In Support of Medical Aid in Dying in the U.S.

On New Year’s day, 2014, Brittany Maynard was diagnosed with brain cancer. Within a matter of months, the cancer had become terminal — Brittany had less than 6 months to live [1]. Facing increasingly worse seizures and the reality of a painful, drawn out death, Brittany made a difficult choice to move to Oregon, one of a few states where Medical Aid in Dying (MAiD) is legal [2]. On November 1st 2014, Brittany Maynard passed away from a lethal dose of medication at age 29 [3].

This story is just one of thousands that have taken place since MAiD was first legalized in Oregon in 1997 and its continued legalization throughout the United States [4]. MAiD is the option for one to receive life-ending medication from a medical practitioner [5]. It is important to note the distinction between MAiD and euthanasia, which is the practice where a medical practitioner directly administers the medication to the patient, whereas MAiD requires the patient to administer it themselves [6].

The first major landmark case relating to the practice was Washington v. Glucksberg & Vacco v. Quill (1997), in which the Supreme Court opened the debate to individual states on the legalization and implementation of MAiD [7]. Since then, only 10 states and the District of Columbia have legalized MAiD and public opinion remains divided in many areas across the country [8].

There is substantial cause to overturn the ruling and legalize MAiD federally as evidenced by Washington v. Glucksberg (1997) and changing social dynamics over the last 30 years. Consider one’s right to bodily autonomy, and by extension, their right to refuse life-sustaining treatment. MAiD, in the case of patients suffering from terminal illnesses, can be argued to be a valid extension of these rights. The reduction of unnecessary suffering is a key foundation for the legalization of MAiD, with its practice in a number of states proving that it does not lead to coerced deaths or discriminatory practice as was the concern of many justices in previous years. In addition, the current state by state legality of MAiD results in discrimination towards those who have to travel across state boundaries in order to receive treatment; this can be resolved by legalizing MAiD nationally.

The strongest basis for legalizing MAiD is one’s right to refuse medical treatment, even if it results in death. Consider Cruzan v. Director (1990), in which Cruzan had suffered an accident which resulted in her being indefinitely unable to communicate and requiring life support. Her parents tried to pull her life support but the Supreme Court ruled against their wishes as it could not be proven with ‘clear and convincing’ evidence that Cruzan would wish so [9]. One’s right to refuse medical treatment stems from the Due Process Clause, as one must be afforded bodily autonomy and as such they can reject unwanted medical intervention [10]. Proponents for MAiD argue that this case emphasizes one’s autonomy in deciding their choice of death, and as such choosing how one dies is a fundamental liberty that should be protected nationally. However, as discussed in Washington v. Glucksberg (1997), there is significant legal distinction between forced medication, as was the case in Cruzan v. Director (1990) as was the topic of discussion in Cruzan which is seen as battery, and assisting one in committing suicide, which has much less judicial and cultural protection [11]. Despite this rift, there are still some important parallels between the two cases, with both granting one more bodily autonomy and resulting in similar consequences: the ending of one’s life in spite of available medical resources to extend it. In this way, although the precedent of the right to refuse medical treatment is not sufficient in justifying MAiD, it does provide useful comparisons that support its legalization.

However, this line of argument itself was not sufficient in convincing the justices in Washington v. Glucksberg (1997) that MAiD ought to be legalized federally as they had a number of concerns which can be addressed due to the added insight into MAiD [12]. The court first noted concerns over the conflict of MAiD with the history and tradition of preserving life and opposing suicide throughout the United States and the western world [13]. At the time of the ruling, this analysis was accurate, but in the 30 years that followed, cultural opinions on MAiD have changed nationally and internationally. Within the United States, 10 states have since legalized MAiD with national public opinion at 66% in favor of MAiD as of 2024, compared to 52% in 1996 [14]. The rest of the western world is far ahead of the United States in advancing MAiD, with Canada, New Zealand, Switzerland, etc. having legalized MAiD nationwide [15]. This shift in legal and public opinions has had significant effects on a number of cases, notably Obergefell v. Hodges (2015) where the modern interpretations of liberty as understood by the public played a role in the decision, with Justice Roberts saying “when new insight reveals discord between the Constitution's central protections and a received legal stricture, a claim to liberty must be addressed [16].” The liberty provided by giving one the choice in how to die, especially when they are faced with imminent death, provides a similar instance of restricted freedom that is currently not available to many citizens, but is desired by a majority of the population.

