Medical aid in dying is still called ‘assisted suicide.’ An anthropologist explains the problem with that | Health
[ad_1]
More than 20% Americans live in a state with access to a medically assisted death. nathamag11/iStock / Getty Images Plus
Several states around the U.S. are currently considering whether to legalize medical aid in dying for terminally ill patients. More than 20% of Americans already live in a state with access to a medically assisted death. Despite this rapidly changing legal climate, the language for describing this new way to die remains surprisingly antiquated.
People are also reading…
The term that continues to dominate media coverage on the issue is “assisted suicide.” The American Medical Association uses the term “physician-assisted suicide.”
A quick look at Google Trends reveals that nine times as many people search for “assisted suicide” as “assisted dying.”
As a cultural anthropologist, I know that how we name something determines how we think about it. Until just recently, the primary term in the English language for the purposeful, voluntary death of oneself was “suicide.” Besides martyrdom or sacrifice, there was no other way to refer to an intentional self-death.
But times have changed. For the past 25 years, since Oregon enacted the country’s first assisted dying law, a medically assisted death has occupied a new legal and moral category. An assisted death is a medical response to the devastating reality of terminal illness.
Equating assisted dying with suicide isn’t only antiquated or misleading – it’s actually harmful. I have spent five years shadowing patients, families and physicians involved with assisted dying in America, and I saw how damaging this conflation can be. In my new book, “The Day I Die: The Untold Story of Assisted Dying in America,” I explore the complexities and constraints of the choices that people who pursue an assisted death face.
A loaded term
Until well into the 19th century, suicide was viewed as a crime in the United States, punishable with confiscation of the deceased’s property and denial of a Christian burial. Although suicide – but not its assistance – has been decriminalized today, it remains heavily stigmatized. As philosopher Ian Hacking writes, “News of a suicide among us has an immediate response: horror.” Calling assisted dying “suicide” taps into the social taboos and moral outrage that surround the act of taking one’s life.
That stigma can lead to very sick patients’ hiding their desire to pursue an assisted death from loved ones for fear of being judged for “suiciding” – leaving patients without critical support. It also poses a problem for terminally ill patients who have a strong wish to be released from their suffering but whose religion considers committing “suicide” a sin. One devout homeless patient from Portland with end-stage renal failure spent his last waking moments before he drank the lethal medication agonizing about whether God would forgive him for ending his life.
As I found during my research, the conflation of assisted dying with suicide sometimes causes families to feel isolated in the bereavement process. Afraid of being shamed for “abetting” their loved one’s “suicide,” some have had to mask their grief.
Valerie, whose elderly mother used Oregon’s assisted dying law in 2018, told her supervisor at work about her mother’s chosen death. He emitted a “hushed groan,” offering no condolences for her loss. “After that encounter, I only revealed the details to trusted friends and family,” Valerie told me. “It added a layer of sadness to expend energy trying to figure out what someone’s reaction might be.”
Bereavement experts call this type of mourning “disenfranchised grief” – hidden grief that is not fully acknowledged or even allowed by society because of the way someone died, such as from a drug overdose or in utero.
A medical procedure
From their inception, assisted-dying laws in America were designed to mobilize the tools of medicine to ease suffering at the end of someone’s life. These laws draw a clear line between assisted dying and a suicidal act. The nation’s first assisted-dying statute, Oregon’s 1997 Death with Dignity Act, specifies that “Actions taken in accordance with [the Act] shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law.”
As Roger Kligler, a physician and cancer patient who is suing the commonwealth of Massachusetts for his right to die, put it, “Calling it suicide means that we’re not talking about end-of-life issues.”
The participation of medicine and a patient’s social network, write psychiatrists John Michael Bostwick and Lewis Cohen, are what differentiate assisted dying from suicide. An assisted death is collaborative and sanctioned by a patient’s support system – not unilateral and covert. “When they acquiesce to requests to facilitate dying, [physicians] are not abetting suicide or committing homicide,” Bostwick and Cohen write. “The distinction between clinical suicide and other types of end-of-life decisions demands a new formulation.”
Key differences
Terminally ill patients who seek an assisted death aren’t suicidal. Absent a terminal prognosis, they have no independent desire to end their life. In fact, prescribing physicians must uphold the distinction between assisted dying and suicide in their clinical work by screening for mental illness, such as depression (which is clinically associated with suicidal thoughts). A patient who shows any signs of mental impairment must undergo further scrutiny by a mental health expert.
Patients who pursue medical aid in dying are no longer looking at an open-ended life span either. To qualify for an assisted death in states with these laws they must already be on the verge of dying – that is, within six months of the end of their life. These patients don’t face a meaningful decision between living and dying, but between one kind of death and another.
As more states are inching closer to legalizing assisted dying, it’s time that we revise and refine our cultural lexicon around this emergent end-of-life practice. A medically assisted death definitively warrants a linguistic and conceptual category of its own.
Anita Hannig does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
States where the most people live in maternal health care deserts
States where the most people live in maternal health care deserts

