This is Part 4 of “Wholly Pro-Life”, a 6-part series on what a consistent pro-life ethic requires across the full span of human life and condition.

The Safeguard’s Cost

Every U.S. state that allows medical aid in dying builds in the same core safeguard: the patient must administer the medication themselves. No physician injects it. No family member helps guide the dose. The law wants absolute certainty that the final act was the patient’s own hand, because that hand is the only proof available that nobody else made the choice for them.

That safeguard has a cost few people talk about. Some patients, particularly those with advanced ALS or other neuromuscular conditions, physically cannot lift a cup, swallow reliably, or complete the act, even though they meet every other qualification and have expressed the same wish as anyone else seeking this option. The law built to prove a choice is truly free ends up excluding people whose choice is just as real, because their bodies cannot perform the proof it demands.

That irony is where this article starts, but it is not really about the law itself. It is about two different ways our culture has learned to talk about a good death, and why neither one, examined closely, actually delivers what it promises.

Death on My Own Terms

The most common way to defend assisted dying treats control as the whole point. A good death, in this view, is one a person shapes entirely according to their own wishes: the timing, the setting, the people present, the moment itself. Losing control to disease, to a hospital bed, to a body that no longer obeys, is treated as the real indignity, worse than death itself. Taking charge of the ending becomes the last available act of self-determination, and self-determination becomes the measure of a life well finished.

There is something genuinely sympathetic in this. Watching a body fail slowly, in ways a person never chose and cannot stop, is frightening, and wanting some say in how that story ends is not an unreasonable wish. But notice what this framework quietly assumes: that dignity is a possession secured by control, and that losing control is the same as losing dignity. Once that assumption takes hold, every erosion of control, weakness, dependence, the indignities of a failing body needing to be fed or cleaned by someone else, starts to look like evidence that life itself has become less worth living.

That assumption does not come from nowhere. It reflects a broader cultural instinct that treats autonomy as close to the highest good a person can have, the thing dignity is made of. Scripture does not share that instinct. It never treats a person’s worth as contingent on their capacity to control their own circumstances, and it repeatedly locates dignity in people who had lost every form of control imaginable: the leper, the paralytic lowered through a roof by friends because he could not get there himself, the woman with the twelve-year hemorrhage who could not even control her own body’s bleeding. None of them are described as having lost their dignity to their disease. Their dignity was never staked on controlling it in the first place.

Self-sovereignty as the framework for a good death runs into a deeper problem the moment it is pressed. If dignity depends on maintaining control, then every person whose illness strips away more control than another’s has, by that framework’s own logic, a less dignified death. A person who dies suddenly, unconscious, having made no choices at all in the final moments, would apparently have the least dignified death of anyone, since they controlled nothing. Almost no one actually believes that – which suggests the framework is not describing something real about dignity so much as expressing a fear, a very understandable fear, of helplessness, and mistaking the relief of avoiding that fear for the presence of dignity itself. That fear deserves compassion, not mistaking it for theology.

Whose Terms, Really?

There is a second, quieter version of the “choice” language that deserves separate attention, because it is not really about the dying person’s control at all. Ask who benefits from a decision to pursue an early death, and sometimes the honest answer includes people other than the person dying: a family exhausted by caregiving, a household strained by medical costs, an adult child who has rearranged an entire life around a parent’s decline. None of that makes anyone a villain. Caregiving is genuinely hard, and exhaustion is real. But it does mean the word “choice” can end up doing work it was never built to do. This is not a hypothetical dynamic. In 2024, 42 percent of people who died under Oregon’s Death with Dignity Act cited feeling like a burden on family, friends, or caregivers as one of their reasons for choosing it, a figure that has held in roughly that range for years.^[2]

A dying or seriously ill person does not need anyone to say the word burden out loud to receive the message. It arrives in smaller ways: a sigh nobody meant to let slip, a comment about how tired everyone is, silence where reassurance used to be. A person absorbing that message long enough may arrive at a decision to pursue an early death that looks, on paper, exactly like the confident self-determination described in the previous section. It has the same form. A request is made, forms are signed, a choice is documented. The choice did not originate the way self-sovereignty language assumes it did, though. It was shaped, quietly and often without anyone intending it, by someone else’s exhaustion.[1] 

This is why “it was her choice” can be true and still not be the whole truth. The choice is real in the sense that she made it. It may not be free in the sense the word autonomy implies, because autonomy assumes a self acting from its own center, not a self responding to pressure it never consciously registered as pressure at all.

