Collaborative authorship, listed alphabetically by surname.

Abstract

Assisted dying raises complex ethical questions surrounding autonomy, justice and equity. Socioeconomic circumstances, including poverty, housing, financial hardship, education and access to healthcare, may influence the choices available to individuals at the end of life. This review examines how these factors relate to assisted dying requests, attitudes and access. This narrative review was conducted using PubMed. Articles published from 2021-2026 were identified using search terms related to assisted dying, euthanasia, socioeconomic factors, ethics and health equity. Studies were screened using predetermined inclusion and exclusion criteria, and relevant findings were extracted according to socioeconomic factors, assisted dying decisions, ethical concerns and implications for justice. The literature suggests that socioeconomic disadvantage does not consistently increase assisted dying requests but can influence the circumstances surrounding them. Limited healthcare, palliative care, housing, financial resources and social support may reduce meaningful alternatives. Higher socioeconomic status was associated with greater acceptance of assisted dying in some studies, while geographic and institutional barriers also affected access. Socioeconomic factors may shape assisted dying decisions indirectly by influencing access to alternatives and the conditions in which choices are made. Future research should further examine these relationships to balance respect for individual autonomy with justice and fair access to end of life care. 

Introduction

Assisted dying is one of the most debated issues in medical ethics because it involves a difficult balance between a person’s right to make decisions about their own life and the responsibility of healthcare systems to protect vulnerable individuals (Downie & Schuklenk, 2021).  Assisted dying is often discussed through ideas such as autonomy, dignity and relief from suffering (Downie & Schuklenk, 2021).  However, one factor that may influence a person’s decision that is sometimes overlooked is their socioeconomic situation. A person’s income, access to healthcare, housing, education, employment, social support and overall life can affect the choices available to them, especially when facing serious illness or the end of life (Downie & Schuklenk, 2021; Perlman et al., 2021). 

This raises an important ethical question: Can a decision to request assisted dying truly be considered autonomous when a person’s circumstances may influence that decision? Individuals experiencing poverty, financial stress, homelessness or limited access to healthcare may experience illness and the end of life differently from someone with greater financial and social resources (Downie & Schuklenk, 2021). Financial difficulties may make long-term care feel inaccessible, while a lack of housing or social support may increase a person’s sense of vulnerability (Downie & Schuklenk, 2021). However, assisted dying requests are not only caused by socioeconomic disadvantages. People who are financially secure and have access to high-quality healthcare may also request assisted dying because of factors such as loss of independence, dignity or quality of life (Steck et al., 2014; Steck et al., 2018). 

This makes the relationship between socioeconomic status and assisted dying much more complicated than simply asking whether disadvantaged people are more likely to request it. The ethical concern is not whether socioeconomic status directly determines a person’s decision, but whether inequality can influence the choices available to them (Downie & Schuklenk, 2021). 

From an ethical perspective, this issue connects closely to the principles of autonomy, justice and equity. Autonomy supports a person’s right to make informed decisions about their healthcare, while justice and equity require healthcare systems to provide fair access to care and prevent social inequalities from influencing medical choices. If a person requests assisted dying because they genuinely wish to end their suffering, respecting their autonomy may be ethically justified. However, if that decision is influenced by circumstances that could have been changed through better healthcare, financial support, housing or social care, the ethical situation becomes less clear (Downie & Schuklenk, 2021). 

This narrative review examines existing research on the relationship between socioeconomic factors and assisted dying requests, with particular attention to poverty, homelessness, financial circumstances, access to healthcare and social support. It also considers whether people from more financially secure backgrounds request assisted dying and explores the reasons that may influence these decisions (Steck et al., 2014, 2018; Tran et al., 2022).  By examining these factors together, this review aims to explore where the ethical boundary should be drawn between respecting individual autonomy and protecting vulnerable individuals from decisions shaped by inequality or limited choices.

Methodology

Search Strategy

A narrative literature review was conducted to examine the relationship between socioeconomic factors and assisted-dying requests, with particular attention to issues of justice, equity, autonomy, vulnerability and access to care. A literature search was conducted using the PubMed database on 26th August 2026. The search strategy combined Medical Subject Headings (MeSH) and title/abstract terms relating to assisted dying with terms relating to socioeconomic circumstances. The search focused on terms related to euthanasia or assisted death and various socioeconomic factors. The exact PubMed search string can be found in the supplementary file. The following PubMed filters were applied: publication date within the previous five years (26th August 2021 – 26th August 2026), free full text, English language and human species. 

