Article body

introduction

Peer support (PS) is, in its most expansive sense, “a naturally occurring, mutually beneficial support process, where people who share a common experience meet as equals, sharing skills, strengths and hope; learning from each other how to cope, thrive and flourish” (1). Self-help and mutual aid was a common way of life until the 1850s when, particularly in white, Western jurisdictions, a culture of professionalism developed; important roles were extracted from communities and transformed into elite areas of expertise (2). In the Canadian context, one effort to reclaim and re-practice peer support is a tradition that traces its roots to the 1960s-1970s psychiatric consumer/survivor/ex-patient (C/S/X) movement, where participants engaged in political action to expose the dehumanization of psychiatric practices and to advocate for legal and social rights. They also developed their own independent alternative supports (3).

This C/S/X movement-inspired PS was initially available informally through naturally occurring interpersonal relationships and grassroots groups like Vancouver’s Mental Patients Association, formed in 1971, and the Ontario Mental Patients Association founded in 1977 (4,5). Increasing in the 1980s and 1990s, PS was intentionally fostered through government funding of community initiatives run by and for people with lived experience (PWLE) of mental health and/or substance use concerns as an alternative to conventional, hierarchical service models. Over the last 15 years, we have seen a growing recognition of the value of lived experience, an increase in paid PS roles, and the movement of these roles from grassroots initiatives into formal mental health services (6,7).

Although PS has been growing, it remains poorly resourced in Canada (8). In the national expansion of medical assistance in dying (MAiD) over the past decade, larger, well-established and funded health professions have been acknowledged as having a significant role and have had the resources to develop and disseminate discipline-specific position statements, policies, and educational materials on MAiD. PS has had scant resources to develop its own materials. Yet a study by one of our co-authors on patient and family perspectives on MAiD for persons with mental illness suggested the importance of ensuring access to peer supporters for those considering MAiD and providing peer supporters with relevant training on MAiD (9). In this paper, we share what we have learned from coming together to respond to this need.

Our colleagues in Mad Studies, the academic discipline that has developed from the C/S/X movement, have been weighing in on MAiD conversations (10-12). PWLE of mental health conditions have been providing testimonials (13-16). There has also been some discussion within C/S/X movement news sources, though these have largely not been noticed by academic scholarship (17-19). To date, lessons from the C/S/X movement’s historical and contemporary national PS practice have not been explicitly part of scholarly discussions about MAiD. We seek to address this gap. In doing so, we see this work as one of “Mad Ethics,” the elaboration of how PWLE of mental health and/or substance use concerns put values into action in the context of PS. To reflect this contribution, we draw on several common terms to refer to our communities, including peer (peer support participant), peer supporter, and people with lived experience (PWLE).

After briefly outlining our collaborative initiative over 2024 to develop tailored educational resources for peer supporters on MAiD, we share learnings from this initiative that have much to contribute to national conversations. We demonstrate how peer supporters play a unique and important role in peers’ explorations of MAiD, building on the PS discipline’s long experience supporting peers’ explorations of desires to die, possibilities for living, and options other than dying. This role is distinct in notable ways from those of regulated health professions or a peer’s informal support network of friends and family, offers a special contribution to MAiD discourse, policy, and care in Canada, and requires greater recognition and resources.

Background: Project Design and Approach

Our work to facilitate opportunities for learning and dialogue for peer supporters on MAiD proceeded in seven steps.

Exploring the Focus

Our initial work began over November 2023-January 2024, when there was uncertainty over whether MAiD for Mental Illness as a Sole Underlying Medical Condition (MI-SUMC) would be decriminalized on March 17, 2024, following a one-year extension of ineligibility announced the year before. We proceeded with the knowledge that regardless of whether the government extended the ineligibility date (as became the case), peer supporters had much to contribute to holistic support for people considering and pursuing MAiD. For example, through supporting peers already participating in PS who were receiving terminal diagnoses and planning for end-of-life, potentially through Track 1 MAiD for individuals whose natural death is reasonably foreseeable, as well as people experiencing unbearable suffering from chronic pain, illness, or disability who were considering Track 2 MAiD for those without a reasonably foreseeable death. Regardless of their identity or experience with respect to the mental health system, peers expressing desires to die sooner or differently than they might otherwise may seek or benefit from PS. We wanted peer supporters across the country to feel prepared for these conversations.

