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Stably Unstable with Dr. Jeff Yoo
Should Doctors Let Personal Beliefs Influence Patient Care? Dr. Margaret Cottle [SUJY #005]
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What happens when two physicians approach medicine from very different ethical frameworks?
In this episode, I sit down with Margaret Cottle, a palliative care physician, author, speaker, and prominent voice in the Christian medical community. Dr. Cottle has spent more than 20 years caring for patients with terminal illness in Vancouver, BC, and is a clinical instructor at UBC Medical School. She serves as Vice President of the Euthanasia Prevention Coalition and is involved with the Christian Advocacy Society of Greater Vancouver. Together with her husband, she also helps host gatherings for the Christian Medical and Dental Association of Canada community in Vancouver.
Dr. Cottle is a vocal advocate for pro-life medicine and has been an outspoken critic of Medical Assistance in Dying (MAID) in Canada. While many of her views are rooted in her Christian faith, our conversation explores how those beliefs intersect with modern medical practice and some of the most controversial healthcare issues facing society today.
As an emergency physician, my own approach is grounded in patient-centered care, respect for patient autonomy, and the recognition that people bring different values, beliefs, and life experiences into medical decision-making. This discussion examines where those perspectives align, where they diverge, and how physicians can navigate ethical disagreements while still caring for patients with compassion and respect.
Topics discussed include:
• Medical Assistance in Dying (MAID)
• Abortion and reproductive healthcare
• Contraception
• Patient autonomy and informed consent
• The role of personal values and faith in healthcare
• Palliative care and end-of-life decision making
• What patient-centered care means in practice
Whether you agree with Dr. Cottle, disagree with her, or fall somewhere in between, I hope this conversation encourages thoughtful discussion about some of the most challenging ethical questions in medicine.
What are your thoughts? Where should the balance lie between patient autonomy, physician conscience, and ethical responsibility? Let me know in the comments below.
So supportive or against? Evidence-based medicine.
SPEAKER_03Supportive.
SPEAKER_01Supportive. Patient-centered care.
SPEAKER_03Supportive, depending on how you define it.
SPEAKER_01Supportive. Medical assistance in dying.
SPEAKER_03Against.
SPEAKER_01Against. Okay. Supportive. Contraception, like condoms and birth control.
SPEAKER_03Supportive in the right context.
SPEAKER_01Okay. Yeah, we'll dive into that. I'm supportive. Elective abortion.
SPEAKER_02Against.
SPEAKER_01Against. Okay. Supportive. Gender-affirming care for adults, whether that's medical or surgical transgenderism.
SPEAKER_03I can't give a one-word answer on that. I I really care about the people that are caught in that, but I have a hard time supporting something that I don't think is addressing the underlying issue.
SPEAKER_01I will say, in general, supportive.
SPEAKER_03Okay.
SPEAKER_01Okay. Do you think that a doctor's religion affects their medical decisions for the patients that they are treating? Yes or no?
SPEAKER_03I think a doctor's core beliefs affect that, so yes.
SPEAKER_01I agree. Yes, I do believe that. Do you think that it's okay if it does?
SPEAKER_03I don't see how it can't.
SPEAKER_01Okay, but I guess the question is whether you think it is okay for someone to impose their own, I guess, uh, religious beliefs and the moral compass that they have derived from it onto patients that don't necessarily share the same religion as them. Thanks so much for joining me on the podcast. Um I've been wanting to do a podcast talking about faith, religion, and personal beliefs and how that shapes doctors' uh care for patients. And one thing that I want to say before we even start the podcast is that the point of this podcast and discussion is not to debate whether or not God is real or really to kind of argue whether the way that you practice or I practice is correct or not, but really it's really to explore how these personal beliefs shape patient care when you're face to face with a patient. I personally feel that so many topics around healthcare have become so polarized in the recent years, and this forces people to separate into separate silos and leads to things like identity politics and groupthink, and I think that this is one of the biggest modern tragedies. So, you know, like I know that you and I are coming from different perspectives, and I really do appreciate that you were willing to sit down with me because you honestly, when I was searching for people and reaching out to people to speak with me on some of these things, a lot of people are either not brave enough or not stupid enough as you and me to actually talk about this in a public forum, you know. So thank you. Um, and one thing that I'll say to anyone that's watching or listening to this is um, you know, please watch and listen with an open mind. Um, you know, if what we say does not totally align with your personal beliefs, please don't demonize us. This is really supposed to be an open conversation and a constructive one for that matter.
SPEAKER_03I I totally agree. I think the world is a better place if we listen to each other and understand where the other person is coming from, understand some of the wounds that they may have from the past. But one of the things that is the top of the list for marriage counseling is always to put the best spin on things. So always expect the best interpretation of what's been said. So I think we did that when we had a telephone conversation. Absolutely. And I hope that we can do that, and I hope that your listeners or your watchers will be able to have that same idea that maybe either of us doesn't express things in the way that they can hear the best, but that we are not intending to be inflammatory or to disrespectful in any way.
SPEAKER_01Absolutely. So on that note, Dr. Margaret Coddle, please introduce yourself, maybe talk about what you uh have done in your medical career and how what your involvement is in the Christian faith.
SPEAKER_03I graduated from the University of BC in 1978 before most of your watchers were probably born. So I've been involved in medicine for over 50 years, and I was drawn to medicine partly because of my Christian faith and through lots of experiences that came through that, but because I really, like most of us who are in medicine, really wanted to help people. And I felt that there was a very holistic part of medicine where we were able to help physical needs as well as spiritual and emotional needs as well. And when I was in medical school, there was no such thing as palliative care. The big textbook of pain didn't even, excuse me, the big textbook of cancer that's about this thick, didn't have a single entry in the index for pain. So it was a new concept when I was about 10 years out of medical school. I attended a morning conference in Halifax when my husband was doing his residency that was included four of the original bright light people from the palliative care world. And I came home just stunned because I felt that this was an area of medicine that took into consideration all those things that I had loved about medicine for so many years when I would start to talk to my preceptors about wow, this person had been in a concentration camp in World War II, and they'd roll their eyes and they'd say, Well, what's the blood pressure? And I finally found a discipline within medicine that was interested in people's stories, interested in who they were, and understood the power of that narrative in their life. And so I never looked back. I ended up doing what was available then, which was four weeks of training in Montreal with Dr. Balfour Mount and his team. I came back to Nova Scotia. I had little kids. My dad, who had lost his wife to cancer a few years before, came to Nova Scotia and was the mom for our children while my husband was in residency. And I came home from my four weeks of training and was on call the first weekend. So it was trial by fire, but there was so much about it that really just fed something important in me as well. That there were people who were fearful, and I was able to come into their lives and say, I'm here. I'm I'm I can come alongside you. There were people who were in pain, and I knew how to help that. There were families who were in kind of disarray, and I knew how to help them come together. And that was a really beautiful thing in my life. And we moved back to BC after my husband's residency, and I've been involved in all aspects of palliative care, home care, care on the palliative care unit, care on the consult team, um, all those sorts of things, and I'm and teaching. And I um really have enjoyed the home care the most. I think partly because I'm kind of a nosy person, and I love going into people's homes and and seeing a picture. Oh, this is when I met the Yaga Khan. Like, whoa, this is interesting, or pictures of where where they came from and stories that they can tell me. And I'm I still I think cause some of the home care nurses to roll their eyes because when I I do a home visit, it usually takes longer than somebody else because I'm so interested in their lives and in what's going on. But I've I have found in my practice that that time is never wasted. You know, you make those connections with people and they come back to you and they uh they feel like they can trust you and that you understand them, and then you can determine a uh course of where to go from here together. And anytime that you can do that collaboratively, it's always it's always going to be better.
SPEAKER_01Yeah. I mean, so much of what you just said resonates so deeply with me. Uh just taking the time to hear someone's life story, hear their values, um, and just like yeah, develop a basic connection on a human-to-human level, just goes such a long way in terms of patient-physician trust, and uh I think it's just even the overall fulfillment that you get from your job as a physician, right? Uh, we're not there to treat patient with chest pain or girl with gastroenteritis. We're there to treat the human that's in front of us, not only the biological portion, but the biopsychosocial portion of them, right? So that's uh that's wonderful.
