Laws & Policy Around MAID

Reporting and documentation requirements for medical aid in dying (MAID) can vary based on state-level legislation regarding assisted death. Physicians and medical examiners are expected to adhere to the standard requirements for reporting a death regardless of whether the patient died as a result of MAID or other circumstances. However, in most states, the attending physician is required to submit additional paperwork following the death of a patient if it is related to MAID. For example, in New Jersey, the attending physicians are required to submit the following documentation within 30 days of the patient’s death: 

• Request for Medication to End My Life in a Humane and Dignified Manner form 
• Consulting Physician Compliance Form
• Attending Physician Compliance Form 
• Mental Health Professional Compliance Form 

These forms are then submitted to the state medical examiner for further review and may be used as generalized de-identified data in an annual report by the state’s legislature for assisted death. Since laws surrounding MAID often change rapidly, visiting the Department of Health’s website in your state is generally recommended for the most recent information regarding necessary documentation.

The Death Certificate in MAID

In the United States, the death certificate typically does not indicate that the patient died due to MAID. Instead, the cause of death is usually attributed to the underlying disease, and the manner of death is listed as natural causes. This practice is consistent across states where MAID is legal. Due to concerns surrounding patient privacy, most state-level legislation also includes language that prevents any reference to the use of MAID.This means that the manner of death cannot be listed as assisted death or suicide, and the death certificate cannot mention the medications used to bring about the patient’s death. 

It is worth noting, however, that other countries may follow different procedures for reporting the cause and manner of death. In Canada, for example, where there are no national guidelines for death reporting,  the cause of death may be reported as toxicity from the aid-in-dying medications and the manner may be recorded as medically assisted death.

Sources

“Completion of Medical Certificates of Death after an Assisted Death: An Environmental Scan of Practices”. Healthcare Policy/Politiques de Sante’. https://pmc.ncbi.nlm.nih.gov/articles/PMC7008676/ 

“New Jersey Medical Aid in Dying for the Terminally Ill Act”. Official Site of the State of New Jersey. https://www.nj.gov/health/advancedirective/documents/maid/MAID_FAQ.pdf

Of the countries where MAID is legal, there are two in which children and minors are able to receive medical assistance in dying. Starting in 2014, Belgium has legally allowed MAID for minors of all ages. In order to receive it, strict medical criteria must be adhered to, the child must be able to understand the situation — including undergoing evaluation by a pediatric psychiatrist — and there must be written consent from parents. In Belgium, emancipated minors are able to request MAID according to the same criteria as adults. 

In the Netherlands, children up to the age of 16 require a parent or guardian’s permission, while there must be parental involvement for those aged 16 or 17. All patients must have “unbearable suffering” without the possibility for improvement, and the request for medical aid in dying must be “voluntary, well considered and with full conviction.”

Even in these countries with legally sanctioned MAID for minors, it is worth noting the practice is quite rare. In 2022, there was one instance in the Netherlands, and from 2016 to 2019 in Belgium, four minors received MAID. 

Sources

“Legislative Background: Medical Assistance in Dying (Bill C-14, as Assented to on June 17, 2016)”. Government of Canada. https://www.justice.gc.ca/eng/rp-pr/other-autre/adra-amsr/p3.html 

“Child Euthanasia in Belgium”. O’Neill Institute. https://oneill.law.georgetown.edu/child-euthanasia-in-belgium/ 

“Netherlands to broaden euthanasia rules to cover children of all ages”. The Guardian. https://www.theguardian.com/society/2023/apr/14/netherlands-to-broaden-euthanasia-rules-to-cover-children-of-all-ages 

“’Dying With Dignity’: Dutch Mark 20 Years of Euthanasia”. VOA. https://www.voanews.com/a/dying-with-dignity-dutch-mark-20-years-of-euthanasia-/6510974.html 

“Belgium euthanasia data from 2019 shows continued expansion”. Australian Care Alliance. https://www.australiancarealliance.org.au/belgium_euthanasia_data_from_2019_shows_continued_expansion

Medical aid in dying (MAID) legislation has undergone many significant changes over time. The collective effort to legalize the practice of MAID originates back in the early 1990s when Oregon became the first state to pass the Death with Dignity Act in November 1994. In the decades that followed, several other states were able to implement their own laws pertaining to MAID. However, it is worth noting that the practice of MAID in the United States is still noticeably restricted in comparison to its practice in other countries. 

