Article body

introduction

This paper investigates when it is morally permissible for a healthcare professional to provide Medical Assistance in Dying (MAiD) in Canada. While MAiD is legally permitted under defined statutory conditions, the legality of an act does not establish that it is morally permissible. The ethical question at the heart of this paper is under what conditions are healthcare professionals morally permitted to provide MAiD. This is particularly relevant for Canada, where the Supreme Court of Canada (the Court) envisaged MAiD as a carefully monitored exception to the criminal prohibitions on assisted dying, permitted only in clearly defined circumstances with stringent safeguards (1). In reality, however, the legal eligibility criteria are sufficiently broad and subject to such discretionary interpretation that nearly any autonomous patient with a serious illness, disease, or disability may qualify for MAiD, particularly if they are assessed by a healthcare professional predisposed to endorsing requests on the basis of respect for patient autonomy (2).

It is important to clarify that most MAiD procedures in Canada involve patients living with serious, chronic, or terminal conditions, such as cancer, neurodegenerative disorders, or advanced cardiovascular disease (3). Many of the healthcare professionals involved with these patients see their role as one of compassion, ethical responsibility, and responsiveness to patient suffering (4). This paper does not claim that MAiD is routinely provided inappropriately or that those receiving it are ineligible. The concern is not with individual decisions but with the legal structure itself, which requires healthcare professionals to exercise normative discretion while presenting those decisions as if they are purely legal or procedural. In doing so, the law conceals the ethical nature of these judgments, allowing them to proceed without explicit ethical justification. In the absence of a principled ethical framework, legal compliance cannot ensure that decisions to provide MAiD meet the ethical standard of moral permissibility.

To address this gap, this paper develops an ethics framework grounded in the fiduciary duties that structure the healthcare professional–patient relationship. These duties arise from the patient’s vulnerability and the discretionary authority exercised by healthcare professionals. They require that discretionary decisions be guided by obligations of trust, loyalty, and the patient’s best interests, not merely by legal permissibility. Although fiduciary duties remain part of the common law, they are not meaningfully engaged by the legal framework governing MAiD, which is situated within the criminal law. Because MAiD is structured as an exception to the prohibitions on culpable homicide and assisted suicide, legal compliance protects healthcare professionals from prosecution but does not require that fiduciary duties be fulfilled. The presumption of innocence and the burden of proof beyond a reasonable doubt further limit the ability of the legal system to evaluate whether a discretionary decision to provide MAiD was ethically permissible. In practice, a healthcare professional who can demonstrate compliance with the procedural requirements for MAiD (including the eligibility criteria and safeguards) may be able to establish reasonable doubt, even if those requirements were met through highly permissive interpretations or in a manner that is ethically questionable. As a result, decisions that satisfy legal criteria may still fall short of the ethical standards expected from healthcare professionals.

This paper proceeds in three parts. First, it demonstrates that legal eligibility for the provision of MAiD does not logically entail moral permissibility. Second, it argues that MAiD constitutes a legal privilege rather than a claim right, rendering the decision to provide it a matter of discretionary judgment. Third, it develops an ethics framework grounded in the four principles of healthcare ethics: respect for autonomy, beneficence, nonmaleficence, and justice. This framework is not a supplement to legal compliance but a necessary condition for determining when the provision of MAiD is morally permissible. Without such a framework, the provision of MAiD risks being reduced to a procedural affirmation of patient autonomy rather than a substantive ethical decision.

Definitions and Legal Context

MAiD refers to an intervention where a medical or nurse practitioner (healthcare professional) either administers a lethal substance to a patient upon their request to cause the patient’s death or prescribes the substance for the patient to self-administer to cause their own death (5). These practices have historically been referred to as “voluntary euthanasia” and “assisted suicide.” (6-9) However, this terminology is contentious. Some critics argue that the anacronym MAiD sanitizes and obscures the nature of the act of killing, while proponents contend that it more accurately captures the medical and compassionate context in which the practice occurs (10). The term MAiD was introduced into federal legislation with the passage of Bill C-14 in 2016, but its origin lies in the earlier legislative process in Quebec, which deliberately sought to frame assisted dying as another end-of-life medical procedure rather than as an exception to criminal law.

Quebec began exploring assisted dying in 2009, when the Collège des médecins du Québec released a discussion paper suggesting that physician-assisted death could be considered part of appropriate end-of-life care (11). This led to the creation of the Select Committee on Dying with Dignity, which in 2012 recommended that “medical aid in dying” be legally recognized as another end-of-life option, alongside existing practices such as withdrawal of treatment, palliative care, and continuous palliative sedation (12). In 2014, the Quebec National Assembly enacted Bill 52, An Act Respecting End-of-Life Care, which established a legal regime for “medical aid in dying” within the provincial healthcare system (13). This legislation framed assisted dying as a matter of healthcare provision under provincial jurisdiction and did not rely on federal criminal law exemptions.

Importantly, the term “medical aid in dying” was introduced to replace “euthanasia” and “assisted suicide,” which the Select Committee found to be emotionally charged and poorly suited to the legislative goals. The choice of terminology was deliberately euphemistic (14). By framing the intervention as a form of medical care, the Quebec framework situated MAiD within a model of clinical decision-making, thereby distancing it from its roots in criminal law. This terminology was later adopted at the federal level, though within a distinct legal structure that treats MAiD as an exception to criminal prohibitions rather than as a healthcare service.

While Quebec was implementing its legislation, the Supreme Court was adjudicating Carter v Canada (2015), which held that the blanket prohibition on assisted dying violated section 7 of the Canadian Charter of Rights and Freedoms (the Charter). The Court found that competent adults suffering intolerably from a grievous and irremediable condition should have the option of seeking assistance in dying, provided the request was voluntary and informed. In response, Parliament enacted Bill C-14 in 2016 (amended by Bill C-7 in 2021), which created an exemption from the Criminal Code provisions on culpable homicide, consenting to death, and assisted suicide (15-17). This federal legislation established a distinct criminal law framework for MAiD, grounded in the constitutional division of powers, where criminal law remains a federal responsibility and healthcare a matter of provincial jurisdiction.

Law and Ethics in the MAiD Legislation

Although MAiD emerged from distinct federal and provincial legislative processes, both frameworks share a common feature, namely, that they establish the conditions under which MAiD is legally permitted. However, while the law defines when the provision of MAiD is legal, it does not determine whether it is morally permissible for a healthcare professional to provide it. This distinction is important, because the legal framework prescribes eligibility and procedural safeguards but does not address the ethical responsibilities of those who perform the procedure. To assess these responsibilities, it is necessary to distinguish law from ethics.

Law and ethics are conceptually distinct domains. Law refers to rules and standards established through governmental processes, such as legislation, regulation, or judicial rulings. These rules carry legal authority and are enforceable through courts, regulators, and law enforcement. In Canada, federal laws are enacted through a formal legislative process that includes the introduction of a bill, debate and revision in both the House of Commons and the Senate, and final approval through Royal Assent (18). These processes produce legally binding legislation.

Ethics, by contrast, is concerned with what individuals and institutions ought to do, based on normative reasoning. Ethical principles are not enacted by vote, nor are they enforced by courts, or law enforcement. Rather, they are grounded in values such as respect for persons, beneficence, nonmaleficence, and justice, and are justified through argument, reflection, and deliberation (19,20). Whereas legal reasoning determines what is permitted or prohibited within a legal system, ethical reasoning evaluates the ethical probity of actions regardless of their legal status. In some cases, law and ethics may align, but this alignment is neither automatic nor guaranteed. A law may prohibit actions that are morally required or permit actions that are morally prohibited. For example, the forced attendance of Indigenous children in residential schools was legally required but constituted a fundamental violation of morality (21). The legality of an action, therefore, cannot be assumed to determine its morality.

