It seemed like the stars were aligning for Maryland medical aid in dying advocates. Many felt like the legislature had enough votes in the 2024 session to finally legalize the practice after years of failed attempts and near misses.

Even Senate President Bill Ferguson felt like the bill had a good chance.

“I believe it will pass the Senate,” Ferguson said in January, at the beginning of the session. “I expect it to be a topic of important conversation this year.”

And yet, months later, because of one vote, the End-of-Life Options Act didn’t make it to the Senate floor.

Meanwhile, in neighboring Delaware, a nearly identical bill took a completely different path. A single vote propelled it through the legislature and onto the desk of the governor.

Both states are in the mid-Atlantic, both share similar goals, and, like the animals they are both famous for, the Blue Crab and Blue Hen, the populace of both jurisdictions are heavily blue, at least politically.

Yet, despite about 7 in 10 people in both states supporting medical aid in dying, one legislature put it past the finish line, while another must start anew in 2025.

“This has always been an issue of conscience,” said Peg Sandeen, the CEO of Death with Dignity, an organization that advocates for medical aid in dying. “We allow each member to decide themselves. There's not going to be any arm-twisting here, no whipping votes.”

A disconnect between popular will and policy

Medical aid in dying has overwhelming support in the United States, according to multiple Gallup polls.

In the most recent survey, 74% of Americans believe terminal patients should have the right to painlessly end their life. A majority of Americans have supported that right in every Gallup poll since 1996.

However, only 10 states and Washington D.C. currently allow the practice.

States that legalized medical aid in dying have done it in many ways — through courts, quickly through legislatures or over long stretches of time where the bill has gone through many sessions.

In most states, the rules created around medical aid in dying follow the Oregon model. Oregon was the first state to legalize the practice in 1994.

In order to voluntarily end one’s life, a person must have a prognosis of six months to live or less.

They must not be coerced into their decision, there must be multiple waiting periods and there needs to be witnesses to the agreement.

Both the Maryland and Delaware bills followed the Oregon model.

Yet, even in states where one party holds both legislative houses and the executive branch, and popular will is strong, it’s often a slog to get medical aid in dying bills into law.

A lot of money and a lot of power

In 2019, Maryland nearly passed a medical aid in dying bill. The Senate vote ended in a 23-23 tie.

That same slim margin resurfaced as a bipartisan group of state delegates and senators once again tried to pass the bill in the 2024 session.

Medical aid in dying often creates strange bedfellows when it comes to voting blocs. While it does lean Democratic, it’s not a fully party-line issue.

“I think there is a slight partisan element to it,” Sandeen said “But, that's not the dominant breakdown here of the vote. We will have Republicans who are voting for this bill in the end, and some Democrats who vote against it.”

Instead, different cultural groups seem to be more inclined toward medical aid in dying or to eschew it.

“The Catholics are very much against the bill. Also, a lot of the African Americans don't like it. It seems they feel it's against their religion,” said Ron Young, a former Democratic Maryland state senator, who previously sponsored and supported medical aid in dying bills.

In Maryland, those groups carry a lot of weight.

“There's people with a lot of money and a lot of power that oppose it,” said Thaddeus Pope, a clinical ethicist at the Mitchell Hamline School of Law. “Traditionally, the Catholic Church has been one of the biggest opponents. And, they have spent a lot of money in many states opposing this. It's sort of the same parties that are involved with abortion. It's not just the Catholic Church, but it's pro-life advocacy organizations.”

Pope says some of those organizations have more resources to dig in on medical aid in dying after the Supreme Court’s Dobbs decision.

The Black community in Maryland is a formidable voting bloc and one that legislators represent in the state and listen to closely, Young said. He stated that there is a large percentage of Black voters who oppose medical aid in dying.

According to the U.S. Census Bureau, Maryland is 32% Black, making it the state with the sixth highest Black population in the nation.

“Those two groups [the Catholic and Black population] when you shave them off of the majority, make the vote real close,” Young said.

Democratic Sen. Malcom Augustine represents Prince George’s County, the state’s jurisdiction with the highest Black population. He voted against the bill in 2019 and continues to oppose it.

“What I was hearing from constituents was that this was a very, very personal and very difficult policy decision,” he said.

Augustine said his concerns rose from fears that nursing homes may coerce people into making a decision they hadn’t thought through.

“Maryland is progressive, but it's also very diverse. The African American legislators represent about 30% of the legislators in Maryland,” said Donna Smith, an advocate with Compassion and Choices, which lobbies for aid in dying. “It's very hard to get anything passed without some of their support. Prince George's County also has a very strong church based faith advocacy. And they have come out very strongly against us.”

Of course, there are many outliers. Some legislators find themselves rethinking medical aid in dying.

Smith said former Maryland Governor and now Republican U.S. Senate nominee Larry Hogan was staunchly against the practice in his first term.

“In his second term, he had that bout with cancer. And when I approached him about it during that second term, he was less committed to a ‘no’,” Smith said. “He said it was something that he would have to consider, because going through his own end of life issues with the cancer really made him think about it.”

Others have told stories of losing spouses or family members and rethinking their stance due to the suffering they witnessed.

Keeping frogs in a wheelbarrow

Maryland is the nation’s fourth most diverse state, according to the U.S. Census Bureau. Delaware, ranks down at 15th.

Young, Pope and Smith all said that Maryland has a patchwork of cultures and constituencies that legislators must cater to in their districts.

Despite the letter next to lawmakers’ names, those groups hold a lot of power. In Maryland, there are more diverse groups legislators need to cater to than in Delaware, leaving some to err on the side of caution and vote against a bill that could anger a large portion of the people when November comes for reelection.

The legislative process is fickle in the United States. The will of the minority is strong and a few votes can upturn any piece of legislation.

“The thing about the legislative process is there's so many little gates a bill has to pass through,” Pope said. “The opposition doesn't need to all the votes, they just need to be able to block any one of any one of those gates that it needs to pass through and they win.”

One vote eked Delaware’s legislation over the line.

In Maryland, one vote kept the medical aid in dying bill stuck in committee, dooming the bill for the 2024 session.