It still holds that the “right to commit suicide with another's assistance” seems to clash with the ideals of preserving life and opposing suicide that still hold true across the United States. However, as Justice Breyer pointed out in his concurrence, the practice may be better formulated as a “right to die with dignity [17]." In this way, he argues, the debate is more centered around one’s right to avoid unnecessary suffering and choose how and when they die [18]. This line of argumentation holds much greater weight in cultural and legal opinion. For example, Justice Harlan stated that the Fourteenth Amendment entailed “a freedom from all substantial arbitrary impositions and purposeless restraints [19].” In this way, MAiD can be seen as relieving one from unnecessary pain and medical requirements that are brought about by the complications of terminal illness. Building on the reformulation of the liberty as outlined by Justice Breyer and its strengthened legal position provides substantive basis for the legalization of MAiD when combined with the other supporting points.

A significant problem for MAiD, as posed by Justice Souter, is that its legalization may produce a slippery slope for euthanasia since the practices are similar, and doctors may abuse their powers to administer lethal medication themselves. Souter notes that the response from proponents is to establish strict policy and rules over the practice of MAiD as to avoid this, and yet he also states his caution to accept this — noting that more research into actual outcomes is necessary [20]. This data was not available at the time, but it is evident now that in the United States, no inappropriate use of MAiD has been reported in over 27 years of its practice [21].

Another concern of many of the justices that presided over Washington v. Glucksberg raised at the time were regarding its potential to reinforce ableist attitudes and to undermine end-of-life care. There is a possibility that MAiD is used to pressure those with disabilities into ending their lives prematurely against their best wishes. If this were to be true, or if the growth of MAiD limited options for palliative care, say by reducing funding for hospices, then the practice ought to be illegal. These fears are brought out by cases like that of Roger Foley, a Canadian suffering from chronic pain and disabilities who claims he was repeatedly pressured into considering ending his life [22]. However, as defined by cases like Cruzan v. Director, a procedure like MAiD requires a high degree of certainty and safeguards for it to be legal, there must be ‘clear and convincing’ evidence that one wants the procedure. This is not only supported by theory, but also by studies examining the efficacy of MAiD in states where it is already legal, showing that MAiD has not resulted in any coerced deaths or discriminatory targeting of people with disabilities in the U.S [23]. When considering the significant research and evaluation of MAiD in various jurisdictions for more than 20 years, it is clear that the legalization of MAiD does not constitute a pseudo-legalization of euthanasia, nor does it advance ableist or coercive attitudes.

Consider then that MAiD is currently legalized in 10 states, the District of Columbia, and a number of countries in the western world from Canada to Switzerland [24]. The problem of ‘suicide tourism’ — the act of one travelling across state, or national, borders in order to receive treatment — as in the case of Brittany Maynard when she moved from California to Oregon [25]. One’s right to travel between states and be afforded the same rights as a citizen of that state is supported by the Privileges and Immunities Clause, also known as the Comity Clause, and is bolstered throughout a number of cases (Saenz v. Roe (1999), United States v. Guest (1966)) [26]. Yet, there have been significant challenges to this precedent concerning MAiD due to its state dependent legality. Many states still have a residency requirement, although legal challenges have begun challenging this condition on the basis of the Fourteenth Amendment [27]. As such, those seeking MAiD from states where it is illegal, face significant challenges and may be rejected MAiD if they travel across states to access it. Even in the event one is able to access MAiD in this manner, there is uncertainty whether a family member or friend who helps one in seeking out-of-state MAiD may face charges for assisting a suicide in their home state [28]. While there are no instances of this occurring, the mere possibility of it presents significant hurdles for those seeking MAiD, where the support of family and friends is critical and its friction with the Comity Clause poses a significant problem for the current partial legalization of MAiD.

In conclusion, there is sufficient evidence for the nationwide legalization of MAiD in the U.S that was not present even 30 years ago. This rapid shift in the landscape of the case is due to an equally rapid warming of public and medical opinions, which in turn has influenced the law in U.S states and other western countries alike. A reframing of support for MAiD, armed with new evidence on its benefits and safety from abuses or deterioration of medical standards, tied with its role in allowing one to die with dignity, provides a strong legal case. Combined with the similarities to one’s right to refuse life support as upheld by the Supreme Court, there are a multitude of arguments to be put forward. The strength of the Comity Clause and its potential clash with restrictions on out-of-state travel for MAiD exemplify the benefits of its nationwide legalization.

