Advances in Medical Ethics
Open Access
ISSN: 2385-5495
ISSN: 2385-5495
Review Article - (2025)Volume 11, Issue 1
Ethics Medical Assistance In Dying (MAID), a legal end-of-life option in Canada with expanding eligibility, now accounts for a growing proportion of deaths across the country. Implemented within a universal, publicly funded health system, MAID is offered alongside a relatively robust continuum of care, including palliative and hospice services. In contrast, possible implementation in the United States fragmented; profit-driven healthcare model raises ethical concerns about how MAID might function if legalized. This paper critically examines the ethical implications of introducing MAID into the United States, where financial incentives, private insurance, and unequal access to care has the potential to distort patients’ end-of-life choices. Through comparative analysis, real-world case studies, and hypothetical vignettes, we argue that without significant reform, MAID in the United States risks becoming a tool of abandonment particularly for disadvantaged patients such as those from low-income, disabled, and marginalized populations.
Medical Assistance In Dying (MAID); End-of-life care; Healthcare disparities; Ethical implications
This Medical Assistance In Dying (MAID) is one of the most ethically complex issues in contemporary healthcare policy. This paper does not seek to determine whether MAID is morally justifiable, nor does it advocate for or against its general legalization. Rather, it aims to examine how the structural context of a healthcare system specifically, a profit-driven, privatized model like that of the United States will adversely prejudice the ethical and equity implications of implementing MAID. While the authors of this paper hold differing personal views on the practice itself, they are united in the belief that the surrounding healthcare infrastructure will critically shape how such a policy is likely to be experienced by patients.
Until recently, MAID has tended to be adopted in wealthy Western countries, which almost exclusively feature publicly funded health insurance systems (although more recently some Latin American countries have decriminalized the practice). Canada, where MAID has become more widely available in recent years, provides a particularly relevant case study. Its geographic proximity and cultural similarities to the U.S [1,2]. make comparisons accessible, while the stark contrast between Canada’s single-payer system and the United States' fragmented, multi-payer model offers a valuable lens through which to explore systemic risks. In Canada, MAID is integrated into a publicly financed healthcare system that theoretically ensures universal access to essential medical services, including palliative and end-of-life care. Patients are not expected to choose between death and unaffordable treatment; rather, MAID exists as one option among many, supported by a system that aims to minimize economic coercion. It is notable, however, that even in Canada, there have been concerns that MAID is being offered instead of (as opposed to in addition to) quality palliative care for many patients [3].
Future In recent years, Canada has greatly expanded the availability of MAID, transforming it from a contested ethical concept into a legally practiced and widely debated medical intervention. According to the most recently published Canadian government data on the prevalence of MAID within the country, the practice accounted for 4.7% of all deaths in Canada in 2023, reflecting its rapid integration into end-of-life care [4]. The Canadian model incorporates MAID within a single-payer healthcare framework that strives at least in principle to ensure equitable access to medical services, including hospice and palliative care. Patients who seek MAID are, in theory, choosing from a full range of accessible alternatives, supported by a system designed to uphold autonomy without undue financial or structural pressure.
By contrast, the U.S. healthcare system is shaped by market forces, inconsistent insurance coverage, and vast disparities in care access. Within this context, introducing MAID raises urgent ethical concerns. Though commonly framed as a compassionate option for those experiencing unrelievable suffering, MAID in the American setting could quickly become a financially incentivized alternative appealing not because it best reflects patient autonomy, but because it reduces institutional costs. Without robust safeguards and significant healthcare reform, MAID in the United States risks becoming less a matter of choice and more a function of systemic neglect [5].
Comparative healthcare structures
Canada’s healthcare system is a public, single-payer model that provides comprehensive medical services to all citizens and permanent residents. Funded through taxation, the system ensures that financial barriers are minimal at the point of service. Healthcare spending in Canada constitutes approximately 10.8% of the country's GDP [5]. MAID is presented alongside a range of other fully funded alternatives, including hospice, palliative care, and home support services [4]. Even when patients cannot receive these options, they are at least assured that their sickness will not result in significant financial injury.
In contrast, the United States spends an even greater proportion of its GDP, 16.8%, on healthcare, yet the outcomes are less equitable and often worse [6]. The United States’ healthcare system is characterized by multiple payers, including private insurers, Medicare, Medicaid, and employer-based plans. High out-of-pocket costs, frequent insurance denials, and stark disparities in access remain major barriers.
Medicaid, the primary payer for many low-income Americans, offers reimbursement rates that are often insufficient to cover the true costs of care, particularly for hospice and palliative services [7]. As a result, MAID, if legalized, might be offered as the only option for those unable to afford other choices, rather than one option among many.
