The Nation: Canadian euthanasia practitioner Stefanie Green
On Newshub Nation: Simon Shepherd interviews Canadian euthanasia practitioner Dr Stefanie Green
The euthanasia debate is progressing, with the End of Life Choice Bill expected to have its second reading in Parliament on Wednesday. A similar bill was passed in Canada in 2016 - and it's estimated about 8000 people have had a medically assisted death there. Dr Stefanie Green is President of the Canadian association of doctors and nurses who provide euthanasia services.
Dr Stefanie Green: Thanks for having me.
First of all, you’re a doctor, so how do you reconcile pro-euthanasia views with the spirit of being a doctor?
I think it’s absolutely consistent. No matter what we say at our medical school interviews, most of us go into medicine to help people, and this is another form of helping people at a really vulnerable and terrible time in their lives.
So what do you say to the New Zealand Medical Association’s stance that they say euthanasia in any form is unethical?
I think that’s naïve, to be perfectly honest. I think that when someone is suffering intolerably at the end of their life and we have a legalised medical service that allows for us to help them in that moment. When a competent adult asks me to help them, I feel like I’m helping them by doing that.
And you have done that roughly 150 times, you personally have been involved in medically assisted death, or MAID, as you call it, in Canada, haven’t you?
Yes, I’ve had the privilege of helping 150 people end their life.
Is it a privilege, is it?
Oh, it’s a sincere privilege. It’s a very intimate time for someone. It’s a privilege to witness them through that journey, to support them through that journey, to offer them a care that they’re desperate for and to be able to grant them that and to help them do it in a very comfortable way, it’s a huge privilege.
Does this normalise the process? Does it normalise the idea of assisted suicide?
I don’t think ‘normalises’ is the right word. I think accepting it as another form of care at the end of life, as another end-of-life care option. There are many, and it is only one, and only 1.5 per cent of all Canadians’ deaths are chosen to be in this way. It’s a very small number still, but I think it’s important.
Let’s talk about your experience. In the people that you have assisted, has it always been peaceful?
In the people that I have assisted, it’s always been peaceful. Absolutely, because it’s a controlled procedure that I am there to make peaceful.
And how long does it take?
Well, the majority of assisted deaths in Canada are actually by clinician administered medication, which is what I’m doing. And so, technically, from the initial administration to the end of the procedure and the end of heartbeat, it’s, on average, about 10 minutes.
Most of it is clinician assisted. Do people actually self-medicate?
There is the option in Canada legally to self-medicate. We’ve had very very few – I’d say probably under 20 cases in 8000. I’ve been involved in one. It takes a little bit longer. It’s also peaceful, but it’s a different process.
Because there is that concern here that it doesn’t always go according to plan and that the death is not peaceful. Have you come across this at all?
I have actually not come across that at all. The protocols in Canada we use are based on the Dutch protocols. They’re very very effective. We lobbied very hard with my group CAMAP to have the proper medications available so that we could have a lesser time to dying and a more comfortable experience, and so it’s been good.
Okay. Why shouldn’t high quality palliative care be the answer to people who are at the end of their life?
High quality palliative care is essential. I think that we need to lobby for that. I’m all in favour of that. I’m very lucky where I live my work is very well integrated with palliative care teams. It’s essential for our patients to have that. But we all know that palliative care cannot address every single event, and there are patients that suffer at the end that palliative care cannot help.
Right, so it’s true that palliative care cannot ease every point of suffering.
Of course not.
Every palliative care doctor will tell you that, and if they don’t say so, they’re being disingenuous.
At what point do you say you can’t help someone? If someone comes to you and they have very poor quality of life, but it’s not an irreversible disease or symptom, what do you say to them?
That’s probably the hardest thing of what I do. We have very strict eligibility criteria in Canada that must be rigorously found to be true, and if somebody comes to me suffering at the end of their life with a chronic disease or a chronic pain that they’ve had for many years but they don’t meet all of our criteria, I can’t help them. That doesn’t mean they’re not suffering. That doesn’t mean I don’t want to, but I have to work within the law and so I need to explain to them that I believe what’s happening to them is horrible, but I’m not legally allowed to help them, and I have to help them try and find other resources.
You’re the president of the Association of the Doctors and Nurses that help provide these services. Do your members need counselling?
We offer support systems to our members. There’s a number of different regional resiliency programmes. We do find, though, and early Canadian data is showing a little bit to our surprise that the attitudes and experiences of people providing this care has actually been fairly positive. People find this work incredibly rewarding. Patients are incredibly grateful for the care, and most people actually don’t need that support. It is available for them. We encourage a lot of self-care, a lot of support within collegial groups, and we have a national group where we’re in touch with each other all the time to support each other, which is essential, but it’s been well absorbed.
Because the New Zealand Medical Association here has a stance against euthanasia, I mean, did this issue at the time of debate when it’s coming through drive a wedge through the medical profession?
