MAiD and Mature Minors – Part 1: The Ethical Perspective with Eric Mathison
As if Medical Assistance in Dying (MAiD) weren’t complex enough, we’re diving into one of its most contentious topics: MAiD and mature minors. This three-part series will explore the issue from ethical, legal, and medical perspectives.
In Part 1, we sit down with
, an Assistant Professor of Philosophy at the University of Toronto Scarborough and a Clinical Ethicist. Eric writes about MAiD and other challenging ethical issues on Substack at Value Judgments and shares insights on his YouTube channel.If you don’t subscribe to Eric’s free Substack, you should. In fact, the first five of our subscribers to send us a message will get a free month subscription to Eric’s paid newsletter—that’s a $8 value that gets you access to all his posts for one month. (We’ll take this part down once we receive five messages).
You can watch the video on YouTube, listen to the audio below, or read my summary of our conversation.
Medical Assistance in Dying (MAiD) remains a contentious topic in Canada, and the conversation around its expansion to mature minors is one of the most complex ethical discussions in the field today. I recently spoke with Dr. Eric Mathison, a bioethicist and professor of philosophy at the University of Toronto Scarborough, to explore the ethical underpinnings of this debate. Our conversation touched on fundamental concepts of capacity, autonomy, and the challenges of assessing maturity in medical decision-making.
Presumed Capacity and the Mature Minor Doctrine
Capacity is at the heart of all medical decision-making. In Canada, adults are presumed to have capacity unless proven otherwise. For minors in Canada, the determination of decisional capacity varies by jurisdiction and is assessed on a case-by-case basis.
The mature minor doctrine allows minors who can demonstrate capacity to make medical decisions. This has been recognized by the Supreme Court of Canada1, meaning a minor with full decision-making capacity can make serious healthcare choices, even those that involve end-of-life care, such as refusing life-sustaining treatment. The doctrine is well-established in Canadian healthcare, yet an arbitrary age cut-off still exists for MAiD.
Capacity, Risk, and Ethical Consistency
The principle of informed consent does not change with age—capacity assessments for minors rely on the same criteria used for adults: understanding the relevant information, appreciating how different choices might impact their life, demonstrating a reasoning process, and communicating a decision2. However, as Dr. Mathison noted, capacity is not a binary trait but something that develops over time. Assessing it in minors may be more complex, but it is already part of standard medical practice in pediatric care. Physicians routinely determine whether minors are capable of consenting to or refusing treatment, including decisions with life-and-death implications.
This raises an important ethical question: If a mature minor can refuse life-sustaining treatment, why should they be denied access to MAiD? The Supreme Court’s Carter decision found that in certain circumstances adults should be allowed to actively seek an assisted death. It then becomes ethical difficult to say that a competent 17-year-old suffering from a grievous and irremediable medical condition should not have access to MAiD simply because they are not yet 18.
Should capacity, rather than age, be the major factor?
Concerns About Influence and Slippery Slopes
A common argument I hear against MAiD in general is the concern over undue influence or coercion. Could minors be pressured by family or society into making such a decision? Dr. Mathison pointed out that undue influence is already a key consideration in MAiD assessments, for adults and minors alike, and both Dr. Mathison's and my experience suggest that when external pressure does occur, it is more likely to be pressure to prolong life, rather than to choose MAiD.
Another frequent objection is the slippery slope argument3—the idea that allowing MAiD for mature minors will inevitably lead to further expansions, such as non-voluntary euthanasia for infants. Dr. Mathison dismantled this argument on two fronts. First, slippery slope arguments are predictions, not ethical principles. Many such claims about MAiD have failed to materialize in Canada, and ethical policy should be based on actual evidence, not speculation. Second, extending MAiD to mature minors is a question of respecting autonomy, while infant euthanasia is based on best interests—two entirely different ethical frameworks. Conflating the two does not hold up under scrutiny.
Safeguards and Practical Considerations
If Canada were to allow MAiD for mature minors, should additional safeguards be required? Dr. Mathison sees no ethical justification for imposing stricter criteria than those applied to adults. However, he acknowledged that politically, pragmatism may require some additional steps, such as an extra capacity assessment. That said, excessive safeguards could create new barriers, leading to prolonged suffering rather than genuine protection.
We discussed past Canadian and international examples, such as the now-removed 10-day waiting period for Track One MAiD4 and the onerous review panels proposed in the UK5, which risk making access practically impossible. Safeguards must be evidence-based and proportionate, rather than mechanisms for delaying or obstructing access.
Where Does Canada Go From Here?
Dr. Mathison’s strongest ethical argument for MAiD access for mature minors is simple: if we respect autonomy in medical decision-making, we must do so consistently. Many minors who would qualify for MAiD already make complex healthcare decisions. Denying them this one option not only undermines their agency but does so arbitrarily.
While this issue has not yet reached the courts, a constitutional challenge could be on solid ethical and legal footing. The Carter decision left room for future expansion, and as Dr. Mathison pointed out, the only reason age was specified at the time was because the case involved adults. There is nothing in the ruling that explicitly excludes mature minors.
Final Thoughts
The ethical debate over MAiD and mature minors is not about whether many will choose this path—it’s about whether those few who do should be denied their right to make an informed, autonomous decision. Canada’s mature minor doctrine already recognizes that some minors possess the capacity to make life-altering healthcare choices. Ethically, there does not seem to be a clear justification for excluding MAiD from these decisions.
As Canada continues to evolve its MAiD laws, conversations like this are crucial. Whether one supports or opposes expansion, the discussion should be rooted in facts, evidence, and a commitment to ethical consistency.
Where to Find Dr. Eric Mathison
Dr. Mathison writes about MAiD and other bioethics issues on his Substack, Value Judgments. He also has a YouTube channel under the same name where he explores these topics in greater depth. Check them out for more insightful discussions on medical ethics.
What’s next?
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Part 2 – A discussion with a political scientist and constitutional expert on the legal landscape.
Part 3 – A conversation with a medical doctor about clinical considerations.
Seeking a Contrasting Perspective
We’d love to interview a healthcare professional who supports MAiD in general but has serious concerns about extending access to mature minors. If you or someone you know fits this description, please reach out!
It’s great that you are writing about mature minors. I am still not sure how I feel about including the mature minor in MAiD
What a thoughtful and intelligent discussion. Thanks so much.