For several decades, medical aid-in dying (better known as physician-assisted suicide (PAS)), has been at the core of a controversial debate in bioethics between federal and state legislatures. While the United States Supreme Court has deliberated over a patient’s right to refuse life-sustaining treatment against the state’s interest in preserving life, it has also rejected PAS as a substantive right protected under the Constitution. Despite this, several states have taken steps to ensure their citizens, specifically those suffering from terminal illnesses, have the right to die on their own terms. Currently, in the United States, ten states and the District of Columbia have legalized PAS for terminally ill patients. This has primarily been accomplished via state policy reform and implementation of “Death with Dignity” statutes. These state laws provide terminally ill residents with the legal right to obtain prescriptions that will allow them to end their lives. The question that remains, however, why are the federal government and non-death with dignity states reluctant to extend this decisional autonomy to the rest of the country? Given that the Constitution prevents the federal government from intruding into our personal and often private decisions, should we not be allowed to decide our means of death?

The core issue of PAS boils down to whether an individual right to end one’s life is guaranteed under the Constitution. In Washington v. Glucksberg, the Supreme Court was asked to decide whether Washington State’s prohibition on “causing” or “aiding” suicide went against the Fourteenth Amendment’s  due process liberty interest. Looking to the nation’s history and traditions around the treatment of suicide, the Supreme Court found that no such right to die existed, and that, in fact, it was quite distinct from the right to refuse life-sustaining medical treatment. The court used an originalist approach in its decision and concluded that the legalization of PAS would violate traditional notions of the Fourteenth Amendment’s Due Process Clause. However, they held that PAS legalization was a substantive issue for the states to decide.

States that allow for PAS often enact requirements that follow the regulations and requirements first established under Oregon’s 1997 “Death with Dignity” Act. Statutes like Oregon’s allow qualifying terminal patients the right to end their lives with a prescribed lethal medication approved by their physician. The law requires an extensive patient/physician request process. This ensures a physician provides the correct treatment option to their patient and that the patient is fully consenting and aware of the requested procedure and its outcome. States with “Death with Dignity” statutes will also require the patient be a legal adult, capable of deciding and voicing their own healthcare choices, have a diagnosis of a terminal illness that will result in death within six months, and a resident of the state but this requirement has become loosened in some PAS states. Additionally, the patient must submit various oral and written requests to their physician and may even be required to undergo a physiological evaluation. This decision is only that of the patient and at the discretion of their physician. By states introducing such statutes, they are creating an effective procedural process that, on a state level, would allow their citizens affected by terminal illness to have guaranteed substantive rights even if the federal Constitution does not encompass them.

Although states like Oregon and California have shown the benefits of enacting PAS statutes, there is still significant opposition from various coalitions representing medical professionals, religious groups, and disability rights groups that have made legislative progress towards expanding PAS availability quite tricky. This objection is often rooted in a divide between moral/ethical ideologies and the potential risk of harm to the medical field. There is no doubt that there is a divide between pro-life and pro-choice organizations, reformists, and legislatures who have contradicting views of the practice. Pro-life advocates find legislative initiatives in favor of PAS to defile the sanctity of life by putting a vulnerable population at greater risk of improper treatment and diminishing their rights. On the other end of the spectrum, PAS advocates, such as the organization known as Compassion & Choices, argue that PAS can empower a terminally ill patient to have complete control of the remainder of their life, while also calling for a “patient-directed system” that prioritizes a patient’s wishes while also reforming end-of-life care policy.

Aside from political influences, there is a concern that a wider acceptance of PAS may tarnish the medical field, including potentially increasing the risk for medical abuse. Many have pointed to the fact that a physician taking part in a PAS procedure is in direct contradiction to their role as a healer and violating their ethical duties to preserve life and do no harm. While this is true from a traditional perspective, more modern iterations of the Hippocratic Oath do not prohibit nor make physicians promise not to participate in certain practices. The development of the oath has recognized the necessity of modern medical interventions and shown an awareness of novel health care issues while maintaining a commitment to individuals receiving sufficient care and treatment. Thus, under the modern Hippocratic Oath, PAS could be deemed an acceptable form of care among physicians who choose to participate in the practice.

While a state can legalize the practice of PAS, no law requires or forces physicians to take part in the treatment if they object to its practice on social, political, religious, or ethical grounds. There is also a concern about PAS becoming a sanctioned form of medical abuse were it to take some of the place of current end-of-life care. While this would be an extreme implication, such slippery slope arguments are not without merit given the history of medical abuses that have been targeted towards vulnerable communities. Based on this hypothetical, there is the concern that physicians could push PAS onto patients who cannot afford other treatment options, restrict hospital resources for terminal patients, or even coerce patients towards PAS because it could eliminate the “unnecessary” burdens related to long term care.

A federal right to PAS is unlikely, given the Supreme Court’s focus on only recognizing those rights deeply rooted in the nation’s history and traditions. Other avenues for future legalization, such as through congressional legislation, would be unlikely given Congress’s longstanding opposition to PAS, including a ban enacted by the 105th Congress that prohibits the use of federal funds for PAS programs. However, I envision other progressive states slowly moving towards implementing the pro-PAS legislature. Currently, state legislatures in Maryland, Massachusetts, and Michigan, to name a few, are optimistic about the potential that PAS-related bills will be introduced and voted on throughout 2024, given the uptick in public and legislative support.

The future success of PAS lies in limiting it to a genuine last-resort option. This would require the patient to undergo other treatment(s); if there is no success, then a physician can identify PAS to their patient. From there, the patient must follow the required PAS procedures to be considered a proper candidate for the treatment. Additional safety nets could also be established, such as third-party mediation between patient and physician interactions regarding the treatment and recording the number of patients who have undergone treatment at a particular facility or physician.

PAS is a remarkable treatment option for those who genuinely have exhausted all other options and are confronted with an end to their lives that lacks the dignity and control they’ve exuded throughout the rest of their lives. It allows the individual to have complete autonomy over themselves at a point of extreme vulnerability where they may feel powerless. While controversial, I believe PAS has widespread use within the medical field but must be under stringent regulation and only applicable to the most severe instances. However, we still have to work towards a future in which policymakers and the general public can feel confident in this treatment and change their views of PAS to one centered around the benefits of autonomy and preventing unnecessary suffering.