Paul’s instruction to the Galatian church cuts directly against the dynamic this section describes: “Bear one another’s burdens, and so fulfill the law of Christ” (Gal. 6:2). The command assumes burdens are meant to be carried by the community together, not absorbed silently by the person who is already suffering the most and then handed back to that person as though the decision to end things were entirely their own. A community that has let its exhausted caregiving quietly become the dying person’s problem to solve has inverted Paul’s instruction. It has let the person with the least capacity to bear a burden end up bearing the heaviest one alone.

This is not a new instinct for this series to name. The same self-protective move that quietly narrows who counts as deserving of aid, examined in the previous installment, shows up here in a different form: it is easier to let a system, or a silence, or an accumulated weight of unspoken exhaustion do the deciding than to say plainly that a life has become too costly to sustain. Nobody has to say it out loud. The result lands the same either way.

When the Safeguard Becomes Its Own Exclusion

The self-administration requirement exists specifically to guard against the dynamic just described. If a patient must physically complete the final act themselves, no family member, no caregiver, no accumulated exhaustion can complete it for them. The requirement is not incidental to these laws. Advocates for assisted dying regularly describe it as the central safeguard, the one detail that proves beyond doubt that the choice belongs to the person making it and no one else.

One woman with ALS challenged this exact requirement in federal court. She met every other qualification the law required. Her disability had already taken her ability to lift a cup or complete a swallowing motion, long before it touched her capacity to decide anything at all. The law could not tell the difference between a choice it doubted and a body it had never accounted for.

That is not an argument for loosening the safeguard. It is evidence of something else: a law built entirely to answer whether a choice is free cannot, by its own design, also ask whether the person making it can physically satisfy the proof it demands. A safeguard that measures freedom by what a body can still do is not a neutral safeguard. It is one more place where this series’ pattern holds — protection distributed unevenly, this time by anatomy rather than by intent. This is a real and documented tension, not a hypothetical one, and it deserves more careful treatment than this article has room to give it. This series will take up the disability dimension of these questions directly and at length in its next installment.[2] 

It is worth saying plainly that disabled people themselves are not of one mind on assisted dying broadly. Some disability advocates support the option in principle while objecting to specific safeguards like this one. Others oppose the practice altogether, and their objection is not mainly about safeguards. It is about what “choice” can mean for someone whose life a culture already treats as costly to sustain. Autonomy language assumes a baseline: a person choosing freely against a backdrop of real support and real care, not against a backdrop of subtle signals about what their life is worth to everyone around them. Take that baseline away, and a right exercised under that kind of pressure starts to look like the same borrowed autonomy examined earlier in this article, institutional this time instead of familial. The obligation runs the opposite direction from where “choice” language usually points: not a society granting a right and stepping back, but a society that owes its most vulnerable members active protection before it owes them an exit. Both positions deserve to be heard on their own terms, not flattened into a single storyline. What this article can say with more confidence is narrower: whatever one believes about assisted dying generally, a safeguard that excludes people specifically because of their disability, while claiming to protect free choice, is worth examining rather than assuming it works as intended.

Not My Will, But Yours

Both versions of a good death examined so far share something in common, even though they look like opposites. Self-sovereignty says dignity is found in controlling the terms. Borrowed autonomy says someone else decides the terms while borrowing that same language for cover. Both are answers to the same fear: that dying without mastering the process, or without at least appearing to have chosen it, means dying badly.

Scripture offers something neither of these frameworks anticipates. In Gethsemane, on the night before his death, Jesus faced the most agonizing death imaginable with every standing to demand control over its terms. He was innocent. He had power his accusers did not understand. And in the garden, sweating what Luke describes as drops of blood, he prayed: “Father, if you are willing, remove this cup from me. Nevertheless, not my will, but yours, be done” (Luke 22:42).

That prayer is not passive resignation, the kind that simply lets events happen without a fight. Jesus asked directly for another way. He named what he wanted plainly. But having asked, he surrendered the actual terms of his death to the Father rather than seizing them for himself, and he did this while surrounded by disciples who could not even stay awake to keep watch with him, a presence that failed him even as he leaned into it.

