The right to die is spreading in America

FOR HER 70th birthday, Patricia Ann Courtney requested an unusual celebration. “She didn’t want to party,” her daughter remembers. “She wanted us to buy an abandoned funeral home.” Courtney planned to turn it into a domestic-violence shelter. The family redecorated it with cans of paint. Six years later Courtney died of amyotrophic lateral sclerosis (ALS), a motor-neurone disease. Before her death she lost the ability to walk, eat and speak. “I am all too familiar with the pain of seeing someone you love suffer and feeling powerless to stop it,” says Kathy Hochul, Courtney’s daughter and the governor of New York.

Neurological diseases such as ALS are the second-most-common diagnosis for Americans who ask for a doctor’s help to die. Soon New York is expected to join the 12 other states (plus Washington, DC) where assisted dying is legal. Ms Hochul is expected to sign a bill in the coming days. This is part of a wave (see chart 1). In 2025 Delaware and Illinois approved assisted-dying laws. By the end of the year more than 30% of Americans will live in states where doctors can prescribe a fatal medication to terminally ill patients.

Lawmakers are catching up with public opinion (see chart 2). Slightly more than half of Americans believe that assisted suicide is morally acceptable. This share grows to two-thirds if the patient is in severe pain, has no chance of recovery and is asking for help to die.

The safeguards in America tend to be stricter than in some other Western countries that allow assisted dying. Canada and the Netherlands, for example, allow it in cases where patients are suffering from incurable pain, but are not terminally ill. American states, by contrast, tend to follow the model of Oregon, which was the first to legalise assisted dying in 1994. The terms of the debate have not changed much since then, says Geoff Sugerman, who led the Oregon campaign and still works on the issue with Death with Dignity, a group that campaigns for legalisation. “Our opponents are the same. The bill is essentially the same.”

Assisted-dying laws in America consistently require patients to have six months or less to live, and this diagnosis must be confirmed by two doctors. The patients must be mentally competent, request the medication and be able to take it themselves—rather than letting a doctor administer it. Relatively few people are thus eligible, and since some hospitals and doctors refuse to help on moral grounds, assisted suicide remains rare. In states where it is legal, it accounts for less than 1% of deaths, notes Elissa Kozlov of Rutgers University.

New York has added yet more guardrails. The patient’s mental fitness must be confirmed by a psychologist or psychiatrist, rather than by just any doctor. The patient’s request to die must be filmed, as well as being witnessed by two people. These extra elements were added during negotiations between legislators and Ms Hochul, a Catholic, who wanted the toughest safeguards in the country. Ms Hochul has promised to sign the bill once her proposed changes are passed by the statehouse. The law will take effect six months later.

In Delaware, Illinois and New York lawmakers argued over the bills for years before they reached the governors’ desks. Religious groups opposed them. Chicago-born Pope Leo XIV unsuccessfully lobbied J.B. Pritzker, Illinois’s governor, to exercise his veto. Some groups that represent the disabled objected, too, for fear that people will face pressure to choose death to relieve others of the burden of caring for them. New York’s bill has “a lot of safeguards”, concedes Elizabeth McCormick of the New York Association on Independent Living, but she still worries that it might be abused.

Assisted dying is seldom an urgent priority for politicians. “We might have had to talk to [legislators] dozens of times before something happened,” says Corinne Carey of Compassion & Choices, an advocacy group. It is “an issue that is very difficult for lawmakers to talk about”.

Terminally sick patients have often been eloquent advocates; many have died while bills were being debated. Some Democrats have seized on the issue, which chimes with their recent push to be seen as the party of individual rights. Ms Hochul says that New York “has long led” the struggle for such liberties, citing gay rights and legal abortion as parallels.

Three decades of data have shown that Oregon’s model is “reliable and fail-safe”, says Brad Hoylman-Sigal, the lawmaker who sponsored New York’s bill. “I don’t know of a single documented instance… where it has been abused.” There is scant sign of a slippery slope, either. American campaigners tend to rule out assisted dying for patients who are not terminally sick. Even fewer support it for those whose only illness is mental, as Canada is considering. “We are not looking to expand it in any way,” says Robyn Gabel, the majority leader of the Illinois House of Representatives and sponsor of the state’s assisted-dying legislation. “This is the destination.”

Death with Dignity expects assisted-dying bills to be considered in 13 states this year.  They are most likely to pass in Virginia, Maryland and Massachusetts. The campaign for assisted dying “requires patience and persistence”, says Ms Carey. “Unfortunately, many terminally ill patients do not have the luxury of time.” ■