“Yes if… No but…” : a qualitative study of pediatric palliative care professionals and collaborators’ perspectives on medical assistance in dying

Medical assistance in dying (MAiD) is permitted for minors under specific conditions in the Netherlands, Belgium, and Colombia. In Canada, MAiD became available to eligible adults (18 years and older) under specific conditions as of 2016. Since then, the Canadian Parliament has examined and ultimately recommended extending MAiD eligibility to mature minors whose natural death is reasonably foreseeable; however, this has not been enacted into legislation, and no implementation timeline has been established. Pediatric palliative care (PPC) teams are expected to play a key role in such complex cases, yet their perspectives remain underexplored. This study explored the perspectives of a specialized PPC team and its collaborators on MAiD for minors, with particular attention to their anticipated ethical challenges. We conducted a qualitative study based on semi-structured interviews with members and collaborators of the PPC team at a tertiary pediatric hospital in Montreal, Quebec, Canada. Participants included professionals who have worked within the team since its creation in 1999, as well as institutional and external collaborators. Data were collected between April 2022 and June 2023 and analyzed through descriptive-interpretative thematic analysis. Twenty-four participants were included, over half ( n = 15;62,5%) of whom had worked within or collaborated with the PPC team for more than ten years. Two central themes emerged. First, participants already viewed pediatric MAiD as a concrete issue in practice, expressing ambivalence and conditional openness structured around six ethical sub-themes: (1) decision-making authority and conditions, (2) defining and weighing pain and suffering, (3) comparison with other end-of-life practices, (4) specificities of PPC, (5) professional responsibilities and safeguards, and (6) healthcare system readiness. Second, participants anticipated multiple challenges should pediatric MAiD be legalized, including relational tensions within families and with children, professional and interprofessional tensions, as well as structural and organizational challenges. PPC professionals and collaborators expressed ambivalent and conditionally open views, revealing moral prudence in navigating uncertainty with attentiveness to lived experience. They emphasized the need for robust safeguards, equitable PPC resources, and preparation for potential legislative change. As pediatric MAiD emerges as a concrete reality in pediatric practice and a potential legislative one, these findings call for renewed ethical reflection and offer guiding questions to foster structured, context-sensitive deliberation across clinical, institutional and policy contexts.