A Distinction Without a Difference: Adopting a Unified Framework for Euthanasia
Euthanasia and Medical Aid in Dying (MAiD) are often treated as legally distinct practices, but they are functionally indistinguishable in their core elements of intent, consent, and outcome. Yet, in terms of their legality, they are subject to irreconcilable standards, creating a statutory barrier that prevents individuals — particularly those with physical disabilities — from accessing existing provisions for death with dignity in the United States. In medical terms, the MAiD statute permits individuals with a terminal illness to legally obtain and self-administer prescriptions “to end their lives in a peaceful manner” [1]. Differentiated from MAiD, euthanasia is the administration of such a prescription by another person — typically a physician — to an individual “for the purpose of relieving the patient’s intolerable and incurable suffering” [2]. The core distinction lies with who administers the lethal dose: the physician or the patient [3]. Aside from this procedural difference, the two practices are indistinguishable. Shmuel Thaler, whose mother chose a self-determined end with MAiD, makes a single key distinction between euthanasia and MAiD: “While both practices are designed to bring about a peaceful death, the distinction comes down to who administers the means to that peaceful death” [4]. Both euthanasia and MAiD require voluntary, informed consent obtained from the patient and the mutual intent of both parties to facilitate an end to insufferable pain [5]. Despite the marginal procedural distinction, euthanasia and MAiD are held to disparate legal standards, where the former remains a strictly illegal, criminal act, while the latter is protected in several, though not all, jurisdictions in the United States.
In this regard, the Equal Protection Clause of the Fourteenth Amendment functions as a constitutional mechanism for ensuring legal equality, requiring states to justify any discriminatory outcomes under a tiered system of judicial scrutiny. This essay argues that the current legal separation between Medical Aid in Dying (MAiD) and euthanasia is one without a constitutionally meaningful distinction, which emphasizes the mechanics of the act rather than the underlying intent and informed consent. Withholding a unified legal framework raises serious concerns under the Equal Protection Clause for patients whose physical disabilities prevent them from accessing the only form of legally sanctioned relief, and should be evaluated under rational basis review, which requires that the classification be rationally related to a legitimate state interest.
The expansion of end-of-life autonomy in the United States is characterized by a number of growing but highly regulated frameworks operating at the state level. Fourteen states and jurisdictions have legalized MAiD, but each has drawn the same rigid boundary: Only patients capable of self-administering the prescribed medication qualify for statutory protection. Such legal and medical rights are granted in California, Colorado, Delaware, the District of Columbia, Hawaii, Illinois, Maine, Montana, New Jersey, New Mexico, New York, Oregon, Vermont, and Washington state [6]. The Death with Dignity Act, enacted in Oregon in November 1994 by a margin of 51 to 49 percent, was the first legalization of MAiD in the United States [7]. Guided by voter-approved intentions, Oregon’s Act codified the public’s desire to prioritize individual autonomy around the manner and time of one’s death. The act drew a rigid procedural requirement around self-administration, effectively distinguishing a legally protected medical right from euthanasia. The thirteen other jurisdictions soon followed suit, legalizing MAiD while explicitly criminalizing euthanasia — cementing the “self-administration” requirement as the definitive boundary. According to the American Medical Association’s Code of Medical Ethics, such limitation is predicated on the grounds that euthanasia is “fundamentally incompatible with the physician’s role as healer” [8]. These limitations are often justified as reflecting an effort to preserve the ethical role of physicians while accommodating individual autonomy. In practice, this uniform self-administration requirement excludes a discrete class of terminally ill patients, those physically incapable of ingesting or administering medication, from access to a right that is extended to others similarly situated in all other respects.
The current end-of-life legislation prioritizes the mechanics of administration over the expressed intent of individual patients, creating a discriminatory classification. In the case of Cruzan v. Director, Missouri Department of Health (1990), the Supreme Court recognized the constitutionally protected liberty of individuals to refuse unwanted treatment, serving as a landmark acknowledgement of bodily autonomy [9]. In the case, the Court acknowledged that clear and convincing evidence of a patient’s prior intent was enough to authorize surrogates to carry their wishes out, even in the absence of the patient’s current agency. Thus, the Court accepted that autonomy may be effectuated through third party action when clear and convincing evidence of intent exists. In medical terms, the withdrawal or termination of life-sustaining treatment — in this case the feeding tube — falls under the definition of passive euthanasia, which is the act of “letting someone die either by withdrawing or withholding treatment” [10]. The inconsistent nature of the mechanics of self-administration required for MAiD becomes clear through this case and its clear legalization of passive euthanasia: If legislation authorizes the past intent of an incapacitated patient to withdraw life-sustaining treatment, current jurisprudence remains inconsistent in its failure to recognize the present wishes of physically disabled patients whose lack of motor function prevents them from self-administering medication.