Gathering the Team

Our team included an ethicist, PS learners, lived experience scholars, MAiD researchers, one of us with lived experience of a family member’s death with MAiD, and the Executive Directors of our national and provincial peer support associations. The mission of Peer Support Canada, formed in 2010 as the national voice for PS, is to “increase the recognition, growth, and accessibility of peer support within the mental health and substance use health spaces.” (20) PeerWorks, established in 1991, pursues a mission to “strengthen, amplify and deepen diverse peer voices in Ontario through community building, information-sharing, collaboration, advocacy and education.” (21) Both organizations play an active role in advancing PS in Canada, including through professional development for peer supporters.

Searching for Information

Peer Support Canada and PeerWorks circulated a call for information to their national and provincial membership lists to inquire into existing — or desired — resources for peer supporters on MAiD. We also conducted an environmental scan of roughly 300 academic and community resources, aided by the reference lists provided by colleagues. We learned that peer supporters are eager for educational materials but did not identify any specifically tailored to their role.

Curating and Developing Educational Content

A team of nine PWLE related to PS and the mental health system assessed resources for relevance and accessibility to arrive at a final list of 34 sources considered most helpful to our audience of peer supporters. To meet different learning needs, we ensured multiple formats (e.g., recorded webinars, government reports, podcasts) and summarized key points. The final 14-page list was graphically designed to reduce information overload (22).

Team members also felt that we should facilitate a tailored interactive learning opportunity. We therefore invited peer supporters with a basic knowledge of MAiD to attend a discussion series focused on the PS role. We designed the series as a 3-part discussion (90 minutes weekly over three weeks) so that participants had time to build rapport before the most challenging conversations in week 3. The series was based on five PS scenarios and associated prompts, which covered topics of death, dying, end-of-life, grief, suicide, and MAiD, seeking to situate MAiD within a broader, familiar context for peer supporters, encouraging them to bring forward a range of experiences to inform the discussion. Honouring the PS value of mutuality, facilitators positioned themselves as learners, highlighting that because there are no existing guidelines informing peer support’s relationship to MAiD, we would develop this knowledge together.

Taking a Provisional Stance

In anticipation of mixed reactions to the resources, we included a preamble acknowledging diverse views in PS communities with respect to MAiD (13), and how peer supporters deserve equitable access to education and support:

Peer supporters need to be prepared to have conversations about death, dying, and end-of-life, whether they are supportive or not supportive of MAiD. As people who have often personally navigated challenges associated with death and dying, peer support workers are naturally equipped to be able to navigate these conversations.

[Peer supporters] should not be expected to participate in providing support that they feel unprepared and/or unable to provide due to a lack of training, guidance, support, and/or on the grounds of personal convictions and beliefs. Peer supporters are also entitled to the resources and support they need to be able to have these conversations.

22

This focus is consistent with Peer Support Canada and PeerWorks’ mission statements and work to increase tailored education for peer supporters.

Facilitating the Discussion Series

We advertised the series to peer supporters across the country through the membership lists of Peer Support Canada and PeerWorks. In keeping with our goal to involve a group diverse by geography and other identities, and to ensure that the series would meet participants’ needs, we developed a brief application form. We had over 250 people apply. To date, we have facilitated the series six times with a total of 67 peer supporters representing 8 provinces and 1 territory. 59.7% of participants identified as belonging to one equity-deserving community (beyond mental health/substance use), and 25.4% as belonging to two or more. Each series has included two co-facilitators, a person available to offer confidential PS in a breakout room, and a note-taker/technology support person.

What can peer supporters contribute to MAiD conversations in Canada?

In 1981, the Editors of Phoenix Rising, Canada’s national C/S/X movement magazine, explained that there are “five good reasons” why people became active in the movement: “support; information-sharing; power; developing alternatives to psychiatry; and changing unjust ‘mental health’ laws.” (23, p.2) Nearly 45 years later, we focus below on how contemporary PS practice rooted in C/S/X traditions and unique PS values and standpoints continues to offer support, information-sharing, power, and alternatives to the health system in ways that make a distinct and important contribution to conversations on MAiD. We specifically focus on how PS offers: 1) a vision in which self-determination and active support — often understood to be in tension — are deliberately combined; and 2) alternative ways of being in relationship that offer flexible, resonant, and authentic forms of accompaniment.

A vision in which self-determination and active support, often understood to be in tension, are deliberately combined

In 2013, Peer Support Canada released national guidelines regarding the core values, principles, and standards of practice of PS (24). These values are: hope and recovery; empathetic and equal relationships; self-determination; dignity, respect, and social inclusion; integrity, authenticity, and trust; health and wellness; and lifelong learning and personal growth (25). Similar values have been identified for PS traditions internationally (26-28).