SPEAKER_03Well, I also think that in palliative care, Dr. Cicely Saunders, he's the founder of modern palliative care, um, she was from the UK, and she talked about total pain and how there's uh it's sort of an overlapping Venn diagram. There's there's physical pain, there's spiritual pain, there's psychological pain, and there's social pain or familial pain. And one of my colleagues actually says there's such a thing as bureaucratic pain too.
SPEAKER_00Which I believe it.
SPEAKER_03Which, you know, people we laugh and say in the US, well, they have all these different um insurance and all these things to deal with. But here in Canada, we have bad bureaucratic pain too. If somebody is has a cancer biopsy that's positive and they wait six weeks before they can get an MRI, and then they wait another three weeks before they get the results of that. That's bureaucratic pain. So I think we have that, we have that everywhere. But that that sense of people being whole people is is so important, and that has a real overlap uh or congruence with my Christian faith. When from my understanding of of the Bible, my understanding of who Jesus was as a person and how he treated people around him, every person is made in the image of God. Every person is worthwhile, every person deserves my respect, deserves all the expertise that I can bring to them. Have I always done that well? No, I haven't. My mentor Dr. Mount always loved the the uh Martin Buber's thing with the I thou relationship, that idea of of really connecting with people. And if you look at the person of Jesus, he did that. You know, he he met the woman at the well who he should never even have been talking to, and he connected with her, he knew all about her, and he invited her to serve him. So there were there were things, there are things like that that are the the North Star for me in how I treat my patients, how I treat my colleagues, and the the I guess the standard that I would measure myself against, not whether I'm better than the other doctors or whether I'm better than something that the media feels is a good doctor, but how Christ-like am I in in how I do that? Yes, I was very open about my Christian faith. And we have the student group of the Christian Medical and Dental Society of Canada. They've met in our home now for over 30 years. We've served weekly meals to them for 30 years and invited people to come. And you don't have to be a Christian to come or anything. We had a Sikh young man who came for a year, we had a couple who were um Ishmaeli who came for a couple of years. So it's very open and welcoming, and we talk about lots of different things. But I I was very clear that each one of us has a set of core beliefs, and those core beliefs are important in how we treat other patients, how we treat our patients, how we treat our colleagues. I would say to them, if you don't have an understanding about what those core beliefs are for you, what are the things that you quote won't tolerate? You know, you don't you can be too tolerant about something. So what are the things you won't tolerate? What are the things that are most important to you? And understand how those core beliefs are going to affect how you treat your patients, how you treat your world, how you treat the your your colleagues, and how you treat the other workers who are in the healthcare system with you. I even talked, I've given lots of talks to my Christian colleagues as well about this, and I said, look, I'm very, very strict about this. If you have a messed up idea about why suffering happens, you're going to be dangerous to your patients and their families.
SPEAKER_01Well, everything that you're saying just really, really resonates with me. I love uh what you were saying about having that uh North Star, like a moral compass. And pretty much that is like the entirety of what I want to talk about today. So it's really great that you're bringing that up unprompted. That's lovely. I have a few things that I want to talk about because um, as you can tell, I I've thought about, I guess, faith and personal beliefs and how it applies to medicine and the care that we provide to patients quite a bit. And I you know that I've talked about some of these issues, but um I was thinking maybe to introduce some of the topics, uh, we'll just go through the list of topics, saying one word, whether you and I are supportive or against it. And then after we go through this list, we'll just dive into each one and we can elaborate a little bit more. Is that okay? Sure. Okay. So supportive or against? Evidence-based medicine.
SPEAKER_03Supportive.
SPEAKER_01Supportive. Uh patient-centered care. Supportive, depending on how you define it. Supportive, yeah. Well, we can we can talk about that. Medical assistance in dying. Against. Against. Okay. Supportive. Uh contraception, like condoms and birth control.
SPEAKER_03Supportive in the right context.
SPEAKER_01Okay. Yeah, we'll dive into that. I'm supportive. Um, elective abortion.
SPEAKER_02Against.
SPEAKER_01Against. Okay. Supportive. Uh gender-affirming care for adults, whether that's medical or surgical transgenderism.
SPEAKER_02I can't give a one-word answer on that.
SPEAKER_01Okay.
SPEAKER_03Is that it's this one's a really hard one for me because you know, going back to the evidence-based medicine, I don't see really any evidence that it's been helpful for the the dysphoria that they have. Gender dysphoria? The gender dysphoria that people have.
SPEAKER_01Um we can we can dive into some of the details. We'll see.
SPEAKER_03It's hard for me. I I I would say that I I really care about the people that are caught in that, but I have a hard time supporting something that I don't think is addressing the underlying issue.
SPEAKER_06Okay.
SPEAKER_03So that's where I am. Okay. Sorry, I know it's not one word, but I can't really do that.
SPEAKER_01I will say, in general, supportive. Okay. Okay. Um do you think that a doctor's religion affects their medical decisions for the patients that they are treating? Yes or no?
SPEAKER_03I think a doctor's core beliefs affect that, so yes.
SPEAKER_01I agree. Yes, I do believe that. Do you think that it's okay if it does?
SPEAKER_03I don't see how it can't.
SPEAKER_01Okay, but I guess the question is whether you think it is okay for someone to impose their own, I guess, uh, religious beliefs and the moral compass that they have derived from it onto patients that don't necessarily share the same religion as them.
SPEAKER_03I think that's a different issue than what you are saying. Um I think every single person has that moral compass of their own, and whether they believe it or not or recognize it or not, they are imposing that on um on the patient that comes to them.
SPEAKER_01Lovely. I love that. I love that response.
SPEAKER_03There's there's no way not to.
SPEAKER_01Yeah.
SPEAKER_03Now that you are who you are.
SPEAKER_00Yeah, absolutely. I totally agree with that.
SPEAKER_03On the other hand, if um if you're can being controlling about it, that's not okay.
SPEAKER_01Yeah. Okay. Why don't we just dive right into it? Okay. Why don't we start with evidence-based medicine? Because this is how you and I are connected, right? I posted a story of how this really was kind of the core of why I left my Christian faith. Um, so maybe before I even like we get into it, maybe I'll just share my story. So I grew up in a Christian household. I I went to a Presbyterian church growing up. Um, and you know, like I grew up um as a Christian. I accepted Jesus Christ as my Lord and Savior. And I I don't think I was like the most like quote unquote hardcore Christian uh growing up, uh especially like in high school and even in my first couple of years of uh college or undergraduate, um, you know, I was really into like partying and drinking, you know, smoked weed in high school and stuff like that, right? So yeah, I guess you can kind of I was kind of like a loosey-goosey hippie type of Christian, okay? But um when I was in second or third year of undergraduate, I started going to a church um that was, I guess, much more evangelical. I think like the actual denomination was like Southern Baptist, okay. And um they had a very, very charismatic pastor um who was an excellent speaker. Um, going to church on Sundays really felt like I was going to a lecture, and like they would have been like hand out like pamphlets where you can like write down notes and stuff like that. And you know, that I felt like that was actually quite psychologically stimulating for me, and um I really enjoyed it. I became more and more immersed in the Christian faith. Um, you know, I was going to Bible studies on Wednesdays, going to uh morning prayers on like Saturdays, uh, I was leading a men's small group. Um I was, you know, at one point I took a course on how to evangelize and was going to, you know, college campuses with some of my church uh peers and evangelizing to people on on campus, you know. And um, you know, I can wholeheartedly say I really did believe Jesus Christ was my Lord and Savior, and I was ready to like die for my faith at that point and live for my faith for that matter, right? Um, I think things really changed when I went to medical school. Uh, because I think like in college, you can really surround yourselves with who you want, people that you know subscribe to the same belief systems as you, people that look like you, talk like you, you know. Um, and when I went to medical school, you're thrown into a pool, the one classroom with uh a bunch of really, really intelligent people from many different ethnic backgrounds, religious backgrounds, cultural backgrounds. And I felt like a lot of the narratives that I was taught through my Christian faith were kind of being broken down as I was going through medical school. Um, you know, one of the things was like talking about how people from other religions uh uh don't have like the best theology or uh, you know, their their narrative of Jesus Christ as a person and uh you know him as a deity was not totally accurate. Like uh, you know, oftentimes it's kind of like Catholics are not as following the Bible as closely as Christians, or um Jewish people they've rejected Jesus Christ, and those were the Pharisees that were the ones that actually pinned them to the cross, so and so on and so forth, right? So, you know, when I was in this classroom with all these different people, I'm like, man, these people are really smart and they're really, really nice people, like genuinely people that I loved, you know. And I think that was the first time when I was like, okay, like I think I need to like actually go back to the drawing board and actually determine if this is like really what I want to subscribe my life to. But you know, I continue going to church straight through medical school, and uh when I went to residency, that's when you're really taught how to critically appraise the different research and information that's out there in the sphere, right? So um, you know, you're taught if you ever read a research paper, you need to critically appraise the information that's in there. How was the information gathered? Uh, how was the the population that was in the study, how were they selected to be in that study? Are they applicable to the patients that you're actually treating? Um, what was the intervention? What was the control? Was the study blinded? And what were the outcomes? Uh, specifically, like what's the number needed to treat, number needed to harm, was their statistical significance, what's the confidence interval? And based on all these different things, you're analyzing whether or not the information in that study is actually applicable to your own practice and whether you would want to apply it in your own life, and would whether you would actually want to change your practice and use those the information to treat your patients, right? And um, that was like a true, I guess, like a shift in my mentality where like you're using this hyperlogical way of thinking to uh really determine how you're going to act and and think. And when I went back to my Christian faith, I really felt like there was a lot of circular argument. Like I think the thing that I can't kept coming back to was um, you know, God is real because the Bible says so. God thinks that homosexuality is a sin or it's bad. Why do we believe that the Bible is correct? Well, because the Bible is the Word of God, and therefore we just keep entering the circle. And it doesn't have to be about homosexuality, but it can be about whatever it is, you know?