Presently, ten states and the District of Columbia have legalized MAID. These ten states include Oregon, Washington, Montana, Vermont, California, Colorado, Hawai’i, New Jersey, Maine, and New Mexico. According to the laws in these states, individuals must meet specific criteria in order to be eligible for medical aid in dying. Some states have their own variations on additional criteria, such as how many witnesses need to sign the paperwork or how many requests must be submitted to a healthcare provider. However, the general criteria to be eligible for MAID are as follows: 

• The patient must be an adult of at least 18 years of age or older 
• The patient must be terminally ill with a life expectancy of six months or less
• The patient must be capable of making decisions regarding their care
• The patient must be able to administer the aid-in-dying medications to themselves. 

While there has been progress in the evolution of medical aid in dying legislation, it has encountered controversy and faced challenges in achieving equal representation across various populations. This includes patients with disabilities or those diagnosed with diseases that may eventually hinder self-administration of aid-in-dying medications. In light of these concerns and ongoing advocacy, it is likely that medical aid in dying legislation will continue to evolve to align with shifting public opinion and legal perspectives on the ethical implications of hastening death.

Sources

“Oregon Death with Dignity Act History”. Compassion & Choices. https://compassionandchoices.org/in-your-state/oregon/history/ 

“States Where Medical Aid in Dying is Authorized”. Compassion & Choices. https://compassionandchoices.org/states-where-medical-aid-in-dying-is-authorized/

“Medical Aid in Dying”. Compassion & Choices. https://compassionandchoices.org/our-issues/medical-aid-in-dying/

The Assisted Suicide Funding Restriction Act (ASFRA) is a federal law that was passed in 1997 to prohibit the use of federal funds to pay for healthcare services or items that may cause, assist, or hasten the deaths of individuals by euthanasia, mercy killing, or assisted suicide. This means that patients receiving Medicare, Tricare, Social Security, or other federal healthcare coverage cannot use their benefits to pay for the costs of medical aid in dying (MAID). Patients with these benefits are expected to pay out of pocket for any of the expenses associated with MAID. 

According to ASFRA, the indicated practices are criminal offenses throughout most of the United States. Insofar as the federal government provides financial support for healthcare services and advocacy to protect rights, paying for healthcare services or items that would imply approval of these practices is unlawful. The act also indicates that legal developments at the time increased the likelihood that services intended to assist or hasten death would become legal in different states nationwide. While ASFRA does not directly name medical aid in dying as one of the prohibited practices, it broadly implies that federal funds cannot be used as payment for it due to the purpose of the services and items involved. 

It is important to note that ASFRA does consider intentionality when determining whether a healthcare item or service results in death for a patient. Although ASFRA does not authorize the use of federal funds for services or items that can cause, assist, or hasten death, it does not apply to items or services used to relieve pain or discomfort in end-of-life settings. ASFRA also specifically indicates that the law does not apply to withholding or withdrawing nutrition, hydration, medical treatment, or medical care since these actions are not intended to cause or hasten death. For example, using federal funds to provide an actively dying patient with morphine to relieve their pain despite a known risk of slowing their breathing does not violate ASFRA since the physician’s intent is only to manage the patient’s discomfort. This is different from using federal funds to provide a patient with a specific medication regimen that is certain to result in their death. 

Sources 

“Assisted Suicide Funding Restriction Act of 1997”. Centers for Medicare & Medicaid Services. https://www.cms.gov/files/document/se20014.pdf 

“Assisted Suicide Funding Restriction”. U.S. House of Representatives. https://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter138&edition=prelim

While each jurisdiction defines its policies and statutes on medical aid in dying (MAID), individual healthcare insurers must determine if the procedure is covered by their policies. Insurers are allowed to cover procedures deemed necessary and effective based on each patient’s medical needs. Insurance coverage for MAID often means the insurer covers the costs associated with the prescribed aid-in-dying medications and any related appointments. However, the decision to provide coverage can vary significantly between public and private health insurers. For example, although Medicare does not cover aid-in-dying medications, the federal Medicaid program in California does.

