welcome to hardtalk. i'm stephen sackur. in 2021, more than 10,000 canadians died at the hands of health care professionals. thanks to the country's legalisation of euthanasia. a handful of other countries have also legalised doctor assisted dying, but often with more restrictive rules. so, canada has become something of a global testing ground for the complex ethical, medical and social issues raised by euthanasia.

my guest, dr stefanie green, is a specialist in medically assisted dying, and has overseen more than 300 deaths herself. is canada at ease with its role as assisted dying pioneer? dr stefanie green in victoria, canada. welcome to hardtalk. thanks for having me. it's a pleasure to have you on the show, dr green. now, you are an experienced medical doctor, but your particular focus for the last few years has been offering medical assistance in dying.

so, in terms of your day to dayjob, what does that actually mean you do? mostly, it means i talk to a lot of patients. practically speaking, what it means is i meet with families and patients who are interested in talking about their end of life choices, specifically about the possibility of an assisted death. i do a lot of education and a lot of informing patients what that is, what it isn't, what other options might be. we talk about the process, the procedure. there's a very rigorous process that needs to happen if they want to go down that path. so, we work together through that process if necessary. and of course, ultimately, for some, it's a matter of offering the procedure itself administering the medications that will help somebody to end their life. right. and i do want to delve into the detail of how choices are made by people at that end of life moment. but i'm also actually really interested in your choice.

so, let's start there, because you were trained in obstetrics. you know, your work, before all of this, was with women about to give birth and delivering babies. in a sense, you were there at that moment of new life. why did you choose to make this dramatic switch in your medical career to focus on the moments of death? i'm actually trained as a family doctor, so everything from what we say is cradle to grave medicine. i did general practice for many years and always focused on maternity care. i've always had an interest in the intersection between medicine, ethics and law. and i... i found i was able to find that through women's health, maternity care, reproductive rights. and i very much enjoyed my work. and ifound, much to my surprise, actually, that my work, my 20 years working in maternity care, really, really prepared me well for end of life. there's a similar skill set where you are dealing with families that one of the most intense days of their lives, a very emotional time in their lives,

with a lot of family dynamics going on. and i'm there as a knowledgeable guide to help them through this incredibly intense and natural event. and all of those things can be said at the end of life as well. why did i make that change? i had a number of... it's not a very linear line... a number of issues. i wanted to be home a little bit more. i was finding after 20 years of providing maternity care and delivering babies, that being 2a hours in hospital and recovering from that time was becoming physically harder. i wanted to be around before my kids left. i was looking for a shift, and i'd been following the assisted dying debate in canada for 30 years since i was in medical school, and i believe very, very strongly in patient autonomy and what we call patient centred care. and i found that the idea of assisted dying was really focused on that. and i wondered who would do this work? and i felt that i could do this work. the more i learned about it, the more i was drawn to it.

so, nonlinear path. you talk about your medical training, and ijust looked up the hippocratic oath, at least as it's expressed in the uk and doctors training. and that oath, which of course, all doctors have to swear to uphold, it reads, "i will use my power to help the sick to the best of my ability and judgment. i will abstain from harming or wronging any" man or woman by it." yourjob is to carry around a bag of toxic poisons and administer them, i'm not trying to be flippant, administer them to people who are suffering grievously. i think there are two words in your statement that are important. one is to help. the essence of what clinicians do is we help our patients. we might do that in different ways. we cure sometimes, we care often and we comfort always. i think helping is what the essence of what we do. the other word is harm. i don't think i'm harming anybody. you can ask all the patients and families i deal with, i am helping them and facilitating

theirfinal wish, their illness, their disease. that is what is harming them, that is what is killing them. i am there to help them at a time of great need, so i think it fits perfectly with what clinicians do. it is clear this is a hugely complex, ethical and moral area. end—of—life care. before we get into the details of the cases, i wonder, when pope francis came to canada in 2022 and made a point of addressing the fact that canada has the highest number of euthanasia deaths in the whole world. he said we need to learn how to listen to the pain of the poor and marginalised people in place of affection. in relation to canada he said patients are administered death. that was a message, in a sense, directed at people like you. in place of affection, patients

are administered death. how did you feel about that? it is not something the first time i disagree with something the pope has said. i don't take my directions from him. i don't mind that that is his impression. i take issue with that. i think we offer affection. i think we offer help, caring and compassion. we do it in a professional manner within a rigorous system with oversight. it's a legal framework. it's a rigorous framework. so i'm proud of what we do. i think everyone can think what they wish but that does not faze me. let's talk mechanics if we can, doctor green. when you meet someone who appears to fits the bill, they want to die, they explain the reasons they want to die, how does the process work? from that wish to die to the end point itself and your delivery of death?