Although the state may invoke interests in preserving life or preventing abuse, those interests are underinclusive and inconsistently applied when passive euthanasia and physician-prescribed lethal medication are already permitted under comparable safeguards. In the case of Baxter v. Montana (2009), the Montana Supreme Court legalized MAiD, ruling on a statutory defense against criminalizing physician-provided prescriptions upon the patient’s request. The court granted immunity from criminal prosecution for physicians who received explicit, informed consent from the patient and effectively reinforced the patient’s consent as the decisive legal factor [11]. In doing so, the Montana Supreme Court centered legality on voluntary consent rather than on the identity of the final actor. Once we accept the Supreme Court’s legalization of passive euthanasia (the withdrawal of life-sustaining treatment) and the Montana Supreme Court’s justification of MAiD, the intentionality and informed consent requirement shared by active euthanasia (physicians administering the lethal dose) renders the “self-administration” requirement an arbitrary threshold that does not clearly advance the state’s asserted interests, while excluding a distinct class of the physically disabled.
Such legislative and regulatory requirements preclude individuals with physical disabilities from exercising the terminal autonomy granted to able-bodied individuals, creating a discriminatory barrier that violates the Equal Protection Clause. Terminally ill patients in jurisdictions where MAiD is legalized hold a state-protected right to an autonomous realization of their deaths. However, eligible patients with neuromuscular disabilities like Amyotrophic Lateral Sclerosis (ALS) or physical states characterized by profound motor impairment are “excluded if they are unable to ‘self-administer’ the medications without assistance” [12]. Granted that both able-bodied and physically disabled patients are similarly situated in all constitutionally relevant aspects — they are terminally ill, mentally competent, and have voluntarily expressed a desire to end their suffering — the legislative limitation raises serious concerns under the Equal Protection Clause by conditioning access to a legalized medical practice on a patient’s physical capacity. The resulting discriminatory classification discloses the inconsistency of a jurisdiction that has already legalized MAiD, but distributes such services in a manner that does not grant all similarly situated individuals equal protection under the law.
The exclusionary effect not only conflicts with the Equal Protection Clause but is also in tension with federal disability law. Specifically, the jurisdictional component of MAiD violates a fundamental principle of the Americans with Disabilities Act (ADA) — the equal treatment of individuals with disabilities. The ADA requires that clinicians make accommodations to make healthcare services available to qualified individuals with disabilities “when reasonable accommodation can be provided” [13]. In particular, Title II of the ADA requires state and local governments to provide individuals with disabilities “an equal opportunity to benefit from all of their programs, services, and activities,” including health care [14]. Accordingly, states where MAiD is legalized may be in tension with federal disability law by preventing qualified individuals with disabilities from accessing end-of-life options based solely on physical immobility, highlighting the limitations of the current MAiD framework.
Admittedly, it is important to consider the implications for the vulnerable population and state interests of removing legal distinctions between MAiD and euthanasia. A common concern is that the normalization of voluntary euthanasia will place pressure on members of an already vulnerable population — the elderly and the disabled who are physically able — and transform the procedure into a social expectation, rather than a fully autonomous choice [15]. This is a sentiment echoed by many ethicists and professionals in the field, including Professor John Keown of the Kennedy Institute of Ethics, Georgetown University [16]. Even MAiD, which is legalized in select jurisdictions, has historically conflicted with the state’s general interest in the preservation of life. In Vacco v. Quill (1997), the United States Supreme Court unanimously ruled that withholding lethal prescriptions to patients was not a fundamental violation of the Equal Protection Clause since it was distinct from patients refusing life-saving treatments [17]. However, the Supreme Court’s distinction between MAiD and the withdrawal of life-saving treatment rests on a formal distinction between causation and intent, despite the similarity in both the patient’s objective and the outcome [18]. In both cases, the patient intends to end further suffering, which the physician facilitates by taking a deliberate action — removing a ventilator or prescribing a lethal dose. This line of reasoning undermines the justification for prohibiting euthanasia while permitting MAiD, as it reveals an argument built upon a semantic, rather than legal or moral, distinction.
Once states have accepted patients’ autonomy, intent, and physicians’ role in facilitating death through MAiD, it becomes inconsistent to criminalize another form of assisted dying that encompasses identical intent and outcome based on the mere mechanism of delivery. Even without the legalization of MAiD in other jurisdictions, passive euthanasia — withholding life-saving treatment at a patient’s request — will remain legal. In this case, the legality of letting a patient die will already have conceded the state’s interest in preserving life in favor of patients’ autonomy [19]. Under the same qualifications of obtaining informed consent, respecting patient autonomy, and harboring the same intent on the part of the patient, the legal barrier to active euthanasia becomes logically unsustainable. We must not prioritize the mechanics of the act over the will of an autonomous individual with a right to a dignified death.