Compared to other developed nations, the United States regularly ranks among the worst countries for maternal and infant health outcomes. Childbirth outcomes are often tied to a birthing parent’s circumstances, fueling wide disparities at the geographic, demographic, and income levels.
Research has shown that access to prenatal care, family planning services, and other contraceptive resources decreases maternal and infant mortality. However, an increasing number of counties throughout the country are losing access to obstetric care. Aging populations, limited staff, and low reimbursement rates for Medicaid patients are factors that have made rural hospital birth units costly to operate.
Even in areas with access to maternal care, other challenges like poverty, limited transit, lack of insurance, and systematic racism can put families at risk of poor maternal and infant health outcomes. Estimates from the CDC show that 60% of pregnancy-related deaths in the U.S. are preventable, but inadequate treatment and identification of health risks contribute to hundreds of maternal deaths annually.
Pregnant Black people face disproportionate risks when giving birth. The infant mortality rate for Black children in the U.S. is double the rate for white children. Maternal mortality rates show similarly grim patterns, with 44 deaths per 100,000 live births among Black people compared to 17.9 per 100,000 live births for white people.
Stacker followed the March of Dimes’ definition of a maternity care desert, including counties with no hospitals with obstetric care, OB/GYNs, or certified nurse-midwives. To identify affected counties, Stacker analyzed the Area Health Resource Files from the Health Resources and Services Administration and merged this data with county-level birth data collected by the National Vital Statistics System to calculate how many births in each state are to parents who live in maternal health care deserts.
Stacker also used 2020 Census population data to calculate what percentage of a state’s population lives in counties without access to maternal health care. Stacker used population data across all sexes and ages to include county-level demographic data and more deeply compare racial disparities—although maternal health care deserts have a disproportionate impact on people between the ages 15–44, who can become pregnant.
Keep reading to learn about the challenges facing maternal health care in 15 states and how state policies and community-driven programs seek to bridge rural and demographic health care disparities.
You may also like: Most prevalent chronic conditions in American seniors
#15. Idaho

– Percent of state’s births to parents who live in maternal health care deserts: 9.9% (2,142 births)
– Population who lives in maternal health care desert: 10.3%
— 10.3% of state’s white population
— 2.5% of state’s Black population
— 10.0% of state’s Native American population
— 12.5% of state’s Hispanic population
— 4.4% of state’s Native Hawaiian/Pacific Islander population
— 3.2% of state’s Asian population
With obstetric services limited in rural areas, research has shown that accredited, midwife-led birth centers offer patients with low-risk pregnancies meaningful options outside of a hospital setting. However, Idaho is one of 11 states that don’t regulate birth centers, meaning Medicaid and some commercial insurances won’t cover the costs of childbirth. Although birth centers are the setting for only a tiny portion of the state’s births, midwives in Idaho and other Western states are working to improve health care access for rural, low-risk patients.
#13. Louisiana

– Percent of state’s births to parents who live in maternal health care deserts: 11.2% (6,434 births)
– Population who lives in maternal health care desert: 11.7%
— 13.6% of state’s white population
— 9.5% of state’s Black population
— 14.6% of state’s Native American population
— 7.6% of state’s Hispanic population
— 8.7% of state’s Native Hawaiian/Pacific Islander population
— 3.5% of state’s Asian population
Louisiana was one of the first states to implement a nurse-family partnership program. In 90% of the state’s parishes, eligible people pregnant for the first time are paired with specially trained nurses until the child’s second birthday. Most participants are enrolled in Medicaid, and the median household income is $6,000 annually. 88% of babies in the program were born full-term, compared to the state’s average of 86.9% across all income levels.
Other efforts specifically target Black parents, who are four times more likely to die from pregnancy complications than white people in Louisiana. The first Black-owned birth center opened in Lafayette this year. The Maternal and Child Health Coalition in New Orleans has advocated for municipal/state health care policies and inclusive hospital hiring practices.
#11. Iowa

– Percent of state’s births to parents who live in maternal health care deserts: 14.7% (5,444 births)
– Population who lives in maternal health care desert: 15.6%
— 17.3% of state’s white population
— 2.6% of state’s Black population
— 7.8% of state’s Native American population
— 8.2% of state’s Hispanic population
— 9.0% of state’s Native Hawaiian/Pacific Islander population
— 3.4% of state’s Asian population
In 2019, Iowa was one of nine states to receive a grant from HRSA to address disparities in maternal health. The state has seen rising maternal death rates over the past two decades, and over 30 hospital birth units have closed in the state since 2000. The 2020 census revealed a declining birth rate across America, and in Iowa counties with aging populations, hospitals lose money in the operation of local birth centers. It’s an issue that’s even more prevalent in counties where a high proportion of births are funded through Medicaid since private insurance payments to hospitals are often greater than Medicaid rates.
You may also like: Worst states for health care
#10. Alabama