One of the objectives of an ethical analysis is to determine whether an act is morally required, morally prohibited, or morally permitted. These categories are foundational to normative reasoning, particularly in applied ethics. An action is morally required if an agent has a duty to perform it, morally prohibited if there is a duty not to perform it, and morally permissible if there is no duty either to perform or to avoid it. Therefore, morally permitted actions are those for which agents have no moral obligation either to act or to refrain. They fall within the scope of moral discretion.

In the Canadian context, MAiD is legally permitted under specific conditions, but it is not legally required. Section 241.2(1) of the Criminal Code states that a person “may” receive MAiD if all legal eligibility criteria and procedural safeguards are met. The use of the word “may” is legally significant because it confers a legal privilege to provide MAiD but does not impose a legal duty to do so (22). Even when all criteria are satisfied, no healthcare professional is under a legal obligation to perform the procedure.

The ethical analysis parallels this legal structure. While the provision of MAiD may be morally permissible in some circumstances and morally prohibited in others, it is unlikely that any circumstance could give rise to a duty to provide MAiD. The prima facie duty not to cause death, introduced later in this paper, stands in tension with the claim that MAiD could ever be morally required. Although this prima facie duty may be overridden by other moral considerations, its presence precludes any claim that professionals have a general duty to provide MAiD. This view is also unsupported by the Canadian legal framework, which permits but does not require the provision of MAiD. Accordingly, this paper does not address cases in which MAiD might be morally obligatory or categorically prohibited. Rather, it examines the specific conditions under which providing MAiD may be morally permissible, understood as a discretionary act that must be ethically justified in each case.

Comparative Ethical Frameworks for MAiD — Clarifying the Canadian Model

Justifications for the provision of MAiD are typically structured around two conditions. First, the individual must make a voluntary, competent, and informed request. Second, the individual must be experiencing a medical condition that warrants assistance in dying. This second condition is often framed in terms of either a terminal prognosis, intolerable suffering, or both. Together, these two conditions form what is often referred to in the literature as the joint view (23,24). On this model, both autonomy and welfare are necessary, but individually insufficient. The autonomy condition ensures that the request reflects a voluntary and informed decision by a competent individual. The welfare condition requires that the individual’s medical circumstances be sufficiently grave to justify the intervention. While jurisdictions differ in how they define the welfare condition, for example, some require a terminal diagnosis while others require intolerable suffering, the joint view maintains that neither autonomy nor medical condition alone is enough to ethically justify the provision of MAiD.

A contrasting model, sometimes referred to as the autonomy-only view, holds that an autonomous request is sufficient to justify the provision of MAiD (25,26). On this view, suffering may be a relevant subjective motivation, but it is not a necessary condition of eligibility. The ethical permissibility of MAiD, on this account, derives solely from the individual’s autonomous decision-making authority. So long as the person has capacity, acts voluntarily, and provides informed consent, the professional’s role is to facilitate the person’s autonomous choice.

The Canadian legal framework purports to adopt the joint view model. The Criminal Code sets out eligibility criteria that include administrative requirements, autonomy-related requirements, and the presence of a grievous and irremediable medical condition. Judicial interpretations have reinforced this model. In Carter, the Supreme Court held that MAiD should be permitted only for competent individuals who are affected by a grievous and irremediable medical condition that causes intolerable suffering. These legal and jurisprudential elements reflect a formal commitment to both autonomy and welfare, consistent with the joint view.

Despite this formal structure, the legislation permits interpretations of the eligibility criteria that may render the medically related requirements difficult to distinguish from the patient’s autonomous request. The statutory elements that define a grievous and irremediable medical condition (which include incurability, advanced decline, enduring suffering) are not formulated in a way that clearly separates them from the patient’s autonomous request for MAiD. As a result, the assessment of these criteria may, in practice, rest primarily on the patient’s own account of their condition’s incurability, the extent of their irreversible decline, the severity of their suffering, and their expressed desire to receive MAiD. While the law appears to endorse the joint view, in which both autonomy and a qualifying medical condition are both necessary, the interpretive flexibility built into the statutory language raises the question of whether the legal framework consistently maintains this dual structure or whether it permits practices that approximate the autonomy-only model.

The ethical framework proposed in this paper does not begin with a rejection of the autonomy-only view. Rather, it begins with the observation that the Canadian legal framework explicitly rejects that model and claims to adopt the joint view. The concern, therefore, is not that the autonomy-only model is necessarily incoherent. Jurisdictions such as Germany (27) and Estonia (28) have adopted autonomy-only approaches that treat suicide and assisted suicide as a matter of individual choice rather than as a medical act. These models are internally consistent because they do not frame assisted suicide as a form of healthcare, they do not impose medical eligibility criteria, and they do not require the involvement of healthcare professionals. By contrast, Canada situates MAiD within a healthcare framework while, in practice, relying almost exclusively on patient autonomy to justify it. The aim of this paper is to clarify what would be required to make the Canadian model internally coherent, given its explicit adoption of a joint view structure.

MAiD Eligibility Criteria

MAiD exists as an exception to the Criminal Code’s prohibitions on consenting to death, culpable homicide, and assisting suicide. The legislation establishes legal eligibility criteria and procedural safeguards for its provision. If these conditions are not met, or if the act of causing a person’s death or assisting in their suicide is carried out by someone not authorized by law, the act (of MAiD) would constitute a serious criminal offence. To receive MAiD, a patient must satisfy legal eligibility criteria and adhere to one of two procedural pathways, known as Track 1 and Track 2. The eligibility criteria can be divided into three categories: administrative, autonomy-related, and medically related criteria. The administrative criteria encompass age and residency requirements, although the exclusion of individuals under 18 appears to be an arbitrary restriction without a clear logical justification. The autonomy-related criteria include capacity, voluntariness, and informed consent, which aim to ensure that a patient’s decision to pursue MAiD is genuinely autonomous. However, a closer examination suggests that these criteria create internal inconsistencies within the legislation that verge on logical contradictions. The medically related criteria, which require that a patient have a grievous and irremediable medical condition, ostensibly set independent medical limits on access to MAiD. However, these criteria ultimately collapse into autonomy-based considerations, as their application is primarily guided by the patient’s preferences, values, and goals rather than by objective medical criteria (25). Track 1 applies when the patient’s natural death is reasonably foreseeable (RFND), while Track 2 applies when it is not, thereby including individuals with chronic diseases and disabilities rather than only terminal conditions. However, since RFND is undefined in the legislation, its application relies entirely on professional discretion, without an objective medical basis to guide its determination.

In evaluating the ethical coherence of the MAiD eligibility criteria, this paper adopts the standards of healthcare practice established in Canadian common law as its normative basis. These include the fiduciary duties of healthcare professionals and the common law doctrine of informed consent. In standard healthcare contexts, these principles require professionals to act in the patient’s best interests, provide professional recommendations, disclose material risks and alternatives, answer questions, and assess the patient’s decision in relation to the standard of care. Informed consent in common law also requires disclosure of the information that a reasonable person in the patient’s position would want to know. Although these duties formally remain in place, the shift from a civil law framework to one grounded in criminal law has functionally displaced them. The legal structure governing MAiD functions primarily to protect professionals from prosecution, rather than to ensure that fiduciary obligations are fulfilled or that vulnerable patients are protected. Unlike other areas of healthcare, there is no requirement to assess the best interests of the patient, no duty to recommend for or against the intervention, and no obligation to disclose information that is tailored to the specific circumstances of the patient. Accordingly, this paper compares the MAiD legislation to common law standards in order to identify conceptual inconsistencies and normative gaps that are not addressed by the criminal law framework.