Distorted choice architecture and financial incentives
One of the most insidious threats posed by the introduction of MAID into a market-driven healthcare system is the subtle influence of economic incentives on patients’ decisions. In Canada, some studies have estimated that the provision of MAID could save between CAD $34.7 and $138.8 million annually [8]. While these savings are modest in the context of a national healthcare budget, they highlight how institutional stakeholders may view MAID as an opportunity to reduce spending. Furthermore, it is impossible to fully estimate the future impact of MAID on Canadian healthcare spending, given its rapid increase in use since implementation.
In the United States, end-of-life care is among the most expensive areas of medical treatment particularly in intensive care units and prolonged inpatient hospital stays. Hospitals, insurance companies, and accountable care organizations face significant financial pressure to reduce expenditures [9, 10]. This creates an environment where MAID, if legalized, could be framed not purely as a compassionate option for suffering, but as an efficient solution for resource allocation.
Similarly, medical debt is a significant concern for Americans experiencing illness. The very knowledge that one’s family could face bankruptcy by the “choice” to pursue treatment or standard end of life care could result in guilt and emotional suffering. Patients may feel as though MAID is the best option for them to avoid burdening their families.
Furthermore, we should concern ourselves with the ways that medical institutions might respond to the changes within the system. It is possible that given the massive costs associated with traditional end-of-life care, hospital systems that receive lower reimbursements may, at one extreme, cease to offer options other than MAID, which is likely to import those in resourcepoor regions more heavily.
Even in the less extreme situations, the issue of “choice architecture” is still a concern. The concept of “choice architecture,” as explored by Thaler and Sunstein in their influential work nudge, suggests that the way choices are presented to individuals can subtly guide or “nudge” them toward particular decisions [11]. In the context of United States healthcare, a system manager might structure discharge policies, insurance formularies, or treatment pathways in such a way that MAID appears to be the most logical, or only realistic, option. This is especially dangerous when suffering is not solely from illness, but from systemic barriers to care.
For example, if a patient needs to navigate a maze of websites to find the palliative medicine doctor, but signing up for a MAID evaluation is a quick press of a button, there is a real possibility that this system could nudge the patient towards MAID even if it was not their preferred choice. Creating such a system is likely to happen in profit-driven hospital systems where this choice would offer them massive savings.
Real-world evidence of systemic coercion
Even in states where physician-assisted death is currently legal, such as Oregon and California, we find compelling evidence that financial coercion may already be influencing end-of-life decisions.
In Oregon, the state health insurance plan denied coverage for potentially life-extending medications for a cancer patient. However, it offered coverage for MAID drugs [12]. A similar situation occurred with who also received approval for MAID coverage, but denied conventional treatment [13]. These examples raise the specter of financial motivations masquerading as patient autonomy.
California presents another concerning case. A terminally ill mother, was denied coverage for a new chemotherapy medication by her insurer. At the same time, she was informed that MAID would be covered with a co-payment of just $1.20 [14,15].
These stories illustrate how institutions with financial pressures may promote MAID as a fiscally rational option, rather than a reflection of patients’ true desires. Such examples expose the cracks in the ethical foundation of MAID in systems where healthcare is transactional.
Hypothetical scenarios in United States context
Consider a hypothetical case of a 50-year-old woman diagnosed with metastatic cancer who lacks health insurance. With limited financial resources and faced with out-of-pocket costs running into tens of thousands of dollars, if not more. She may perceive MAID as the only financially responsible decision to spare her family from medical debt not just a compassionate release from suffering. In such a scenario, autonomy becomes entangled with economic despair.
In another realistic scenario, we can imagine a 35 year old man with progressive multiple sclerosis. He is cared for by his aging parents and increasingly dependent on them for basic needs. With no access to affordable long-term care or home support services, he begins to internalize the idea that his life is a burden. Though not suicidal in a psychiatric sense, he views MAID as a means to unburden his family. Here, the choice to die is shaped by a lack of societal support for disability and caregiving.
A third illustrative case involves a stroke survivor who requires prolonged inpatient rehabilitation following hospitalization. A team of resident physicians, tasked with coordinating the patient’s care and discharge, attempts to arrange placement in a skilled nursing facility or inpatient rehab. However, every facility contacted declines to accept the patient due to their public insurance coverage. As the hospital stay extends beyond what insurance will reimburse, the case is reclassified as non-billable, prompting concern that the patient or their family may be saddled with a massive hospital bill. The residents, under increasing pressure to secure disposition, continue exhausting options, but with no viable alternatives available, the question of next steps becomes fraught. If MAID were legally available, it would, by default, need to be included in informed consent discussions for ongoing care. In this context, the patient or their family, if decision-making capacity is impaired might come to view MAID not as an autonomous choice, but as a financial necessity. At the same time, overburdened providers may begin to see it as the only feasible disposition.
In each of these cases, what appears on paper as a voluntary decision could, in practice, be shaped by systemic failures, financial fear, and institutional constraints, rather than genuine desire to die.
