When the Supreme Court of Canada’s decision to strike down the nation’s blanket prohibition on assisted dying took effect in 2016, maternity doctor Stefanie Green decided it was time for a career change. After practicing family medicine and supporting parents through the process of childbirth for over twenty years, Green shifted her focus to the other end of life, becoming one of Canada’s first providers of medical assistance in dying, or MAiD. In her new memoir, This Is Assisted Dying: A Doctor’s Story of Empowering Patients at the End of Life, Green documents her first year as a MAiD provider in and around Vancouver Island, a region that now has the highest percentage of assisted deaths worldwide. By offering a window into Green’s visits with patients and families, the book reveals the intimacy, power, and liberation that are made possible when we are allowed to face death head-on.

Although the court decision and subsequent legislation on assisted dying laid out general criteria for eligibility, a number of questions remained unanswered, leaving physicians to chart the way. One of the first questions Green faces as a new provider is how to talk about her work, given the many cultural taboos around death. Not one to shy away from controversy, Green adopts a direct approach: at the start of her visit with Harvey, a 74-year-old suffering from end-stage liver failure, she states simply, “We’re going to talk about death today, and we’re going to talk about dying. We’re going to talk about your death, and we’re going to talk about assisted dying.” As she pauses, Harvey smiles before saying, “Yes, that’s exactly what I hoped for. No more bullshit.” Some of the tension lifts from his face as he invites Green to continue with her assessment. For Harvey, as for many of Green’s other patients, the physician’s frankness provides a refreshing break from the euphemisms and jargon he is used to hearing. There is a tenderness to her candor, as it acknowledges openly what many providers and family members do not: that the patient is dying, a fact that no amount of avoidance or resistance will change. Sometimes a MAiD assessment can be therapeutic to patients for the simple reason that they feel seen: they know that a medical professional is witnessing their suffering, acknowledging it, and not papering it over with more palatable language.

Upon hearing that they are approved for an assisted death, some wait months or even years before following up. For other patients, it is simply learning they are eligible that provides relief (in Green’s words, “having MAiD in the back pocket”). Occasionally the psychological shift in reframing one’s relationship to the illness is enough, and patients feel empowered to live up to death “with a startling amount of purpose.” In fact, the most commonly cited reasons for requesting an assisted death are not physical but psychological: loss of autonomy, loss of the ability to engage in activities that bring life meaning or joy, and loss of dignity. After all, while most physical pain at the end of life can be managed by palliative care, there is no easy fix for existential distress. For someone feeling powerless in the face of a devastating diagnosis, a MAiD assessment can open up choices where it seems like none remain. Just the possibility of assistance can reduce fear and suffering, and patients are better able to focus on embracing the life they have left.

When a patient does decide to proceed with an assisted death, Green is there to accompany them as they plan out the practicalities of their final moments. As a maternity doctor, she worked with families to develop birth plans, determining who would be present for a newborn’s entrance into the world. Now she helps patients choreograph their exit. In recognition of this symmetry, Green privately refers to assisted deaths as “deliveries,” because she views her work as delivering someone “out of intolerable suffering and through to their death.” In both kinds of deliveries, she is invited to witness some of the most intimate moments of people’s lives. There are patients who choose to be alone or with a single loved one, while others opt for large farewell parties. Some are too weak for anything beyond simply breathing a sigh of relief. Ed, an amateur clown with metastatic cancer, chooses to die in a full clown suit cracking his favorite joke; another man cues up AC/DC’s “Highway to Hell.” One couple decides to spend their final moments together naked in bed, and Green administers the IV medications to the husband, Richard, as his wife holds him tightly in a last embrace. John, a former labor activist, agrees to have a journalist present at his death, heartened by the thought that “dying openly, publicly, and wholeheartedly without fear could be his most meaningful legacy.” He proceeds to host his own Irish wake, where his wife proclaims, “We’re befriending death. We’re holding it, we’re witnessing it, we’re taking it back into our own hands.”

