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One of medicine's thorniest ethical questions concerns the lengths to which a physician should go to ameliorate suffering, including the use of medical means to hasten death. Yet, particularly for those who care for patients who live with serious illnesses, this question is all but inevitable.
In this episode, , the co-founder and current president of the , talks with co-hosts Henry Bair and Tyler Johnson, MD, about her experiences helping patients die and how she views this branch of medicine.
Green has been at the forefront of the change in legal regulation and clinical practice around medical assistance in dying (MAiD) in Canada. In her 2022 book, , she shares the delicate, challenging, and humane moments she has witnessed while navigating this unique work.
In this episode, you will hear about:
- 5:14 How Green transitioned from a career in maternity care to medical assistance in dying (MAiD)
- 6:39 A brief legal history of MAiD in Canada, beginning with and including the sea change that came with
- 12:14 An overview of how MAiD works today in Canada
- 15:43 How MAiD works in the U.S., specifically in California, and the role of prognosis in a patient's eligibility for MAiD
- 20:45 Green's reflections on how two decades working in maternity care prepared her for MAiD
- 24:13 The specific process by which Green helps her patients die
- 27:53 The first patient encounter in which Green provided MAiD
- 35:04 Reflections on the frame of mind Green must adopt in order to perform this work
- 43:22 How Green processes the difficult emotions arising from her work
- 47:50 Green's reflections on her role as a patient advocate when handling family conflicts at end of life
- 51:35 Advice for clinicians about connecting with patients through empathetic presence
Disclaimer: This episode does not advocate for or against medical assistance in dying. Rather, it seeks to understand why a clinician may choose to perform this work. If you are experiencing suicidal thoughts or a crisis, please call or text 988 to reach the Suicide & Crisis Lifeline, available 24 hours a day, 7 days a week.
Following is a partial transcript (note errors are possible):
Bair: Well, to start us off, can you briefly tell us what first drew you to a career in medicine?
Green: Sure, I haven't been asked that question in a while. I love it. Thank you. I think it is a little bit cliche. In truth, I love discovering how things work. And I think that while I was in school, even in high school, I kind of discovered the field of physiology. I find the human body wondrous. I think that I discovered that early and I remember specifically a particular class in high school and grade 12 biology when our teacher had to stand up and actually push all the chairs aside and we walked through and enacted meiosis and mitosis as if we were chromosomes. And I remember being fascinated with finding out how the body worked.
And it quickly evolved into how people work and how they think, how they function, how they heal, how things can go wrong. And I thought if I could just understand how things worked and how they could go wrong, I could help to make them better or I could maybe learn to fix them. You know, the truth is, I didn't plan on a career in medicine, but I came to it as I followed my interests in science and biology. It's really that simple.
Bair: Can you tell us more about your journey in medicine? I understand that before your work with dying patients, you had a previous career in maternity and newborn care. Can you walk us through that path?
Green: Sure. So I'm trained as a family physician. I did family practice in Montreal at McGill University, and I was very drawn to two different fields. I was drawn to end of life and I was drawn to maternity care, both seemingly a little bit polarized. I did partial fellowships in both, to be honest, and I chose a career in maternity and newborn care, primarily with a big emphasis on that. I did 10 years of general medicine with an emphasis on maternity, and then I did another 12 years exclusively in maternity and newborn care, which is a little bit odd, but I absolutely adored it.
So I did that for over 20 years, and then I followed the legal changes coming in Canada when I saw our Supreme Court decision that changed the law about assisted dying. I became very interested in the topic. And it's not a straight path. It's not quite that straight. The issue of assisted dying was first raised in my mind for the very first time when I was in medical school doing a bioethics course and would have been a small sidebar, except that in our national headlines there was a very important case, a challenge in Canada unfolding, the Sue Rodriguez case, and it was literally in the news every day. So we talked about that case and it was the first time I'd really come across the issue, and I'm sure that it's shaped my views.
That case was lost. But over the next couple of decades in Canada, I watched, as a Canadian reading the newspaper, other stories come forward and the debates that happened. And after 20 years of doing maternity care, I was getting a little bit tired physically doing 24-hour call shifts and recovering from that was becoming more challenging. And my children were growing up and about to leave the home and I had some pressure that I really wanted to be home before that happened.
So none of this is a very straight line. But as I was considering pulling back and doing other things in medicine, this other opportunity was coming along in Canada. This event was happening and I was learning more about assisted dying with this lens of having practiced medicine for over 20 years. I had seen things that had made me more interested in what was evolving in end-of-life care in Canada. And the more I learned about it, the more I was drawn to it. So I actually made that shift from transitioning into life and delivering babies to transition to the other end of life and working in assisted dying. So not a clear path, but an interesting one, I think.
Johnson: Can you just walk us through, many -- well, we have listeners actually all over the world -- but many of them do not live in Canada. Can you just talk us through maybe just a little bit of that history that you were just referring to, of when did this become legal and what did the journey to legalization there look like? And then also, can you help us to understand what are the legal specifications right now? So, in what context can it happen? How does it work? Just give us a little bit of a sort of, the logistical framework as well.
Green: So I think it's important to understand that how we came to this in Canada is a little bit unique. The law didn't change in Canada because there was a voter preference for that or because the government of the day decided that it was a good idea and wanted to make a change. This change happened in Canada because patients stepped forward and fought what used to be a blanket prohibition of assisted dying in Canada, which is common in many countries still. And the challenge to that originally, as I mentioned, the Rodriguez case in the 90s was lost, but very, very close.
And so what happened since the mid-90s was this young woman who had a terrible illness, who had ALS or Lou Gehrig's disease, she challenged the prohibition, wanting to have an assisted death at the end of her life. She lost that decision 5-to-4 at our Supreme Court. But it really sparked a lot of debate in our country and really caught and captured the attention of Canadians who really felt for her, felt her plight. And so we had discussions, debates, reports, more cases.
And literally 20 years later, another family, a group of patients, actually came forward with a very, very similar challenge. And it's important because the argument they made was based on a constitutional document in Canada, and that's different than in other countries.
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