The Inequity We Don't Talk About at the End of Life
A reflection on access, trust, and Medical Aid in Dying
We live in a health care system that is not equitable. That truth doesn't pause at the end of life. It follows us there.
Not everyone has insurance, let alone access to primary and preventive care. Depending on where you live, you may have limited access to specialists, and in some places, even a primary care doctor is out of reach. We know these gaps shape birth outcomes, delay treatment for chronic illness, and narrow the choices people have once they are treated. What we talk about less is that end-of-life care follows the same pattern. Medical Aid in Dying is no exception.
MAID gives people facing a terminal illness real agency over what their final days look like. But the process (physician assessments, a prescription, a specific protocol) sits outside almost every insurance plan. And like anything legal, available, and not covered, it gets pushed into the free market, with all the price variability that implies. The medications aren't covered, and they're stocked by only a handful of pharmacies nationwide, which makes them expensive and often genuinely hard to obtain.
A right that exists on paper for anyone with a qualifying diagnosis is, in practice, easiest to exercise if you already have money.
Money isn't the only barrier. Stigma, perceived or real, shapes who even considers MAID in the first place. In communities of faith, choosing the timing and manner of one's death can be understood as refusing to let a higher power have full control, even when death is already certain. And because MAID requires a physician to prescribe the medication, it runs into something deeper than theology: trust. Asking a doctor to prescribe life-ending medication can activate real, earned mistrust in communities that have historically been experimented on, sterilized, and harmed by medical and government institutions acting in the name of "care." That mistrust isn't irrational. It's historical memory doing exactly what it should.
So, as with everything else in health care, we have to look at these inequities directly and address them on more than one front.
We need culturally humble education about MAID, delivered by people the community already trusts, not imported from outside it. We need insurance coverage to catch up: Medi-Cal, California's Medicaid program, now covers MAID for its recipients (real progress), but commercial insurers have largely not followed. And underneath both of those, we need an honest reckoning with how the health care system's own history has shaped who trusts it enough to walk through its doors, in any context.
That reckoning is bigger than MAID. But trust is the currency every recommendation and every novel treatment runs on, from birth to death, and right now, we haven't earned enough of it, equally, from everyone we serve.