SPEAKER_06Yeah.
SPEAKER_01And and so that was the big breakdown in my mentality where I finally decided, you know what, like I'm not totally sure that I can actually keep subscribing to the Christian faith because you know, this hyperlogical way of thinking in medicine just doesn't seem possible to coexist with faith. Um, and so that's kind of my story of like my Christian faith and why I left it. What are your thoughts on that?
SPEAKER_03Well, I mean it's your story. So you know what I mean. I I it's I'm not here to criticize your story or to say you were wrong or anything like that. All I can say is that if there are there have been many people throughout history who have looked at the evidence. Okay. They've looked at the biblical evidence, they've looked at the extra-biblical evidence, the historical evidence, they've looked at the evidence of the change that's happened in people's lives when they become believers. And they have come, they they've looked at the 400 prophecies from the Old Testament that were all fulfilled in Jesus, that were written before he was born. They looked at how um all of the disciples who were, you know, they ran away from him, but then after the resurrection, every single one of them went to his grave without giving up on that. And they just said, you know, if it had been a big conspiracy, that they had no, they had no reason to hang on to this, if it had been a conspiracy for all the things that they were against. So this idea that somehow it's it's all circular, I think I guess I would disagree with that. And there have been a lot of people through history who have sat down and said, I'm gonna prove this wrong, and ended up becoming believers when they when they see all these extra things that have come along. Uh the most recent one that has sort of been out there.
SPEAKER_00Um Case for Christ, Lee Strobel.
SPEAKER_03It is Lee Strobel. And one of the one of the people that Lee Strobel interviewed for his book is a good friend of ours. So Dr. Edwin Yamauchi, who has done a lot of work on the original, he wrote a book called The Stones and the Scripture, so it's the archaeological evidence that he Lee Strobel talked to him about, and all of these different different things that are there. So I don't think that um I don't think one has to throw the scientific method out in order to do that and have it be uh, you know, because there is still a lot of evidence that is there, I would say. And you know, there's even a book called Evidence That Demands a Verdict that it talks about this.
SPEAKER_01Totally. And I I guess like um I'm not really debating whether or not Jesus Christ as a person was real or not, or whether he was yeah, because uh, you know, if it if I'm being honest, I actually think Jesus Christ was a real person. Um, you know, do I believe uh Jesus Christ is, you know, the Son of God and the only the way, the truth, and the life, the only way to get to heaven? I'm not totally convinced. Um, you know, do I believe that there is some kind of deity that kind of guides the universe? It's possible. And just like you said, um, you know, I'm not discounting faith at all. I think faith is yeah, faith is incredibly powerful. And I've seen it myself, like people that are suffering, um, they can find real hope and meaning from their faith. And I think that's incredibly powerful. Yeah, that's something that science can't even up uh one explains, and something that science really can't even offer, really, when someone is in that kind of intense suffering to provide them with that kind of hope and meaning, right? But I guess like the way that you practice your Christian faith. Yeah, like I just feel like it's very counterintuitive to logical thinking in in the way that we practice medicine, looking at specific numbers and dissecting p-values and stuff like that, you know?
SPEAKER_03Well, maybe on the surface.
SPEAKER_01You think so?
SPEAKER_03Maybe on the surface it looks like that. But you know what? The most powerful thing we do in medicine is to relate to other people, is to come alongside them and say, I see you. I know that this is a dark time for you. I'm I'm gonna be here. And I'm gonna be here and I'm gonna get this nausea. I'm gonna make sure that you don't have it. I'm gonna make sure you don't feel breathless anymore. I'm not I'm not leaving this place until you feel better. And that's way more powerful than the oxygen that you're giving. So this idea that somehow these things don't come together, you know, there's so much in medicine. You know, haven't you ever had a patient? I have had many, where you see all the numbers, everything looks great, and something says something's not right about this patient. Okay.
SPEAKER_01The vibes. Yes, you can't put your finger on it, but there's something like that.
SPEAKER_03You know there's something wrong, and the more you go in medicine, the more you trust those things.
SPEAKER_01The sixth sense, yeah, that's something that we always talk about in medicine.
SPEAKER_03Yeah. So where is that in the evidence-based medicine? Yeah.
SPEAKER_01But you know, like at this, okay, I this really does kind of like make me think about that other case that I recently talked about on social media where like I had a patient who had a really bad traumatic brain injury, who is no longer really cognizant of what he's doing, and he's like masturbating in front of nurses, and he's doing all these really inappropriate things, being super nasty and mean to his wife, you know. And it's like, um, I like how do you put your finger on that? Like, how do you make any sense of that at all? You know, like it just that that same argument I feel like goes in the other direction as well, right? It cuts both ways.
SPEAKER_03I don't know, I don't try to make sense of things that are tragedies. I mean, one we had a we had a uh psychiatry prof who said one of the things that we do in medicine is we try to say everything's a problem. But a problem means you can solve it. There are some things that are just tragedies. So we had a friend in Nova Scotia who, when she was a child, had been playing on a train track in Prince Edward Island and had been run over and she didn't have her legs were gone. Now she raised four children and she had artificial limbs and everything, but she didn't have a problem because her legs were, she had a tragedy. The problem was how was she gonna walk? Okay. And so this idea, I think sometimes people come to us with a tragedy in their lives, and um and we say, okay, we're gonna try to solve it like a problem. Okay, so I would say, in for me, seeing a person like that, and I've seen a number of them, I can tell you, you know, people get delirious at the end of life, and it's I think it's way more common than people think it is, actually. Yeah, it is, and we've got lots more that we can do now to help them, so it's not so desperate. And I think um with precedex and some of those things, we're gonna do better too, you know, coming up. But anyway, um, I would say that what what we have there is something that's really tragic. That we we live in a world where tragedies happen. I'm the fact that um how I believe about Jesus or how I believe in the Bible. The Bible's full of tragedies. You know, it's full of things where people made horrible decisions. And uh that's part of the reason I I believe it, because it's not sugar-coated at all. I mean, people are real, even the greatest king in the Old Testament, David, did a whole bunch of horrible things. So, you know, it's it's not like it was all cleaned up, and here we've got this nice little social media Bible. It's it's there, and some of it's pretty awful. Um, and yet, you know, that's the world Jesus came into, became one of us, all of those sorts of things in terms of my belief. So what what that means to me is that when I see this man, I don't see a problem. I don't see uh, I just see it's tragic. You know, here's a man who probably was a decent guy before in his life, and now this is the this is the way he's left. He's trapped into this, and now it's our privilege, really, to sorry, it's okay. It's touching my microphone here. It's our privilege to step up to the plate and care for this man and care for his family, okay? So his poor little wife is not left dealing with him alone. And we don't do that. Our culture does not do that. And we um we what we do is we're more interested in our own comfort and our own entertainment, and we pay people huge amounts of money to chase a puck around the ice. I'm not opposed to hockey, but that's where we're spending our money instead of supporting healthcare workers who could come in and give this woman a break, um, instead of supporting research that would help to figure out how to help people in that situation. So what what we need is intensive caring.