Administrative Eligibility Criteria

The administrative eligibility criteria establish basic restrictions on who can access MAiD. These criteria require that individuals be at least 18 years old and eligible for publicly funded healthcare services by a Canadian government. The age restriction arbitrarily excludes mature minors (individuals under 18 who possess the capacity to make informed medical decisions) from seeking MAiD (29). In contrast, other jurisdictions, such as Belgium (30) and the Netherlands (31), allow minors to access assisted dying under specific conditions. The residency requirement ensures that only Canadian residents can access MAiD, preventing non-residents from traveling to Canada solely for this purpose. This distinguishes Canada from jurisdictions like Switzerland, where assisted suicide is permitted for non-residents (32).

Informed Consent — Descriptive Analysis

The Criminal Code mandates that before proceeding with MAiD, a healthcare professional must ensure that the patient has given informed consent after being informed of the means available to relieve their suffering, including palliative care. The Model Practice Standard (33) and Advice to the Profession (34) documents elaborate on this requirement, outlining the specific information that must be disclosed and the procedural steps involved in obtaining informed consent. The healthcare professional must obtain informed consent directly from the patient because substitute decision-makers are not permitted to consent to MAiD on behalf of incapable persons. Additionally, the patient must be informed that they may withdraw their request at any time and will be given an opportunity to withdraw consent immediately before the procedure, unless they have signed a waiver of final consent.

The Model Practice Standard specifies that informed consent requires the healthcare professional to discuss all reasonable, accepted, and available treatment options with the patient, including their benefits, risks, and side effects. This includes informing the patient of palliative care options and, for Track 2 patients, additional supports such as counselling services, mental health services, disability support services, and community services. The healthcare professional must also offer consultations with relevant professionals who provide these services, but the patient does not have to access them. For patients choosing self-administered MAiD, the professional must inform them of potential complications, including the possibility that death may not occur. Patients who prefer self-administration must be informed that if the procedure fails or is prolonged, the healthcare professional will not be able to intervene and complete the process unless the patient retains capacity and can provide consent, or they have a written arrangement providing advance consent for healthcare professional administered MAiD.

Informed Consent Normative Analysis

While informed consent is a fundamental requirement in both MAiD and traditional healthcare decision-making, its function in MAiD is fundamentally different. In standard medical practice, informed consent operates within a fiduciary relationship that requires healthcare professionals to act in the patient’s best interest (35). Healthcare professionals are required to engage in a deliberative process that includes providing a professional recommendation, disclosing material risks and benefits, exploring reasonable alternatives, and answering any questions the patient may have (36). In addition, traditional informed consent is guided by the standard of “reasonable person in the patient’s position,” which legally requires healthcare professionals to consider what information a reasonable person with the patient’s specific circumstances would want to know before deciding whether to consent (37). This standard emphasizes the importance of tailoring information disclosure based on the patient’s unique situation, which reinforces the fiduciary obligation to act in the patient’s best interest. By contrast, informed consent in MAiD functions primarily as a procedural safeguard designed to verify compliance with legal requirements rather than to facilitate a deliberative process that serves the patient’s best interests. The MAiD legislation requires only that the patient be informed of the legally mandated information, like the means to relieve their suffering and the option of palliative care, without reference to the reasonable person standard or the patient’s specific circumstances. This approach shifts the healthcare professional’s role from guiding the decision-making process to merely confirming that the patient’s request meets the statutory requirements.

This distinction gives rise to three fundamental differences between informed consent in MAiD and traditional medical contexts. First, informed consent in MAiD does not involve a professional recommendation. In standard medical decision-making, informed consent typically involves the disclosure of material risks, benefits, and alternatives within the context of a professional recommended treatment plan. The fiduciary duty of the healthcare professional requires them to apply their medical expertise to assess the patient’s condition and guide them toward a decision aligned with their best interest. While the patient retains the authority to accept or reject a recommended treatment (38), the professional’s role is active and involves a deliberative process that includes professional judgment. In MAiD, however, the process is fundamentally different. The patient initiates the request for MAiD, and the healthcare professional’s role is to assess eligibility and ensure the disclosure of legally required information, not to determine whether MAiD is in the patient’s best interest.

Second, there are no material risks to disclose in MAiD. In conventional healthcare, the duty of disclosure is central to informed consent, requiring the professional to disclose any material risks, which are risks that a reasonable person in the patient’s position would want to know before providing or withholding consent to treatment (36,37). Legal disputes over informed consent typically arise when a patient was not warned about a material risk, experienced harm as a result, and argues that they would have made a different decision had they been properly informed. In MAiD, however, the procedure does not involve the same kind of risk disclosure because the intended outcome is death. While there may be procedural risks associated with the administration of MAiD, these do not constitute material risks in the legal sense established by Hopp v Lepp (36). This distinction underscores that the disclosure requirement in MAiD is limited to informing the patient about the legal eligibility criteria, alternative means to relieve suffering, palliative care, and procedural details, rather than a deliberative assessment of material risks and the potential risks and benefits of the recommended procedure and alternatives.

Third, MAiD exists as an exception to the criminal prohibition on assisting suicide or culpable homicide. Unlike other medical decisions, where informed consent serves as a means of respecting patient autonomy within the framework of a fiduciary relationship, MAiD required a legislative amendment to the Criminal Code to permit healthcare professionals to engage in an act that would otherwise constitute a criminal offense. If the legal framework governing MAiD were not followed, the very same act, administering or prescribing a substance to cause a person’s death, would be classified as culpable homicide. The specific classification would depend on the circumstances, ranging from first-degree or second-degree murder, to manslaughter, or criminal negligence causing death (39). This distinction reinforces that informed consent in MAiD is not a medical requirement but a legal safeguard, designed to ensure that the procedure remains within the narrow confines of the law. In contrast, informed consent in traditional healthcare is governed by civil negligence law, where disputes focus on whether the professional provided an adequate standard of care, rather than whether their actions constituted a criminal offense.

Capacity

The Criminal Code specifies that to be eligible for MAiD, a person must be “capable of making decisions with respect to their health.” In standard medical practice, capacity is a necessary condition for informed consent, meaning that without capacity, a patient cannot meaningfully provide or withhold consent (40). Capacity assessments ensure that a patient’s decisions genuinely reflect their values and preferences, based on their ability to understand, appreciate, reason, and communicate their choices (41,42). However, the treatment of capacity in MAiD diverges from its role in other areas of medicine in ways that create conceptual inconsistencies and weaken the legislation’s intended protections.

In standard healthcare, capacity is embedded within informed consent, which means that a patient who lacks capacity cannot legally provide informed consent. MAiD legislation, however, lists capacity and informed consent as separate eligibility criteria, which creates a logical inconsistency. This separation suggests that a patient could satisfy the requirement for informed consent without having capacity, which is logically incoherent. While in practice, a patient lacking capacity is ineligible for MAiD, the presentation of capacity as a stand-alone criterion creates the illusion of additional protection that does not seem to exist.

