"A public policy, by definition, has to protect the public from harm. Safeguards don’t work. Multiple examples confirm that poverty, housing insecurity, need for paid personal care aides, mental illness, and overwhelming family caregiver burden are often the primary motivator behind the request. In other cases, patients did not even initiate the request but have been offered aid in dying by clinicians as an alternative when needed support services were not covered.

Pressure both from families and overwhelmed healthcare systems is a reality. Given the burdens of care imposed on families when a loved one is seriously ill, access to a legal option to avoid a long period of debility and need for costly personal care has undeniable appeal- but not necessarily to the patient. In one instance I was contacted by email by the wife of a patient with recurrent glioblastoma to discuss his care options. Because of his mobility difficulties, I visited them at home. It quickly became clear that the purpose of the visit was to see if I would help to hasten his death. When I began to explore what had precipitated this request and asked what the patient feared about the future, he looked at his wife and did not answer- his wife did. I explained the benefits of palliative care in terms of symptom relief and support for both patient and the family throughout the remainder of his life- the patient was interested and asked several questions about what home care options were available and about what the process of dying was actually like. I described it. He seemed reassured. His wife however, appeared more and more irritated, saying 'we know all about hospice and we are not interested.' When I asked to speak with him individually, she thanked me for coming and escorted me to the door. Had aid in dying been legal in NY at the time, I have no doubt that she would have found a willing prescriber and helped her husband – who had months to years to live- to hasten his death. When family members are stressed and burdened by the role, when the illness is bankrupting the family, the patient gets the message."