so every case is really individual. that sounds a little bit flippant to say but it is true. there is no standard path that anyone will take, but generally speaking the process is that the patient needs to be the one to make the wish. no one else can ask for that on their behalf. the patient expresses their wish in a written form it is signed and dated and witnessed. it is an official form. two clinicians need to see the patient separately and have an independent assessment to make sure that the medical and legal criteria are met. it is a rigorous system and i won't go through all the details but there are approximately eight or nine things that need to be found to be true. the prime ones that your audience might be interested in, the patient has to make a voluntary request and have the capacity to meet the request. they need a grieve use and irremediable condition.

they need to be suffering intolerably and other issues need to be found to be true. on top of that, there are a number of procedural safeguards that need to be met. if all of that happens, there is the matter of empowering the patient and saying that you are eligible. that doesn't mean you would have an assisted death or that you must, but that you may. that in itself is therapeutic. is there a in—built time lag? so that from the expression of wish to the end, are there time restrictions or controls put in to ensure the decision is fixed and that minds have not changed? how does that work? 0ur original legislation required about a ten day period from the time that the wish was made in writing until the event could happen. we found that that was a false safeguard. we found that created a lot of anxiety in all our patients who were close to the end of life and concerned that they needed to retain capacity. there were refusing the medication and intervention

in order to ensure they could make that final decision which was another safeguard in our system. that ten day wait has been removed from our law, because it was found to be because it was detrimental. now we have two tracks. the first step is for deaths which are reasonably foreseeable. they can make their wish, go through the process and plan their death in whatever timeline works for them. for patients whose death is not reasonably foreseeable, track two, there is a minimum assessment period of 90 days to make sure it is fulsome. i find that is a low bar those cases can be complicated and can take months and months of time but there's a minimum of 90 days for those whose death is not reasonably foreseeable. doctor green let me ask you a blunt and personal question. what is it like for you to be physically with the person

at the time of their death, and for you to be the person administering the lethal cocktail of drugs that kills them? you are killing them, unlike in certain situations, like california and countries in europe where assisted suicide is allowed. where a medical professional can be present, but the person has to administer their own drugs. you are administering the lethal drugs and you are killing that person. i was concerned when i began the work and wondered what that would be, but after some thought, the most accurate thing i can say to describe this work is privilege. i feel incredible privileged to be invited into that intimate time for a patient who is at the end of their life, to be asked to facilitate their final wish. to be trusted in that time

and journey with them and witness their suffering and help them choreograph this very important event. it is, i find very privileged work and ifound it to be profoundly meaningful. people express a lot of gratitude for this possibility, and a lot of relief they can have the open and honest conversation. i have been overwhelmed by the gratitude expressed by the patients and their families for this work. that is a powerful way of putting it. i wonder, whether at that last moment as you are about to begin the administration of drugs, have you ever had somebody say "i can't go through with this?" "this can't happen. " i've never seen that, personally. i have had a significant amount of experience. in that time, i can think of two patients who changed their mind when i showed up. we give them, i give my patients opportunity

to change their mind they know they are eligible to do that, and we give them the opportunity right up until that moment you describe. i had two patients who said they weren't ready and one of them died that night from their own medical complications, and the other call me back the next day and asked me to come as soon as possible. other than that, i have not seen that personally. people do not enter that decision lightly or spur of the moment. they spend months and years thinking about this, and they come to me when they are ready to make this choice and they are frustrated that the process takes time to go through. but i have not seen personally a lot of people change their minds. i think, i see they are very much ready on the day of the event ourselves and very much at peace and ready to move on. theirfamily and friends are grieving and it is harder for them than the patients in my experience.