MAID’s legality in certain states doesn’t always guarantee that insurers in those states will approve coverage for the associated costs. Many state-funded and private insurers in Oregon, California, and Hawaii provide coverage for the cost of medications and evaluation appointments, but standardized coverage has not been established across all states where MAID is legal. Patients who rely on government-sponsored insurance for health care coverage may find that MAID is inaccessible due to prohibitive costs if their insurer is unwilling to approve the procedure. This is largely associated with the Assisted Suicide Funding Restriction Act, which forbids federal spending to pay for end-of-life care.

Concerns and obstacles associated with health insurance coverage for MAID differ slightly when considering life insurance. Life insurance coverage is specific to providing funds when the insured individual dies, so coverage decisions affect whether beneficiaries will receive the designated death benefit payment. For example, term life insurance may opt not to cover the death benefit payment for beneficiaries if the insured dies during the exclusion period. Deaths during an exclusion period are subject to investigation to allow the life insurance company to confirm whether insurance fraud occurred.

The complexities surrounding insurance coverage for MAID highlight the importance of open communication among insurers, patients, and healthcare providers. Individuals considering MAID should be encouraged to understand the extent of their insurance coverage and the potential financial implications associated with their choice. As laws pertaining to MAID continue to evolve and advocacy remains consistent, health care and life insurance coverage for MAID may become more widely accessible.

Sources

“Insurance Coverage & Medical Aid in Dying”. Compassion & Choices. https://compassionandchoices.org/resource/insurance-coverage-medical-aid-dying/ 

“Key Facts About the End of Life Option Act for Patients & Families”. Coalition for Compassionate Care of California. https://coalitionccc.org/CCCC/CCCC/Resources/Consumer-Information-on-EoLOA.aspx 

“Opinion: Medical aid in dying was a blessing for my husband. But a federal law makes it inaccessible for millions of Americans”. CNN. https://www.cnn.com/2022/09/03/opinions/medical-aid-in-dying-inaccessible-fairchild/index.html 

“H.R.1003 – Assisted Suicide Funding Restriction Act of 1997”. Congress. https://www.congress.gov/bill/105th-congress/house-bill/1003 
“How do life insurance companies handle death with dignity cases?”. Quick Quote. https://www.quickquote.com/life-insurance-and-death-with-dignity/

Medical aid in dying (MAID) is currently authorized in 10 states and the District of Columbia. This authorization means that eligible patients can request a prescription for a medication regimen to hasten their death and their physician can prescribe the medications without any legal implications. Every state in which MAID is authorized has an act that indicates the criteria that must be met to legally provide MAID to patients. These states include: 

• California
  • California End of Life Option Act
• Colorado
  • Colorado End of Life Options Act
• Hawai’i
  • Hawai’i Our Care, Our Choice Act
• Maine
  • Maine Death With Dignity Act
• New Jersey
  • New Jersey Medical Aid in Dying for the Terminally Ill Act
• New Mexico
  • New Mexico Elizabeth Whitefield End-of-Life Options Act
• Oregon
  • Oregon Death with Dignity Act
• Vermont
  • Vermont Patient Choice and Control and the End of Life Act
• Washington
  • D.C. Death with Dignity Act
• Montana
  • Baxter V. Montana
• District of Columbia

Laws pertaining to MAID only exist at the state level at this time, which is why regulations and authorizations vary from state to state. Oregon was the first state to authorize MAID back in 1997, whereas New Mexico is the most recent state, having passed its legislation in 2021. The majority of these state authorizations were obtained through legislation; Montana is the only state that legalized MAID through a court ruling. 

It is important to acknowledge that Medical Aid in Dying (MAID) is still inaccessible to the majority of patients in the United States. Presently, 36 states have explicit prohibitions against MAID, while four states either lack legislative provisions or have not yet addressed their legality. It is crucial to note that, despite the absence of defined laws against it in certain states, MAID remains an illegal practice unless authorized by specific state legislation.

Sources

“States Where Medical Aid in Dying is Authorized”. Compassion & Choices. https://compassionandchoices.org/states-where-medical-aid-in-dying-is-authorized/ 

“MAID: Medical Aid in Dying”. Britannica. https://www.britannica.com/procon/MAID-medical-aid-in-dying-debate