SPEAKER_05Yeah.
SPEAKER_03Intensive caring. And not only is that best for the patient, it's best for the carer.
SPEAKER_05Yeah.
SPEAKER_03It's best if we can, and and part of the reason we're so burned out now is that we're not given enough time and resources to do that intensive caring. You know, you have to push people through, you have the the ambulances are lined up outside the door.
SPEAKER_01Um and well, this is uh I feel like a perfect segue into the next point, which is patient-centered care. What does patient-centered care mean to you?
SPEAKER_03Patient-centered care means to me that I do the best I can in presenting options, if they want options. I've had a few patients who say, well, I don't know why I'm even here. But if people want options, of presenting the options that I think are reasonable, yeah, helping them to figure out based on who they are, which of those options might work for them.
SPEAKER_06Yeah.
SPEAKER_03And um probably from my own standpoint, discouraging things that I think in the long run are not going to help them.
SPEAKER_01Okay. So that's great, because I feel like you, you and I have a very similar concept of what patient-centered care. Like to me, patient-centered care is the embodiment of medical ethics in real day-to-day medicine when we're treating for care of a patient in front of us, right? And as you very likely know in medical ethics, there's like four main pillars. There's autonomy, which is essentially informed consent. Patients, we just as you said, you present the options and patients can make whichever decision that they want based on their own values and their own goals for the future, right? The second one is beneficence, uh, essentially doing good for the patient, yeah. Yeah, doing what is in the patient's best interest. Number three is non-malfeasance. Yeah, exactly. So do no harm, um, essentially not doing something that's gonna uh put the patient in a worse situation, whether that's in a physical state or a psychological state or whatever. And the last one is justice, exactly. So ensuring that we're being fair and equitable in the care that we're providing to patients, right? And so there are obviously times where some of these pillars are in direct conflict uh with each other. For example, like, you know, um, I deal with a lot of people from the downtown east side who suffer from addiction and mental illness, and you know, it's quite common for me to have people that are addicted to opiates who come in with really, really bad uh leg infections, and I want them to stay in hospital so that we can treat them with wound care and Ivy antibiotics and get them well nourished and fed and get some weight, you know. And um, they don't want to stay. And as long as they are a competent competent decision maker, meaning that they know uh you know the risks and the benefits of and the possible consequences of whatever decisions they make, if they don't want to stay in hospital, they can make that decision to leave, right? And so that's where an example where autonomy and beneficence are in contrast. And what if they're ever in contrast, usually in patient-centered care, we default to autonomy, making sure that patients are allowed to make decisions for themselves, right? Because I think that really historically medicine used to be quite a paternalistic model of care where you know, I am doctor, doctor knows best, therefore I make the decisions for you, the patient in front of me. But we've really quickly moved away from that, where it's like, you know, everyone has different values and goals for their own life. We are there to present the different options and you know guide them and do this, you know, shared decision-making model where we can get them the best care possible, right?
SPEAKER_03And I think like um I guess I have a little bit of pushback on that. So I refuse to call myself a provider because I'm not a provider. I'm a professional, I'm a physician, I'm a clinician, but I'm not there to be a vending machine. So you don't come to me and ask, and I provide. And I think that we've we've kind of thrown the baby out with the bathwater in this idea of autonomy and non be not being paternalistic. So what we've done is we've taken away this paternalistic trained doctor telling the untrained patient what to do, and we've gone to the extreme in some cases of the untrained patient without all the information possible telling the trained physician what to do. And that our our culture is saying, well, autonomy trumps everything else, and so if the patient wants it, you should, you should, you should have to do it. But we are we're kind of schizophrenic about how we do that. So if a patient comes to us and says, um, if a patient comes to us and says, uh, a mother say brings her child to you with an ear infection and says, I want antibiotics for this. This was on one of the the exams that they did for the students to pass, you know. And if the if the student gave antibiotics to that mom, they failed that station. Okay, we know that that's not good. But you know, there's all sorts of other things where we have less evidence than we have that, where we've been told that, okay, you need to do this. Yeah, you need to step in and do that. And so I I do I think that those pillars are more intertwined.
SPEAKER_06Yeah.
SPEAKER_03And I think a good, and I to be honest, I really think that sometimes autonomy is used as a form of abandonment, as a form of washing our hands. We say, well, that's what the patient really wanted anyway, so you know I'm not responsible for that. And it it maybe not even consciously, but we excuse ourselves from maybe being more confrontational and saying, look, I think this is a really bad idea. And and we're worried that we're going to we're worried that we're going to incur the wrath of our superiors or our colleagues if we if we push against some of those things. They're going to say, hey, that's what the person wants. What are you doing getting in the way when you know that three steps, you can see three steps down the line. I mean, we don't let our six-year-old children be completely autonomous because we care about them, not because we want to be paternalistic, quote unquote. And I think sometimes we aren't paternalistic enough with some of our patients. And, you know, case in point, we we decided that it was much better for people who had mental illness to be treated in the community, to be part of a community. Very true. But all they did was open the doors of the mental institutions and turn people loose without support. Now, a lot of those people ended up on the streets with drug addictions, lighting themselves on fire, having all these horrible um wounds and trench foot and everything else, not being not having their family be able to find them or visit them, when they they had a more it was a more confined existence. It was where they were. But some of them were better off in a in a in a residential situation where they could be helped. Now, I don't have all the answers to that, and I'm not saying that that it was right to keep people. I mean, I didn't like one flew over the cuckoo's nest any more than anybody else did. But somehow, when we just opened the doors and turned them out and said, Oh my, look at this, we have drug addiction, we have mental illness on our streets. We could have figured that out ahead of time.
SPEAKER_01Okay. Well, um, I would say for the most part, I actually do agree with you on a lot of the points that you made, right? Like, so uh coming back to the example that I shared where someone needs to be admitted for Ivy antibiotics and wound care. You know, I'm not gonna just be like, okay, like you don't want to stay, goodbye, see you later. Here's your sandwich and juice, take off, you know.
SPEAKER_03It's like some people are though, yeah.
SPEAKER_01For sure. There are people like that. But no, usually it's like, hey, no, I really think you need to stay. Like, this is gonna get a lot worse. You might have to have your leg amputated. Please, please, please stay. And I'll like negotiate with them and try to ease the transition into the hospital as much as possible so that there's absolutely no friction for them to stay, you know. And but you know, again, if it really does come like push to shove where they are a competent decision maker, I just don't have the legal grounds that's it's the same for me.
SPEAKER_03They're trying to, you know, with the opiate crisis right now, there are so many people that are so afraid to take an opiate medication even when it would really help them, or they're so afraid to um have their loved one go to a hospice where it would be really helpful. And I I do my best at those things. And I understand that. I just think that this focus on autonomy is letting us off the hook in some of these things. Yeah. Um not okay, so there's there's the micro level, one-to-one with the patients, but there's the meso level, okay, with our healthcare policies and you know the the macro level of the funding and everything. But we're we're letting autonomy run the meso level of things so that you, when you're up against this person in the ER, me when I'm trying to help somebody at home, I don't have the resources that I need. If you had somebody who was assigned to St. Paul's Hospital Emergency Room who was an addictions counselor who could come and talk to this person and be safe and do that, you'd have a much higher buy-in from the patients to do that. But we're not, we're not at a meso level, we're not supporting that kind of thing.
SPEAKER_01Yeah, I mean, like I think you are touching on another really, really fairly big contentious issue, that being like involuntary care for addictions. And uh, you know, I have a lot of thoughts on that. Um, I don't think that I totally agree on the.
