The Doctor Behind One of Canada’s First MAID Deaths Speaks Out

According to the most recent federal figures, of the 326,230 deaths registered in Canada in 2024, 16,499 were medically assisted. That year, Ontario reported 4,944, and British Columbia 2,997. Quebec registered the highest rate of medical assistance in dying, or MAID, by any jurisdiction in the world, contributing 36.3 percent of medically assisted deaths that occurred in the country.

If one were to classify MAID as a cause of death in Canada, in 2024 it would have been the fourth after cancer, heart conditions, and accidents, and ahead of cerebrovascular diseases. Consistent with previous years, the vast majority of medically assisted deaths in 2024 were for people of a median age of seventy-eight whose natural deaths were considered reasonably foreseeable, with 4.4 percent for people of a median age of seventy-six who might otherwise live indefinitely (albeit intolerably).

In Canada, how people die with medical assistance varies legally: legislation defined eligibility criteria but not how the death was to occur. Trends emerged: 99.99 percent of medically assisted deaths in Canada have been instances of active euthanasia—for obvious reasons. Whereas assisted suicide usually involves an anti-nauseant, the passage of an hour, and drinking half a cup of lethal liquid with or without observation, active euthanasia—directly administered by a medical or nurse practitioner—consists of the three-drug cocktail midazolam (an anxiolytic), propofol (a coma-inducing sedative), and rocuronium (a paralytic) injected in this sequence. It has a near-zero failure rate, and death typically occurs within minutes.

Born in Ottawa, Ian Michael Ball is an associate professor in the Division of Critical Care Medicine and the Department of Epidemiology and Biostatistics at Western University, a trauma physician with the London Health Sciences Centre Trauma Program, and the Critical Care Medicine lead for Southwestern Ontario. He was among the first physicians in Canada to administer MAID. With an LHSC ethicist, Ball was instrumental in developing a step-by-step procedural guide for hospitals across the country establishing MAID programs.

The interview has been edited for length and clarity.

Was euthanasia a component of your education?

Yeah, absolutely. I was interested in bioethics right from the beginning and remain so. I took some religion and philosophy courses with a bioethics focus. After I finished my clinical training at Western, I went back to Queen’s, joined the faculty, and completed a master’s in clinical epidemiology at the University of Ottawa. But I don’t have any formal training in ethics per se. I can tell you how I got involved with MAID, which I think is what you’re getting at. As a clinician, my job is to take a practical approach while being aware of complexity.

I was at a meeting with an LHSC ethicist probably in 2015. They were working extremely hard to prepare LHSC for MAID. I was there to ask, “Well, what would happen if we had an organ donor who wanted MAID?”

At the end of the meeting—there were four or five of us—almost everyone left, except for just the ethicist and I. I asked him, “How did you find providers, people willing to do MAID?” He said, “Well, people just kind of hang around after talks, just like you are now, and volunteer.” I said, “How many do you have?” He said, “A few.” Without having given the matter a whole lot of thought, I said, “If you’re ever stuck, and you need somebody, maybe add me to the list,” not thinking I would ever hear from him again about that.

A few months later, I get an email from him saying, “I just got our first case. Would you be willing to do this?” There were very few people at the time willing to do it. I was really scared. We performed one of the first cases in Canada outside of Quebec. My terminology may be off here, but at that time, we had to get a court order. The patient had to present to the court, stand in front of a judge, plead their case. The judge had to make a ruling because this was early 2016, around Easter time, before a policy existed.

Tell me more about your experience of helping to develop MAID.

At the start, I insisted that my identity be kept as confidential as possible. To patients and their families, I said the same thing: “Please, please, please do not mention my name. I’m fearful that people will go after my kids, my wife, my school.” One of the abortion providers in London used to wear a bulletproof vest, drive a bulletproof car. I didn’t know if that was going to be the case. Would I be ostracized by colleagues at the hospital?