Institutional ethical implications
The pressures illustrated in the previous cases are not unique to any one family, medical practice, or hospital. They reflect systemic patterns that could emerge across American medical centers if MAID were to become legally available. Institutions already operating under resource constraints may find themselves navigating difficult ethical terrain when financial limitations intersect with end-of-life decision-making. In this context, it is crucial to ask: If MAID becomes part of standard practice, who will be offered this option first and under what circumstances?
It is not unreasonable to imagine that MAID might be introduced more frequently in underfunded settings, or among patients reliant on Medicaid or charity care programs, where alternative options such as long-term rehabilitation, home care, or palliative services may be scarce or outright unavailable. Conversely, patients with private insurance or those treated in better-resourced departments may receive more comprehensive support and a broader range of options before MAID is ever raised in conversation. Such discrepancies would further entrench and intensify existing healthcare inequities.
Hospitals, particularly those grappling with capacity shortages and budgetary pressure, might begin to see MAID as a means of alleviating institutional burdens whether to reduce length of stay, free up beds, or limit costly interventions. Even absent overt coercion, the ways in which options are presented can profoundly influence patient and family decision-making. A quiet institutional preference, expressed through subtle cues or default framing, can have an outsized effect on vulnerable patients making decisions under emotional, physical, or financial strain. Even subtle suggestions or institutional preferences can have outsized effects on vulnerable patients making decisions under duress. As we consider the integration of MAID into U.S. medical institutions, these ethical questions demands great forethought.
Broader social and structural risks
The ethical challenges of MAID cannot be separated from the structural inequalities that permeate the United States healthcare system. Canada’s experience already demonstrates that poverty, homelessness, and social isolation are associated with MAID decisions [16]. In a more unequal society like the United States, these social determinants may play an even larger and more dangerous role.
Disabled individuals are especially at risk. Structural ableism in the healthcare system often results in devaluation of disabled lives, a concern echoed by the United Nations Special Rapporteur, who warned that MAID in unjust societies can become a tool of “ableist harm” [17]. Additionally, racial and ethnic minorities face well-documented disparities in end-of-life care, including lower hospice enrollment and poorer pain management [18,19]. These groups also harbor long-standing mistrust of the medical system due to historical and ongoing discrimination, making them even more vulnerable to subtle coercion or neglect.
Medicaid’s low reimbursement rates further entrench inequality by creating a two-tiered system of access. Patients with on Medicare can typically qualify for hospice benefits (though they are challenged in access to long term custodial care, but patients enrolled in Medicaid are often denied comprehensive palliative care services. As such, this results in disproportionate morbidity and mortality rates for those with lower income in the United States. This sets the stage for MAID to be offered because treatment is unaffordable, and not because the suffering is untreatable [20].
Medical Assistance In Dying (MAID) remains one of the most ethically charged and divisive issues in modern medicine. The authors of this paper do not present a unified position on whether MAID is ever morally acceptable, and this analysis should not be read as an endorsement of the practice in any setting. Rather, our focus has been on the ethical and structural risks posed by introducing MAID into a healthcare system shaped by profit, fragmentation, and long-standing inequities.
MAID is frequently justified as an expression of patient autonomy a way to honor choice in the face of terminal illness. But autonomy requires more than the absence of restraint; it depends on the presence of real, accessible alternatives. In the current U.S. healthcare system, those alternatives such as quality palliative care, long-term support, and financial security are too often out of reach. When essential services are unavailable or unaffordable, choosing to die may not reflect genuine self-determination, but a response to systemic failure.
Canada’s single-payer system offers a comparatively stable framework for MAID, yet even there, poverty and social marginalization have shaped patient decisions. In the United States, with its deep disparities and market-driven infrastructure, the ethical risks are even greater. Patients who are already underserved would be the most likely to face limited options, and the most vulnerable to pressure whether overt or subtle.
Given these conditions, any move to legalize MAID in the United States must be approached with caution. At a minimum, it would require significant structural reforms to ensure that all patients have meaningful access to alternatives before such an irreversible option is even considered. Absent those reforms, the ethical justification for MAID collapses not because the concept itself is necessarily flawed, but because the system in which it would be embedded is too compromised to support its ethical use.
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Citation: Zwillenberg JA, Schwell J, Teichner EM,Haghshenas C, Patil S, Majdan JF (2025). Medical Assistance in Dying in a Profit-Driven Health System: Ethical and Equity Challenges in the United States vs. Canada. Adv Med Ethics.11:150.
Received: 03-Mar-2025, Manuscript No. LDAME-25-38661; Editor assigned: 06-Mar-2025, Pre QC No. LDAME-25-38661 (PQ); Reviewed: 20-Mar-2025, QC No. LDAME-25-38661 ; Revised: 27-Mar-2025, Manuscript No. LDAME-25-38661 (R); Published: 03-Apr-2025 , DOI: 10.35248/2385-5495.25.11.150
Copyright: © 2025 Zwillenberg JA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.