The experience of other constitutional democracies suggests that an intent-based regulatory framework can accommodate both assisted suicide and physician-administered euthanasia without collapsing into the harms predicted by opponents. Under Carter v. Canada (2015), the Supreme Court of Canada found the Criminal Code prohibiting physician-assisted suicide to be a violation of the Canadian Charter of Rights and Freedoms, leading to the legalization of MAiD [20]. Thus, the Court repudiated the formalist distinction between active and passive euthanasia. Under Bill C-14 (2016), Canada legalized both euthanasia and assisted suicide (MAiD), where a nurse practitioner or physician can either directly administer a substance or prescribe a substance for the patient to self-administer [21]. Such legalization was a deliberate act on the part of the Canadian government “driven by compassion, an end to suffering and discrimination, and a desire for personal autonomy,” allowing eligible patients who lacked physical capability to self-administer to access the protected legal medical service [22].
Legalization of euthanasia, in states where MAiD is already legalized, would ensure that all Americans, regardless of their physical ability, will possess the same level of autonomy in choosing a dignified death. Under the same circumstances — terminal illness, mental competency, and ability to offer informed, voluntary consent — the “self-administration” requirement that distinguishes MAiD from euthanasia presents itself as an arbitrary barrier, privileging those with motor functions while penalizing patients whose physical impairments deter them from exercising their protected medical right. In providing patients with a choice between self-administration and clinician-administered euthanasia, a unified legal framework would eliminate the physical ability barrier that currently excludes those with limited mobility and would uphold the constitutional promise of equal protection under the law. Ultimately, the current distinction fails to adequately prioritize informed consent and intentionality. Legislatures should shift to emphasizing constitutional coherence and equality from merely considering a patient’s physical capacity to exercise autonomy.
References
[1] Death With Dignity, Frequently Asked Questions (2022), https://deathwithdignity.org/resources/faqs.
[2] AMA Code of Medical Ethics, Euthanasia (2022), https://code-medical-ethics.ama-assn.org/ethics-opinions/euthanasia
[3] Maxim Institute, Frequently Asked Questions (2021), https://www.maxim.org.nz/article/faq1-euthanasia-and-assisted-suicide/
[4] Shmuel Tahler, A Good Death: A Personal Account of My Mother and Medical Aid in Dying (2024), https://nppa.org/magazine/article/magazine-feature-shmuel-thaler-mom-death.
[5] J. Pereira, Legalizing Euthanasia or Assisted Suicide: The Illusion of Safeguards and Controls (2011), https://pmc.ncbi.nlm.nih.gov/articles/PMC3070710/.
[6] Death With Dignity, In Your State (2026) https://deathwithdignity.org/states/.
[7] Legislative Committee Services, Background Brief on Death with Dignity Act (2012), https://www.oregonlegislature.gov/citizen\_engagement/reports/deathwithdignityact.pdf.
[8] Faith Lagay, Physician-Assisted Suicide: The Law and Professional Ethics (2003), https://journalofethics.ama-assn.org/article/physician-assisted-suicide-law-and-professional-ethics/2003-01.
[9] Cruzan v. Director, Missouri Dep’t of Health, 497 U.S. 261 (1990).
[10] Vinod Srivastava, Euthanasia: A Regional Perspective (2014), https://pmc.ncbi.nlm.nih.gov/articles/PMC4158780/.
[11] Baxter v. Montana, MT 449 (2009).
[12] Lonny Shavelson, Neurologic Diseases and Medical Aid in Dying: Aid-in-Dying Laws Create an Underclass of Patients Based on Disability (2022), https://pmc.ncbi.nlm.nih.gov/articles/PMC9931932.
[13] U.S. Department of Justice Civil Rights Division, Guide to Disability Rights Laws (2020), https://www.ada.gov/resources/disability-rights-guide/.
[14] Ibid.
[15] British Broadcasting Corporation, Overview of Anti-Euthanasia Arguments (2008), https://www.bbc.co.uk/ethics/euthanasia/against/against_1.shtml.
[16] John Keown, Voluntary Euthanasia & Physician-assisted Suicide: The Two ‘Slippery Slope’ Arguments (2021), https://www.bioethics.org.uk/media/vrkdjlgu/voluntary-euthanasia-physician-assisted-suicide-the-two-slippery-slope-arguments-prof-john-keown.pdf.
[17] Vacco v. Quill, 521 U.S. 793 (1997).
[18] Brett Feinberg, The Court Upholds A State Law Prohibiting Physician-Assisted Suicide (1998), https://scholarlycommons.law.northwestern.edu/cgi/viewcontent.cgi?article=6961\&context=jclc.
[19] Kristina M. Conner, Medical Aid in Dying (2025), https://www.dynamed.com/management/medical-aid-in-dying-maid/.
[20] Carter v. Canada (AG), SCC 5 (2015).
[21] Marlisa Tiedemann, Medical Assistance in Dying in Canada After Carter v. Canada Hill Studies (2019), https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/201943E.
[22] Dying With Dignity Canada, Get the Facts: Canada’s Medical Assistance in Dying (MAID) law (2022), https://www.dyingwithdignity.ca/end-of-life-support/get-the-facts-on-maid/.