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In June of 2016 Canada’s parliament enacted legislation to permit medical assistance in dying (MAiD). The measure has been widely embraced. In less than a decade, Canada has become one of the most prolific providers of medical assistance in dying in the world, with more than 15,000 MAiD deaths reported in 2023. Annually, almost 5% of all deaths in Canada are actively assisted by a physician or nurse practitioner. Quebec is now the most liberal MAiD regime in the world with over 7% of deaths resulting from MAiD (1).

Many view the expanding use of MAiD in Canada as evidence of the realization of a previously unmet need. Advocacy groups call for further expansion. Others are concerned that expansion has already been too rapid, that safeguards are inadequate to protect some vulnerable groups from feeling compelled to choose MAiD, and that further efforts to extend access should be curtailed.

It is this ongoing debate on whether and how to manage Canada’s evolving MAiD regime that motivated us at the Centre for Bioethics at Memorial University to convene a symposium on MAiD in the fall of 2024. The title of the symposium was: MAiD in Canada: A Sober Second Look. A majority of the papers included in this special issue were presented initially at that symposium. In the spring of 2024, we issued a call for abstracts on any aspects of MAiD. The submitted abstracts went through blind review, and ten papers were accepted for presentation. We made the deliberate decision to keep the symposium small, and to avoid concurrent sessions, thus allowing all attendees to participate in every session.

In addition to ten accepted papers, we were pleased to have four invited keynote speakers, each of whom is an active contributor to the current MAiD debates. We were fortunate to host Isabel Grant (University of British Columbia Allard School of Law), Scott Kim (National Institutes of Health, Department of Bioethics, USA), Trudo Lemmens (University of Toronto Faculty of Law and Dalla Lana School of Public Health), and Wayne Sumner (University of Toronto Department of Philosophy). We thank each of our keynotes for their contributions but want to extend a special word of gratitude to Professor Sumner. When we first issued our call for papers, we’d already confirmed the other three keynotes, and we included information about their participation in that call. Each of those individuals is known to harbour reservations about aspects of Canada’s current MAiD regime. Professor Sumner contacted us when he saw the call for papers, noting that our symposium might be viewed as an echo-chambre in which only those who shared negative perceptions of MAiD were given a voice. We took his concerns seriously and extended an invitation for him to join us as a fourth keynote. He graciously accepted. His contributions throughout the symposium did much to enhance the quality of the discussion and debate and his contribution to this issue serves as a counterpoint to several of the other papers.

Despite the at times passionate and animated discussion, a genuine sense of community emerged as interlocutors engaged in respectful dialog throughout the two days of our meeting. We were pleased that many participants commented later that the symposium provided a safe and constructive environment in which to discuss the issues.

This special issue is comprised of eleven papers, only eight of which were presented as part of the symposium at Memorial University. After consultation with the journal editorial team, the papers by Pesut et al. and Pullman were included to help round out this collection. The perspective piece by Trudo Lemmens, one of our invited keynotes, was not part of the symposium, but addresses concerns raised by the recent report from the Ontario ‘MAiD Death Review Committee’ which functions under the auspices of the Office of the Chief Coroner (2). The 2025 Report focuses on cases of MAiD for persons with dementia.

At the risk of doing a disservice to the careful scholarship evidenced in the papers included here, we have categorized them into four broad themes: 1) empirical explorations of some aspect of MAiD practice (empirical bioethics); 2) ideology, autonomy and the ethical probity of MAiD; 3) MAiD and disability; and 4) MAiD and mental illness. We acknowledge at the outset that some authors may feel their paper does not fit neatly into one of these categories or that it may have fit better in another category. Nevertheless, for present purposes we have categorized the papers in this manner.

Empirical explorations of some aspect of MAiD practice

Empirical bioethics is concerned primarily with the descriptive aspects of particular policies and practices and their effects on individuals or groups. It is less concerned initially with the normative implications of these observations, although the latter often figure in the discussion. The papers by Pesut et al (3) and de Bie et al (4) fall broadly into the category of empirical bioethics.

Barbara Pesut and her team have published extensively on various aspects of MAiD practice over the past number of years. In the current paper, they examine the perspectives of persons living with chronic illness who are potential candidates for Track 2 MAiD. One observation, based on this research, is that participants expressed concerns that a lack of adequate health and social care services might influence some to consider Track 2 MAiD.

Lee de Bie et al examine the role and contributions of peer supporters to MAiD in Canada. Peer support, as they describe it, involves people who share a common experience, meeting as equals to share skills, strengths and hope in order to learn from and support each other in coping, thriving and flourishing in their life situations. In this paper, they outline work their group is doing to develop tailored educational resources on MAiD for peer supporters, especially as it pertains to those suffering with mental health conditions.