SPEAKER_03No, I don't agree with that either. I I I just that wasn't what I meant by that. What I meant was if we are going to put people out into the community, I've I've seen it, I've seen it happen. When we were in medical school, we were in a small group at our church, and there was a young man who had been hospitalized for a long time with depression. He came to our home group every week and he was he was close to being catatonic, you know. And he he went out and during the day he would collect cans and do these sorts of things. It took him about two years to come out of his depression. He ended up becoming a teacher, getting married, raising a family, doing all of this. But if he hadn't had that little community for two years where he could come every week, there was an an older lady who would meet with him during the week and give him meals and do things, but he knew he was loved and cared for. Even if he didn't say very much, even if he just came and we all we all brought our cans and things for him. You know, there's there's something that's so important about that community. And I I definitely think that's the best way to go. Okay. But this this idea that but you have to fund it. Yeah, you you have to train people to do that. You can't, I think it's it's just is mean to just turn people loose, which is kind of what we've done. But I I agree that it's better to have I agree that it's better to when push comes to shove that you get to make decisions for yourself unless you're you're blatantly suicidal at the moment. You know there are a few things that are like that or unless it's a parent that's doing a Munchausen's or something like that and you have to apprehend the child. There's there's some places where I think we do need to step in.
SPEAKER_06Okay.
SPEAKER_03But you know for I I understand that but I think part of the reason we have more people doing that is because we don't have enough supports for them to feel safe to go in the places that are best for them.
SPEAKER_01Okay. I want to provide you with a hypothetical situation. Okay? And hear your thoughts on this. So let's say hypothetically there's an ICU doctor who believes that suffering is from God and therefore he decides to not provide opioid analgesia to people who have recently come out of surgery or suffered from traumatic injuries.
SPEAKER_03He's a malpractice.
SPEAKER_01He also believes that he believes in divine intervention and he discourages families from withdrawing care even if the patient is being kept alive on machines, whether that's a ventilator or vasopressors to augment the blood pressure because he thinks that there could be some kind of intervention where God will intervene and patients should be allowed to pass when it is their time. What what are your thoughts on that?
SPEAKER_03Well the first part is just malpractice.
SPEAKER_01Okay.
SPEAKER_03I mean if if somebody's suffering and you're not you're it's not that's not a controversial thing. Okay. I mean there are very few doctors in the world who would say oh you know don't give don't give opiate medication to patients who are who are suffering legitimately. You know we're not talking about addictions and all of that but post op palliative care any of those things that is that's beyond mainstream that's just like 99.9% and I would say that somebody that goes against that is just that's just malpractice. Okay. You know Christian physicians have been at the forefront of providing palliative care and dealing with suffering. That conference that I went to when I first found out about palliative care, Dr. Mount's a Christian John Scott is Catholic now but he was a Presbyterian minister at the time David Skelton who started St. Boniface in in Winnipeg he is an Anglican minister as well as a geriatrician and Sister Noala Kenny was the head of pediatrics doctor Sister Noala Kenny was the head of pediatrics at Dalhousie at the time so it's not it's not antithetical to the Christian faith. In fact you look at all the people down through the ages dot Dame Cicely Saunders felt like she had a a word from God to help her found St. Christopher's Hospice and do all these things so that's just dumb. Okay. I mean really but the the other part of it I think I think there we have to take a much broader view of things and I think that I do think that sometimes we in medicine give up too soon not because the person's going to recover but because the family isn't quite ready yet. So one of the things this is another thing I taught my um my ComSkill students was you know we s we stay in the ER or excuse me in the intensive care unit and we watch the numbers we see the kidney function is going down we see all these other things we know that the canoe is headed for the falls okay but all the family sees is treat treat treat treat you know work really hard put in the lines get the blood work do all of this they have no idea that the falls are coming so it's our responsibility to be saying hey you know we're watching this it's not looking good you know we're thinking that we're not going to be able to do much more from a medical basis within a few days within a week one of the things that I talk to patients and families about I say it's like your loved one is on a tightrope a high wire with no net and you know the thing that's odd is sometimes they can stay up there for quite a long time but when they fall that's it. Or another example I give is it's like your loved one is in an elevator that's not working and you get this drop and then it kind of bounces for a little while and you're never quite sure what's going to happen and then boom but it never goes back up to where it was before or very seldom. No I never say never but it's very rare that it goes back up to where it was before. So that it's our our job to help the patients and their families get to that place where there's a consensus about what needs to be done and the team is with it so that there's not this lingering nastiness this taste in their mouth of the doctors killed my my dad. Absolutely and you know I think an extra day or two in the ICU and the money that you spend on that compared to the what we call morbidity that down the line where all these other family members are going to say I want everything, everything, everything because of what happened to their mother I think some of it is that we need to be better and have the resources and the time to be better at helping families understand this and figure out like that doctor just is he's not a good doctor if he's doing that. You know that I I don't I don't want to give up on people too early either. I heard a story the other night where somebody came into the emergency room with a broken hip and was offered maid you know because of oh I saw I think I saw that segment on like CTV or something like that.
SPEAKER_01Like I have some thoughts on that. Just like I I've never heard of any emergency physician offering someone MAID for a hip fracture. If they did they are a terrible doctor. Straight up they are a terrible doctor like even in other circumstances even if someone is suffering from terminal cancer as an emergency physician that's not something that I would ever ever do. You know it's just not within my wheelhouse.
SPEAKER_03Well there are there are some who who do do believe it you know a friend of mine was approached by a fellow emergency room physician who said to him you know all of us in the ER should get trained to be made assessors so we could do the the first assessment and then if the person wanted to go all we'd have to do would be to call the maid team. So I think there's there's some of that out there. I don't think it's the norm.
SPEAKER_01I'm not trying to say that I think the just well in regards to many many different issues the pendulum swings so far back and forth and uh if people are trying to convince emergency providers or acute care providers to you know one be trained in offering made and to be offering that as a major contender for medical care when something is that truly reversible like a hip fracture that can easily be fixed with surgery that's I do not agree with that. No I wholeheartedly disagree with that.
SPEAKER_03There are some places like Nova Scotia right now is requiring physicians to offer offer it as you can lose your license in Nova Scotia for not offering made in a situation where it it might uh even ER doctors well I don't know about the ER doctors but family doctors and others are uh and surgeons and other people are being told that you know if if you have a person who would qualify and you don't offer it as quote unquote a treatment option you can lose your license they're very Nova Scotia the college there has been very um militant about this yeah I I would need to look at that and actually like verify the facts it's like part of me just doesn't want to believe it. Well you can that that's it's out there you can you can verify it there were there was a group of more than 40 Nova Scotia doctors who hired a lawyer put their names that they kept the names were kept at the lawyer's office but put forward to the the um the the registrar and to the minister of health and the registrar just basically told the Minister of Health oh these people are just whining but there have been several people who have been uh one of my one of my friends in Nova Scotia has been pulled pulled before the uh she's had a complaint because when the person had um had cancer or something and said well I just want to have made she said well let's try some other things let's look at some other things that made a complaint and she's got it on her record now. Wow okay so those it there are other places so Nova Scotia's the worst right now yeah but there are other places across Canada where it's kind of variable and BC has not been that way. So I I agree with that but yeah you know there's just some stuff that's there.
SPEAKER_01Out of curiosity I did look at the statistics of um MAID uh in Canada compared to other countries and I was really surprised and shocked to see that Canada does have the highest rate of MAID something like 5.1% of deaths in hospital or under medical care are from MAID and that's like um I think compared to like something like less than 1% in the USA when it's assisted suicide that's the difference.