I don’t think so. I think that the Canadian Medical Association has had a neutral opinion about this in an effort to support all 85,000 members of our association, because there is, obviously, a wide variety, but I don’t think there was a wedge. I think there was a bit of a fear at the beginning. A lot of physicians didn’t understand what this was or how to do it. A little bit scared to step into that space. The very few who did step forward banded together very quickly in our organisation, and we’ve built a really strong network of support for each other. So I don’t think ‘wedge’ is the right word.
It’s three years on. No law is perfect, I guess. Do you believe that Canada’s law could work better?
Actually, I have to say that Canada’s law is working really really well. There’s obviously people on both sides of the debate saying it’s not liberal enough or it’s already too restrictive. There’s lots of debate. But it’s quite rigorous. The eligibility criteria have stood for three years. There’s no rollback, there’s no location locally, provincially or nationally looking to expand that. It’s holding well. I think that there’s a number of safeguards in place that are holding, and I think there’s absolutely no evidence of any sort of misuse. There’s been no charge of any clinician.
Okay, so you say that the safeguards are in place. In particular, what are the safeguards that you support that are in place?
There’s a number of safeguards in place. Whether I support them or not we could talk about another day. But a patient needs to give consent both previously when they have a written consent. They actually need to give consent at the moment of the death. So it has to be the patient themselves. There’s a 10-day waiting period reflective to think about their decision, to discuss it with family and have other opinions involved. There’s lots of safeguards. There’s many more.
You talked before about the legislation being reasonably stable, but there is debate in Canada at the moment about whether to increase it, and there have been reports on whether mature minors should be accessible.
I’m really glad you asked me. This is a misrepresentation of the facts of Canada. There is absolutely, in no jurisdiction in Canada, any current move to expand our eligibility criteria. Let me make that very very clear. Including mature minors. So if you just give me exactly 30 seconds, it used to be that there was a blanket ban on assisted dying in Canada. The highest court in our country carved out an exception where that could be legalised, and then the government legislated a law which is more restrictive than that, which is our current law for MAID in Canada. There is current debate. There are two court challenges challenging the restricted law to put it back to the High Court’s definition of criteria, and whether that does or doesn’t happen, it was yet to be seen. But other than that, there’s no expansion of any criteria. The issue of immature minors, which has been raised in your media, is an issue which has been discussed well before our law, during the law, and currently there’s a group of academics that have written a report about the issue of whether… Actually, the report is a collection of international data about the issue of mature minors and euthanasia. It makes no recommendation to government, and there’s no government anywhere considering expanding our law to include mature minors at this time.
So you believe that this has been misrepresented by anti-euthanasia advocates over here?
Okay. What about our law? Have you had any experience or have you looked at our law and do you see any problems with it, our proposed law?
I’m not going to comment on the New Zealand legislation that’s been proposed. I think that there is a lot of similarities, from what I’ve read, to the Canadian law. There’s also some significant differences – most significantly, I believe that there’s going to be a move towards making it restricted to terminal illness with the prognosis of six months. It’s very very different to Canada.
In Canada, it’s what?
In Canada, one of the criteria is that the natural death of the patient must be in what’s called the reasonably foreseeable future. And that is a bit of a vague term that required some time to get used to interpreting. We now have a better idea, but there’s nowhere about terminal illness or a particular time.
Would it make it easier for you if you had those kinds of restrictions that are proposed here?
No, I don’t think so. I think that would be… I think the idea of terminal illness in six months is very very restrictive and really cuts out a significant group of people that are suffering intolerably.
And those kinds of prognoses are often wrong, aren’t they?
They are. We’re not very good at that.
Okay. What about a couple of other issues that get raised here. What about the issue of coercion, that somebody is vulnerable and in a vulnerable state and they don’t want to be a burden to their family and are coerced into electing this? Have you seen that?
I actually haven’t seen that at all. I think it’s a bit condescending to people to tell them that they can’t make up their own mind. It’s part of my job to ensure that there is no coercion – both external or obvious coercion or even subtle coercion. And I always speak to patients privately and alone and have a conversation with them. I take that very very seriously. But every physician every day in their practice talks to patients about capacity and consent and coercion. They don’t use those words, but that’s exactly what they’re doing. So when people tell me that I’m challenged to do that properly, I think that’s a little bit insulting, and I certainly do know how to do my job.
Okay, and one last question. So since it’s been in place, about 8000 people up to the end of last year have taken advantage of this legislation. Has there been an increase, a jump in numbers as they years have gone past? You’re talking about 1.5 per cent of the deaths in Canada being assisted. Is that a jump? Has it been going up?
Well, it’s been going up because basically to use kind of a vulgar analogy, there’s a new product in town. It takes time for people to understand it’s available, it’s legal and it’s available in their place and how to access it, so of course the numbers are going to increase slowly over the first couple of years. This is exactly what happened in Europe. The numbers are exactly what we expected in the first couple of years. It’s still very little. It’s still about a third of what’s happening in the Netherlands. I do expect we’re going to see an increase still in Canada. I don’t think we’ve plateaued yet, but we’re getting there.
Okay. Dr Stefanie Green, thank you very much for your time this morning.
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