Discussions about MAiD in Canada often emphasize a tension between dominant ethical principles of bioethics — on the one hand, autonomy (capacity to make a free choice) and on the other, beneficence (promoting a person’s welfare, acting in their best interests). PS follows a different intellectual tradition where self-determination and active support are deliberately combined rather than incompatible, which we unpack below.

The peer support value of self-determination is different from the medical ethics principle of autonomy

The conception of autonomy that has become dominant in Western bioethics and medicine is focused on an individual’s capacity to reason and express a voluntary choice. This principle has been primarily operationalized in healthcare and research with human subjects through the practices of informed consent and confidentiality (29)[1]. However, this informed consent view of autonomy does not serve PWLE well in part because of its focus on ‘reason’ and ‘capacity’ (32). PWLE continue to be routinely treated as incapable of making their own treatment decisions and therefore not given the opportunity to consent to or refuse treatment (33).

In contrast, the C/S/X movement traces its practice of self-determination to the 1960s-1970s civil rights, Indigenous sovereignty, feminist, gay, and other liberation and consciousness-raising movements of the era, the 1966 International Bill on Human Rights, the counterculture writing of Thomas Szasz (USA), Michel Foucault (France), Erving Goffman (USA), R. D. Laing (UK), and others critical of psychiatry, and the experiential knowledge exchange and generation among ex-patients (33-38)[2].

Empowerment is the fundamental philosophical basis for this tradition, wherein self-determination is one component. Both are core and pervasive concepts in C/S/X history and practice that have not been precisely and comprehensively defined (36). But we know that thinkers like Foucault and Szasz were concerned about the power of the psychiatric establishment over the liberty of psychiatric patients. To them, empowerment meant: 1) oppositional efforts to address perceptions that patients are incapable of exercising free will and associated restrictions on freedom, and 2) liberation from professional control and its negative consequences (36).

This focus on regaining power and control is ubiquitous in C/S/X literature: “By participating in the Movement, people experience a real sense of power. They…are listened to and taken seriously for a change. …The Movement will help us gain power to control our own lives and live the truth as we know it.” (23, p.3) In contrast with a narrow conception of autonomy as the personal autonomy of an individual, the C/S/X movement advocated for the self-determination of PWLE as a population group. And rather than rely on the state, health system, or health professionals to produce meaningful options, the C/S/X movement created its own peer-led and controlled alternatives (discussed below). Aspects of this vision of empowerment and self-determination echo in current disability advocacy around MAiD[3]. This is a much more expansive view of liberty and freedom than the definition of autonomy that has become dominant in Western healthcare.

Peer support is wary of beneficence, and acts to protect against paternalism

The C/S/X movement emerged as a critique of psychiatric practices justified by a bioethics principle of beneficence, such as involuntary hospitalization and treatment defended in the name of promoting a person’s welfare. (3,34) Alongside the primacy of the value of self-determination, contemporary PS values remain wary of paternalism and protect against it in several ways.

The value of equal relationships requires peer supporters to minimize power differences by affirming a peer’s self-knowledge and focusing on “what people have in common and can teach each other, rather than on how one person may diagnose and treat another.” (41, p.247)

The philosophy of peer support is that each individual has within themselves the knowledge of what is best for them and a strong desire to find a path towards improved health [or quality of life]. The peer supporter supports that person as they search for that inner knowledge.

24, p.3

Peer supporters in our discussion series explained how in intervening to ‘protect’ a peer, they would be adopting a clinical approach inconsistent with PS values and outside of the scope of their role[4].

Peer supporters also differentiate their professional role from that of a friend, who may experience a felt duty to promote a loved one’s welfare, a conflict between their personal interests and the loved one’s interests, or entitlement to greater influence over a loved one’s decision (42). Peer supporters are instead in a special relationship with a peer bound by PS values and practice standards to nonjudgmentally support peers to explore and make decisions that are right for them.

In our discussion series, it was evident that through daily use of their lived experience, peer supporters have developed strong practices of self-awareness and personal reflection. They notice their own biases, personal values, and discomfort, actively resist value-laden connotations that specific choices are good or bad, and skillfully ensure their own needs and interests do not exert influence or control over a peer’s choices.