Inclusion and Exclusion Criteria

Studies were selected according to their relevance to the research question as listed in Table 1. 

Table 1: Inclusion and Exclusion Criteria.

Screening and Data Extraction

The search identified 30 initial papers. These papers were then screened for relevance against the inclusion and exclusion criteria, resulting in 22 papers selected for inclusion in the final narrative review. Information from the included papers was extracted using a structures extraction table. Data collected included the paper’s title and publication year, authors and journal, study population, type of assisted-dying examined, socioeconomic factors considered, main findings, effects on assisted-dying requests or attitudes, ethical issues, relevance to justice and equity at the end-of-life, limitations and potential themes for synthesis (refer to Supplementary Text 1). 

Given the narrative nature of the review, findings were compared and synthesised thematically rather than statistically. Particular attention was given to how socioeconomic circumstances may influence the choices available to individuals considering assisted-dying, while recognising that socioeconomic disadvantage does not necessarily determine an individual’s decision to request assisted-dying.

Results

Following the screening of 30 initial papers, 22 articles were selected for inclusion. The overall theme is that while socioeconomic status does not consistently predict the frequency of assisted dying requests, it significantly alters the context and options available to patients, leading them to make differing decisions. These findings are synthesised into three sub-themes: material hardship, structural barriers and the influence of relationships and professional attitudes.

I. Material Hardship and Individual Economic Determinants

A. Poverty, homelessness and subjective suffering 

Research indicates that socioeconomic disadvantage is a significant factor in how individuals experience the suffering that leads to assisted dying considerations. Tobore (2026) observes that current medical aid in dying (MAiD) eligibility frameworks generally restrict access to specific medical conditions, even though subjective suffering can arise from non-medical circumstances such as extreme poverty and homelessness. In a qualitative study of individuals with mental illness in Ontario, Bastidas-Bilbao et al. (2023) found that 30% of participants reported precarious housing and identified financial insecurity as a direct contributor to their suffering. These participants expressed concerns that for those with fewer resources, MAiD might appear as an option because effective social and healthcare alternatives remain inaccessible. 

B. Income levels and global trends

Evidence regarding the frequency of requests shows a correlation with socioeconomic status, though this does not necessarily translate to higher completion rates. A regional study by Tran et al. (2021) found that low-income patients in Ontario accounted for 58.1% of all formal MAiD assessment requests, despite making up only 39.4% of the population. However, the study found that socioeconomic status had no impact on whether a patient actually received MAiD; the rate of non-completion was nearly identical between lower-income (63.3%) and higher-income (63.7%) groups. 

Public attitudes also vary by economic context. Inglehart et al. (2021) found that higher national GDP per capita and life expectancy are associated with greater general acceptance of euthanasia globally. In Canada, Choi et al. (2024) reported that while high-income individuals ($150,000+) show greater general support for MAiD (82.9%) than those in the lowest income bracket (66.4%), they are significantly less supportive – only 8.2% compared to 25.1% of lower-income respondents – in specific scenarios where a patient lacks access to medical resources.

II. Structural Barriers and Systemic Inequities

Healthcare systems often fail to provide equal opportunities due to forced irremediability or health inequity due to geographical location, health illiteracy or economic disadvantage.

A. Forced irremediability and specialist access

Forced irremediability is a concept whereby a person’s condition is not incurable due to a lack of treatment options but in fact due to limitations such as financial strain or remote, inaccessible geographic location. Chronic health conditions or mental illnesses requiring long term support, in particular, could force people to seek assisted dying due to a lack of resources or access  (Berens et al., 2022). This raises the question if the process honours the patient’s autonomy or whether the patient is a hostage to the circumstance. Other constraints that can influence decision making can include lack of access to specialist beds, length of waiting lists, insurance coverage (Ayton et al., 2026) and adverse socioeconomic situation (Silitti et al., 2025). 

B. Geographic and institutional barriers

Administrative barriers related to the patient’s geographical location (e.g., rurality, remoteness, specialist access) can also force or misdirect decision making regarding assisted dying, lending support to the concept of “postcode lottery” (Close et al., 2023). Other administrative barriers include poor remuneration for medical practitioners providing support for patients requiring voluntary assisted dying processes (Haining et al., 2022). The aforementioned factors such as financial capability and geographical access also influence decisions regarding suicide tourism as a means of assisted dying, highlighting the existing disparity both in terms of healthcare provision as well as legal framework (Zang et al., 2023). 

