethical guidelines for physicians.³⁹ In one passage, it states: “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.”⁴⁰

Although the Oath is a powerful symbol of long-held wisdom, the original version is rarely used in modern medical schools.⁴¹ Oaths in use today diverge on whether to retain the prohibition against PAD; most do not include it.⁴²

A related argument invokes the familiar phrase of medical ethics, “First, do no harm,” as an argument against PAD. The problem is, in end-of-life contexts, what constitutes harm is disputed. For some, it is a greater harm to prolong the life of a terminally ill patient who is profoundly suffering; for others, intentionally ending a life is the greater harm. Invoking “do no harm” therefore restates the underlying disagreement about PAD rather than settling it.

All that said, there is a long-standing resistance in the medical profession to PAD. We sought to reflect that in the Physicians’ Role section by quoting the American Medical Association’s opposition. In our view, that was a better way to convey the underlying concern that arguments invoking the Oath and “do no harm” are meant to express.

An advance directive is a written instruction made while a person has full decision-making capacity, specifying what medical care they want—or don't want—if they later become incapacitated. Advance directives are widely used and legally recognized for decisions like refusing life-sustaining treatment. Some advocates argue that advanced directives should also be available for PAD. Ahead of time, a person could specify that PAD should be carried out if and when they reach a defined condition and are unfit mentally at that point.

In principle, this could apply to several conditions, but in practice the question concentrates on dementia, including Alzheimer’s disease. Most people with dementia lose their decision-making capacity gradually, over a period of many years. But PAD laws require the patient to have sound decision-making capacity when they request PAD, which can only be within six months or less to live. So, lacking support for advanced directives, PAD becomes impractical for most people with dementia.

This issue is real, but it is downstream from the core debate about whether PAD should be legal or not at all. As a result, we did not include it in the main content.

PAD opponents sometimes note that there is typically no requirement for a clinician or independent witness to be present when the medication is self-administered. They argue this creates a potential gap at the final stage, where coercion—especially by family members or caregivers—would be hardest to detect.

We did not include this in the main text because it’s about a secondary tension in the design of PAD laws:

• On one hand, safeguards against coercion would be tighter if clinicians were required to be present for the patient’s self-administration.

• On the other hand, requiring the physician’s presence further implicates them in the act, deepening the role-conflict discussed in Physicians’ Role and likely shrinking the pool of physicians willing to participate.

Some opponents argue that legalizing PAD undermines the trust between patient and physician. In its crudest form, patients might worry their physician will steer them toward PAD to free up resources or reduce the physician’s workload. Although it appears in the discourse, this argument is about an extremely unlikely combination of conditions: a physician acting in bad faith to encourage a patient to kill themself, a failure of safeguards like the required second opinion, and the patient (and family) going along against their interest.

A more widely applicable version of the trust concern is that the legal availability of PAD will taint the physician-patient relationship. Critics say that especially in end-of-life matters, the availability of PAD as an option invites ambiguity about the physician’s purpose and agenda, eroding trust generally.

We did not include this angle in the main content for two reasons:

• Primary Issue Already Covered: The Physicians’ Role section covers the primary concern articulated by medical groups against PAD: that it puts physicians in a conflicted position and asks them to make judgments they’re not trained for. A potential erosion of trust is a consequence of this and tends to be raised secondarily.

• Evidence Points the Other Way: A 2005 national survey found that only 20% of U.S. adults said they would trust their physician less if PAD were legal, with 58% disagreeing.⁴³

In the Slippery Slope section, we addressed amendments to PAD laws, such as waiting-period changes, residency rules, and types of authorized clinicians. But PAD availability and rules can also change through other means: judicial rulings, litigation seeking expansion, and clinical or administrative interpretation. For example:

• Montana permits PAD not through a statute but through a 2009 state Supreme Court ruling that physicians can use a “consent” defense against homicide charges when assisting a terminally ill patient's suicide.⁴⁴ Montana remains the only U.S. jurisdiction where PAD operates this way.

• In Shavelson v. California Department of Health Care Services, a physician and an ALS patient sued to allow physicians to administer PAD medication for patients unable to self-administer—effectively, to expand California’s law to permit euthanasia in those cases. The court dismissed the suit in 2022, holding that such an accommodation would cross a fundamental line “from the ability to end your own life to the ability to have someone else end it for you.”⁴⁵ Although the court rejected this attempt, it is nonetheless an example of how courts could be used to expand PAD.

• Oregon’s Death with Dignity Act defines “terminal disease” as “incurable and irreversible” but does not specify whether available treatments must be tried. The Oregon Health Authority states it does not interpret the statute beyond reporting requirements.⁴⁶ This has left physicians as the interpreters when unusual cases emerge. For example, a non-terminal Oregon woman with early stage dementia was able to access PAD while still being of sound mind. She voluntarily ceased to eat and drink, thereby creating what her physician judged to be a terminal condition, which resulted in a PAD prescription and her death.⁴⁷

We are addressing these examples here rather than in the Slippery Slope section because, across nearly three decades of PAD in the United States, non-legislative changes have been exceptions rather than the rule. For the sake of brevity and clarity, we chose to focus the main content on the more central aspects of the debate.

Religious institutions are mostly against PAD. The Catholic Church in particular has been among the most prominent voices in opposition. That said, some smaller denominations support PAD, such as the United Church of Christ.⁴⁸

If this guide was about whether you personally should undertake PAD, your personal religious beliefs would be key. But this guide is about a question of public policy: Should PAD be legal? In the U.S. legal system, laws are expected to be justifiable on non-religious grounds and to apply across people of different faiths or none.⁴⁹

Also, as a practical matter, it is difficult to reason together in a pluralistic society when participants appeal to religious authority that others do not share. This is why even the Catholic Church regularly makes public policy arguments about PAD in secular terms.⁵⁰

For these reasons, the guide focused on arguments framed in non-religious terms.