That is the third option missing from both frameworks examined earlier: not control seized as the measure of dignity, and not control quietly ceded to someone else’s exhaustion while still called a free choice. A good death, on this pattern, is one entrusted, offered up rather than gripped, in the presence of others even when that presence is imperfect or asleep, rather than settled alone through either raw self-determination or an unspoken debt to someone else’s weariness.

A good death, in Scripture, is neither seized nor surrendered to someone else’s exhaustion. It is entrusted to God, which is the one option both self-sovereignty and borrowed autonomy quietly rule out, because both frameworks assume a person’s own hand, whether acting freely or acting under pressure, has to be the final word. Gethsemane says otherwise.

None of this settles every hard case a family will face at a bedside, and Scripture was never meant to function as a policy manual for one. But it offers a different question than either framework asks, one that is not about who is in control or whose burden this really is: whether a dying person, and everyone gathered around them, can hold the terms of that death open before God rather than closing them off through force of will or force of circumstance. That is a harder question than either framework’s, though closer to what dying actually asks of a person.

What Remains When Control Is Given Up

A gospel-shaped view of a good death refuses both of the stories our culture tells about dying well. It will not say dignity depends on maintaining control until the end, because Scripture consistently locates dignity in people who had none. It will not accept “it was their choice” as the final word when a choice was quietly shaped by someone else’s exhaustion, because Paul commands communities to carry burdens together rather than let the person suffering most carry them alone. And it does not pretend these are easy distinctions to draw in an actual hospital room, at an actual bedside, with an actual family exhausted in ways no article can fully address.

What it offers instead is Gethsemane: a real death, faced honestly, its terms entrusted rather than seized or silently imposed. That is the pattern underneath every branch of this series, applied here to the last and hardest test a human life faces. Worth was never something to be proven through control any more than it was something to be earned through productivity, examined in the previous installment, or granted only where a legal process built a courtroom for it, examined two installments ago. It was given, at every stage, including the last one, and it remains entrusted to the God who gave it, right up to the moment it is finally received back.

Questions for Reflection

• Where in your own life have you equated losing control with losing dignity?
• Have you ever sensed you were becoming a burden to someone, without them ever saying so directly?
• How does Gethsemane’s picture of a good death challenge the way you imagine your own end?
• What would it look like, practically, for a community to bear a dying person’s burden rather than let them absorb it alone?
• Where do self-sovereignty and borrowed autonomy show up in decisions you make that have nothing to do with dying?

Prayer Points

• Ask God to help you locate your own sense of dignity somewhere other than your capacity for control.
• Pray for families currently caring for a dying loved one, that exhaustion would be met with real support rather than silent pressure.
• Ask the Lord for the kind of trust Gethsemane models, honest about what you want while surrendering the actual terms to him.
• Pray for The Gospel Lens as this series continues, that readers facing real mortality would find more than an argument here.

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^[1]New York State Bar Association, “Medical Aid in Dying in New York: A Changing Medical and Legal Landscape for Terminally Ill New Yorkers and Healthcare Professionals,” by Edward McArdle, Mary Beth Quaranta Morrissey, Adrienne Borschuk, and Epiphany G. Ramirez, 2026, https://nysba.org/medical-aid-in-dying-in-new-york-a-changing-medical-and-legal-landscape-for-terminally-ill-new-yorkers-and-healthcare-professionals/. New York’s Medical Aid in Dying Act took effect August 5, 2026, following two federal lawsuits: Carmelite Sisters for the Aged and Infirm, Inc. et al. v. James, N.D.N.Y., filed July 17, 2026 (temporary injunction granted July 30, 2026), and Brooklyn Center for Independence of the Disabled et al. v. Hochul et al., E.D.N.Y., filed June 11, 2026 (dismissed July 30, 2026 for lack of standing). See also US Funerals Online, “Medical Aid in Dying (MAID) in the United States 2026,” https://us-funerals.com/medical-aid-in-dying-maid-in-the-united-states/, on the self-administration requirement. Accessed August 26, 2026.

^[2]Oregon Health Authority, Public Health Division, “Oregon Death with Dignity Act: 2024 Data Summary,” 2025, https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year27.pdf. Accessed September 2026.