as you alluded to in our conversation, there are rules regarding those who are terminal and those who are suffering unendurable long—term pain but are not actually terminally ill. the canadian law has expanded its scope over the period from 2016 to the present day. many canadians it seems are worried that as it stands, the rules around assisted dying essentially give a signal to the country that enduring disability is now a sort of qualifier for euthanasia. is that a fair comment? i think that is inaccurate, to be honest. i think context is important. the original high court decision, the change in our laws didn't come because patients demanded it, or the government thought it was a good idea. this was a rights issue in

canada which is quite unique. it determined that the blanket prohibition of assisted dying was infringing on certain peoples rights in certain circumstances. and in that decision it is important to note that the court decision did not require a link with end—of—life or a terminal illness. the government imposed what they called reasonably foreseeable death, which was never meaning terminal illness. it was never an eligibility criteria in canada. it was put in place by 2016 by the government and was felt to go against the court decision and challenged in the courts. the court in 2019 verified it was constitutionally invalid and removed it from our law. so we never required terminal illness and we don't now, but we do have a path for those whose deaths are reasonably foreseeable with a time frame around it. that in mind, it doesn't mean that because your enduring

disability that you qualified for assisted death. there are many things that need to be true. serious illness, disease or disability is one factor. patients also need to be in advanced stage of decline. you are outining it very clearly but people in canada today say that the fact is some people, severely disabled, with different kinds of conditions that are giving their lives enormous pain and difficulty, they turned to assisted dying, simply because the health care and economic situation they are living in in canada today is not able to improve their lives to a point where life would be endurable. they say, rather than offering these people a chance to die, what we should really be doing is entirely focusing our attention on fixing

the problems on health care and economic situations which would give them a better quality of life. yeah, i think that we absolutely need to recognise that there are social inadequacies. we have done terribly, like many countries. canada has not lived up to its promise in terms of community mental health services, disability support. some areas don't have palliative care. we need to do better in housing and income stability. these are real problems. i stand loudly and proudly with anyone demanding better. i can't do myjob properly if i can't offer these things to my patients. federal law requires me to make patients aware of the means to reduce their suffering, including those resources. and to make sure that they seriously consider them. if they don't exist, it's very difficult for me to do myjob. 0n the other hand, if those things don't exist we can't hold individuals hostage

to society's failings. we need to do better in those issues, but that doesn't mean we shouldn't allow assisted dying for people who are suffering intolerably in a system inadequate to help them. there is a difficult question about prioritisation. one case about the four canadian veterans who in the autumn of 2022, it seems, were offered the possibility of assisted dying by a caseworker who looked at their individual circumstances. one of them was a well—known para—0lympian who said she was offered the option of dying by this health care employee after she said that she didn't have a ramp, a wheelchair ramp in her home, and was struggling to get one installed. that is terrible. that is so shocking. how can that happen in canada?

it is ludicrous, i agree. you mention it was a caseworker. i don't know why a caseworker in veteran affairs would be bringing up assisted dying with someone. clearly, someone has stepped out of their lane. it is not theirjob or ability to do so. they don't have a professional responsibility to do so. that is a ludicrous error. in some countries, where euthanasia is legal, in victoria, australia, there is a rule where no professional involved in care can initiate a conversation about assisted dying. but that is absolutely not the case in canada, is it? so, and i agree it shouldn't be the case. we're going talk about that. no caseworker should ever be bringing it up. i agree with that and it was clearly a ludicrous

error someone made. in the circumstances, when a clinician is dealing with a patient, it is my professional obligation to offer all options to a patient when they are available. if i have a a patient that requires chemotherapy and i know of three regimens and i only offer one i am professionally liable for not doing myjob. if a patient is in a specific situation and talking about end—of—life choices and exploring their goals of care and discussions about what they want and don't want, and talking about palliative care and what is available, it would be professionally obligated for me to say, something along the lines of some people in canada are interested in hearing about assisted dying, it is newly available, is it something you want me to discuss with you? i think you can ask a question and raise an issue in a compassionate way and the patient can guide that conversation. for me to not do so would be not doing myjob. but outside of that it is something that

