When Stephanie Packer, a terminally ill mother of four, called her insurance to confirm coverage for her treatment plans, she was shocked to hear they were refusing to pay. Conveniently, for less than the cost of a Snickers bar, she could kill herself instead.
“Medical Aid in Dying” (MAID) is the term used by proponents of legislation allowing physicians to prescribe deadly medication to the terminally ill. In 2016, the same year Stephanie Packer found herself battling her insurance company, California enacted the “End of Life Options Act,” making it the fifth state to legalize physician-assisted suicide.
Problematic Incentives to Die
Opponents of MAID are concerned that such legislation provides dangerous incentives. In this case, Stephanie dying was cheaper than treatment, and California’s legalization of this possibility did her no favors. Dr. Brian Callister, outspoken advocate against physician-assisted suicide and director of Academic Hospital Medicine at the University of Nevada, argues, “the cheapest thing in the world for an insurance company is to collect your premiums and then, when you actually need to use them, it’s ‘Oh, your life’s not worth living. Here’s some pills. Go kill yourself.’”
Incentives pose a limitless philosophical dilemma for physician-assisted suicide. Compulsion from an insurance company is an incentive most people would find obviously problematic, whereas helplessness and pain are cited as legitimate. However, there will always be other inevitable pressures present towards the end of life, such as financial advantage, emotional duress, or mere preference. Where do we draw the line?
Final Exit Network, a “right-to-die” advocate group based in Florida, goes as far as to say that dementia patients should be free to “minimize the amount of time they spend in a demented state,” citing “loss of self-hood” as a potential impetus.
Currently, American MAID laws, present in 11 states, require that patients be terminally ill with six months left to live. Dr. Thaddeus Pope, widely published bioethicist and law professor at Mitchell Hamline School of Law, as well as an advocate in favor of MAID, is in favor of applications beyond terminal illness.
“I’m the best judge of what’s best for me. So, if this is intolerable, if you can’t live with this anymore, then who am I to say, ‘Yes, you can live with it, and you’re going to,'” Pope told me in an interview.
When pressed on whether this decision could be circumstantially influenced, he responded, “Reasons that have nothing to do with something that the illness did to you, that gives me a lot of pause. That’s an uncommon situation. Those are not the main patients that we’ve seen.”
Packer, reflecting on her circumstances, argued otherwise. “Life insurance can still go to families even if someone kills themselves, using this option. So, ‘I have no money for treatment, and I’ve got life insurance. I can take care of my family that way.’ And to say that that’s not coercion, to say that that doesn’t affect somebody’s decision — it’s ridiculous.”
Complicating the issue, six-month prognoses are more liberally applied than their description implies. In Packer’s case, despite financial difficulties, pain, and personal hardships, she opted out of a medically assisted death. She also wasn’t killed by her illness. She is alive today, almost ten years later, and her story has been reported by the Washington Times, CNN, and NPR. The option to kill herself was available despite the possibility of a much longer life.
Furthermore, the patient need not be actively dying to receive an adequate prognosis. Dr. Callister explains, “What’s really important to note here is that’s not with treatment, that’s with or without treatment. A person with diabetes who decided to stop their meds or their insulin would technically be terminal.” According to Oregon’s Death with Dignity statistics, more than two percent of 2024 deaths in their state that resulted from ingesting lethal medications were people with a metabolic or endocrine disease, any number of whom could have been suicidal diabetics who stopped insulin.
Diabetes is one of many controversial conditions that can qualify a person for MAID. Anorexia is another. Matt Vallière is the executive director of the Patients Rights Action Fund, an organization fighting assisted suicide laws. He told me that the way that laws are currently written, “allow for people like young women with anorexia to access lethal drugs.” His suggestion is not a fringe possibility.
The Journal of Aid-in-Dying Medicine published an article in 2024 explaining the usage of MAID under what they define as “ethical” circumstances. Dr. Jenifer Gaudiani, an internationally recognized eating disorder specialist who runs Gaudiani Clinic in Colorado, advocates that MAID be used for anorexic patients who qualify as “terminal.” Such liberal application, whether someone with diabetes, anorexia, or someone like Packer, sounds like suicide to opponents’ ears.
‘Voluntary Stopping Eating and Drinking’
Compassion and Choices, formerly called the Hemlock Society, is a national organization advocating for “expanding end-of-life options,” and dislike the term “suicide.” Their website reads, “Medical aid in dying is sometimes incorrectly referred to as ‘assisted physician suicide,’ ‘physician aid in dying,’ ‘death with dignity,’ and ‘euthanasia.’ Medical aid in dying is not assisted suicide, suicide, or euthanasia. These terms are misleading and factually incorrect.”
By their standards, “suicide” is inapplicable language regarding MAID. In Cody Sontag’s case, this included using “Voluntary Stopping Eating and Drinking” (VSED) as a bridge to a terminal diagnosis when she was diagnosed with “mild cognitive impairment,” which Pope documented in his article for the Journal of American Geriatrics Society. Wanting to avoid the lifestyle of a late-stage dementia patient, she voluntarily stopped eating and drinking after experiencing “bothersome and not intolerable” symptoms, qualifying her with a terminal diagnosis based on her resulting dehydration. Her reason given to end her life was “to avoid imposing burdens of caregiving on her family.” She was given medication and died around age 70.
Pope has written one article for the Journal of the American Geriatric Society and another for the Journal of Medical Aid in Dying Medicine, exploring how physicians can use VSED as a bridge for dementia patients. The Final Exit Network also provides logistical and informational assistance for VSED, training “death doulas” and linking VSED resources for patients.
Oregon was the first to pass MAID legislation in 1997, calling it the “Death with Dignity Act.” Death with Dignity is also the name of an organization advocating “end-of-life options.” They promise, “Proven safe, effective, and above all, meaningful, the Oregon Death with Dignity Act works exactly as intended and exactly for whom it was intended, without fail.”
The Death with Dignity Act does not require anyone to witness the subject ingesting medication. Since the Act’s passing, 4,481 people have received medication, and 3,243 have died via ingestion. This leaves lethal medication in the hands of 1,238 citizens unsupervised. Of those who ingested medication in 2024, 63 had no one present and for 84 it is unknown.
Dr. Callister suggests there are certainly scenarios this law could be abused:
“You’ve got a granny who’s barely getting around and you have a freeloading grandson with his live-in girlfriend. There’s your two witnesses. ‘Hey, granny, you’re in pain all the time. You have intractable pain. You don’t want to live like this.’ There’s your two witnesses to get the prescription, and then there’s no required health care provider or witness when you do the pills. So what’s to keep those two from putting it in her apple sauce? There’s no way we could know!”
In June 2025, New York passed legislation making it the 12th state to legalize MAID, if Gov. Kathy Hochul signs it into law. It would be the first to not require a mandatory waiting period between request and fulfillment, allowing a patient access to death in a moment of intense duress.
The ever-increasing legalization of MAID throughout the United States requires that Americans decide how easy death should become. Packer encouraged patients to consider, “There’s such a beauty in an end-of-life journey. There are special, special things that you can take away and can be learned and experienced at no other time in your life.”