SPEAKER_03If if the places where it's been by lethal injection um the growth has been exponential. The places where the patient has to have some kind of agency in it by taking the pills or do whatever the growth has been steady but it's been um slow. So for example Oregon where they've had assisted suicide for um since the late 1990s it's it's it wasn't it was kind of a soft entry into things there they for years they were 0.2 to 0.3% of all deaths and now they're up to about 1% 1 to 2% of all deaths after you know almost 30 years. Whereas us in the first 10 years were nationwide were up to more than 5% and there was one quarter in Victoria that one of my palliative care colleagues who works in that area said that 12.3% of all the deaths in Victoria at in that health region for the that quarter were lethal injection deaths. Wow and people were complaining I think the other thing about it is that you know I've had numerous people who have come to me with complex issues. Yeah as a palliative care doctor I'm not the same as surprised yeah and or even people who just have complex pain issues and reflux sympathetic dystrophy or whatever we're supposed to call it now you know all of these things and for them to get in to see the complex pain folks at St. Paul's hospital it can take 12 to 18 months for them to be seen. Yes but you know you can be dead very quickly. And I had one woman that who uh I got called about and she came to see me and she said I don't want to die I don't want to do this but the only thing I've really been offered in a timely manner is made and I've got a husband who has um who has has disabilities and I don't want to leave him behind you know and I was able to working through her family doctor fortunately in the past she had seen the people at the complex pain clinic and I was able to call them and say look this is what's happening with this woman you know she really needs to be seen on an urgent basis and they said well we'll put her down for cancellation and one came up and so she got to be seen within a month. Okay but that's like clearly the exception not the rule right yeah yeah that's it you know it's just gosh you know what is it and I think here's the deal we're talking about all these things as being autonomous but what does it say about us as the uh as a family as a community if people are able to get a lethal injection so much faster than they're able to get care for what they really need. When they don't really want to be dead they just don't want to have this awful pain. What is it we've we've had this thing in Canada this really important part of who we are that we are altruistic. Okay we're willing to stand in line we're willing to welcome refugees we're willing to have um you know not have every all the bells and whistles on our health care so that everybody can participate um we're welcoming we want to we want to be inclusive we want to do all these things what does this say about what is this doing to our national identity to our our national psyche if we get to the place where we we start to realize that that's what we're doing where we're saying okay that's what you want we'll do that but the person who's in terrible pain or the person who has no supports or the person it's it's not really a choice they're making yeah you know okay so that that bothers me because I think that you know I had some long discussions with Margaret Somerville about this and I was uh I met a man in Winnipeg years ago he's passed away now who was one he had uh post polio syndrome and he was in a wheelchair and he was uh one of the leaders in well maybe not just post polio syndrome I think he had polio when he was younger and so he um he was one of the leaders of the disability community there and we were talking about things at the end of life and this was before any of the laws came in and he said you know for years for for millennia around the world people have had a wisdom about what it means to die and how we do that well and everything and we're just throwing that out the window and that got me thinking and I thought you know our Hippocratic tradition of saying every life matters and I'm not gonna help you even if you ask me to die. That that's kind of like an old growth forest for us in our in our in our philosophy, in our morality all these things that we say you know we're gonna protect this. We're not going we're not gonna kill each other that's what's going to happen. And so what we understand that we understand that when we cut down our old growth forest that we're responsible to the generations that come after us for the physical environment that we have and I would say that we're just as responsible to those who come after us to my grandchildren and your grandchildren when they come for the metaphysical environment that we're leaving. And if the metaphysical environment says that there are some lives that aren't worth living and that sometimes taking a person's life is better than caring for them. Yeah then I I'm concerned.
SPEAKER_01You know I I don't disagree with any of the points that you said um but the one thing that I will say is that um you know just like you I've seen so many patients that come in suffering. I recently saw a young younger patient with terminal cancer with mess to their spine recurrent small bowel obstructions who came in and the patient first thing the patient said to me was I want made yeah I want it to be over I want my suffering to be over you know and so you know this is someone that's already had you know radiation and chemo and all the different things and she and the patient has already come to the the decision that that is the way that they could best be treated to protect their own dignity and to die in a way that I guess like gives them power and autonomy in uh in their last final moments right and so you know I I said I'm absolutely happy to refer you to a paleo care doctor um that's not something that I can offer you but certainly that's something that I can offer you and you know this isn't someone that um death is something that's abstract it's like something that's very very real and foreseeable so this is like you know if we're talking about made you know oftentimes it's separated into track one and track two right track one track one this is track one where someone has like terminal illness uh terminal cancer ALS uh severe hunting's disease where death will happen in the foreseeable future it's it's just like really a matter of time and it gives people that autonomy to die in the way that they see fit compared to track two which like I am probably a bit more hesitant like I'm not totally like rah-rah track two made kind of thing you know like that's where death is not really imminent but people are suffering and they are opting for medical assistance in death because that's the way that just what we were talking about before yeah exactly so um you know like on that point I am hesitant I'm not totally on board with track two uh especially when when it comes to the discussions about like implementing made for mental illness and depression where it's like there's so many different therapies that are coming out where we could potentially treat these people and give them a happy meaningful high quality of life moving forward like whether it's like electroconvulsive therapy or psychedelics or whatever it is you know so um that's something that I am much more hesitant about but for the track one people I I'm kind of of the opinion that man like if that's if they've explored all their options and this is really what they want yeah like why wouldn't you do that? That seems compassionate to me.
SPEAKER_03Well there's a couple reasons first of all I totally understand how that woman would want that okay my colleague Dr. Romaine Gallagher um who's been a big St. Paul's person she's retired now from that but she and her colleagues wrote an article that physical suffering that leads to MAID is actually a form of malpractice that we need to have an there's there's enough out there that we could control this woman's physical pain. We can do that whether or not we have the will as um as a medical community we have the will as Canadian people to implement those things is another is another issue. So that I know what you're gonna say we'll okay let me say this let me say this okay so if I I want to take the physical suffering part of it off the table. Yeah okay because that she should not be well if if she has a total pain crisis she should be in the ER you know people do have these things that that happen like she ruptures her bowel or she bleeds or something like that she could come to the emergency room for something like that. But basically for just basic pain control we do that pretty well at home we've even we've had people on lidocaine drips at home we've had people on spinal things at home and everything else so that have you know been able to do Lego with their five year old daughter and things like that. Okay so but the other piece of that is okay what about what about the people who just say I've had enough I've had enough I don't I don't want any more treatment I just have had enough I've I've suffered enough with this I'm ready to go I want to go at a time when I can call my family we can just do this and everything. Well it's not that simple is all I can say that I have had a number of people who have come to me and who have said that was the worst experience of my life. Everybody else said that we should just let him go it should be fantastic but I was not able to be present for those last moments because all I kept doing in my mind was counting down the hours and I was such a mess by the time I knew the doctor was going to come and he was going to be dead that I couldn't even be present for him for that last that last bit of time and that's that's not an unusual thing.
SPEAKER_01So but I guess my pushback against that is that it's not about it's not entirely about the family members it's really about like the patient that that's not true.
SPEAKER_03That's not true because in palliative care we talk about the unit of care being um what I love the the French version of it les prochaines the people who are close. Okay. It might be family it might be friends it's whatever the Hawaiians call it your ohana right and one of the things that I ask people to to think About is how autonomous is this really? Okay. If you are going to commit suicide, okay, kill yourself. You it's it's not something we encourage, we don't love it. If you take too many pills, you go out behind the barn and shoot yourself, you know, we we grieve that. We we second guess ourselves. How could we have stepped in? How could we have known? But when you decide to have a maid death, it is not completely autonomous. It is it's it's not, you have doctors, nurses, pharmacists, healthcare workers, um, the people at the funeral home, the people who make the laws, first responders, family, friends, there's social workers. All these people.
SPEAKER_01Wouldn't you call those safeguards though? To make sure that it's actually done in a reasonable manner and not just willy-nilly, oh, you get made, you get made, you get made.
SPEAKER_03I I'm just saying that all those people are complicit in the death. Okay? They have they they participate in it. The nurse who starts the IV, the doctor who who pushes the medicine, the the pharmacist who does, who who prepares the prescription. All of those people have are involved in it. Okay, complicit is kind of a bad word, but they all have have a part to play in that death. And we understand in our culture that autonomy is not absolute. You I don't care how good a driver you are, you're not allowed to drive 120 kilometers an hour down Fraser Street. I don't in Vancouver, you're not allowed to smoke a cigarette outdoors on a public beach because of how it might affect other people. There are, I can't have a little nuclear reactor in my backyard because I want to live off grid. Heck, I can't even keep a donkey or something that I might like to have. You know, the number of dogs I'm allowed to have is is monitored. All of those things. And we understand that we accept limits to our autonomy because of how it affects people around us. And to think that how I die has no effect on my world and the people around me, and it's all up to me, it's all about me, is just a fallacy. How each one of us dies makes a difference to how all of us are going to die and how all of us see ourselves and what kind of a culture we're building.
SPEAKER_01Yeah. So, I mean, I I do hear your point that some family members might have had a really bad experience because of like the anxiety leading into it. But I feel like for the most part, most of the people that I've heard that have had family members, even people that have commented on some of my posts talking about their experiences we've made, it was overall a very positive thing because people were able to leave this world in a very peaceful way without suffering, right?
SPEAKER_03We we provided a way for the sufferer to go so we didn't have to watch it anymore.
