Background Fast Fact #525 reviewed Provider Assisted Death by Prescription (PAD-P) in the U.S. including the state law commonalities, eligibility criteria, epidemiology, patient demographics, and reasons for requests. This Fast Fact will review ethical, clinical, and practical considerations of PAD-P.

The ethics of PAD-P are intensely debated in the U.S.: PAD-P raises many contentious ethical questions. There are many facets to this debate, and it is beyond the scope of this Fast Fact to cover them comprehensively. Central to the debate is the role of the provider who must balance respect for patient autonomy with the principles of beneficence and nonmaleficence. Many proponents of PAD-P hold that competent, terminally ill adults have the right to decide the timing and manner of their death as an extension of their established right to self-determination in medical care. Proponents also may note that PAD-P promotes a beneficent approach to end-of-life care where patients can avoid prolonged suffering. Public opinion appears to support this, with many Americans (66%) favoring the legal option for terminally ill patients to end their lives with provider assistance (1).  Despite this, there are many who think PAD-P is unethical. Some argue that PAD-P is beyond the role of the provider (2). Others have raised concern about arguments for PAD-P that are based solely on autonomy. For example, in an unjust society, autonomy may be undermined in disadvantaged populations who may request PAD-P due to societal pressures or external forces. Additionally, many argue that PAD-P could divert focus from more impactful policy improvements for terminal illness care such as the expansion of open access hospice programs, long-term care insurance coverage, and home caregiver benefits.

Many national professional groups like the AMA, ACP (2), ANA, and AAHPM have released positional statements on PAD-P which reflect the complexity of the topic and have evolved over time (3). Attitudes of individual providers toward PAD-P exist on a spectrum from advocacy to opposition, often influenced by religion, personal and professional identity, and institutional norms. This lack of ethical and legal consensus (across U.S. states and countries) can create angst and confusion when providers are asked by patients about PAD-P. Below are clinical considerations providers may find helpful when navigating common complexities of a PAD-P request.

Discussing PAD-P with patients 

• Patients living in states where PAD-P is illegal still may inquire about it. Rather than shutting down the conversation by using legality as a definitive response, explore the patient’s underlying values and reasoning behind the request (see Fast Fact #156 and Fast Fact #159). Providers could inform patients of the jurisdictions where PAD-P is legal and/or do not have residency requirements. However, patients need to consider the feasibility of traveling to another jurisdiction based on their health status and prognosis. The Academy of Aid-in-Dying Medicine (4) and advocacy groups may be able to assist patients interested in exploring the option of moving to a state where it is legal (5,6). 

• No U.S. law requires a provider to participate in PAD-P if it violates their moral code. Providers who express conscientious objection to PAD-P can do so without harming the patient relationship or alienating the patient by maintaining a non-judgmental stance, avoiding polarizing language such as “wrong” or “sin”, and practicing non-abandonment (7).  

• Recognize that using the term suicide could induce patient/family shame given its usual connotation and generally should be avoided in the context of these discussions with patients and families. 

Clinical and practical considerations  

• PAD-P in the U.S. is differentiated from voluntary euthanasia by mandating patient self-administration or “self-ingestion”. This can be done through any enteral route, allowing patients with dysphagia, esophageal obstruction, or severe upper gastrointestinal dysmotility to use enteral tubes or rectal catheters (8). Assistants may prepare the medications or enteral access, including connecting a plunger to tubing, but only the patient may perform the final step (e.g., pushing the plunger, releasing the clamp) (8,9). For patients with progressive neurological diseases who retain swallowing but lose strength, an assistant could hold a straw while the patient controls suction (8,9).  Intravenous (IV) use is illegal nationwide given prohibition of “lethal injection” in statutes.
• Patients must have intact decisional capacity to make an informed decision at the time of their PAD-P requests and time of ingestion. The prescriber and any consulting provider evaluate for capacity which includes an assessment of the presence of a mental health condition.  Some states stipulate that a history or current diagnosis of a mental health condition (e.g., depression), regardless of severity, triggers a referral to a mental health professional to complete a third capacity evaluation; some states mandate a third capacity evaluation for all patients regardless of mental health history. Regardless, providers need to be aware of their state and institutional laws and practices.
• Depression is common among terminally ill patients, and it may be difficult to tell how much it is impacting the patient’s outlook and reasoning for PAD-P.  Providers should offer depression treatment and if there is any concern for impaired judgment, refer to a mental health specialist.
• Patients requesting PAD-P who have a short prognosis should be enrolled in hospice and/or receiving care from a palliative medicine specialist. At the very least, providers should provide their best holistic symptom management since reversible symptoms can drive PAD-P requests.
• Close collaboration the patient’s hospice agency or care facility is paramount if the patient wishes to proceed with PAD-P; some hospice agencies and care facilities may oppose the request. 
• While legal frameworks do not require informing a patient’s family, it is highly recommended to involve them with the patient’s permission. Collateral information from family can help further understand the patient’s request. Furthermore, informing family early on can prepare them for the patient’s death.

References 

1. Yi R. Most Americans favor legal euthanasia. Gallup. Published August 8, 2024. Accessed September 21, 2025. https://news.gallup.com/poll/648215/americans-favor-legal-euthanasia.aspx.
2. Sulmasy LS, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167(8):576-578. doi:10.7326/M17-0938.
3. Barsness JG, Regnier CR, Hook CC, Mueller PS. US medical and surgical society position statements on physician-assisted suicide and euthanasia: a review. BMC Med Ethics. 2020;21(1):111.
4. Academy of Aid-in-Dying Medicine. Patient intake. Accessed September 21, 2025. https://www.aadm.org/for-patients-and-families/patientintake.
5. Compassion & Choices. Contact a consultant—end-of-life consultation. Accessed September 21, 2025. https://compassionandchoices.org/eolc/contact/.
6. Death With Dignity. Traveling to Oregon and Vermont to access medical aid in dying. Accessed September 21, 2025. https://deathwithdignity.org/resources/traveling-to-oregon-and-vermont-to/.
7. Quill TE, Back AL, Block SD. Responding to patients requesting physician-assisted death: physician involvement at the very end of life. JAMA. 2016;315(3):245-246. doi:10.1001/jama.2015.16210.
8. Shavelson L, Battin MP. Medical aid in dying: clinical considerations. UpToDate. Updated September 11, 2023. Accessed August 25, 2025. https://www.uptodate.com/contents/medical-aid-in-dying-clinical-considerations.
9. Pope TM. Medical aid in dying: key variations among U.S. state laws. J Health Life Sci Law. 2020;13(1):25-52.

Conflicts of Interest: None to report.
Author Affiliations: Mount Sinai New York, NY.
Version History: Originally edited by Sean Marks MD, first electronically published in December 2025.