These stories form the heart of the book and testify to the joy, humor, and love that are possible at the end of life along with the inevitable grief and heartbreak. Green makes no claim to be an impartial observer, however. In some ways, the assisted deaths are spaces of mutual discovery, and Green emerges from each encounter transformed, if only temporarily. As her patients are empowered to live with intention and purpose, the doctor learns—in small ways—to do the same. These are no grand, sweeping changes but rather subtle lessons that add up as she begins to reassess her own priorities and values. After watching an 88-year-old mother say goodbye to her dying daughter, Green makes a commitment to be more available to her own children. As her own mother’s illness progresses, she broaches conversations around end-of-life wishes. Eventually, through witnessing scenes of confrontation and reconciliation, she learns, slowly, to forgive her parents. Over time, helping people die helps Green discern how she’d like to live.

When she is asked what she does for work, Green’s answer is simple: she helps people by offering them choices. Sometimes these choices are practical: who they want by their side in their final moments, when and where they’d like to die, whether they’d like to proceed with an assisted death at all. But taken together, these seemingly small decisions amount to larger ones, like the choice to befriend death, to seek reconciliation with an estranged family member, or simply, to cut the bullshit. For many, the existence of assisted death reminds them that they have an option to begin with. Accepting the certainty of their death alleviates some of their fear of the unknown and allows them to access a sense of freedom and joy they may have believed they had lost forever. Whether or not we are seeking an assisted death, perhaps we can learn from Green’s model of compassionate accompaniment and carry it forth into the choices of our daily lives, as we begin to have open and honest conversations about death with those we love, to examine the roots of our fears about dying, and to embrace whatever life we have left.

The Buddhist Ethics of Assisted Death

Assisted death can be a divisive topic, and it raises a number of ethical questions that resist easy answers. Perhaps unsurprisingly, Buddhist approaches to the practice are decidedly divergent and vary by lineage and community: some teachers advocate staunchly against it, while others adopt a more flexible stance based on context and circumstance. After all, the world of medicine has changed almost unrecognizably since the time of the historical Buddha, and decisions regarding end-of-life care have become increasingly complex. Because there isn’t a clear doctrinal solution across traditions, evaluating the practice of MAiD requires us to investigate our own understanding of what it means to offer support. In this way, MAiD offers a case study in applied Buddhist ethics: How do moral principles meet the murky circumstances of our everyday lives? And what happens when we are confronted with the concrete suffering of a human being before us?

A foundational precept across Buddhist traditions is to abstain from killing and causing harm. At first glance, MAiD seems to flagrantly violate this injunction, as a MAiD provider hastens a patient’s death through administering a lethal combination of medications. (In the language of medical ethics, this goes against the Hippocratic pillar of non-maleficence, or the duty to do no harm.) Yet assisted death also points to the ambiguities of what constitutes harm. MAiD exists as an option for Canadian residents or citizens over the age of 18 who are deemed to be capable of making their own health-care decisions and who are suffering from a “grievous and irremediable condition.” For those living with such conditions who request an assisted death, each day can be excruciating (as many of the anecdotes in Green’s memoir illustrate). In such cases, prolonging life can sometimes cause more harm than offering the option to end it, and honoring a person’s desire to regain a small sense of agency can be a profound act of compassion. In this light, presenting the option of an assisted death can be a skillful response to someone’s suffering. MAiD thus offers an example of how the Buddhist principle of nonharming and the commitment to compassion can come up against each other in practice.

But the work of a MAiD provider goes beyond the administration of medications. As she describes in her book, Green spends most of her time meeting with patients to determine their eligibility, discuss why they are seeking an assisted death, and help them create a care plan that aligns with their values and needs. Like a death doula or a spiritual teacher, a MAiD provider can open up honest, direct conversations around illness and impermanence, facilitating practical reflection on how to accept the certainty of death so as to live more fully in the present.

In challenging conventional understandings of compassionate care, the practice of assisted dying, a field that continues to evolve (and that remains ethically ambiguous for many), presents an opportunity for us to reexamine our own assumptions and resistances. Perhaps the process will help us puzzle through how Buddhist wisdom addresses the messiness of life and the inevitable occasion of death.

—Sarah Fleming