– Percent of state’s births to parents who live in maternal health care deserts: 15.3% (8,703 births)
– Population who lives in maternal health care desert: 16.2%
— 17.9% of state’s white population
— 13.2% of state’s Black population
— 19.1% of state’s Native American population
— 13.1% of state’s Hispanic population
— 8.9% of state’s Native Hawaiian/Pacific Islander population
— 5.7% of state’s Asian population
Alabama finally decriminalized midwifery in 2016, after the practice had been illegal for over four decades, although certified nurse-midwives were allowed to work in hospital settings. This decriminalization has promoted the resurgence of Alabama’s rich midwifery history. Under Jim Crow laws, Black parents couldn’t access white hospitals, and Black midwives played a crucial role in overseeing births. Today, in a state where Black people are nearly five times more likely to die during pregnancy than white people, reproductive justice advocates believe historic midwifery models of care could better serve pregnant Black patients, especially in rural areas.
#8. Oklahoma

– Percent of state’s births to parents who live in maternal health care deserts: 16.7% (8,205 births)
– Population who lives in maternal health care desert: 18.0%
— 19.7% of state’s white population
— 7.9% of state’s Black population
— 27.3% of state’s Native American population
— 11.1% of state’s Hispanic population
— 4.4% of state’s Native Hawaiian/Pacific Islander population
— 3.4% of state’s Asian population
Since 2010, 14 hospital birth centers have closed in Oklahoma. In rural hospitals across the country, balancing the cost of keeping trained obstetric staff on call with the dwindling birth rates in rural areas has left large swaths of the state without hospitals with birth units. Oklahoma is also one of the worst states for maternal mortality, with 2018 data showing 30.1 maternal deaths per 100,000 live births, compared to 17.4 nationally. A recently formed maternal mortality review committee reviewed eight maternal death incidents in the state and found that seven of those cases were preventable with timelier interventions.
#7. Missouri

– Percent of state’s births to parents who live in maternal health care deserts: 17.9% (12,881 births)
– Population who lives in maternal health care desert: 17.9%
— 20.7% of state’s white population
— 3.9% of state’s Black population
— 22.0% of state’s Native American population
— 11.1% of state’s Hispanic population
— 22.2% of state’s Native Hawaiian/Pacific Islander population
— 3.7% of state’s Asian population
A report from Missouri’s Office of Rural Health revealed that pregnancy-related deaths were 47% higher in rural areas than urban areas. Nine of the 10 Missouri counties with the highest infant mortality rate are considered rural. As an increasing number of hospitals close, nonprofit health care systems like Missouri Highlands have sought to expand their presence in rural parts of the state. Missouri laws now allow nurse practitioners to work up to 75 miles away from a collaborating physician, expanding a clinic’s rural reach.
#6. North Dakota

– Percent of state’s births to parents who live in maternal health care deserts: 19.7% (2,072 births)
– Population who lives in maternal health care desert: 21.1%
— 21.6% of state’s white population
— 3.8% of state’s Black population
— 36.0% of state’s Native American population
— 15.6% of state’s Hispanic population
— 7.4% of state’s Native Hawaiian/Pacific Islander population
— 6.7% of state’s Asian population
You may also like: Healthiest states for seniors
#2. South Dakota

– Percent of state’s births to parents who live in maternal health care deserts: 23.2% (2,715 births)
– Population who lives in maternal health care desert: 22.6%
— 21.8% of state’s white population
— 4.8% of state’s Black population
— 41.2% of state’s Native American population
— 15.7% of state’s Hispanic population
— 25.2% of state’s Native Hawaiian/Pacific Islander population
— 5.8% of state’s Asian population
In 2016, the Rosebud Sioux Tribe sued the federal government for closing the emergency department of the reservation’s only hospital. Services like obstetric care were disrupted, and patients were diverted to alternative facilities ranging from 45–220 miles away. A federal appeals court recently ruled in the tribe’s favor, but the legal battle highlighted the challenges facing underfunded Indian Health Service hospitals.
Across South Dakota, pregnant Native Americans face poorer outcomes than pregnant white people. The maternal mortality rate for Indigenous people is 121 per 100,000, compared to 44 per 100,000 among white parents in the state. Access to transportation, eligibility for Medicaid, and systematic racism are some of the core factors causing this disparity. Proposed solutions to these complex challenges include reservation-based birthing centers, supporting traditional birth methods, and deploying telemedicine.
#1. Mississippi

– Percent of state’s births to parents who live in maternal health care deserts: 23.6% (8,484 births)
– Population who lives in maternal health care desert: 23.5%
— 23.8% of state’s white population
— 23.9% of state’s Black population
— 51.3% of state’s Native American population
— 19.1% of state’s Hispanic population
— 11.9% of state’s Native Hawaiian/Pacific Islander population
— 5.6% of state’s Asian population
According to the CDC, Mississippi has the country’s highest infant mortality rate, at 9.7 deaths per 1,000 live births. A report from the state’s department of health shows that the high mortality rate connects to a large number of preterm births. Effective ways to reduce preterm births include screening pregnant people for conditions that may put them at a higher risk.
Community-driven health measures have been shown to improve infant health outcomes, and Mississippi has begun pilot programs to coordinate prenatal support for pregnant people living in poverty. However, Mississippi is also at the center of a major Supreme Court battle over whether it is constitutional to ban abortion after 15 weeks.
You may also like: America’s most common ticks and how to identify them
[ad_2]
Source link