should not be happening. in numbers, canada has the highest number of deaths by different forms of assisted dying in the whole world in 2021. some doctors involved in this are now getting worried. i'm talking about doctor lee for example who also works in this field as you do, she is now worried. she says the laws are too vague and "i don't think death should be the society's solutions for its own failures. i think the canadian populace and maybe legislators are not not now aware of who is qualified and who has been dying in this way." she is beginning to get very worried. are you? i very much respect doctor lee. i work with her and i respect her point of her view and disagree with it. i think we have a rigorous

system with a number of safeguards and eligibility criteria that are being exceptionally well adhered to. i know the colleagues in my country that do this work do it carefully and conscientiously and are aware that if they get it wrong, they are liable for jail. we have been careful in the past 6.5 years. there has not been one charge against a clinician for doing this work in an abusive way or in any way out of the system. i think there are people who are concerned about the role of government in supply and the social needs, but that is different than the main programme. quickly before we end. the canadian government is wrestling about whether to go with another expansion of the parameters of assisted dying to include severe forms of mental illness. do you support that expansion? it's not whether i support it. it's up to the constitutional experts in our country and they have i spoken about that.

this is a measure of inclusivity. not an expansion of our law but a restoration of the rights of those with severe mental health disorders in rare cases. so they also have the access to this legal care should they qualify. whatever the law says, i will follow. it is not whether i agree or not. the question is not whether it would happen but how to do it safely and we are grappling with how to do that. canada is seen across the world as the place with the most liberal assisted dying laws in the world. do you think that is something that canadians should be proud of, or something right now canadians need to think hard about or worry about? i think we need to remember that canada has learned from otherjurisdictions.

we saw what was working in europe and what wasn't, we saw what was working in the us and what wasn't. we have clinicians who can administer the medications and taking that has allowed us to create models that has allowed us more to the point what patients need and require with still a very rigorous system. i think canadians are supportive and proud of the opportunity to have this care available to them and are grateful for that, and i don't think there's anything to be particularly concerned about in that. doctor stefanie greene, it has been a pleasure talking to you. thank you for being on hardtalk. thank you for your time.

hello there. gales to begin with on monday, warmth to finish it. in fact, it was a very mild day, pretty much across the country, but highs of 17 celsius recorded in east anglia, 63 fahrenheit. the average for this time of year across the country, generally around eight degrees. now, we do have these weather fronts across the far north which are bringing outbreaks of light rain. but this milder air sandwiched between those two weather fronts is what's known as a broad, warm sector, and it can often at this time of year bring a lot of clouds. so, it's going to be a gray start, but an incredibly mild start first thing on tuesday morning. here's the rain from those weatherfronts, then, pushing out of the western isles up into the northern isles. not as windy as monday morning, but a noticeable breeze and the cloud always thick enough for a spot or two of drizzle. now, on the whole, greyer skies more cloud around, but where we do get some breaks, temperatures will tend to respond.

13, 1a degrees, not out of the question. a change to come, though, as we move out of tuesday into wednesday, there's a cold front sinking its way steadily south. not bringing that much in the way of rain, but certainly introducing a change of wind direction. coming round from the northwest to cool a fresher source. so, to begin with, on wednesday, we'll have some light showery rain sinking its way into east anglia and the south east of england, brightening up considerably behind with a few scattered showers being driven along by those northwest winds. and some of them to higher ground in scotland, turning increasingly wintry. notably fresher feel to the day, seven to 11 degrees, the overall high. now, through wednesday into the early hours of thursday morning, mightjust have to keep a close eye on the chance, perhaps, of a few wintry showers running down through the north sea here under clearer skies and lower temperatures. so, it's going to be a chilly start to thursday morning. touch of light frost in the far north, not out of the question, but high pressure always sitting out to the west. so, the wind direction coming round from a north westerly, not too cold, but certainly

fresher than it has been in recent days. so, there will be a little bit more in the way of sunshine around on thursday. thicker cloud and outbreaks of showery rain into the far north, but in the sunnier moments shouldn't feel too bad. top temperatures of around eight or nine degrees, down to where we should be really for the time of year. it looks likely that we will continue to see a good deal of dry but fresher weather for many as we head towards the weekend.

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