This editorial appears in the May 2025 issue of the American Journal of Bioethics.
Medical aid in dying (MAID) is an important and highly sensitive aspect of end-of-life care reflecting broad ethical considerations. Internationally, approaches to assisted dying vary dramatically in accordance with legal developments, cultural norms, and local advocacy. Medical aid in dying in the United States offers an evidence-based, time-tested, end-of-life option to support patient self-determination. As highlighted in “Canadian Medical Assistance in Dying: Provider Concentration, Policy Capture, and Need for Reform,” the Canadian model of medical assistance in dying has seen an extraordinary increase in cases and reported concerns about legal oversight, ethical violations, and the role of clinicians in facilitating euthanasia. In contrast, the U.S. approach to MAID is purposefully structured to ensure that MAID remains centered on patient autonomy rather than clinician authority. MAID laws in the United States emphasize patient control, safeguards against coercion, and integration into comprehensive end-of-life care. In addition, MAID in the United States exists only in the context of terminal illness, with objective eligibility criteria and clear protections in place. These clear and restricted eligibility requirements and enforceable safeguards protect against ethical violations and clinician overreach.
This commentary does not dispute nor confirm the facts or interpretations of Canadian law referenced in the article. Instead, it highlights key aspects of the U.S. legal framework, exploring its effectiveness and the principles that distinguish it from the Canadian model. Any comparisons are intended for context and insight, not to assert superiority or to question the legitimacy of the Canadian approach.
A Safeguarded Option Within End-of-Life Care
Compassion & Choices, the leading U.S. organization advocating for end-of-life options, supports MAID as one option within a full spectrum of quality end-of-life care. Our mission is to empower everyone to chart an end of life journey consistent with their values, priorities and beliefs. Terminally ill patients must be able to choose a peaceful death on their own terms, and that choice should exist alongside disease-specific treatment options, hospice, palliative care, and advance care planning.
There is currently no fundamental right to healthcare or to medical aid in dying in the United States. Therefore, our model to effectuate change is consumer based. Our mission is twofold: to expand options at the end of life while simultaneously improving the quality of end-of-life care. This dual focus aims to ensure that patients receive holistic support and that MAID remains an option only for those who truly desire it—not as a response to inadequate healthcare services and a lack of support.
In the United States, availability of medical aid in dying benefits all patients at the end of life by changing the power dynamic in a relatively narrow but profound way. By shifting the power to decide when enough is enough from a physician to the patient, decision making moves into the hands of the terminally ill individual. Due to differences in the rulings of their respective highest courts, the U.S. practice of medical aid in dying is more limited than Canada’s. A patient in the United States must be a terminally ill, mentally capable adult with a prognosis of six months or less to live in order to initiate a request from their healthcare provider for medication they may decide to self-ingest. The U.S. patient-directed approach has maintained a measured and stable rate of MAID usage substantially below Canada’s rate for over 25 years.
The U.S. Focus On Patient-directed Care
MAID statutes in U.S. jurisdictions authorize a practice that is patient directed and patient controlled from start to finish. One fundamental safeguard is the requirement for self-administration of MAID medication, distinguishing the practice from the predominant Canadian practice, where clinician-administered euthanasia dominates. In every U.S. jurisdiction where MAID is legal, the patient must ingest the medication themselves. The clinician does not administer the medication. This requirement is not accidental; it is an intentional safeguard designed to ensure that MAID is patient directed and voluntary.
Patient-directed requirements also serve several essential functions:
1. Reinforces patient autonomy: The decision should be a conscious and voluntary act and not a decision based on a medical provider’s values, motivations, or external pressures.
2. Prevents abuse and coercion: Patients must have the cognitive ability to understand the seriousness of their decision and the physical ability to ingest the medication, ensuring that MAID is confined to those who actively seek it.
3. Encourages comprehensive care: A study conducted in the United States found that when patients request a prescription for MAID, clinicians often increase efforts to provide high-quality palliative care and explore alternative solutions to suffering. In other words, a conversation around MAID often leads to better symptom management, improved hospice access, and more support for patients and families.
Terminal Illness Requirement: A Critical Safeguard
A defining aspect of the U.S. model is its limitation to terminally ill patients—adults with an incurable and irreversible disease that will, within reasonable medical judgment, result in death within six months. This restriction ensures that medical aid in dying eligibility is determined according to objective medical criteria and remains a carefully considered option, rather than a broad response to subjective suffering. The U.S. model maintains a firm, objectively determined boundary. This limits MAID to those at the end of life and ensures the practice does not become a substitute for reforming the gaps in healthcare or broader systemic failures that lead to patient suffering.
The terminal illness requirement also serves as a safeguard against coercion. With a clear medical standard—six months or less to live—patients are protected from subtle or overt pressure toward MAID by social or economic factors. By restricting eligibility to those with a terminal prognosis, the U.S. model minimizes the risk of MAID becoming a desperate decision in response to external factors and ensures that MAID remains true to its original purpose: a choice for those at life’s end, rather than an imperfect solution to suffering in a fractured healthcare system.
The Dangers of Specialization: U.S Laws Do Not Authorize Stand-alone MAID Practice
Another significant difference between the U.S. and Canadian models is the role of clinicians in MAID. The U.S. approach promotes mainstream healthcare provider participation, ensuring that MAID remains a thoughtfully regulated option within a full spectrum of end-of-life care, rather than a distinct medical specialty. This structure prevents the overreliance on a small group of MAID specialists, which has become a concern in Canada. When a limited number of clinicians handle the majority of MAID cases, the practice risks becoming routine and industrialized rather than patient driven.
In the United States, MAID statutes establish the practice in the context of a patient’s overall end-of-life medical care. They stipulate that the clinician attending a patient for MAID is also the one primarily responsible for treating the patient’s terminal illness. Thus, participating healthcare providers are typically general practitioners, oncologists, or palliative care specialists. These healthcare professionals offer MAID within the broader context of patient-directed treatment plans, ensuring it remains integrated into comprehensive end-of-life care rather than existing as a standalone medical service.
U.S. providers are also required to disclose all available options, such as improved pain management, psychiatric care, and hospice services, before a patient proceeds with MAID. This step ensures that patients understand all available interventions before making their decision. As Canada expands its eligibility criteria to include individuals whose grievous and irremediable medical condition includes a serious and incurable nonterminal disease, mental illness, or a disability, increasing reliance on full-time MAID providers is concerning.
Conclusion: A Measured, Patient-directed Approach
The data from Canada’s rapidly growing MAID system raise ethical and procedural concerns. The U.S. approach, with safeguards that include self-administration and terminality requirements, has created a system in which MAID remains integrated within broader healthcare rather than a specialized practice. That system has provided assurance of compassionate and peaceful dying to many, while effectively and reliably protecting patients against abuse, coercion, and medical overreach.
Patient utilization rates of MAID in the United States have remained stable over time, demonstrating that a careful, patient-driven approach prevents the practice from expanding beyond its intended purpose. Compassion & Choices will continue to advocate for both expanded end-of-life options and improved healthcare. We are confident that every patient can receive the support and care they deserve, without incurring a risk that MAID becomes a substitute for comprehensive high-quality healthcare.
By keeping MAID in patients’ hands rather than relinquishing control to a small group of specialists working under vague standards, the United States ensures that the decision to end one’s life remains a deeply personal, autonomous choice—rather than an imperfect response to systemic inadequacies.