Additionally, in most areas of healthcare, capacity is presumed unless there is evidence to the contrary (40). The burden is on the healthcare professional to establish incapacity if it is in doubt. In MAiD, however, capacity must be affirmatively established through an assessment, yet there is no standardized method or tool for making this determination within the MAiD context (43). This lack of standardized capacity assessments raises concerns about consistency and reliability (44). The requirement to establish capacity, combined with the absence of clear evaluation criteria, once again, risk creating the appearance of heightened scrutiny without ensuring substantive protection.

Another major deviation from standard healthcare practice is the exclusion of substitute decision-makers in MAiD. In most areas of medicine, if a patient loses capacity, substitute decision-makers are authorized to make decisions on their behalf, either by following previously expressed wishes or, in their absence, by making best-interest decisions (45,46). This aligns with the fiduciary nature of healthcare, in which professionals must balance autonomy with their fiduciary duties. However, in MAiD, substitute decision-makers are not permitted, and outside of Quebec (47), advance directives for MAiD are prohibited. While a narrow legal exception exists in the form of a waiver of final consent (which is applicable only if the patient was already assessed and found eligible before losing capacity) this provision does not allow for new decisions based on prior wishes or substitute judgment. If a patient loses capacity before the procedure, their prior expressed wishes are legally irrelevant, and MAiD cannot proceed. The exclusion of substitute decision-makers and the inability to rely on prior wishes reinforce that MAiD is fundamentally structured as an act of protecting the healthcare professional from prosecution rather than as a treatment decision governed by fiduciary duties.

The decision-making task required of a MAiD patient varies significantly between Track 1 and Track 2 patients. Track 1 patients, whose natural deaths are deemed reasonably foreseeable, must have the capacity to decide when and how to die, but not whether to die. The decision primarily concerns the timing and manner of death, rather than an existential judgment about the value of continued life. Track 2 patients, by contrast, must decide whether death is preferable to continued life. Their decision involves a complex value judgment about suffering and quality of life, which makes this decision qualitatively different from the decision required of Track 1 patients.

The legislation acknowledges this difference implicitly by imposing an additional protection for Track 2 patients, because they must have given serious consideration to alternative means of relieving suffering. The Advice to the Profession document (34) clarifies that this requirement is distinct from capacity itself. It mandates that the patient must have actively engaged in the process of considering alternatives, rather than merely possessing the ability to do so. The requirement of “serious consideration” implies that Track 2 decisions demand a higher level of deliberation than Track 1 decisions. This distinction raises an important concern because if Track 2 decisions require a more complex evaluative process, then should the capacity standard for these patients be different? Unlike Track 1, where the decision is about controlling the manner and timing of an inevitable death, Track 2 patients must justify why continued existence itself is no longer preferable. This qualitative difference suggests that capacity assessments should logically differ for the two Tracks, yet the legislation does not explicitly account for this disparity.

The distinction between Track 1 and Track 2 patients is further complicated by the ambiguity of “reasonably foreseeable natural death” (RFND). The legislation does not define RFND, leaving its interpretation entirely to professional discretion. In practice, most MAiD cases fall under Track 1, but it is unclear whether this classification is based on the patient actively dying or merely on an assessor’s judgment that death is foreseeable at some indeterminate point in the future (3). For example, some providers have interpreted RFND to include cases where a patient is not actively dying but is expected to follow a predictable trajectory toward death based on age, frailty, or progressive illness (48). This demonstrates that there are some patients assigned to Track 1 who may, in reality, be making Track 2 type decisions, deciding whether to die, rather than when. However, because they are classified under Track 1, they are not subject to the heightened “serious consideration” requirement imposed on Track 2 patients. This analysis suggests that this effectively eliminates any meaningful distinction between Track 1 and 2.

Taken together, these concerns suggest that the treatment of capacity in the MAiD legal framework lacks logical coherence and consistency. The separation of capacity from informed consent creates an eligibility criterion that does not enhance substantive protections. The exclusion of substitute decision-makers and advance directives has no logical basis. The Track 1 versus Track 2 distinction implies that capacity should be assessed differently, but the legislation does not acknowledge this disparity. The ambiguity surrounding RFND allows for broad discretionary interpretations that weaken the consistency of capacity evaluations. Ultimately, the lack of a coherent capacity framework in MAiD risks undermining the integrity of informed consent. By failing to distinguish between different levels of decision-making complexity and by structuring MAiD exclusively around autonomy, the legislation introduces internal contradictions that are absent in other areas of healthcare.

Voluntariness

Voluntariness, like capacity, is a separate eligibility criterion for MAiD. The legislation requires that the patient must have “made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure.” In most areas of healthcare, voluntariness is a necessary condition for valid informed consent; if consent is not voluntary, it cannot be valid. As with the analysis of capacity, presenting voluntariness as an independent eligibility criterion creates a conceptual inconsistency. By listing voluntariness separately, the legislation creates the appearance of a more rigorous standard without providing any additional protection. This approach raises concerns about the internal coherence of the eligibility criteria.

The legislation requires that a request for MAiD must be voluntary and not the result of external pressure. This requirement differs fundamentally from traditional healthcare contexts, where it is the consent to a treatment that must be voluntary rather than the request itself. In traditional healthcare, a patient’s consent is typically a response to a professional recommendation and must be free from coercion, undue influence, and misrepresentation to be valid (49). The focus is on ensuring that the patient’s decision to accept or refuse a recommended treatment reflects their autonomous will, following a deliberative process guided by a healthcare professional’s recommendation. By contrast, in MAiD, it is the request that must satisfy the criteria of voluntariness and freedom from external pressure, independently of informed consent. This distinction suggests a fundamental conceptual difference in how voluntariness is understood in MAiD compared to traditional healthcare. Since the request must be voluntary and free from external pressure, it is unclear what additional role informed consent plays beyond the procedural disclosure of legally required information.

Next, the legislation’s requirement that a MAiD request must not result from external pressure introduces a further conceptual difference. In most areas of healthcare, the voluntariness of a patient’s consent requires the absence of coercion, undue influence, and misrepresentation. If these conditions are already implied by the requirement of voluntariness, then the additional stipulation that the request must be free from external pressure logically implies that external pressure must encompass something beyond these forms of influence. However, the legislation does not define what constitutes external pressure, leaving its meaning undefined rather than merely unclear. The Model Practice Standard (33) and Advice to the Profession (34) documents reinforce that MAiD requests must be made freely and without undue influence from family members, healthcare providers, or others. However, these documents do not clarify what external pressure might entail beyond interpersonal forms of coercion or influence. The Advice to the Profession document, for instance, briefly addresses the impact of social determinants of health but does not provide a substantive explanation of how these factors might constitute external pressure. The absence of a clear definition of external pressure risks making this requirement an empty criterion that lacks substantive meaning.

One possible interpretation is that external pressure may include unjust social conditions that influence a patient’s decision to request MAiD. Reports of patients seeking MAiD due to factors such as homelessness, economic hardship, inadequate access to medical care, social isolation, or fear of becoming a burden on others suggest that such conditions may function as a form of external pressure (50-52). If these factors significantly influence a patient’s request, it raises a significant ethical concern about whether such requests can be genuinely considered voluntary. If external pressure is understood to include social and economic pressures, then many requests for MAiD might fail to meet the voluntariness requirement. Conversely, if social and economic pressures are not recognized as threats to voluntariness, the current legal framework may allow MAiD to function as a response to social inequities rather than solely to medical suffering. This raises a profound ethical dilemma. A patient may meet all the legal requirements for MAiD but the request is primarily because of intolerable social conditions rather than from a medical condition. Does society want MAiD to be a viable option for them?

