On Sept. 11, 1984, Céline Dion found God. At Montreal’s Olympic Stadium, she sang “Une Colombe” (“A Dove”) for 65,000 young people and Pope John Paul II. When the song ended, real doves were released. One landed on the pope’s shoulder and stayed there: a miracle, Céline claimed, that made her a believer.

Josée Lamère was 20 that day. She had helped organize the visit as a youth adviser to the archbishop of Montreal, in a province that had spent 20 years dismantling the church’s grip on its hospitals, schools, and public life. Josée wasn’t watching the doves at Olympic Stadium that day. Instead, she was live broadcasting at Radio-Canada’s Montreal studios, telling the province’s young Catholics they owed the church no automatic loyalty, that their own values had to be part of any new contract with the institution. The dove had landed for Céline. For Josée, it never quite would.

She spent the next three decades teaching religion in Quebec’s public schools, which under Quebec’s value of laïcité (freedom from religion) effectively meant she taught ethics: morality, identity, how to live. In her obituary decades later, students remembered how much she cared: When students came to her in distress, she drove some of them to the hospital herself, guiding them toward choosing life.

The church’s view on choosing life was clear, too. But it came with nuance: By the 1950s, the church declared patients had no obligation to pursue lifesaving “over-zealous” treatment — a distinction French bioethics would secularize into l’acharnement thérapeutique, “therapeutic relentlessness,” years before the English medicine settled on its own term, “medical futility.”

The debate played out for decades on the front pages of Quebec’s Francophone press: A 1992 spread in La Presse interviewed Nancy B., a paralyzed woman who won the right to have her ventilator disconnected. By 2009, the province had convened a National Commission on Dying with Dignity to decide, formally, how far that right extended. Canada legalized medical aid in dying (MAID) outright in 2016.

In 2027, the law will expand to allow mental illness as a reason to petition for MAID.

The debate over MAID — including in New York, where it will become legal on Wednesday — has focused primarily on who qualifies, rarely on how people live once they decide.

Medicine assesses who is eligible for MAID through two criteria: terminality and suffering. Both aspire to objectivity. But suffering is not a biological fact. It is lived privately and unevenly: shaped by culture, by history, by the particular weight of lived experience.

This is Josée’s story of assisted dying in Quebec, where 7.9% of all deaths are now through MAID, the highest rate in the world.

Josée became aware of MAID through this widespread media coverage. In the 2000s, she became the sole caretaker for her mother with Alzheimer’s. Her mother’s decline was slow, a burden that began to accumulate as her mother disappeared in degrees. “It frayed her,” Josée’s child Constance said. (Constance had responded to a request I had posted online for stories of MAID, several months after my father received his terminal diagnosis.) After her mother died, Josée began posting to Facebook in support of expanding MAID; the law required consent at the moment of death, which would have been no use to a patient like her mother, who would lose the capacity to ask before she needed it. “If you’ve seen the ravages of Alzheimer’s on a loved one, please sign,” she wrote. In 2024, Quebec’s courts agreed. By then, she already knew what she would choose, whenever her own time came. “Just let me die in peace,” she told Constance. “I don’t want to be alive for the sake of being alive.”

Her own time came sooner than either of them expected. On Dec. 1, 2023, an MRI found stage 4 gallbladder cancer. She asked for MAID that day, and received it 18 days later.

Between April 1, 2024, and March 31, 2025, 7.9% of all deaths in Quebec were through MAID, the highest of any jurisdiction in the world. Across Canada, the figure for 2024 was 5.1%. Researchers tried to explain the rapid uptake: Quebec’s laïcité, Canada’s strong individual rights framework, improving practitioner access.

In 2027, lawmakers are set to expand MAID eligibility criteria to include severe mental illness. The most complex cases — where poverty, disability, and psychiatric illness intersect — are the ones that dominate American coverage of MAID. Critics argue that a terminal decision could not be truly autonomous if made under duress: if a person was choosing death because physicians or health systems had failed to make their suffering tolerable.

But less attention is paid to the most common case: Josée asking to be spared more pain in her last few weeks.

The critique is serious. But it shares a flaw with the system it critiques. Both — the skeptic questioning whether MAID was chosen freely, and the clinician determining whether it was chosen legitimately — focus on the circumstances around the patient’s final decision. Is the disease terminal enough? Is the suffering grievous enough? Was the system adequate enough? Autonomy, in both framings, is adjudicated by a physician, verified at the bedside. What neither sees is everything that came before.

Our deaths, like our lives, are shaped by what we know to be possible. Josée did not arrive at her decision in her final months. Her choice was made possible not just by medical infrastructure, but by decades of La Presse front pages, the slow cultural work of a secular society deciding, together, this was something a person could choose. “People had fought for there to be legislation that allowed this,” Constance told me, “and so I was grateful, not just for MAID, but for all the people that made that law possible.”

Autonomy, in this light, is not simply the absence of coercion. It respects the accumulated weight of life — the broader society, experience, and belief — that makes a particular life and death meaningful. I wonder whether, as physicians, we are equipped to adjudicate that; or whether, in our quest for clinical precision, we risk compressing life into its last illness-ridden chapter.