That first case, I had a brown paper bag full of medications prepared by one of my pharmacists, one whom I worked with for many years. She said to me, “Don’t worry. Keep this between us. I’m very, very supportive.” That came as a big relief. I remember tucking a brown paper bag full of lethal drugs under my arm and walking to the parking lot in the hospital thinking that everyone knew what I was doing, everyone was looking at me. Just nervous.

I thought of a conversation with my mom, whom I’m really close to, when I used the words “killing a person.” And she said, “Well, you’re not killing them.” And I said, “I’m not murdering anyone, but I am killing someone.” For the patient would be awake, walking around, talking, eating, drinking, and then I’m going to do something that ends their life? That’s killing someone. It’s not murder, in my opinion. So, I drove there, nervously, and parked my car. With this paper bag. Thinking everyone on the street was looking at me.

I felt that way for about a year. Confidentiality is difficult to maintain because there are so many people involved. For example, the pharmacy team had to be involved; if one walks up on a ward to see a patient, the nurses want to know who they are. The nurses think, Why is an ICU doctor up on the palliative care ward or up on the cancer ward seeing a non-ICU patient? Support came gradually.

People I knew and people I didn’t know would whisper to me, “I know what you’re doing, and I support it.” I slowly became more comfortable talking about MAID, even becoming public about offering it. Another researcher and I, as well as an LHSC ethicist, started giving education sessions, and it really snowballed. Suddenly, we had too much work. We were having trouble keeping up, and that’s when we also started publishing papers on how to do this, because there was no recipe.

How would you describe your “moral orientation”?

I was raised Roman Catholic. MAID is a huge sin.

One of the big ones.

Yeah. Over the years, I’ve become more of an atheist. One of my colleagues, who’s been doing this with me from early on, one of his first patients was a Catholic priest. And the priest said to him, “God will judge me by the way I’ve lived, not by the way I choose to die.” Funny thing is, I still had to be pretty confident that I didn’t think I was going to hell for what I was doing.

I thought I knew where I stood religion-wise but—that needs to be crystal clear in your mind before you start doing this work. During a later case, I had to drop off a death certificate at a funeral home near my house. Still early days, and it was the first time I had to drop paperwork off myself. I went in not knowing what kind of reception I would get. I handed the certificate to the manager of this very reputable funeral home. I was with my youngest daughter. The manager looked at her, who, at the time, was probably eleven or twelve, and said, “Hey, I want you to know that we all think your dad’s a hero.” I have goosebumps repeating that to you now. I just said to them, “Thank you.”

There are some cases that I won’t do, and it’s my right to pick and choose. Some families get very upset with me for declining, but I’ve never lost sleep over a case, because I put the thought in ahead of time to become comfortable that this is both legal and not contradicting my morals. I lost track of how many I’ve done a long time ago. It’s a big number.

Returning to that first case of yours, can you sketch in the particular circumstances in terms of the condition, the deterioration, the rapidity of that decline?

I have to protect patient confidentiality. I had zero doubt that this person’s death was “foreseeably imminent,” which was, at the time, one of the mandatory requirements to meet MAID criteria. There was 100 percent support from their family. It was a clear, black-and-white case, very straightforward, not like some other situations which are a little grey.

So, meds in a brown paper bag. Doorstep. Can you offer a few details?

It’s a Sunday, midday, sort of early afternoon. I remember knocking on the door and hearing those knocks echo through the hallway. It was a lovely apartment, well furnished and neat. Candles were burning. Soft classical music was playing. I went into their bedroom—and that’s very personal, right? To go into a person’s bedroom? The sun was streaming through the window. Family photos were arranged around the room. The patient was lying there in bed.

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Without a precedent, how were you feeling? What guided you in that moment?

Before each case, I think about what I would want if I was the patient or family member, trying really hard to put myself in their shoes. I try to adapt my approach to individual needs, but in general, I go see the patient and do an assessment to determine whether or not they meet criteria. Usually, the medical side of it is pretty clear. Mostly, I’m assessing their capacity to understand what they’re asking for—which takes twenty seconds, right? Usually. Not always. Occasionally, you have to get more into it. But usually the patient says, “Hi. How are you? I’m glad you came. I’m requesting MAID because I have terminal cancer.” Pretty much tick, right?