Bibliography

[1] People.com. “Terminally Ill Woman Brittany Maynard Has Ended Her Own Life.” Accessed February 28, 2025. https://people.com/celebrity/terminally-ill-woman-brittany-maynard-has-ended-her-own-life/.

[2] Ibid.

[3] Ibid.

[4] “Your End-of-Life Options.” Accessed February 28, 2025. https://www.americanbar.org/groups/senior_lawyers/resources/experience/2023-july-august/your-end-of-life-options/.

[5] Ibid.

[6] Ibid.

[7] https://compassionandchoices.org/. “Washington v. Glucksberg & Vacco v. Quill - Compassion & Choices.” Accessed March 9, 2025. https://compassionandchoices.org/case/washington-v-glucksberg-vacco-v-quill/.

[8] “Your End-of-Life Options.” Accessed February 28, 2025. https://www.americanbar.org/groups/senior_lawyers/resources/experience/2023-july-august/your-end-of-life-options/.

[9] Cruzan v. Director, Missouri Dep't of Health, 497 U.S. 261 (1990)

[10] “Right to Refuse Medical Treatment and Substantive Due Process | Constitution Annotated | Congress.Gov | Library of Congress.” Accessed March 9, 2025. https://constitution.congress.gov/browse/essay/amdt14-S1-6-5-1/ALDE_00000903/.

[11] Washington v. Glucksberg, 521 U.S. 702 (1997)

[12] Ibid.

[13] Ibid.

[14] Inc, Gallup. “Most Americans Favor Legal Euthanasia.” Gallup.com, August 8, 2024. https://news.gallup.com/poll/648215/americans-favor-legal-euthanasia.aspx.

[15] Dobec, Sarah. “Medical Assistance in Dying around the World.” Dying With Dignity Canada, October 28, 2022. https://www.dyingwithdignity.ca/blog/medical-assistance-in-dying-around-the-world/.

[16] Obergefell v. Hodges, 576 U.S. 644 (2015)

[17] 521 U.S. 702 (1997)

[18] Ibid.

[19] Ibid.

[20] “Fact: Medical Aid in Dying Laws Work to Protect Patients - Compassion & Choices.” Accessed March 8, 2025. https://compassionandchoices.org/.

[21] Ibid.

[22] CTVNews. “Chronically Ill Man Releases Audio of Hospital Staff Offering Assisted Death,” August 3, 2018. https://www.ctvnews.ca/health/article/chronically-ill-man-releases-audio-of-hospital-staff-offering-assisted-death/.

[23] Battin, Margaret P., Agnes van der Heide, Linda Ganzini, Gerrit van der Wal, and Bregje D. Onwuteaka-Philipsen. “Legal Physician-Assisted Dying in Oregon and the Netherlands: Evidence Concerning the Impact on Patients in ‘Vulnerable’ Groups.” Journal of Medical Ethics 33, no. 10 (October 2007): 591–97. https://doi.org/10.1136/jme.2007.022335.

[24] Dying With Dignity Canada, “Medical Assistance in Dying around the World.”

[25] People.com, “Terminally Ill Woman.”

[26] “Interstate Travel as a Fundamental Right | Constitution Annotated | Congress.Gov | Library of Congress.” Accessed March 8, 2025. https://constitution.congress.gov/browse/essay/amdt14-S1-8-13-2/ALDE_00000840/. ;“Overview of Privileges and Immunities Clause | Constitution Annotated | Congress.Gov | Library of Congress.” Accessed March 8, 2025. https://constitution.congress.gov/browse/essay/artIV-S2-C1-1/ALDE_00013777/; Saenz v. Roe, 526 U.S. 489 (1999); United States v. Guest, 383 U.S. 745 (1966)

[27] “End-of-Life Options Act.” Accessed March 8, 2025. https://www.nmhealth.org/about/erd/bvrhs/vrp/maid/. ;https://compassionandchoices.org/. “Medical Aid in Dying: Residency Restrictions - Compassion & Choices.” Accessed March 8, 2025. https://compassionandchoices.org/legal-advocacy/residency-restrictions/.

[28] “Medical Aid in Dying: Residency Restrictions - Compassion & Choices”