In peer support, self-determination is a positive right, requiring extensive action and supportive conditions to be realized

In healthcare, autonomy and informed consent are often treated as a negative right to non-interference. To honour this right requires ”inaction” and not providing healthcare without valid consent. In PS, self-determination is a positive right; it requires extensive action and supportive conditions to be realized. Accordingly, core features of PS are to “facilitate the self-determination and the empowerment of peers,” (24, p.8) to “demonstrate knowledge of local resource options and how to access these resources,” (24, p.11) and to “support peers to identify their needs and rights to make informed choices.” (24, p.10)

Through their lived experiences, peer supporters are attuned to how powerlessness, hopelessness, and isolation can influence decision-making. The mental health system and other experiences of oppression “often are experienced as a stripping away of choices, personal control, and decision-making.” (43, p.115) Peers may therefore “need assistance in recognizing that they do have choices and are capable of making choices. …[They] benefit from knowing about what choices are available and when their choices are being limited.” (43, p.116) Peer supporters can assist peers in developing their choice-making competencies and to “recognize that their lives have value, dignity, and worth,” (44, p.6) thereby enhancing the voluntariness of a peer’s choices.

Peer supporters have a deep, experiential knowledge of what it takes to navigate resources and services, the energy and persistence required to do so, challenges with access, and the importance of creating their own unique survival strategies. In contrast, clinical professionals are often unfamiliar with (or misinformed about) peer, community, and grassroots support (45). For example, a MAiD assessor in a study led by one of our co-authors spoke of knowing a lot about medical services but much less about social and community services. Some, but not all, assessors have access to system navigators or social workers to help address these gaps (46). As the PS role is to “support an individual’s expressed wishes,” (1) but not to determine or carry out the wish, peer supporters in our discussion series described the practical ways they might support a peer raising the topic of MAiD, such as offering to look with the peer for resources and information or accompanying them to a MAiD-related medical appointment to take notes and debrief afterwards.

Peer supporters shared with us how, regardless of their personal views on MAiD, the PS value of self-determination would keep them focused on honouring and not judging a peer’s choice. As peer support movement leader Theresa Claxton put it, “It is a principle of peer support to encourage self-determination and respect the fact that people will make their own choices, whether or not I, as their peer support worker, agree or would choose the same for myself.” (47, p.20) PS affirms how “people make good decisions when they are free of shame and blame. A fundamental aspect of peer support is that it provides a relationship and ongoing exchange that purposely avoids shame and blame.” (48, p.32)

Alternative ways of being in relationship that offer flexible, resonant, and authentic forms of accompaniment

Peer supporters’ unique positionality enables them to engage in conversations and support less constrained by conventional norms, assumptions, and practices. We unpack these alternative ways of being in relationship in four sections below.

Sharing power in peer support relationships and initiatives sets peer supporters outside of and less constrained by the mainstream healthcare system

Peer supporters endeavour to share power. In contrast to the considerable authority granted to registered health professionals by health legislation[5], the day-to-day work of peer supporters is not as heavily influenced by this legislation, legal authority, standards of care, fee-for-service compensation schemes or fear of litigation, complaint, or losing a license. Peer supporters are thus in a position to accompany people expressing desires to die in a greater range of ways.

In the context of MAiD, this means that peer supporters are not focused on playing an evaluative, clinical, or legal function within the formalized MAiD process. In the discussions we facilitated, peer supporters were not riveted by a peer’s mention of MAiD and did not zero in to further investigate a peer’s eligibility, legal capacity, or motivation for MAiD, or referral pathways. Nor did peer supporters rush to try to create an offramp from the path to MAiD. Peer supporters instead sought to follow the peer’s lead on where they wanted to take the conversation, with no agenda, no power, no judgment[6].

Peer supporters described how their approach to supporting someone raising the topic of MAiD would be no different from their everyday experience discussing desires to die with peers, or other important decisions a peer might be considering (49). Peer supporters provide a space for peers to explore aspects of their choices that they may not be able to in other relationships due to particular clinical consequences. For example, opening a space for ambivalence, where peers have the opportunity to talk confidentially about the dynamic nature of desires to die without this fluctuation being used to deem them ineligible for MAiD as evidence of a kind of “lack of persistence” in their desire.

This sharing of power in PS extends to the operations of small, grassroots, peer-led initiatives and creative crisis supports, such as Alternatives to Suicide groups, Emotional CPR (eCPR) conversation methods, ‘warm’ PS phone lines, and peer respites (4,50-53), which are less common in hierarchical, bureaucratic, risk-averse clinical organizations. Several peer supporters in our discussion series shared how working in a peer-led initiative gave them more control and flexibility with their schedule so they have time to listen to a peer’s whole story and build a relationship without an arbitrary time or session-limit. Peer supporters are able to use flexible modalities like meeting people in the community, connecting by phone or virtually, and accompanying peers to appointments.