I also need to assess that they are free of coercion and have had access to all available treatments and palliative care options. Once I’ve confirmed that they meet criteria, I explain to them what I’m doing and why I’m doing it. I talk about what meds will be given, what those meds do. I describe what it will be like for them. I say very clearly, “At this point, you will lose consciousness.” Then I describe what everyone else in the room will see. I reassure them, “I’m going to explain this again on the day of the procedure.” Then I ask everyone in the room if they have any questions. They rarely do because things are pretty simple. I read the room and watch family reactions.

Often, during this, there’s a lot of alternating between laughing and crying, and so I have the same cheesy jokes that I’ll go to. For example, I’ll ask, “Do you snore?” And then everybody usually gets a little giggle if Grandma is known to snore. And so, I say, “It’s not uncommon to snore three or four times,” just so everyone in the room can expect that. Then somebody has a little joke, and they laugh, and then they start crying again. I tell them that it’s usually surprisingly fast, a matter of minutes—sometimes less—so that they’re as prepared as possible.

We kind of invented this on our own. No one taught me how to do this. The closest thing that helped me prepare for this was the withdrawal of life support in the ICU, but that’s very different. Legally, ethically, but also from an emotional perspective. In the ICU, the patient is critically ill. You withdraw the life support, the machines that are keeping them alive. Their disease kills them. Most of those patients without those machines and the medications would die. MAID patients often drive themselves in. They walk in. They had breakfast. They would not die without those medications.

So, there’s a big difference between withdrawal and actively giving medications that will kill someone. And that’s more clear to the person who’s pushing those medications than anybody else. When you’re the person doing it, it’s a big deal.

What I hadn’t prepared myself for was after. I didn’t think that would be tough, but then suddenly, there you are sitting in a person’s bedroom. They’re dead because of some things you did. You’re standing with their spouse, and then you wonder, Is this person going to hate me? Are they angry with me? Usually, they were grateful.

But I’ve learned that my duty is to the patient. If doing right by the patient is in conflict with what the family wants, then I’m okay with that. If the family is angry with me because I’ve supported their loved one, my duty is not to them, and it’s important for me to try to always remember that. That said, I try to support both and try to make it as positive an experience as I can. Sometimes that includes offering for families to leave, because some family members just can’t witness it. We go get them once the patient has died. Some don’t want to come back; they want to say their goodbyes right before and leave. I’ve had family members crawl into bed during the procedure. Someone kissed their loved one as they died. People’s cats and dogs climb into bed with them.

I wonder whether you ever feel compelled to make it very clear to people how little time we have and how precious the time we have together is. Not that you could invite them to the room to observe the administration, but . . .

I used to wonder, Will providing MAID make me a dark, depressed, sad person who’s surrounded by death all the time? Quite the opposite: I appreciate life and health more than many people, because I’m aware of how quickly things can turn.

Finally, what would you like to leave the reader with?

I think the most important message about MAID is that there’s still a lot of people who are unaware this is even an option. I had personal experience with that with a family friend who was clearly dying of brain cancer; it’s difficult to say, from the side of the sports field, “Have they thought about MAID?”

I think a doctor’s duty is to provide all the reasonable therapeutic options to a patient. If you have cancer, you can have surgery, chemotherapy, radiation, palliative care, MAID, you know? And if the patient says, “No, I’m not interested in MAID,” then perfect. The physician won’t bring it up again. But other patients will say, “Well, hold on. Let’s talk a bit more about MAID. I want to know more about that option.” We should provide it as an option when it’s reasonable. One of the most positive aspects of MAID is the benefit to patients’ and families’ sense of well-being when you tell them, “Look, you are eligible. If and when you want this, we’re here. Call us. We’re here to support you.”

Adapted and excerpted, with permission, from The Writing on the Wind’s Wall: Dialogues about Medical Assistance in Dying by Kevin Andrew Heslop, a compilation of seventeen perspectives on MAID, published by Guernica Editions, 2026.