SPEAKER_01Well, I it's part of it, Jeff. Well, okay, like I think it's um do you believe in comfort care? If someone is so then so how do you draw a clear line between comfort care and maid? Because I feel like the lines can kind of get blurred between those two, right?
SPEAKER_03It's all about intent, okay? It's intent. Now, people say, oh well, you're just as dead. It doesn't matter what your intent is. Let me give you an example. Our entire legal system is based on intent. If I tell you I was driving my car this morning and I hit a little boy on the street in front of my house and I killed him with my car, what's my punishment?
SPEAKER_01Yeah, I mean, if that was if you were intentionally doing that, intentionally trying to hit So you can't tell.
SPEAKER_03You don't know. Yeah. Because what if if he was chasing a ball, he ran out in front of me, I slammed on the brakes, I wasn't texting somebody on my phone, I wasn't drunk, you know, it would be sad, he would be just as dead. But I I had witnesses that showed that I would be, I wouldn't even be charged. Okay. But if any one of those things was involved, then I would be charged. And if I hated the little guy and I was waiting around the corner until he crossed the street on his way to school and I ran him down, you know, that's murder. And and so the intent really matters. And I think that's the bright line that I want to draw. I have no problem with with withdrawal of care when when the per when it's no longer serving the person. I don't like the word futility because I think it's been been used against patients and and families. Oh, it's just futile. You know, nobody's futile to me. It doesn't mean that the the care has to continue, but I I when when the when the burden of the care becomes too much and it's not doing any good any farther, it's gone, it's gone to make it even worse for the person, then I have I have no problem in in withdrawing care. I have no problem with providing comfort care. I've been doing it for over 30 years. And and I have no problem in saying, okay, if you don't want to have these other things that may prolong your life, you don't have to have those. That's fine with me. But when we make a conscious decision, we come into a room, we bring medications that are going to end this person's life with the intent to do that. Because, you know, when we withdraw care, we don't say, okay, well, up until recently anyway. We didn't say we take somebody off a ventilator. We keep them comfortable. But if the person doesn't pass away right away, we don't say, oh, well, we need to inject them with something so they're dead. We're we're our intent was to remove a treatment that was no longer helpful.
SPEAKER_06Okay.
SPEAKER_03So I think that there is something really important as members of the human family that we don't cross that bright line that says we don't kill each other.
SPEAKER_01So, okay, let me present a hypothetical case to you. Okay, so I have a patient in the ER who has terminal cancer, has recurrent small bowel obstructions. The patient has to drink out of a straw because if the person is eating any solid foods, you know, it causes severe abdominal pain, bloating, nausea, vomiting. They're wasting away, they have literally no muscle or fat, they're just skin and bones, they're so weak that they can't even get out of bed.
SPEAKER_02Yep.
SPEAKER_01And they say that tell me that they want to get made. And I refer to you as a palliative care doctor, um, saying that they want to get made. And that they've already explored all the different pain modalities, all the different supports that they can have in the community, and really the only thing that they want to do is to end their suffering and they want to go.
SPEAKER_03Well, you don't send them to me then. You call the maid team. If that if I were called to see somebody, I mean I've gone in to households before where the person has made scheduled for the next day. Because the nurses are saying, I want, I just want to be sure that that everything's been done. And you know, I I am respectful of of the person and I say, look, one one home that I went into was um uh a very successful uh businessman who had his maid scheduled for the next day. His wife of many, many years was distraught about this because she's she's she was saying, I was hoping he would just go to sleep, you know, and die and do that. I didn't want it to be so formal like this. Um his one of his children is there saying, Mom, you need to get over yourself. This is what dad wants. We're gonna have it. I go to see this gentleman, and he actually had none of those things you're talking about. He was actually in pretty decent shape. He hadn't even gotten a commode in his room yet. And I said to him, you know, I I'm not afraid to say, why are you wanting this? Yeah, you know, because I think that that's a really good question. You know, why are you feeling like you'd like to have this? You know, now some of our nurses who say ask that in the home have been reprimanded by their superiors to say, well, you're just getting in the way of the maid team. You need to just call the maid team. If somebody says they want maid, don't be asking them questions. So to me, that's a failure of our medical system if somebody is is really wanting wanting maid because they're worried that they're not valuable to the people around them anymore, or they're not loved, or they're not cared for, or they're too big a burden, all of those things. Anyway, so I said to this person, I said, Why why are why are you wanting this? What's what's behind this? And he says, Well, there's just no joy anymore. There's just no joy anymore. And you know, I thought to myself afterward, I talked to him about all the things that were available and everything, and he just said, No, that's it. So, you know, I didn't stand up and yell at him or do anything like that, but I felt afterward, you know, before this was legal 15 years before, 10 years before, we would have worked really hard to reframe hope for this man, to s help him figure out how there could still be joy in his life. And it doesn't just have benefits for him. What he would end up having at the end of his life is an understanding that the people around him loved him, not just for the the money he was bringing in and the things that he could give them, but just for who he was. And the children and his wife, who maybe hadn't been able to give much to a guy like that, yeah, um, could have the sense that they they um they were able to help him eat, or they were able to stay up with him at night and read to him, or they were able to, you know, even clean his body or do those other things. And and there's something that's like gold refined by fire that you get when you are in a tough place, when you're in a place that's challenging, and you come through and you care for people you care about that you can't get any other way. And and I think that when I see people, I mean, I've seen some heartbreaking people in my life. You know, that patient that you're talking about would be would be one of them. I I did a home visit on a on a young mother who had four children under 10. She was in her 40s, she's in a neck brace because of all the the metastases she has in her neck and her spine. And she says, am I just gonna crumble? Am I just gonna crumble? And this was before made and I said, No, we're going to come alongside you and we're gonna help you and we're not gonna leave you alone. And what what we did by doing that is we showed her children that it's important to care for one another, and that you can't, you know, if one of those kids ever got a spinal cord injury, they know that people cared for my mom even when she wasn't physically pretty. Okay, she this person has to drink from a straw. What about all those folks that we see in their little scooters and everything who every day have to drink for a straw and say, oh, well, I don't I don't want to have anybody helping me with my toileting. So Marilyn Golden is a is a uh uh uh woman in the United States who's pretty feisty, but she's a um a disability rights activist. And she says, have we gotten to the place where we're willing to let people to have people die simply because they don't want somebody to wipe their butt? You know, so there's there's yeah, it's a little bit more complicated than that. Well it is, but that's she's being, I mean, she's part of the disability community. She's in a a wheelchair, she needs help with that, all of those things. And what what people from the disability community are saying is that most of the time, the reasons that people give, and you look at the stats from the reasons that are given, are things like not being able to do the things there that bring them pleasure or that they've been able to do before, not being able to care for themselves, being worried that they're going to be a burden on their family. Um, all of those kinds of things.
SPEAKER_01But those are kind of valid, valid reasons too, right?
SPEAKER_03Like it's it depends on the individual and what they value and yeah, you know, but is it a valid reason for us as a society to say, okay, we agree with you, your life is not worth living? That's what I'm saying.
SPEAKER_01But that's not for us to decide. That's the whole point of the life.
SPEAKER_03Well, it is though. It is. We as a culture get to decide who we protect. Do we protect everybody, or do we only protect those people who um who don't have disabilities? Whether the disability is you're born with it, or whether the disability comes because of a as a result of an illness.
SPEAKER_01But that's what I'm coming back to is autonomy means that they have made that informed decision, right? They have looked at all the various issues and they've decided for themselves this aligns with my values and this aligns with how I want to go. And so who are we to argue?
SPEAKER_03They they aren't just doing it, it's not autonomous. They're asking us to say, yes, this is good. That's what that's what this is in our society. We have decided, we've decided that there are some lives that are not worth living.
SPEAKER_01Well, I I would I would frame it as like as a physician who's treating patients uh who come in with many different life circumstances, whether they are drug addicted, whether they have uh different outlook on life. Um, my moral compass that I've come to is that I'm gonna leave my own personal beliefs at the door and treat the patient that's in front of me based on what they value. It's not based on what I personally value, you know?
SPEAKER_03But you don't do that. You don't do that at all. If somebody came to you, all right.
SPEAKER_01Well, I wouldn't personally be uh administering me.