PS that involves a drop-in, groups, or other community-building aspect is especially well suited to easing loneliness and isolation (54), such as the loneliness that nearly 50% of people report as an aspect of the unbearable suffering underlying a request for Track 2 MAiD (55). Our Voice / Notre Voix, a peer-led initiative that has been publishing a national newsletter for 38 years, has advocated that these grassroots alternatives for relieving suffering need more attention by the Government’s MAiD policy (17).

Shared frustration and harm from the health system creates a point of connection between peer supporters and peers exploring MAiD

PS communities hold deep, lived experiences of frustration and harm from health and social service systems. For example, they share experiences related to coercion and not being believed or taken seriously; abandonment from being passed from one professional to another, not being able to tell their full story, and having conversations shut down; and the limits of biomedicine, such as unsuccessful or inaccessible treatments and medical errors (3,34,56). While these forms of suffering do not appear in Government reports of why people choose MAiD, peer supporters understand how such experiences can contribute to broken trust in the health system and a sense of having no other options to help relieve one’s suffering.

Because frustrations with the health system are among the causes of persistent, long-lasting suffering that has led to poor quality of life (56), conversations between people requesting Track 2 MAiD and health professionals can be tense: As one MAiD assessor explained (in a study one co-author is undertaking with colleagues), efforts to understand whether suffering is ‘intolerable’ can be experienced as raising doubt about the legitimacy of (for example) chronic pain, and questions designed to assess whether a condition is ‘irremediable’ can suggest disbelief about the person’s efforts to seek help or participate in their recovery.

Because peer supporters are intentionally an alternative to mainstream health services, their relationships are not conditioned by these difficult histories. Peer supporters’ own experiences of disappointment and distrust in healthcare is a source of connection, uniquely positioning them to build trust with people seeking MAiD, especially those on long waitlists, found ineligible, or living with government policy delays and uncertainty. For example, in our discussions about responding to a peer’s despair over the postponement of the legalization of MAiD for MI-SUMC, peer supporters in our series expressed how they would validate the peer’s feelings and experiences, reflecting on their own challenges accessing desired resources, their experiences of hopelessness, and strategies to cope.

Peer support’s experiential, critical perspectives on mainstream interventions into desires to die enable them to create safe spaces to talk about these desires

Peer supporters have distinct standpoints on suicide that differentiate them from other disciplines in conversations about MAiD and may mean they face fewer barriers in supporting people considering MAiD.

Informed by their unique positionality[7], PS communities de-medicalize suicide and de-professionalize strategies for addressing suicide. In PS, desires to die are not assumed to result (primarily or solely) from untreated mental illness and perceived impairment in reasoning. Instead, PS actively recognizes suicidal people as legitimate knowers who have deep insight into their living conditions, suffering, and options (49,61,64). Furthermore, PS does not stigmatize the decision to end one’s own life. Stigmatizing suicide blames the peer for the unjust social conditions that contributed to their death, hides the peer’s resistance, obscures broader society’s responsibility in the death and its role as the perpetrator of harm (59), and disenfranchises the grief and bereavement of peers and peer supporters who disproportionately lose community members to suicide.

Additionally, in PS, suicide is not viewed as a failure of care or a peer supporter’s ‘fault.’ (49,55) In contrast to psychiatry, psychology, and mental health counselling, PS is not grounded in an established tradition, expectation, and professional self-image around preventing people from dying (66). Peers act from a place of mutuality, not clinical expertise, recognizing the importance of validating a person’s suffering and desires to die, not exerting force to talk them out of this (67). Peer supporters admit that they are powerless to save anyone or radically alter another person’s circumstances or feelings; and let go of the idea that they are responsible for a peer or that it is their job to keep someone else alive. Instead, peer supporters feel honoured when a peer trusts them with their story around desires to die; are realistic about what they can do, with no expectation of fixing or finding a solution; and do their best to work with peers to “figure out how to go on living,” (50, p.198) while accepting that peers may still choose to end their life (49,51,65). Living this philosophy can take serious unlearning and self-exploration: to de-escalate a conditioned panic or fear response, live with uncertainty, and not shut down conversation, and to remain present and authentic, listen, witness, and stay emotionally close (49,51,65,67).