The treatment of voluntariness in the MAiD legal framework diverges fundamentally from its treatment in traditional healthcare contexts. By separating voluntariness from informed consent and introducing the undefined concept of external pressure, the legislation creates a conceptual ambiguity that raises significant concerns about the coherence and adequacy of the eligibility criteria. They present the appearance of rigorous criteria intended to protect the vulnerable but lack the necessary conceptual clarity and definitional precision to ensure that voluntariness is meaningfully assessed and safeguarded.

Grievous and Irremediable Medical Condition

In addition to the administrative and the autonomy-related criteria, there are the medically related eligibility criteria. The legislation requires that a patient have a grievous and irremediable medical condition, which is defined as meeting three conditions: 1) a serious and incurable illness, disease, or disability; 2) an advanced state of irreversible decline in capability; and 3) physical or psychological suffering that is intolerable to the patient and cannot be relieved under conditions the patient considers acceptable. These criteria ostensibly impose a medical threshold that must be satisfied before MAiD is permitted. However, a closer analysis reveals that these terms lack independent medical definitions and instead defer to the subjective preferences, values, and goals of the patient. As a result, the requirement that a person have a grievous and irremediable medical condition functions as a validation of patient autonomy rather than as an independent medical standard.

Incurability

The term “incurable” appears to impose a medical requirement by implying that only those with a condition that cannot be treated are eligible for MAiD. However, the Model Practice Standard and Advice to the Profession documents explain that incurability means “no reasonable treatments remaining,” where reasonableness is determined through a collaborative discussion between the patient and professional. This means that incurability is not based on an objective clinical determination of medical futility, but rather on whether the patient subjectively deems available treatments acceptable. Furthermore, patients are not required to attempt available treatments before being considered incurable. While a professional must confirm that “recognized, available, and potentially effective treatments” exist, the assessment of whether they are reasonable depends on the patient’s subjective preferences, values, and goals. The patient’s subjective interpretation of what constitutes an acceptable treatment ultimately determines whether a condition is “incurable.” If a patient refuses treatments that a provider might consider effective, they can still be considered to have an incurable medical condition.

Irreversible Decline

The requirement that a person be in an advanced state of irreversible decline in capability also appears to introduce a medical standard. However, the Model Practice Standard and Advice to the Profession documents specify that “capability” refers to the ability to undertake activities that are meaningful to the person. The definition of “irreversible decline” depends on whether a person’s ability to function in ways that matter to them has been severely reduced. This means that decline is assessed in relation to the patient’s personal values and expectations about their life. A patient may have a stable condition with minimal change in physical health but may still be considered to have experienced an irreversible decline if they perceive their ability to engage in meaningful activities to be significantly diminished. The criterion for irreversible decline thus shifts from a clinical determination to a value-based interpretation of function. Because of this subjectivity, there is no fixed medical standard for what qualifies as an “advanced state of irreversible decline.” The same condition might be deemed irreversible for one patient but not for another, depending on how the individual interprets their own functional capabilities.

Intolerable Suffering

The third element of a grievous and irremediable medical condition is physical or psychological suffering that is intolerable to the patient and cannot be relieved under conditions they consider acceptable. The phrase “intolerable to them” makes clear that the patient’s assessment alone is decisive. Unlike incurability or irreversible decline, which at least involve some degree of medical interpretation, intolerable suffering has no external validation requirement whatsoever. A patient does not need to demonstrate suffering through any objective measure. A professional does not assess whether the suffering is medically unmanageable. Instead, the only relevant question is whether the patient states that their suffering is intolerable.

Summary of the Grievous and Irremediable Medical Condition Criterion

Taken together, the three components of the grievous and irremediable medical condition criterion are defined and assessed in ways that rely heavily on the patient’s own account of their illness, decline, and suffering. Each element requires a professional to confirm the presence of a condition but ultimately defers to the patient’s preferences, values, and goals in determining whether it qualifies. While this approach may be ethically appropriate in many cases and may reflect good clinical practice, it carries an important conceptual consequence, namely that the medically related eligibility criteria become extensions of the patient’s autonomous request, rather than objective medical criteria. The result is that Canada’s MAiD framework, while formally adopting the joint view that requires both autonomy and a medical condition, in practice permits interpretations that closely resemble the autonomy-only model. This observation is not a critique of individual decisions but a clarification of how the structure of the law functions in practice.

Summary of the MAiD Eligibility Criteria

The MAiD eligibility criteria appear to impose distinct legal requirements, but a closer analysis reveals significant conceptual and structural inconsistencies. The separation of voluntariness and capacity from informed consent creates the illusion of enhanced safeguards, despite the fact that these conditions are logically inseparable from consent itself. The informed consent requirement is reduced to a procedural formality focused on legal compliance, rather than a deliberative process grounded in fiduciary obligations. The medically related criteria, while ostensibly establishing objective clinical standards, are ultimately determined by the patient’s subjective interpretation of incurability, decline, and suffering. As a result, the legal framework collapses into a model that affirms autonomous requests rather than constraining them through objective medical standards. These features create the appearance of rigour without ensuring substantive protection, particularly for vulnerable individuals. While the law formally adopts a joint model that combines autonomy with medical criteria, in practice it permits applications that align more closely with an autonomy-only model. This gap raises serious ethical concerns about whether the eligibility criteria can fulfill the Supreme Court’s requirement that MAiD be accompanied by stringent and well-enforced safeguards to protect the vulnerable. Given these structural and conceptual deficiencies, the fact that a patient meets the legal eligibility criteria cannot, on its own, establish that it is morally permissible for a healthcare professional to provide MAiD.

MAiD and Professional Discretion

The provision of MAiD is not a legal duty but a legal privilege, a distinction that has significant implications for when it is ethically justifiable for a healthcare professional to provide MAiD (53). In legal theory, a claim right imposes a corresponding duty on another party. A competent patient’s right to refuse medical treatment, for example, creates a legal obligation for healthcare professionals to respect that decision, even if they believe it is not in the patient’s best interest. This duty is rooted in the concept of bodily integrity. A healthcare professional may not touch a patient without consent, which puts them under a legal obligation to obtain consent. Otherwise, they could be liable for the tort of battery. In contrast, a privilege permits an action, but the action is not a requirement. MAiD falls into this category, it is legally permitted under specific conditions, but no healthcare professional is legally required to provide it.

This distinction is explicitly reflected in section 241.2(1) of the Criminal Code, which states that “A person may receive medical assistance in dying only if they meet all of the following criteria.” In legal terms, “may” means that an action is permitted but not obligatory (54). If the law intended to impose a duty to provide MAiD, it would have used the word “must.” The permissive wording makes clear that the decision to provide MAiD remains at the discretion of the healthcare professional. Unlike a competent patient’s right to refuse treatment, which creates a legal duty to comply, even if a patient meets all the eligibility criteria for MAiD, the healthcare professional does not have a corresponding duty to perform the procedure.