III. Vulnerability, Relationships and Professional Attitudes

A. Mental health, social isolation and relational autonomy

Autonomy can become more complicated when a person’s mental health and social circumstances are taken into consideration. Hawke et al. (2024) found that people considering MAiD for mental illness sometimes viewed their decision as a way to escape ongoing and intolerable suffering, while also highlighting how access to treatment and social support can affect these experiences. Pronk et al. (2023) similarly found that relatives often experienced conflict between respecting a patient’s autonomy and believing that further treatment or support could lead them to choose life. Their findings also raise an important issue of relational autonomy, as patients with strong family or social networks may have support that socially isolated patients do not. This creates a tension between respecting someone’s right to make their own decision and making sure that the decision is not being shaped by circumstances that could potentially be changed. Wels and Hamarat further highlight this issue by showing that euthanasia involving psychiatric disorders and dementia remains an area where vulnerability and safeguarding are especially important, while also pointing out that the lack of socioeconomic data makes it difficult to know whether access is equal across different groups. Therefore, protecting autonomy does not only mean respecting a person’s final choice, but also making sure they have proper support and alternatives before that choice is made. 

B. The impact of healthcare provider backgrounds

The personal backgrounds and beliefs of healthcare providers can also affect how assisted dying is viewed and discussed. Lachowski et al. (2023) found that religious involvement and family size significantly influenced medical students’ attitudes toward euthanasia, while factors such as age, gender and place of residence did not have a significant effect. Religiously engaged students were much more likely to have negative views of euthanasia, while non-religious students showed greater acceptance. Grundnig et al. (2025) similarly found that religion, clinical experience, and cultural and legal background can influence medical students’ attitudes toward end-of-life decisions. This matters because patients should be able to receive fair and objective information regardless of who their doctor is. If a healthcare provider’s personal beliefs strongly influence the way they approach assisted dying, two patients with similar medical circumstances could potentially have very different experiences. This creates an issue of equity, as access to balanced counselling should depend on a patient’s medical needs rather than the personal beliefs of the professional treating them.

Discussion

The synthesis of global and regional data reveals a significant “support paradox” regarding the relationship between wealth and assisted dying. On a theoretical level, higher national economic development and higher individual household income are associated with greater general acceptance of the practice (Inglehart et al., 2021; Choi et al., 2024). This suggests that for those with financial security, assisted dying is primarily viewed through the lens of autonomy and the right to self-determination (Choi et al., 2024). However, this support is highly conditional: wealthier individuals are significantly more resistant to the legalisation of assisted dying when the request is motivated specifically by a lack of social or medical resources (Choi et al., 2024). This creates a notable tension with clinical realities, where regional evidence indicates that the frequency of formal assessment requests – nearly 58% – comes from patients in the lowest income quintile. This goes on to show that socioeconomic status does not determine whether assisted dying is autonomous, but it does play a part in affecting patient care outcomes. A lower-income patient might take on the decision of assisted dying as more favourable than a patient with a higher-income. This all comes down to social-circles, poverty and mental health, and for the lower-income patients, the combined burden of isolation, chronic illness, financial suffering, and unmet healthcare and social needs play a part in reducing alternatives to assisted dying. Therefore, assessing autonomy requires looking beyond where the patients mental health stands and into the reason behind asking for assisted dying.

A significant limitation of the current literature is its heavy reliance on small, non-probabilistic samples, particularly in qualitative research exploring the intersection of mental health and assisted dying. For instance, critical insights into experiences of relatives and patients living with mental illness are often drawn from cohorts of as few as 12 to 30 participants. While these provide rich narrative detail, we believe they offer a narrow perspective that may not accurately represent the diverse experiences of the broader population. This issue is often compounded by selection bias, as many participants are recruited through advocacy organisations, potentially overrepresenting individuals who already hold favourable views toward assisted dying. 

We also note a pervasive reliance on self-reporting surveys and hypothetical vignettes to gauge public and professional attitudes. While studies by Berens et al. (2022) and Choi et al. (2024) are useful for identifying moral thresholds, we contend that these snapshots cannot capture the high-stakes, nuanced reality of a real-world clinical request. We interpret this reliance on “vignette-based” data as a barrier to understanding how systemic pressures and physical suffering truly interact in a clinical setting.

