(Dr. Pagano is a forensic psychiatrist at Cherry Hospital in Goldsboro, North Carolina. This article, used with permission from the author, appeared online at psychiatrictimes.com.)
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I recently read an excellent article here called “Is ‘Death with Dignity’ Really Possible?” Ronald Pies, MD, delivered some powerful arguments that stayed with me long after I finished reading it, and that challenged me to reconsider my own opinions about medical aid in dying (MAiD). The following is the result of my meditation (and a fair amount of reading).
The preference of many patients with terminal illness is to pass away peacefully while surrounded by family and friends. This pastoral scene is unlikely to come true in states that discourage discussing the topic of MAiD by making it illegal. The threat of legal actions against those who help the dying hasten their deaths is a significant deterrent. But perhaps most devastating is that the shadow of stigma prevents meaningful communication and closure with loved ones. The family members of those who have chosen their time and place to die with dignity describe a feeling of gratitude that they were able to be there with their lucid loved one as they gently fell asleep for the last time.
Eleven states – California, Colorado, Delaware, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington – and the District of Columbia have legalized MAiD. (Editor’s Note: Since this article was written, Illinois and New York have both enacted Medical Aid in Dying (MAiD) laws—Illinois on December 12, 2025, and New York on February 8.)
One in five Americans now has access to this option. While vocal opponents may give the misleading impression that the majority of physicians are against aid in dying, the numbers tell a very different story. For example, a 2020 Medscape survey of 5,130 US doctors across medical specialties found that 55% of physicians believe MAiD should be available as an end-of-life option. There is even greater support among the general public. A 2018 Gallup poll found that 72% of Americans support medical aid in dying. Similarly, the Pew Research Center found that 68% support “doctor-assisted suicide” in their 2015 poll. There is public demand for this service.
MAiD has gained momentum over the years, as many patients find it necessary to fight for the option to end their suffering. I am reminded of Brittany Maynard, who, in 2014, was diagnosed with terminal brain cancer at 29 years old. At that time, California did not have the end-of-life option. So, Maynard moved to Oregon to die with dignity. As a consequence, California Governor Jerry Brown enacted the End of Life Option Act in 2016.
Many opponents are concerned with the possibility that MAiD may target traditionally vulnerable populations. However, Maynard’s journey illustrates that the opposite is true: Only the most privileged with the greatest resources are able to successfully obtain medical aid in dying.
Al Rabadi and colleagues conducted quantitative research (2019) with a retrospective observational cohort study of all lethal medications prescribed for MAiD in Oregon and Washington, from the passage of those states’ death with dignity laws until 2017. A demographic analysis of the 76% of patients who chose to ingest their lethal medication shows that 51% were male, 95% were white, 72% went to college, and 89% of them had health insurance.
The speculation that physician-assisted dying will target marginalized groups has been shown to be mistaken. As in the rest of healthcare, only the most privileged are accessing this service.
It is worth noting that, as with many prescriptions, after receiving their lethal drugs, patients will not necessarily use them – indeed, 24% of patients in Oregon and Washington chose not to. Merely having the option is sufficient reassurance. The peace of mind of knowing they can choose to die offers enormous comfort. One advocate, Dan Diaz, reflects, “This truly is an option. If a person has decided on their own to apply for and qualify for the prescription, then you get to focus on living life.”
The stigma surrounding both suicide and medical aid in dying is a challenging topic. On one hand, some of the previous efforts to distance physician-assisted dying from suicide have increased the stigma surrounding suicide, thus making suicide more difficult to discuss. Barriers to discussing suicidal thoughts cause people to suffer in silence, and ultimately, increase suicide attempts. Shaming people for having a mental illness is reprehensible. Further stigmatizing those suffering with suicidal ideation in the context of mental illness – in order to positively differentiate those with a terminal illness who desire MAiD – is not the way forward. We need to work to decrease stigma for all people, to improve access to care, and to prevent suicide in the context of an untreated or undertreated mental illness.
On the other hand, there is something distinctly different about the terminally ill person who is staring at their last six months of life – six months filled with loss after loss, indignity after indignity, and grief after grief, all inexorably culminating in a slow death by starvation. To conflate this wish for a physician-assisted death with the suicidal thoughts of someone suffering with mental illness invalidates the reality-based appraisal of the terminally ill patient’s very stark situation.
The desire to avoid both foreseeable and inevitable suffering is rational. And finally, perhaps most undeniably, my sympathy for those who request medical aid in dying comes from within. For, I cannot in good conscience deny someone a choice that I myself would want as an option under the same grim circumstances.
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Final Exit Network (FEN) is a network of dedicated professionals and caring, trained volunteers who support mentally competent adults as they navigate their end-of-life journey. Established in 2004, FEN seeks to educate qualified individuals in practical, peaceful ways to end their lives, offer a compassionate bedside presence and defend a person’s right to choose. For more information, go to www.finalexitnetwork.org.
Payments and donations are tax deductible to the full extent allowed by law. Final Exit Network is a 501(c)3 nonprofit organization.
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Death With Dignity National Center, https://deathwithdignity.org/ is an excellence source of information and data on Medical Aid in Dying.