Expand Right to Die Options for Older Americans: Eleven Ways to Avoid Late-Stage Dementia

I have a forthcoming book chapter, "Expand Right to Die Options for Older Americans: Eleven Ways to Avoid Late-Stage Dementia" in Law, Health Care, and the Aging Brain and Body (I. Glenn Cohen, Nina Kohn, Francis X. Shen eds. 2026).   

This volume developed from the Harvard Law School Petrie Flom Center’s Annual Conference in June 2025. A video of my presentation is available here. My slides are available here. This expands on a December 2024 presentation to the Hemlock Society of San Diego video available here.

Averting late-stage dementia is difficult to accomplish under U.S. laws and policies. Four well-established end-of-life options include: 

1. Traditional advance directives
2. Voluntarily stopping eating and drinking (VSED)
3. Medical aid in dying (MAID) in Switzerland
4. Inert gas asphyxiation

These four options work for patients dying from cancer, heart disease, stroke, or COPD. But they remain a clumsy fit for patients with dementia. These options suffer significant limitations in achieving the goals of patients seeking to avoid living into late-stage dementia.

Therefore, we must expand right to die options. Under settled legal and bioethical principles of anti-paternalism and informed consent, laws should permit adults with capacity to end their lives under conditions that they determine intolerable. First, I present already emerging end-of-life options: 

1. VSED by advance directive
2. VSED by substitute decision maker,
3. Minimal Comfort Feeding by advance directive or substitute decision maker
4. VSED bridge to MAID

While patients are already using these options, we must better clarify their ethical and legal legitimacy. Without regulatory and clinical guidance, too few healthcare professionals or facilities are prepared to support these options. Plus, these options still suffer significant limitations.

Consequently, I turn to three more end-of-life options: 

1. MAID
2. MAID by advance directive
3. MAID by surrogate

None is available in the United States and none is likely to be authorized in the foreseeable future. But because these options avoid the limitations of existing ones, we should start studying experience in other countries.