On Nov. 29, 2023, Josée developed severe abdominal pain. She had no family doctor — over a quarter of residents in her home province of Quebec didn’t — so she went to urgent care. The nurse who reviewed her labs ordered further testing. On Dec. 1, an MRI confirmed stage 4 gallbladder cancer with metastases. Josée was 58.

Her physician, whom I’ll call Dr. Poulin, listed the treatment options, but Josée wanted to know: How much time did she have left if she did nothing? A few weeks, Dr. Poulin told her. Maybe three.

Josée had no intention of pursuing treatment. When the physician returned to provide some opioids, Josée asked about the process for medical aid in dying.

In Canada, two tracks for MAID exist. Track 1 — 95.6% of cases — applies when natural death is foreseeable, and permits MAID without a waiting period. Track 2 covers serious conditions not near death and requires a 90-day waiting period. She qualified unambiguously for Track 1. Two Canadian physicians could certify the request immediately. Her physician was a generalist, however, and she wanted her to see an oncologist first. Josée would have to wait for the biopsy results on Dec. 14 — nearly two weeks away.

What scared Josée wasn’t dying, but the uncertainty of when her pain would end. “She really needed to feel that control,” Constance told me, “to know that she had power over this situation. I think she was more afraid of suffering than she was of dying.” I wonder if we’ve delegated too much of that power to specialists who know the disease best — who can say how terminal it truly is — and too little to the physicians who know the patient best: a primary care doctor, a psychiatrist, someone equipped to judge how much a person is suffering.

Dr. Poulin prescribed half a milligram of hydromorphone every three hours; she would increase the dosage slowly to not cause a lethal overdose. Ironic, given the context. “I think she could have done without the extra two weeks of pain,” Constance told me. “That’s most of what she felt, and most of what occupied her mind.”

Philosopher Miranda Fricker coined the term “epistemic injustice,” specifically damage done to someone in “one’s capacity as a knower” — when their testimony is discounted, their account of their own experience refused. I think about this in relation to both the biopsy and her pain. The biopsy presupposes that Josée’s testimony of terminal suffering was insufficient evidence of terminal suffering — that our medicolegal institutions needed to verify, through biological and specialist testimony, what she already knew.

There is something worth protecting in that caution; suffering can distort judgment, and irreversible decisions deserve scrutiny. But there is something worth questioning in it too. When suffering is the very reality being assessed, asking a patient to wait while it is confirmed is not a neutral act.

Constance (who uses the pronouns they/iel) had their own version of this reckoning. One afternoon they asked their mother directly: Was there anything — any event, any reason — that would make it worth staying? “If I was getting married in three months? If I was going to have a baby? Is there anything?”

Josée said no.

“That was a crazy answer to me,” Constance said. “Because I feel like there has to be some amount of joy that counterbalances the pain. The pain can’t be stronger than everything. But it really was. And I don’t know if it was the physical pain alone, or the psychological pain of knowing you’re going to die, so everything is tainted — or maybe a kind of indifference. Like: If you’re getting married in three months, it doesn’t really matter if I’m there to see it. Just knowing that you’re going to be happy is good enough for me.”

In the end, “I just had to accept her math and not try to impose my own.”

The oncologist informed Josée any treatment would only extend her life by months, possibly a year: Josée declined. Dr. Poulin called to schedule the MAID assessment. It was Friday, Dec. 15. Josée could come into the hospital on Monday. A specialist, the second doctor needed, would assess her over three days. She would receive MAID on Dec. 21 — three weeks after her diagnosis. But just knowing that the pain had an end date changed something in her. “She was able to be a little more present,” Constance told me. “A little more joyful for the days she had left.”

“It freed her.”

The colored Post-It notes on Josée’s wall counted down the days left, a playfully moribund teacher’s calendar. When there’s no new page to turn to, there’s an instinctual sense that for almost anything you do — calling a friend, watching a movie — this will be the last time, giving the action an additional weight.

But Josée was adamant about not thinking that way. She refused to taint the joys of the final chapter with an anticipatory grief that the book was ending. Josée and Constance went to see “Ru,” a Québécois film adaptation of Kim Thúy’s novel about a Vietnamese immigrant’s journey to Canada. “It was incredibly depressing,” Constance told me. “But it didn’t feel like a waste of something special because we didn’t make it particularly special.”

Constance, also a teacher, took off the last weeks of the December school year to be with their mother. Life continued much as it always had: making meals, watching TV, spending time together. “We didn’t worry so much about laundry or work,” Constance said. “I think the best parts of life continued on.”

On Dec. 16, Josée succinctly announced on Facebook that she would be dying. Messages flooded in: final goodbyes, expressions of gratitude, people saying what she had meant to them. She refused to read them. Constance was perplexed. Didn’t Josée want to see what she meant to all these people?

But Constance came to accept it, even without fully understanding the reason why: Did Josée not want to absorb other people’s grief as a responsibility? Was there a kind of indifference — not cold, but settled — in which nothing felt particularly more significant because an end was coming? Did she simply not want to spend her last days staging a farewell?