The discretionary nature of MAiD is not an unintended consequence of legislative wording but a necessary structural feature of the law. The Supreme Court, in the Carter decision (1), recognized that MAiD must operate within a system of stringent limits and scrupulous monitoring. This requirement necessarily involves the professional judgment of healthcare professionals, who must determine whether those limits have been met in each case. Additionally, the MAiD legislation creates a narrowly controlled legal exception to the prohibition on culpable homicide. This reinforces that MAiD is a permissible but restricted act. The discretionary nature of MAiD is further demonstrated by variability in its application. Some providers adopt a more restrictive interpretation of the eligibility criteria, while others take a more permissive approach. Doctor shopping has emerged as an observable phenomenon, where some patients seek out high-volume MAiD providers known for their more flexible interpretations of eligibility (55).

Since every decision to provide MAiD involves professional discretion, ethical practice requires that this discretion be exercised in a manner that is transparent, accountable, and guided by principled ethical reasoning. Some professionals may argue that once a patient meets the legal eligibility criteria and safeguards, MAiD should be provided as a matter of course (56). However, such a position is neither a legal requirement nor a medical determination. Rather, it is a normative stance that defers entirely to the principle of respect for patient autonomy. Every decision to provide MAiD is a normative judgment about whether providing MAiD is appropriate in a given case. The next section will develop an ethical framework to structure this discretion, outlining the conditions that must be satisfied for it to be morally permissible for a healthcare professional to provide MAiD.

Ethics Framework

The need for an ethics framework for MAiD arises from a fundamental gap in Canadian public policy and legislation. While the legislation sets out conditions under which a patient may be eligible for MAiD, there is little guidance in Canada to help determine when it is morally permissible for a healthcare professional to administer this procedure. This paper proposes an ethics framework grounded in the fiduciary obligations of healthcare professionals and structured around the four core principles of healthcare ethics: autonomy, beneficence, nonmaleficence, and justice. The framework recognizes that every decision to provide MAiD involves a normative judgment, and that such judgments must be guided by professional duties to respect patient autonomy (autonomy), to promote the patient’s best interests (beneficence), avoid harm (nonmaleficence), and ensure that the request arises in a context justice (justice). On this account, it is morally permissible for a healthcare professional to provide MAiD only when the patient is autonomous (understood in terms of capacity, voluntariness, and informed consent), when the intervention aligns with beneficence and nonmaleficence, and when the request arises from a situation of injustice or cruel choice that renders the patient unable to act on their autonomous wish to die without assistance.

Moral Foundation of the Ethics Framework

The term “Medical Assistance in Dying” (MAiD) was deliberately created to replace more emotionally charged terms like “voluntary euthanasia” and “assisted suicide.” (11-14) This linguistic shift was not merely semantic but a deliberate effort to frame MAiD as an ordinary end-of-life option, comparable to palliative care or the withdrawal of life-sustaining treatment. The goal was to present MAiD as a neutral and medically legitimate option for patients at the end-of-life. However, this framing overlooks the ethical concern that MAiD involves the deliberate act of killing. Since killing is prima facie morally wrong, it requires a compelling justification to be considered morally permissible. Recognizing this reality is the starting point for the ethics framework, which contends that there is a prima facie duty not to cause death.

According to W.D. Ross’s moral theory, a prima facie duty is a moral obligation that holds unless overidden by a compelling justification (20). The duty not to kill, therefore, creates a strong presumption against the provision of MAiD, which can be set aside only if there are sufficiently strong ethical reasons. The fact that MAiD is legally permitted does not, in itself, provide such a justification. The ethical question is not merely whether MAiD can be legally provided but under what conditions it can be morally permissible for a healthcare professional to provide it. Ross’s distinction between the right and the good is particularly useful in this context. Even if a specific act of killing could be justified for morally good reasons, such as relieving intolerable suffering, it remains a prima facie wrong act. The duty not to kill is not negated by the presence of good reasons but must be weighed against them. This distinction underscores that the act of causing death is not rendered ethically neutral simply because it is pursued for compassionate reasons or aligns with a patient’s autonomous choice.

The distinction between legal eligibility and moral permissibility is crucial because moral permissibility depends on individual circumstances rather than being a member of a category or group of people. Legal eligibility for MAiD establishes a class of individuals who may access the procedure, but it does not follow that MAiD is morally permissible for every member of that class. The law determines eligibility by setting broad criteria, but ethical reasoning requires a case-by-case evaluation to determine whether it is justifiable for a healthcare professional to provide MAiD in a given instance. The prima facie duty not to kill remains in effect unless specific ethical conditions are met that justify overriding it. Therefore, even if a patient meets the legal eligibility criteria, the provision of MAiD is not automatically morally permissible. The ethical permissibility of providing MAiD must be assessed in each case by evaluating whether the healthcare professional’s decision aligns with the principles of autonomy, beneficence, nonmaleficence, and justice, understood within the fiduciary obligations of clinical practice.

Informed Consent, Capacity, and Voluntariness

The ethical analysis of informed consent in MAiD must begin by acknowledging its deficiencies in the current legislative framework. While the legislation presents informed consent as an eligibility criterion, it emphasizes the disclosure of legally mandated information but does not sufficiently address the deliberative process that characterizes informed consent in traditional healthcare contexts. In contrast, outside of MAiD, informed consent is a fiduciary obligation that extends beyond mere disclosure of information; it requires healthcare professionals to engage in a meaningful exchange of information, assess the patient’s capacity and voluntariness, and support autonomous decision-making within the professional’s duty to act in the patient’s best interest.

The inherent power imbalance between patients and healthcare professionals necessarily entails a fiduciary relationship (57). A fiduciary relationship is one that imposes legal and ethical obligations on healthcare professionals to act with loyalty, honesty, and good faith towards their patients. Fiduciary duties include the positive duty to act in the patient’s best interest (beneficence), the negative duty to do no harm (nonmaleficence), as well as duties to provide accurate information, and to exercise independent judgment that balances professional expertise with the patient’s preferences. Thus, respecting autonomy in the context of MAiD requires more than merely disclosing legally required information; it requires fulfilling fiduciary duties to genuinely attempt to compensate for the patient’s vulnerabilities.

One of the fundamental deficiencies of the current legislative framework is the separation of capacity and voluntariness as independent eligibility criteria. This separation is both illogical and misleading because capacity and voluntariness are necessary conditions for valid informed consent. If a patient lacks capacity or if their consent is not voluntary, then the consent itself is invalid, regardless of whether it meets the legislative criteria. By treating these elements separately, the legislation creates the appearance of additional safeguards while adding no substantive protection beyond what informed consent already requires. To address this conceptual inconsistency, the ethics framework reintegrates capacity and voluntariness as inherent components of informed consent.

The current legislative standard for capacity in MAiD, which requires that patients be “capable of making decisions with respect to their health,” mischaracterizes the nature of the decision involved in MAiD. The decision a patient must make is not a general decision with respect to their health but about when and how to die (Track 1) or whether death is preferable to continued life (Track 2). Framing this decision as a decision about healthcare in general fails to capture its distinct ethical dimensions. The ethics framework contends that capacity in the context of MAiD must involve a comprehensive assessment of the patient’s understanding, appreciation, reasoning, and ability to express a choice, directly related to the decision to request MAiD, not to healthcare decisions in general. For Track 1 patients, the decision primarily concerns the timing and manner of death. Therefore, the capacity assessment must focus on the patient’s understanding and appreciation of the implications of this decision, including the available alternatives and the foreseeable consequences. For Track 2 patients, who are not facing imminent death, the decision is fundamentally different. It involves evaluating whether death is preferable to continued life. This type of decision requires a more rigorous assessment of the patient’s understanding, appreciation, and reasoning capabilities, as it entails a complex value judgment about the patient’s quality of life and why it is so poor that death is the preferable alternative. In both tracks, the ethics framework requires that capacity be assessed concerning the specific decision facing the patient in their specific track, not as an ability to make healthcare decisions in general.