Perhaps the most critical barrier to ensuring equity is the “data gap” in national registries. Researchers frequently lack access to individual-level socioeconomic metrics, such as income or education, because this information is not consistently collected in health databases. Consequently, studies like Tran et al. (2021) must rely on postal code proxies to estimate wealth, a method that can lead to misclassification and an incomplete understanding of individual poverty or wealth. Furthermore, the lack of longitudinal data means we cannot track how a person’s desire for death might fluctuate if their material circumstances, such as housing or financial support, were to improve. Without more precise, long-term data, it remains difficult to verify if current safeguards are truly protecting the most marginalised members of society.

Future Directions

Future research should investigate whether socioeconomic disadvantage directly influences assisted dying requests or instead affects the alternatives available to individuals. Studies should collect individual data on income, housing, education, access to healthcare and financial situations among people who request or receive assisted death. Researchers should also examine whether access to mental health treatment, housing and social services changes end of life preferences over time. Comparing across different regions or countries could reveal whether these relationships differ depending on socioeconomic conditions and assisted dying laws. Ultimately, future work should address the ethical balance between respecting autonomy and ensuring justice, determining how individuals can maintain meaningful choices while preventing poverty or lack of social support.

Conclusion

Socioeconomic factors can influence assisted dying decisions and access, particularly through financial hardship, limited healthcare and palliative care, and unequal access to support. However, the evidence does not consistently show the socioeconomic disadvantage directly causes assisted dying requests. Therefore, justice and equity require protecting patient autonomy while ensuring that assisted dying does not become a response to remediable socioeconomic disadvantage.

Ayton, A., Ibrahim, A., Solmi, M., Bulik, C. M., van Furth, E. F., Mehler, P. S., Bauschka, M. & Guarda, A. S. (2026). Addressing the false dichotomy between autonomy and preservation of life: Clinical, legal, and ethical considerations in severe and longstanding anorexia nervosa. International journal of law and psychiatry, 105, 102179.

Bastidas-Bilbao, H., Stergiopoulos, V., van Kesteren, M. R., Stewart, D. E., Cappe, V., Gupta, M., Buchman, D. Z., Simpson, A. I. F., Castle, D., Campbell, B. H., & Hawke, L. D. (2023). Searching for relief from suffering: A patient-oriented qualitative study on medical assistance in dying for mental illness as the sole underlying medical condition. Social science & medicine (1982), 331, 116075.

Berens, N., Wasserman, D., Wakim, P., Bernhard, T., & Kim, S. Y. H. (2022). Resource Limitation and “Forced Irremediability” in Physician-Assisted Deaths for Nonterminal Mental and Physical Conditions: A Survey of the US Public. Journal of the Academy of Consultation-Liaison Psychiatry, 63(4), 302–313.

Choi, W. J. W., Astrachan, I. M., Sinaii, N., & Kim, S. Y. H. (2024). When medical assistance in dying is not a last resort option: survey of the Canadian public. BMJ open, 14(6), e087736.

Close, E., Jeanneret, R., Downie, J., Willmott, L., & White, B. P. (2023). A qualitative study of experiences of institutional objection to medical assistance in dying in Canada: ongoing challenges and catalysts for change. BMC medical ethics, 24(1), 71.

Downie, J., & Schuklenk, U. (2021). Social determinants of health and slippery slopes in assisted dying debates: Lessons from Canada. Journal of Medical Ethics, 47(10), 662–665.

Grundnig, J. S., Roehe, M. A., Trost, C., Anvari-Pirsch, A., & Holzinger, A. (2025). Attitudes of undergraduate medical students towards end-of-life decisions: a systematic review of influencing factors. BMC medical education, 25(1), 642.

Haining, C. M., Willmott, L., Towler, S., & White, B. P. (2023). Access to voluntary assisted dying in Australia requires fair remuneration for medical practitioners. The Medical journal of Australia, 218(1), 8–10.

Hawke, L. D., Bastidas-Bilbao, H., Cappe, V., van Kesteren, M. R., Stewart, D. E., Gupta, M., Simpson, A. I. F., Campbell, B. H., Castle, D., Stergiopoulos, V., & MAiD Study Team at the Centre for Addiction and Mental Health (2024). Medical Assistance in Dying for Mental Illness as a Sole Underlying Medical Condition and Its Relationship to Suicide: A Qualitative Lived Experience-Engaged Study: Aide Médicale à Mourir Pour Maladie Mentale Comme Seule Condition Médicale Sous-Jacente et Son Lien Avec le Suicide: Une Etude Qualitative Engagée Dans l’Expérience Vécue. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 69(5), 314–325.