Over decades of experience in the C/S/X movement, and increasingly demonstrated in peer reviewed research, this approach is known by peer supporters to be profoundly meaningful for those experiencing desires to die (62,68-70). Peer supporters in our discussion series talked about how peers entrust them with stories that the peer has not felt safe sharing with anyone else, and has been struggling with in silence (50). Peer supporters understand firsthand how being able to talk about wanting to die or thinking about killing themselves, being listened to and respected, can help peers go on living, at least for a time (11).

Likewise, for some people exploring MAiD, particularly where their death is not reasonably foreseeable, having their request for MAiD taken seriously, and a place to talk about death, has helped people better cope with suffering, regain control over their lives, realize they do not want to die, and/or delay MAiD (56,71). Peers exploring options to die — whether they frame this in terms of suicide or MAiD — can benefit from peer support. Drawing on PS knowledge to offer this support, such as in the form of PS groups for people exploring MAiD, is likely to produce more dividends than focusing on distinguishing MAiD from suicide[8].

The peer support value of authenticity encourages honest human discussion of love and the impact of loss in a context of MAiD and suicide

In their unique role, peer supporters are empowered to speak honestly and sincerely about how a peer matters to them, that they do not want the peer to die, that they hope the peer won’t end their life, and how the peer will be missed if they do. Love and care for their peer, and the PS value of authenticity, encourages this kind of earnest expression of desire for the peer to continue to live, all the while nonjudgmentally affirming the peer’s power to choose (49,53,60,64,65).

These relationships, conversations, and losses can have a profound impact on peer supporters. Participants in our discussion series talked about the importance of personal boundaries, limits, and consent — how they need to be a willing participant in accompanying someone on their journey, and to regularly reflect on whether they are in a place where they can carry the peer’s story (49). They spoke about the importance of affirming their humanity, their background experiences (e.g., of loss, death, grief, mental health recovery), what it will be like for them to bring their lived experiences in these areas to work every day, and the support they need. To remain loving, genuine, and sincere in a relationship with a peer, they are mindful of only committing to what is possible and manageable for them (49).

In contrast with the formal MAiD policy that emphasizes legal language of eligibility, safeguards, rights, and conscientious objection, PS approaches MAiD in a way that emphasizes our common humanity, the meaning of our relationships with each other, and how people matter to us. PS suggests pathways for grounding MAiD policy and practice in this common humanity.

Conclusion: Valuing the peer support role in MAiD conversations

Peer supporters have an important role to play in conversation and care related to people exploring MAiD, building on long experience and values-based approaches to supporting people who express wishes to die. PS values and standpoints offer a different way of being in relationship, caring for and not abandoning each other, and supporting decision-making.

Yet, peer supporters cannot have the positive impacts described above when they are restricted from contributing (62,74), or when they feel they must work outside the lines of organizational policy in order to maintain integrity with PS values, as several worried about in our discussion series. We have not yet seen an organizational MAiD policy that references the role of peer supporters in the process — and we imagine very few, if any, peer supporters have been involved and consulted in such policy development at organizational, provincial, or national levels. Organizational policies that block (or fail to encourage) peer supporters from having meaningful conversations with peers about desires to die should be revised through consideration of PS knowledge (74).

Peer supporters also require support that is rarely available, due to a lack of dedicated funding towards peer support within community mental health care in Canada and severe underfunding of independent PS initiatives (8). Talking about desires to die is emotionally challenging. Peer supporters in our discussion series made difficult decisions about how they might be able to support a peer’s journey based on whether their employer would provide the support needed to replenish. Most peer supporters face significant employment precarity, such as low pay, part-time roles, lack of paid sick days, bereavement, or holidays, or health benefits. They are often working in isolation on interdisciplinary teams without PS from colleagues with lived experience (8). There is much work to do to ensure PS programs across the country are properly resourced and supported, with tailored educational opportunities, particularly on the topic of MAiD. Peer supporters are owed this social solidarity and reciprocity in recognition of their love labour to honour the painful stories entrusted to them.

All people experiencing social and existential suffering, loneliness, and the emotional and spiritual impacts of societal prejudice deserve access to the support, information-sharing, power, and alternatives offered by social movement-inspired PS initiatives. MAiD policies and programs should require the offer of PS to people exploring MAiD, and access to it, if desired. Registered health professionals who have benefited from increasing professionalization and associated disintegration of informal supports have a duty to ensure every patient they treat also finds opportunity for belonging and connection in their community.