Using ethics to guide end-of-life decisions

By Martin LaSalle Feb 20th, 2026

In 5 seconds Marie-Eve Bouthillier sheds light on the often-overlooked role of clinical ethicists who, with healthcare teams and families, navigate the complexities of medical assistance in dying.

When analyzing a request for medical assistance in dying, the clinical ethicist must, among other things, discern the underlying causes of suffering and determine if it is truly intolerable, and ensure that the person's consent is free and informed.
Photo : Getty

A woman with terminal cancer requests medical assistance in dying (MAID), but her healthcare team is hesitant. The patient appears depressed. Does her mental state validate or invalidate her request?

A clinical ethicist is called in to ask the difficult questions. Have all the causes of her suffering been fully explored? Is her consent truly free, or is it clouded by fear of burdening her loved ones?

Marie-Eve Bouthillier, a professor in Université de Montréal’s Faculty of Medicine and a researcher at the CHUM Research Centre, has documented this rarely discussed role in a recent study spanning Quebec and Switzerland.

As the former head of the Ethics Centre at the CISSS de Laval, where she oversaw thousands of MAID requests over nearly a decade, Bouthillier understands the ethical dilemmas involved.

Four focus groups

Between 2019 and 2023, Bouthillier and her team conducted four focus groups with 21 participants—10 clinical ethicists and 11 healthcare professionals—in Quebec and francophone Switzerland.

Their goal: to explore how, in two very different jurisdictions with very different rules, ethicists support medical teams and families in making decisions about whether to go ahead or not with MAID.

In the end, the researchers identified eight distinct roles played by ethicists. The most critical? Ensuring that no ethical considerations are overlooked.

“One of our primary roles is to make sure no stone has been left unturned, to ask the questions people don’t dare ask themselves,” said one Quebec ethicist interviewed for the study.

This means doing three things: uncovering the roots of the suffering and determining whether it is intolerable, ensuring that consent is both free and informed, and reconciling the inherent tensions between palliative care and MAID.

A second major role is providing moral support to healthcare professionals, and “this work is emotionally fraught,” said Bouthillier. “We’re not consulted when things are going well, but rather when life and death hang in the balance," she said.

"Ethicists provide clinicians with a space to express their discomfort, navigate value conflicts and maintain their moral integrity when dealing with deeply unsettling requests.”

In addition, they organize post-intervention debriefings, design training programs, shape institutional policies and mediate conflicts among team members or within families. In Quebec and the rest of Canada, ethicists also have the unique role of coordinating MAID requests to ensure continuity of care and proactively identify ethical issues.

Marie-Ève Bouthillier, professor in Université de Montréal’s Faculty of Medicine
Photo : Amélie Philibert, Université de Montréal

Starkly different approaches

The comparison between Quebec and Switzerland revealed starkly different approaches.

In Quebec, MAID is available in all healthcare facilities, everywhere from hospitals to hospices. Ethicists are brought in upon request through institutional ethics structures (ethics committees, departments or units) or interdisciplinary support groups.

Of the 24 interdisciplinary support groups in this province that one of the study's co-authors, Catherine Perron, looked at, only 13 included clinical ethicists – this, despite the ethical weight of the issues at hand.

In Switzerland, under Article 115 of the country's Penal Code, assisted suicide is legally permitted, provided the motive is not selfish.

At Lausanne University Hospital, for instance, clinical ethicists sit on the evaluation committee that reviews every assisted suicide request to determine whether ethical grounds exist for the hospital to proceed.

Which model – Quebec's or Switzerland's – is best geared to having decision-makers act ethically instead of simply applying bureaucratic rules?

“The Quebec ethicists agreed their involvement should remain optional, a response to expressed needs,” Bouthillier reported. “They worry that their systematic participation could reduce ethical consultation to a box-checking exercise.”

By contrast, the Swiss participants viewed their mandatory involvement as positive: they saw it as providing a layer of institutional support that reassures physicians making difficult choices of whether a patient lives or dies.

Mounting challenges, insufficient resources

The study also highlights three major obstacles.

First, access to clinical ethicists is severely limited. “We have two ethicists for 22,000 employees,” one Quebec participant said. This shortage is especially concerning given that Quebec has the highest rate of medically assisted dying in the world: 6,058 people chose that route in 2024, accounting for 7.9 per cent of all deaths that year.

Second, the Quebec participants pointed to a risk that they may be used as rubber stamps to justify decisions that have already been made.

Finally, there were concerns about the limits of ethicists’ expertise and the possibility that they will be perceived as advocates for MAID, thereby undermining their neutrality.

Bouthillier believes the ethical challenges of medical assistance in dying are part and parcel of the process. This is particularly true for physicians tasked with assessing “intolerable suffering,” a highly subjective criterion, she said.

Clinical guidelines often focus on physical and functional factors, frequently overlooking the psychological distress of patients requesting MAID.

Expanding training and access

Solutions to these challenges are taking shape in Quebec, Bouthillier noted.

Since the COVID-19 pandemic, a clinical ethics community of practice called the Regroupement en éthique clinique et organisationnelle has been established. It meets weekly to discuss common cases.

With UdeM pediatrics professor Antoine Payot, director of clinical ethics programs in the medical faculty and a neonatologist at Sainte-Justine hospital, Bouthillier has set up a philanthropic fund to support fellowships in clinical ethics. It will enable candidates to train in the field for a year before being hired by institutions.

“Clinical ethics isn’t abstract theory; we deal with real-world problems,” Bouthillier said.

“But we have to improve training, provide institutions with qualified ethicists and expand access outside the major urban centres. Only then can clinical ethicists fully support professionals and patients facing some of medicine’s most complex decisions.”