Voluntariness and capacity are necessary conditions for informed consent, and their significance lies in ensuring that the patient’s consent to MAiD is autonomous. While there is no objection to ensuring that the request for MAiD is made voluntarily, the ethically decisive issue is whether the patient provides informed consent to undergo MAiD while they still have capacity and that they do so voluntarily. The focus must be on the validity of consent, rather than merely on the voluntariness at the time of the initial request. The legislation, however, separates voluntariness and capacity as independent eligibility criteria, creating the misleading impression that voluntariness applies specifically to the request, while capacity is reassessed at the time of the MAiD procedure. This separation fails to enhance patient protection and instead introduces a structural inconsistency. Since a MAiD request is written, signed, and witnessed without a healthcare professional present, the professional cannot assess voluntariness at that time. What is logically and ethically more relevant is that the patient has capacity and gives voluntary consent to undergo MAiD at the time of providing consent, not necessarily at the time of the request.

The legislation imposes an additional requirement that the patient have capacity at the time of the procedure, but this does not reflect the fundamental principle of informed consent in medical ethics. Informed consent is a process, not a singular event, and its validity hinges on the patient’s capacity and voluntariness at the time of providing consent, not at the time of the procedure. The critical issue is whether the patient had capacity and provided consent voluntarily, not whether they retain them at the time of the procedure. Applying this standard to MAiD would mean that if a patient had capacity at the time of providing informed and voluntary consent, then requiring a final capacity assessment at the moment of the procedure would be an arbitrary requirement that does not offer any additional ethical protection. The legislation’s separation of capacity and voluntariness from informed consent creates an illusion of rigour while undermining the ethical coherence of the decision-making process.

Beneficence, and Nonmaleficence

In the beneficence and nonmaleficence analysis of this framework, the healthcare professional’s task is to make an independent, professional determination of whether providing MAiD meets the ethical requirements for professional involvement. This determination must be made independently of the patient’s personal preferences, values, and goals, which are addressed separately in the autonomy analysis. It is analogous to the process in ordinary clinical practice where, after diagnosis, the professional identifies the standard of care and the range of clinically reasonable alternatives before engaging in shared decision-making with the patient. In this framework, the standard of care refers to the course of action that a reasonably prudent practitioner — with comparable skill, knowledge, and expertise — would judge to be appropriate in similar circumstances, based on an assessment of the patient’s condition and the available evidence (58).

Beneficence requires that the professional act in the patient’s best interest. This involves an objective, evidence-based determination that MAiD meets the standard of care and would serve the patient’s best interest better than any other available option, including palliative care, medical interventions, or psychosocial supports. The principle is not satisfied by simply affirming the patient’s own assessment of their best interest. If beneficence is not met, the provision of MAiD is not ethically defensible, regardless of the patient’s autonomy.

Nonmaleficence requires that the professional avoid causing harm. In this framework, death and killing are treated as a harms, and the prima facie duty not to kill establishes a strong prima facie duty that MAiD should not be provided if a less harmful option exists. The professional must therefore determine, from among all clinically reasonable alternatives, whether any option can relieve the patient’s suffering with less harm than causing death. This includes considering medical, palliative, and psychosocial interventions. Nonmaleficence is satisfied only if violating the duty not to kill is the least harmful course of action available. If another option offers equal or greater relief with less harm, MAiD must not be provided.

For Track 1 patients, who are approaching natural death, the assessment focuses on whether an earlier death, chosen and controlled by the patient, is both in their best interest and the least harmful option. For Track 2 patients, who are not facing imminent death, the assessment is more demanding. It must be shown that death itself is in the patient’s best interest and that MAiD remains the least harmful option after all other reasonable interventions have been considered and exhausted.

The principles of beneficence and nonmaleficence require the healthcare professional to determine the standard of care and assess all clinically reasonable alternatives independently of patient preferences. (Patient preferences are already addressed via the autonomy analysis of the previous section as well as the cruel choice section.) Under this framework, MAiD is ethically permissible only if it meets the standard of care, serves the patient’s best interest, and is the least harmful available option. Assessing these principles as independent, objective determinations ensures that professional judgment plays a substantive role in the ethics analysis. If either principle is applied with reference to patient preferences at this stage, it becomes a restatement of autonomy, which collapses the joint view into an autonomy-only model.

The Cruel Choice is Necessary for the Provision of MAiD

A major part of the ethical justification for MAiD has its origins in what the Supreme Court, in the Carter decision (1), referred to as the cruel choice. The Court identified this dilemma as arising when individuals, due to the natural history of a medical condition, foresee a future in which their quality of life will become unacceptable to them. When they reach this point, they anticipate that they will no longer have the physical ability to end their life without assistance. Before MAiD was legalized, the prohibition on assisted suicide and consenting to death forced individuals facing this cruel choice to decide between ending their life prematurely while still physically capable of doing it on their own (which means that they will miss out on a quality of life that they find acceptable) or continuing to live until their suffering becomes intolerable, at which point they would be unable to end their life without assistance. This dilemma was central to the Court’s ruling in Carter and illustrates a structural injustice. It imposes a disadvantage on those whose medical condition impairs their ability to act on their autonomous wish to die. In this respect, the cruel choice is not merely a legal concept, but an instance of a broader ethical concern grounded in the principle of justice.

Accordingly, this ethics framework treats the justice considerations like the cruel choice as a necessary component of the ethical permissibility of MAiD. In the absence of this condition, MAiD risks being reduced to a mere accommodation of patient preference rather than a professional response to a legitimate medical need. Canadian law does not prohibit individuals from ending their lives without assistance (i.e., suicide). What requires ethical justification is the involvement of a healthcare professional. That justification must rest on more than a patient’s autonomous request; it must include a reason for professional intervention. A core function of medicine is to assist individuals whose illnesses impair their ability to act on their autonomous decisions. When a medical condition renders a person physically incapable of ending their life unaided, the need for professional involvement arises not to fulfill a preference, but to address a medical limitation that constitutes a form of structural injustice. It is in this sense that the cruel choice transforms MAiD from an expression of autonomy into a response to a medical and ethical dilemma that justifies professional involvement under the principle of justice.

There are three necessary elements that when taken together constitute the cruel choice. All three conditions are necessary. First, the patient must be able to provide informed consent as outlined in the previous section. This guarantees that the pursuit of MAiD is truly autonomous. Second, the patient must determine that their quality of life is unacceptable. This is a purely subjective determination, meaning it is entirely up to the individual to decide when their quality of life has become intolerable. The Supreme Court in Carter and, before that, in Rodriguez (59), made it clear that the standard was when the person finds their quality of life intolerable to them, in their own judgment. There is no requirement that the person be experiencing physical suffering. They may consider their quality of life unacceptable for any reason that is significant to them. Third, the patient must be incapable of ending their life without medical assistance. This condition makes professional involvement a matter of justice (60) — in the sense that it helps those who are the worst off — rather than patient preference, which ensures that MAiD remains a response to a medical dilemma rather than an accommodation of patient autonomy. The mere presence of an illness, disease, or disability does not justify a healthcare professional’s active role in assisting suicide or causing death. Instead, the patient’s physical functioning must be such that they are unable to act on their autonomous decision without medical assistance.

