Delineating a Spectrum of Physician Participation in Medical Aid in Dying: A Qualitative Exploration

BACKGROUND: Physician participation in medical aid in dying (MAID) is commonly framed as a binary choice between participation and objection. Emerging evidence suggests physician involvement is nuanced, with levels of engagement shaped by ethical beliefs, professional responsibilities, and organizational structure. Improved understanding of how physicians make these decisions is needed to inform policy, clinical practice, and discussions about conscience-based practices. METHODS: We conducted a qualitative descriptive study of 20 physicians practicing in US states where MAID is legal. We used purposive sampling to recruit typical cases, seeking maximum variation across geographic region, practice specialty, and MAID involvement. Participants completed virtual, semi-structured, in-depth interviews between April and August 2025. Interviews were analyzed using rapid qualitative analysis. Coding was adductive with deductive codes derived from extant literature, focusing on physicians' experiences with MAID, ethical orientations, and interpretations of bioethical principles. RESULTS: Analysis identified a spectrum of physician participation classified across four broad categories: (1) discusses MAID only; (2) refers patients to MAID providers, because of ethical opposition or organizational constraints; (3) serves as a consulting provider only; and (4) serves as an attending provider. Although participants referenced the same core bioethical principles, variations in participation reflect differing interpretations of shared ethical principles and the influence of organizational and legal environments. CONCLUSIONS: Findings challenge the prevailing dichotomous view of MAID participation and demonstrate that physician engagement exists along a spectrum. Recognizing this spectrum may improve policy development, support clinician decision-making, and foster more nuanced discussions regarding conscience, ethics, and access to MAID.