Ideology, Autonomy and the Ethical Probity of MAiD

While MAiD is now well entrenched as an increasingly common end-of-life practice in Canada, the question of whether, when and how it is practiced continues to be debated. On the one hand some would argue that such ongoing debate should be encouraged. MAiD, after all, involves state sanctioned homicide whereby some individuals (medical professionals) are granted the power and authority to terminate the lives of others, albeit presumably with the latter’s consent. This is a weighty matter, and as such, ongoing debate should be encouraged. On the other hand, some argue that there is nothing particularly unique about MAiD and it should be regarded much the same as any other commonly practiced medical procedure. Ongoing debate is thus a distraction at best; at worst, it represents ideologically driven attempts to subvert a legally sanctioned and apparently much needed medical intervention.

Philosopher Wayne Sumner (5) takes the latter view, arguing that concerns raised about MAiD in Canada are misplaced or disingenuous. He is particularly vexed by those who claim they are not opposed to MAiD in principle, but who nevertheless voice concerns about aspects of how the service is delivered, including ongoing efforts to expand it. Sumner systematically dismisses such concerns and suggests the fact he can do this so readily is reason to believe that opposition to MAiD must be ideologically motivated.

Ideology is also the focus of the contribution by physician/bioethicist Scott Kim (6). Kim argues that the rhetoric around MAiD, as practiced in Canada, makes it sound as if this is just another medical procedure. However, he argues, the language employed in these discussions gives novel meanings to common terms used in healthcare thus obfuscating the conversation by giving the impression that Canadian MAiD is about something medical. Instead, Kim argues that Canada’s MAiD regime is an “autonomy only” model that demands “death on autonomous demand” As a result, it is ideology masquerading as medicine.

The contribution by bioethicist Timothy Christie (7) tends to support Kim’s position. Christie argues that the ostensibly medical eligibility criteria for MAiD (incurability, irreversible decline, intolerable suffering) are not objective medical criteria but instead presuppose and enforce patient autonomy. MAiD assessments are thus reduced to procedural confirmations of autonomy rather than substantive medical assessments. He goes on to outline an ethics framework intended to guide the discretionary judgment of MAiD assessors.

In “MAiD and the Death of Dignity” (8), bioethicist Daryl Pullman attempts to clear up some of the ambiguity surrounding the notion of human dignity. While Dying with Dignity Canada (DWDC) is a vocal and aggressive proponent for expanding MAiD, Pullman argues that the notion of ‘dignity’ (lower case) which they promote presupposes a narrow and somewhat skewed conception of autonomy that is more akin to an aesthetic judgment than a moral notion per se. Such aesthetic judgments should be constrained, he argues, by the more fundamental moral notion of Human Dignity (upper case) that underwrites such treatises as the Universal Declaration of Human Rights. When aesthetic conceptions of dignity are untethered from this more fundamental notion, we risk the death of Dignity itself.

MAiD and Disability

The papers by Janz (9) and Grant (10) each address concerns about MAiD raised by the disability community. Heidi Janz takes on the argument advanced by some bioethicists that MAiD should be considered a form of “harm reduction” for people living in “unjust circumstances” who are facing intolerable suffering. Janz uses a disability ethics framework to dismantle this argument, which she claims trades on the endemic ableism central to much of the medical and bioethical discussion of MAiD in Canada.

Legal scholar Isabel Grant argues that Track 2 MAiD is discriminatory against people with disabilities in general, and particularly so for women with disabilities. In her view, Track 2 MAiD poses heightened risks for those already disadvantaged by structural inequalities. Track 2 MAiD exceptionalizes the suffering associated with disability, Grant argues, treating it as different and inherently worse than other human suffering. Many of the factors motivating Track 2 requests for MAiD are social factors that are not unique to disability but are often exacerbated by it.

MAiD and Mental Health

Although the federal government has now deferred until 2027 the implementation of MAiD for those suffering from mental illness but with no other underlying medical condition, there are ongoing concerns raised about offering MAiD to this vulnerable population. Locky Butcher (11) takes on the notion of ‘vulnerability’ itself as he seeks to provide some clarity to this central but often poorly defined concept in the context of MAiD. He argues that a clarified notion of vulnerability suggests that current assurances that adequate safeguards are available for those suffering from mental illness are misguided.

Philosopher Kyle Barbour (12) questions whether those suffering from mental illness would have the capacity to provide a properly informed consent to receive MAiD. He argues that a mental disorder has the potential to affect one’s values thereby impairing an individual’s decision-making capacity. The high potential for invalid consent raises concerns on Barbour’s part, about the ethical probity of extending MAiD to those suffering from mental illness in the first place.

Finally, Trudo Lemmens (13) raises concerns about providing MAiD for persons with dementia. He comments that current practice, as revealed in the recent report from the Ontario MAiD Death Review Committee (2), ignores legal restrictions and safeguards, often with impunity. In the context of Canada’s aging population there is an urgent need for more stringent oversight of these practices.