“I guess she did sort of live a little bit as though she wasn’t going to die,” Constance said, “in the sense that she didn’t take on any responsibilities she hadn’t taken on before, and she didn’t try to have any experiences she hadn’t had before. I think she was satisfied with her choices in her life and continued to make those same choices.”

Medicine requires objective clinical criteria to ensure a patient is making a rational decision. Does pain cloud judgment? Is there underlying depression? What is the disease course? Will they change their mind? These are not unreasonable questions. But I wonder if in the medical framing of terminal suffering, we do not weigh enough the story the patient tells of their life up to that point — whether, for some people, MAID is even experienced as an end.

In life, Josée had spent decades in caretaking roles that were thrust upon her: her ailing mother, her ex-husband, a child she raised as a single mother. She had become an efficient problem-solver, someone whose care others orbited. In her final Facebook post, Josée straightforwardly leaves a link to the time and place of her funeral. “You will understand that I will not answer the phone nor comments left under this post. Leaving with no regrets, glad that our paths crossed,” she concludes.

In the American cultural imagination, deathbed narratives tend toward dramatic conclusions — confessions, final goodbyes, Make-A-Wish trips. Some of this might be the narrative logic of storytelling: a beginning, middle, exciting end. In the Catholic sense, at least, there is also the promise that something more follows. When she arrived at the hospital on Dec. 18 — the same woman who, as a girl, had helped organize the papal visit to Montreal — she was offered the chaplain. “She was really annoyed,” Constance told me. “I think they asked three times, but that was two too many for my mom, borderline three too many.” For Josée, nothing in life felt unfinished. Her last days would be lived like any other.

A new doctor knocked on Josée’s hospital room door. He introduced himself — I’ll call him Dr. Aubin — as the MAID specialist. Constance had difficulty recalling his face. An elderly man, white hair, a slow gait. Instead, what Constance remembered of Dr. Aubin is a feeling. Death itself arriving in the room, a shrouded presence that was, unexpectedly, soothing.

He spoke slowly, in a low baritone, explaining what would happen. First, he would inject an intravenous benzodiazepine to relax Josée. The second drug, an anesthetic, would place her into a deep coma. The final drug, a muscle paralytic, would stop her heart. It would be painless, over in minutes. He would return three times before the procedure for her signature — she could refuse at any point.

Josée signed the consent immediately. The next day, she signed again. MAID had initially been scheduled for Dec. 21, but Dr. Aubin had an earlier opening. Josée jumped at the chance. Constance was taken aback, expecting one more day. “But that was her choice, so we respected it.” On Dec. 20, Josée signed for the last time.

That morning, Constance read aloud the Facebook message they planned to post on Josee’s passing. It named what she had taught them over 27 years: to know and cherish their language and culture, to show empathy and selflessness. The post catalogued her service: pastoral work, a school LGBTQ+ committee, a Relay for Life. “I’m going to do what you taught me,” Constance read aloud. “It’s your turn to rest. Knowing you, you’ll become bored shitless. That’s why I give you permission — if you’re not busy showing St. Peter how to handle his affairs — to haunt me, to watch me, to ‘come back and tickle my toes’ as your mother used to say. I hope you’ve found her, she whom you miss, and I hope to find you again one day,” Constance narrated.

Josée began to cry. “Wow,” she said. “I really did everything I wanted to.”

After lunch, they walked across the street to Parc La Fontaine, past the 10-meter obelisk of Charles De Gaulle: smooth and triangular on the side facing the hospital, jagged and sloping at its rear. They walked through the Alley of Trees, now barren spindles in a gray winter. Josée savored her last time outside. When she was ready, she motioned to Constance. “Let’s return.”

Her boyfriend, John, later joined by her four siblings and her ex-husband, Yves, came to say goodbye. They began to play a mundane game of trivia around her bed. No one kept score.

Around 3 p.m., Dr. Aubin returned and placed an IV port. As the first medication was administered, Constance began to sing. A French lullaby — a berceuse — about a baby dove that Josée had sung to them as a child. Josée had not been told this was coming. As her eyes closed, she smiled. Constance, usually remarkably forthcoming, asked me not to print the song. “It’s the one thing that’s personal,” they told me. “I don’t think I can ever sing it again.” By the fourth verse, as the baby dove falls asleep beneath its mother’s wing, Josée had stopped breathing.

For those left behind, I wondered how grief would feel when the ending had been chosen rather than imposed. When Dr. Aubin pronounced the time of death, Constance broke down. They had held their tears through the last hour to keep their mother’s final moments pleasant. “I get to know that she left in her own way and her own time,” Constance said. Without MAID, there would have been, added to the ordinary weight of loss, a “deep, deep sadness that the last moments of life were not good ones.” And the existential questions that death tends to open, the ones usually answered through religion or community, felt easier too. MAID connected Constance to those who fought for dignity in dying. “How could someone who had so much light and so much more to give be gone and I’m still here? Or other people who suck are still here, you know? And I think MAID gave me a little bit more faith in the world through that grief process, because I knew that people had fought for this. People had fought for there to be legislation that allowed this.”

“It gave me peace.”

Sai Rajagopal is a Canadian physician and researcher at Stanford Hospital.

If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: Call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.