Inglehart, R. C., Nash, R., Hassan, Q. N., & Schwartzbaum, J. (2021). Attitudes Toward Euthanasia: A Longitudinal Analysis of the Role of Economic, Cultural, and Health-Related Factors. Journal of pain and symptom management, 62(3), 559–569.

Lachowski, S., Łuszczki, J., Lachowska, B., & Florek-Łuszczki, M. (2023). Euthanasia in opinions of students of medicine. Annals of agricultural and environmental medicine: AAEM, 30(1), 148–155.

Moreno, S., Medina-Rico, M., Osorio Clavijo, K., Rodríguez, N. A., Vicuña Jiménez, V. M., Calvache, J. A., & de Vries, E. (2025). End of Life in Patients With Advanced Non-curable Cancer: Patient Considerations Around the Moment of Death. Omega, 92(2), 831–848.

Narayanan, D., Chandrasekaran, A. S., S, E. A. R., & Vyas, N. (2025). Gender disparities in end-of-life care: A scoping review of patient, caregiver and care provider perspectives in low-and middle-income countries. BMC palliative care, 24(1), 62.

Perlman, C. M., Stukel, T. A., & Scherer, C. (2021). Association of socioeconomic status with medical assistance in dying: A case-control analysis. CMAJ, 193(23), E852–E861.

Pronk, R., Willems, D. L., & van de Vathorst, S. (2023). What About Us? Experiences of Relatives Regarding Physician-Assisted Death for Patients Suffering from Mental Illness: A Qualitative Study. Culture, medicine and psychiatry, 47(1), 237–251.

Sillitti, P., Meier, C., Blanc, S., Jones, L., & Gamondi, C. (2025). A public health perspective on assisted dying and its different modalities. The Lancet. Public health, 10(11), e1001–e1005.

Steck, N., Junker, C., & Zwahlen, M. (2018). Increase in assisted suicide in Switzerland: Did the socioeconomic predictors change? Swiss Medical Weekly, 148, w14684.

Steck, N., Egger, M., Maessen, M., Reisch, T., & Zwahlen, M. (2014). Suicide assisted by right-to-die associations: A population based cohort study. International Journal of Epidemiology, 43(2), 574–583.

Tobore T. O. (2026). On the topical issue of assisted dying: the insurmountable challenges of human existence, and the right to exit. Frontiers in public health, 14, 1695897.

Tran, M., Honarmand, K., Sibbald, R., Priestap, F., Oczkowski, S., & Ball, I. M. (2022). Socioeconomic Status and Medical Assistance in Dying: A Regional Descriptive Study. Journal of palliative care, 37(3), 359–365.

Wels, J., & Hamarat, N. (2025). Trends in assisted dying among patients with psychiatric disorders and dementia in Belgium: A health registry study. PLoS medicine, 22(11), e1004522.

Zhang, H., Miao, L., Gao, F., Yang, Y., & Wang, Y. (2023). Assisted Dying: More Attention Should Be Paid to the Epistemic Asset of Personal Experience. The American journal of bioethics: AJOB, 23(1), 46–49.

Supplementary Text 1: PubMed Search String

( “Euthanasia”[Mesh] OR “Euthanasia, Active, Voluntary”[Mesh] OR “Suicide, Assisted”[Mesh] OR “Right to Die”[Mesh] OR euthanasia[tiab] OR “assisted dying”[tiab] OR “assisted death”[tiab] OR “assisted suicide”[tiab] OR “physician-assisted suicide”[tiab] OR “medical aid in dying”[tiab] ) AND ( “Socioeconomic Factors”[Mesh] OR “Socioeconomic Disparities in Health”[Mesh] OR “Economic Status”[Mesh] OR “Social Class”[Mesh] OR socioeconomic*[tiab] OR “socio-economic”[tiab] OR “socioeconomic status”[tiab] OR income[tiab] OR poverty[tiab] OR deprivation[tiab] OR “financial hardship”[tiab] OR “financial burden”[tiab] OR “financial stress”[tiab] OR “economic hardship”[tiab] )

Supplementary Table 1: Extraction Sheet