Authors:
Professor David Albert Jones, Professor of Bioethics, St Mary’s University, Twickenham. [ORCID ID: 0000-0001-7268-6353]
Professor David Paton, Professor Industrial Economics, Nottingham University Business School [ORCID ID: 0000-0002-7486-9353]
The authors explore why people in Oregon and Washington chose to end their lives under Death with Dignity laws, including stated reasons such as concerns about finances and fear of being a burden.
Introduction
In a recently published study,[1] we analysed the end-of-life concerns that are reported to have motivated people to seek death under Death with Dignity laws in Oregon and Washington.
The aim was to achieve a greater understanding of why people have chosen to end their lives in this way and, more specifically, whether these reasons have evolved over time.
Debates over whether to legalise ‘assisted dying’, that is, euthanasia or physician assisted suicide (PAS),[2] often focus on criteria of eligibility. However, eligibility criteria, however specified, do not explain why eligible patients seek death under these laws. Eligibility opens a door, but the reasons some people step through this door are various and include wider, non-medical considerations.
Of those jurisdictions with assisted dying laws, only Oregon and Washington have more than ten years of data on end-of-life concerns. These states have very similar laws and both use the same categories for reporting end-of-life concerns. This allows comparison of data on end-of-life concerns in more than 6,850 deaths across 14 years in Washington,[3] and 27 years in Oregon.[4]
Significant trends
The two most common end-of-life concerns reported in Oregon and Washington are losing autonomy and becoming less able to engage in activities that make life enjoyable. These concerns have remained the most frequent with no significant trend over time.[1]
Loss of dignity is also a commonly reported concern. However, loss of dignity has been cited significantly less frequently over time in Oregon and Washington.[1] The reasons for this are not clear. It may be that people increasingly think that concerns about dignity can be addressed in other ways, for example, by ‘dignity therapy’.[5]
The pattern is less clear in relation to concern about losing control of bodily functions. This concern seems to have declined but the trend is less significant after controlling for other factors.
The three remaining concerns identified in official reports: fear of becoming a burden on family, friends/caregivers; fear of inadequate pain control, and fear about the financial implications of treatment, have all increased significantly over time.[1]
Financial concerns
While financial concerns remain the least commonly cited in official PAS reports, the significant increase in people choosing to end their lives in part for this reason is concerning. Whatever one’s views about the legalisation of assisted dying, this must never be a choice forced on people due to financial restrictions on access to adequate care.
Pain
From the perspective of supportive and palliative care it is disquieting that concerns about adequate pain relief have increased significantly in Oregon and in Washington since the introduction of PAS.
It might have been hoped that, as the percentage of patients enrolled in hospice care has risen in these states, a smaller proportion would express concerns about pain control. Instead, the percentage has increased. In this respect at least, the introduction of PAS seems to have had a detrimental impact on the quality and/or perception of palliative care.[6]
Feeling a burden
The apparent increase in concern about fear of being a burden has been noted previously.[7] Our paper demonstrates that this trend has been statistically significant, even after controlling for other factors. Since the change in the law, significantly more people have sought to end their life by PAS in part because they felt that they might become a burden to family, friends or caregivers.
This end-of-life concern is deeply problematic at a conceptual level. It is not determined by objective features of the situation such as financial costs or measurable physical symptoms but by interpersonal relationships.[8] The idea of being a ‘burden to others’ relates to how people are perceived and how they perceive themselves, and such perceptions influence one another.
It is shocking that around half of all deaths by assisted dying in Oregon and Washington are shaped in part by the idea that the patient is a burden to others. It is still more worrying that, as the practice has been normalised, this fear of being a burden has increased in these jurisdictions.
Comparison with data from Canada
The practice of Medical Assistance in Dying in Canada is quite distinct from PAS in Oregon and Washington. In Canada the healthcare professional directly brings about the death of the patient. The eligibility criteria are also much boarder and while Canada has fewer years of implementation, it has recorded far larger numbers of deaths.
Canada has only six years of data on end-of-life concerns but these show some features that are similar to Oregon and Washington. For example, the most common reason cited from seeking MAID in Canada is ‘loss of ability to engage in meaning activities’.[9]
Unlike Oregon and Washington, the number of people citing concerned about pain control has not increased in Canada. However, the level of this concern (between 50% and 60% of patients) is higher than in the US states. This does not speak well of the provision or quality of palliative care in Canada.
As with Oregon and Washington, reports of fear of becoming a burden on others have increased in Canada over time, from around 35% to over 50%. In all three jurisdictions normalisation of the practice is associated with an increase in people seeking death lest they become, or are perceived to be, a burden to others.
During the progress of the Terminally Ill Adults (End of Life) Bill several parliamentarians put forward amendments aiming to mitigate the danger of people taking their life due to fear of being a burden. Regrettably these amendments were rejected by the Public Bill Committee.[10]
It is unlikely that any law can entirely eliminate its application to people motivated by the fear of becoming a burden to those who care for them. However, if a Bill on this topic does return to Parliament in the UK, at the very least, it is imperative that it includes robust safeguards to prevent people being given the means to end their life, not for their own benefit but for the perceived benefit of others.
[1] Jones DA, Paton D, Rutaquio P. Trends in Reported End-of-Life Concerns after the Legalization of Physician-Assisted Suicide. South Med J. 2026 Jun 2;119(6):281-287. https://pmc.ncbi.nlm.nih.gov/articles/PMC13193167/
[2] Jones DA. ‘Assisted dying’ is assisted suicide and/or euthanasia. JME Forum Jan 31, 2025. https://blogs.bmj.com/medical-ethics/2025/01/31/assisted-dying-is-assisted-suicide-and-or-euthanasia/
[3] Washington Death with Dignity Data Annual Reports https://doh.wa.gov/data-and-statistical-reports/health-statistics/death-dignity-act/death-dignity-data
[4] Oregon Death with Dignity Act Annual Reports https://www.oregon.gov/oha/ph/providerpartnerresources/evaluationresearch/deathwithdignityact/pages/ar-index.aspx
[5] Chochinov HM. Twenty Years of Dignity Therapy: Evidence, Challenges, and Implications for Person-Centered Care. Journal of Palliative Medicine (2026): 10966218261424181. https://doi.org/10.1177/10966218261424181
[6] D.A. Jones, Evidence of Harm: Assessing the Impact of Assisted Dying / Assisted Suicide on Palliative Care. London: Augustine Bioethics Network, 2026. https://abnethics.org/evidence-of-harm-assessing-the-impact-of-assisted-dying-assisted-suicide-on-palliative-care/
[7] Regnard C, Worthington A, Finlay I. Oregon Death with Dignity Act access: 25 year analysis. BMJ Support Palliat Care 2024;14:455–461.
[8] Cukrowicz KC, Cheavens JS, Van Orden KA, et al. Perceived burdensomeness and suicide ideation in older adults. Psychol Aging 2011;26:331–338. https://pmc.ncbi.nlm.nih.gov/articles/PMC3699192/
[9] Sixth Annual Report on Medical Assistance in Dying in Canada: 3.4 Nature of Suffering https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-medical-assistance-dying-2024.html#a3.4
[10] Amendment 94 see Public Bill Committee Terminally Ill Adults (End of Life) Bill cols. 435-465 https://publications.parliament.uk/pa/bills/cbill/59-01/0012/PBC012_Terminally_Ill_Adults_1st-29th_Compilation_26_03_2025_REV.pdf
Competing Interests: The authors have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None