The Paradox at the Heart of American MAID

 

American medical aid in dying (MAID) legalization rests on a strange logic: its ethical defense depends on people not using it. Bioethicist Mara Buchbinder's recent NEJM essay captures this precisely — in Oregon, where MAID has existed since 1997, only about 1% of all deaths in 2025 (roughly 400) occurred under the Death with Dignity Act, and this rarity is exactly what has persuaded thirteen more states and DC to legalize it. Fourteen U.S. jurisdictions now permit MAID, covering nearly a third of the population, but eligibility remains narrow: a six-month terminal prognosis, mental competence, and self-administration.

What Buchbinder shows is that MAID's cultural weight far exceeds its clinical footprint. Many more patients request it than ever use it, and simply having the option changes how people talk about death, often opening deeper conversations about pain management and existential fear that outlast the prescription itself.

Canada's Very Different Trajectory

If Oregon's model is "rare by design," Canada shows what happens when the same underlying logic of autonomy is pushed further and faster. Since legalization in 2016, medical assistance in dying has grown to account for about 5.1% of all deaths nationally in 2024, with Quebec reaching 7.2%, the highest rate of any jurisdiction in the world. That is roughly five to seven times Oregon's utilization rate, and the annual count has risen dramatically over the past decade to nearly 16,500 deaths in 2024.

The two systems differ structurally, not just in numbers. Oregon requires a terminal prognosis of six months or less and only allows self-administered oral medication. Canada dropped the requirement that death be "reasonably foreseeable" in its 2021 reforms, opening the door to people with chronic, non-terminal suffering, and it permits clinician-administered injection as well as self-administration. That single legal change is the real reason Canada's usage diverged so sharply from the American model — it converted MAID from a narrow terminal-illness option into a broader response to grievous and irremediable suffering more generally.

Canada is now debating whether to go even further. A planned 2027 expansion would allow mental illness alone to qualify, without any accompanying physical condition. That expansion has become deeply controversial: a parliamentary committee recently recommended shelving it indefinitely, and dozens of disability and mental-health organizations have pushed back hard. This is exactly the scenario Buchbinder's paradox warns against. Once eligibility broadens and rarity disappears, the ethical argument that leaned on infrequency starts to erode.

If U.S. states keep adding Oregon-style rules but hold the line on terminal prognosis and self-administration, the country is unlikely to approach Canadian utilization rates anytime soon. Convergence would require the kind of eligibility broadening Canada undertook in 2021, not simply more states adopting the existing model.

A Different Way to Read MAID

There's a sharper lens for thinking about all this than either country's policy debate offers on its own: the distinction between lifespan, healthspan, and wellspan. Lifespan is simply how many years someone lives. Healthspan is how many of those years are free of serious disease. Wellspan is narrower and more important than both — it's the stretch of time during which a person remains recognizably themselves, retaining autonomy, relationships, and a sense of meaning, even if illness or disability is already present.

Seen through that framework, MAID isn't really a debate about ending lifespan early. It's a mechanism for protecting wellspan from the stretch that comes after it ends — the period when the organism is still alive, but the person inhabiting it is less and less present. Cognitive unraveling, loss of physical autonomy, and the quiet shift from "I decide" to "they decide for me" are what people are actually trying to avoid when they seek control over their own death. This erosion of identity has no code in any diagnostic manual and therefore officially doesn't exist, even though it may be the thing patients fear most.

Buchbinder's own data supports this reading. Many more Oregonians request a MAID prescription than ever use it — 637 people received prescriptions in 2025, but only 358 actually ingested the medication. That gap suggests what people want isn't necessarily death itself, but the restored sense of agency that comes from holding the option. Simply having it available seems to matter almost as much as using it, because it returns a measure of the autonomy that terminal decline otherwise strips away.

This points to a broader idea worth sitting with: when a cure isn't possible, the goal of medicine can shift from maximizing the number of days to steering a person's remaining time along whatever path preserves the most selfhood. MAID becomes one tool among several for pursuing that goal — alongside palliative care, treatment refusal, and hospice — rather than a stand-alone endpoint. Decisions about euthanasia, ventilator withdrawal, or forgoing aggressive treatment all sit on the same continuum: attempts to draw a line under a stage of life that no longer contains the person we recognize.

The real cultural shift MAID represents may not be about death at all. It may be a quiet rebellion against medicine's default setting of maximizing lifespan regardless of wellspan — a theme that shows up equally in Oregon's tiny, carefully bounded numbers and in Canada's much larger, faster-growing population of MAID recipients.

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Mykola Iabluchanskyi together with Andriy Yabluchanskiy