Assisted Suicide and Voluntary Euthanasia

A crucial aspect of the ethics framework is the distinction between assisted suicide and voluntary euthanasia, a distinction that the current legislative framework for MAiD in Canada does not use fully. Assisted suicide involves a healthcare professional providing a patient with the means to end their own life, such as a prescription for a lethal substance that the patient self-administers. In this case, the act of ending life remains the patient’s own. Voluntary euthanasia, by contrast, involves a healthcare professional actively administering a substance that causes the patient’s death, making the professional the direct agent of death. This distinction is morally significant because it shifts the ethical burden. Assisted suicide respects patient autonomy while minimizing the professional’s direct role in causing death, whereas voluntary euthanasia makes the professional the agent of death.

The case of Sue Rodriguez illustrates this distinction. Diagnosed with ALS, Rodriguez argued before the Supreme Court for the right to receive assistance to end her life once she decided that her quality of life was no longer acceptable but could no longer end it herself without assistance. Importantly, Rodriguez did not seek voluntary euthanasia but only the assistance of a qualified medical practitioner to set up the technological means for her to self-administer a lethal substance, by her own hand. Her case emphasized the ethical justification for assisted suicide, which is maintaining patient autonomy without making the healthcare professional the direct agent of death. While the Court ultimately rejected her appeal, her case laid the groundwork for the subsequent Carter decision.

This distinction is not merely theoretical. A number of jurisdictions that permit assisted death explicitly allow assisted suicide but prohibit voluntary euthanasia. In the United States, assisted suicide is legal in more than eleven states, none of which permit voluntary euthanasia. For example, states such as Oregon (61), Washington (62), and California (63) have legalized assisted suicide under Death with Dignity Acts but prohibit healthcare professionals from performing euthanasia. Similarly, Switzerland permits assisted suicide if the act is not motivated by self-interest yet bans euthanasia outright. These practices reflect a widely recognized ethical and legal principle that actively causing death carries a heavier moral burden than providing the means for a patient to end their own life. In Canada, however, over 99.9% of MAiD procedures have been voluntary euthanasia, a statistic that raises significant ethical concerns about whether the current practice adequately distinguishes between those who need professional assistance due to physical incapacity and those who do not (3,64-67).

In both Track 1 and Track 2 cases, the cruel choice framework applies equally. The ethical justification for professional involvement arises only when a patient’s medical condition will make them physically incapable of ending their life without assistance (i.e., suicide). Where a patient retains the physical ability to self-administer, assisted suicide should be the preferred option, with voluntary euthanasia ethically reserved for those who cannot self-administer even an oral medication. The case of Sue Rodriguez illustrates this principle. She sought to preserve the ability to end her life by her own hand at the point when ALS would make this physically impossible, requesting professional assistance only to set up the means for self-administration. This reflects the ethical distinction between respecting autonomy through assisted suicide and making the professional the direct agent of death through euthanasia. Without such incapacity, the mere presence of illness, disease or disability does not, on its own, justify a professional actively ending a patient’s life.

Summary of the Ethics Framework

The ethics framework establishes that the prima facie duty not to kill can only be overridden under specific conditions. These conditions require that the patient provide informed consent, which necessitates capacity and voluntariness, and that the healthcare professional independently determine that MAiD is in the patient’s best interest and represents the least harmful option. Additionally, the patient must be facing a situation where they find their quality of life unacceptable and are physically incapable of ending their life without medical assistance. When these conditions are not met, the prima facie duty not to kill remains in force.

The logical implication of a patient not meeting the ethical standards for MAiD is that other, less harmful interventions remain available, or the patient does not need the assistance of a healthcare professional to achieve their autonomous desires. This does not amount to abandonment or a denial of care but rather affirms the principle that professional participation in MAiD is only ethically permissible when no better alternative exists. Patients who do not satisfy the conditions outlined in the ethics framework retain access to treatments and supports that better serve their interests and mitigate harm. The ethical significance of this conclusion is that healthcare professionals cannot justifiably provide MAiD when these alternatives remain viable. The ethics framework does not prescribe what a patient must do; rather, it delineates when it is morally permissible for a healthcare professional to provide MAiD. Upholding this ethical boundary ensures that MAiD remains a response to a legitimate medical need rather than a mechanism for accommodating patient preference.

An important implication of this framework is that when a patient remains physically capable of ending their life without assistance, the justice-based rationale for professional involvement in MAiD does not apply. Suicide has been decriminalized in Canada since 1972, so the question is not whether individuals may end their lives, but when is it morally permissible for a healthcare professional to assist. The Truchon decision distinguishes suicide from MAiD partly on the basis that professional involvement may spare loved ones the trauma often associated with suicide (68). Empirical studies have explored how individuals and families experience this distinction, including perspectives from those with complex chronic conditions and from people living with mental illness as a sole underlying condition (69,70). While such accounts shed light on the emotional and relational dimensions of these decisions, they do not in themselves establish a principled ethical basis for professional involvement in an autonomy-only model. Other jurisdictions, such as Germany and Estonia, address such concerns outside the healthcare system. Within this framework, a necessary condition of morally permissible professional participation is when it addresses a medical limitation that prevents the patient from acting on their autonomous decision without assistance, thereby making MAiD a matter of justice.

This framework sets out the minimum ethical conditions that must be met for the provision of MAiD to be ethically defensible. Any critique of this framework, aside from a categorical rejection of MAiD as inherently unethical, must challenge one of two (or both) necessary conditions: either 1) the conception of informed consent incorporating fiduciary duties of beneficence and nonmaleficence, or 2) the justice condition. However, rejecting the fiduciary model of informed consent reduces any alternative position to an autonomy-only model, where professional judgment plays no substantive role. Likewise, if one rejects the justice condition, then no medical basis remains to justify healthcare professional involvement, again collapsing into an autonomy-only model. This demonstrates that any alternative position must ultimately rely on the claim that patient autonomy alone is sufficient to justify the provision of MAiD by a healthcare professional. Neither the Courts nor Parliament envisioned an autonomy-only model for MAiD, yet by failing to define substantive ethical and medical criteria, the legal framework has effectively allowed an autonomy-only model to emerge under the guise of legal eligibility criteria and procedural safeguards.

Conclusion

This paper has critically examined the ethical foundation of MAiD in Canada. It demonstrates that the legal framework establishes the conditions under which a patient is considered eligible for MAiD but there is little guidance to help healthcare professionals determine when it is morally permissible to provide MAiD. A fundamental flaw in the current system is that it treats professional participation as a matter of procedural compliance rather than substantive ethical judgment. By focusing primarily on patient values, goals, and preferences, the legal criteria collapse into a verification of patient autonomy rather than an independent medical determination of a grievous and irremediable medical condition. This approach fails to recognize that professional participation in MAiD, demands an explicit ethical justification beyond mere legal eligibility.

To address this gap, this paper proposes an ethics framework grounded in the fiduciary duties of healthcare professionals and structured by the four core principles of healthcare ethics: respect for autonomy, beneficence, nonmaleficence, and justice. The framework holds that providing MAiD is morally permissible only when the patient is autonomous, understood in terms of informed consent, voluntariness, and capacity; when the intervention aligns with the duties of beneficence and nonmaleficence, requiring the professional to exercise independent clinical judgment; and when the request arises from a context of justice, exemplified by the cruel choice, in which a medical condition impairs the patient’s ability to act on their autonomous wish to die without assistance. This approach ensures that MAiD is not merely a discretionary affirmation of patient autonomy but a medically and ethically permitted intervention grounded in professional fiduciary duties.