SPEAKER_03That's not something that I do, but but you you don't even do that with leaving your personal values at the door. If somebody came into you and said, you know, the thing that I I really like doing is going over to the local school and picking up three little girls and taking them home and having sex with them, you would not be saying, Oh, that's your personal value.
SPEAKER_01No, but that I feel like that's a false equivalent and it's quite extreme, right? Obviously, in that situation, I'd have to there's someone else that's part.
SPEAKER_03It's pretty extreme to say it's okay to kill somebody. Now, come on.
SPEAKER_01I think these are two completely separate things. Like the example that you're saying is like someone that's taking young, innocent children that are have many, many potential years of quality of life ahead of them and taking them and like, I don't know, torturing them or doing whatever to them, right? That's not at all the same as the hypothetical patient that I've presented you with who is actively dying of a malignancy, who essentially by easing their suffering, you get that double effect of actually allowing them to pass in peace.
SPEAKER_03That's different. Double effect is different. I am all for giving the person, even if we have to do sedation, giving the person everything they need to have to be comfortable at the level that they want to be comfortable at. Not everybody wants to be completely out of it, but I'm I'm okay with that.
SPEAKER_01So then you would administer maid.
SPEAKER_03Is that no no not?
SPEAKER_01So how would that look? So you would administer, say, uh big doses of midazlam and uh No, I would give what I what I call um oh I'm losing the word here, what I call um the proper proper um sedation, so that you would give appropriate sedation to get the person to the level of comfort that they're looking for. Okay, so you would give them very large doses of say hydromorphone depending on what they needed. Okay, to alleviate the suffering, and by doing that they would stop breathing and pass away?
SPEAKER_03No, no, not necessarily. In fact, the the palliative sedation at the end of life, those the studies show, if you're going to evidence-based medicine, that it doesn't actually shorten the life. And part of the reason that we think that is the case is this is this part of speculation, is that the person is able to rest. And so they're not fighting against all of those things and having all of that happening. But the proper uh proportional, that was the word I was looking at, proportional sedation. So that and sometimes you know, all the person needs is actually some time to have a good rest. So, for example, um, I don't know about your family, but when I was in the middle of labor, I had per a completely natural.
SPEAKER_01Before you uh tell the story, I I just want to come back to like how the practical application that you were talking about. So you were saying you believe in double effect. That's what I'm gonna talk about.
SPEAKER_03Okay, okay. When I was in when I was in labor, I would have paid a lot of money for a five-minute nap, but I didn't have that opportunity. You know, I didn't have epidural or anything, but you know, it would have meant a lot to me. So sometimes with the sedation, we have found that all the people need is to say, okay, I need to be out for a while, just so I've got to rest, and then I can then I want to come back and talk to my family or do whatever. So the person that you presented to me was not somebody who had what I sometimes call the dwindles, you know, where they were just kind of this person was on an active trajectory of dying. And I am I throughout my entire career, I have done gone above and beyond, done whatever I could to keep that person comfortable without stepping across the line of actually intending to kill that person. Okay, and there is that there's a beauty, and I don't expect everybody to see this, and I don't expect everybody to agree with me. All I can say is over my 50 years in medicine, even before palliative care, I was always drawn to those kind of people, but uh, and the the 35 plus years that I've been doing palliative care, I I have seen it over and over again that there is there's healing that comes. There's when you provide that space, that sort of liminal space for people to to have that opportunity to say, I love you. And it doesn't matter to me what you look like, it doesn't matter to me what abilities you have, it doesn't matter what you can do for me, that there is so much healing that happens on both sides of that equation. Um, and you've seen it too, I'm sure, when you've got somebody who's uh I'm I'm sure there have been people in in the ER where you've been able to get a hold of a daughter or a son of somebody who's an addict who's probably in his last days, and and they come down and and they say, Oh dad, I've always loved you. And the healing that takes place there, and and the dad that's able to say, I'm sorry, I wasn't as good a dad as I really wanted to be for you, and and how that carries on as a legacy for that daughter or son going forward, that he really did love me, but he just had this disease or or addiction problem that that he he couldn't love me the way he could. And and I was able to to tell him at the end how much I loved him. And there's there's something that's so deeply human about coming along somebody in the darkest hours of their life that that builds something into us, builds something into our culture that is what I call it, gold refined by fire. It's things we don't we can't get in other ways because it shows that it it doesn't matter. I'm gonna fight for you. You know, it doesn't matter what you look like, um, I'm I'm gonna fight for you. And if fighting for you means I get you the pain relief, if fighting for you means that you need to, that I need to keep other people away who are trying to bring you down, I will do that. If fighting for you means that I need to work on the rest of the family so that they'll be able to let you go because because you're ready now to do that, um, I'm gonna do that. But I'm I'm not I'm not gonna participate in causing your death.
SPEAKER_01Okay. Yeah, those are really interesting insights. Thank you for sharing that. Um, I guess like for me, it's a lot more hypothetical than it is for you as a palliative care doctor, right? Like the closest thing that I've dealt with in that realm is providing comfort care to people that are actively dying. Like they can't breathe, their oxygen saturation is low, their blood pressure is tanking. Yeah, and uh I provide morphine or hydromorphone anti-nausea medication to ease their suffering as they are passing by natural means, right? So obviously that is like quite, quite different from me being like they're kind of dwindled, they've got the dwindle, as you say, and then boom, you're gone, you know. So, like uh, you know, maybe my opinion would change, like uh if I was kind of thinking it on a very different Metacognitive level, so to say, if I'm actually the one pushing uh the drugs and being the so-called dealer of death. Um, but I kind of have always just thought of it as compassionate care and easing suffering and um really honoring patients' wishes and quality of the time that they have or the quality and uh of their autonomy over the quantity of the time that they have left on earth. But so the next thing I want to talk about is contraception, and I know like in the quick rapid fire things you said, maybe I think like on on some topics. So uh maybe you can just elaborate like conyms and oral contraceptive pills or birth control. Like, what are your thoughts on that?
SPEAKER_03Well, there's not very many of my patients that um that are too concerned about contraception at this point, and I think that um I think it's something that's kind of personal for each physician as well. Um, I don't I don't have any problem with um barrier methods or with most of the time with the with the birth control pill, I prefer to have ones where it's it's very unlikely to have a post-conceptive effect.
SPEAKER_01Like plan B kind of thing.
SPEAKER_03Yeah, I'd I'm opposed to that.
SPEAKER_01Yeah, okay.
SPEAKER_03I j I just think from if we're talking about science, that you start as a fertilized egg.
SPEAKER_00Yeah.
SPEAKER_03That's the it it makes no sense to me on anybody's timeline that somehow you become a person some other place. That's just kind of where I go with the science. And you know, uh I don't like anything that uh would um interf would interfere with implantation or would happen sort of with the with the morning after pill and other things like that. And I don't even really think, you know, here we are worried about all these hormone levels, and then we're willing to give these huge doses of hormones for on plan B that uh it feels kind of schizophrenic that we we have our teenagers taking those things and we're worried about their plastic water bottles. Yeah.
SPEAKER_01Um, maybe I will tell you a real story. So when I was in medical school, I had a classmate of mine who was a devout Catholic, and he um had what I would consider quite extreme views. Yeah. Um he was anti-contraception, anti-condoms, anti-birth control pills, so far to the point where he said that if a young woman had come to him asking for oral contraceptive pill or the IUD, um, he would refuse care, and uh he would also refer refuse to refer the young woman to another provider who would be willing to offer that to him. Um, and I this raised a lot of alarm bells in my classmates uh and he was actually reported to the dean, and he had to sit down with the dean to actually talk about patient-centered care because it really felt like he was imposing his own um religious views and ideology on the patients that he would be ultimately caring for, right? So, what are your thoughts on that?
SPEAKER_03I think that there are probably enough Catholic patients out there, if you're just looking at it from a democratic standpoint, there's probably enough Catholic patients out in the world who would be really grateful to have a doctor that shared their views. Okay. We understand this about people from First Nations, we understand this about other minorities.
SPEAKER_01I think that's besides the point though.
SPEAKER_03What I'm I guess that's not really well because the point that I'm trying to touch on is like the doctor has a specific uh personal set of views and a religious uh standpoint and they use that yeah, there's people but there's people that are going to want I know that there are people who want to come to my colleagues who are family doctors who refuse to participate in MAID because they know that on their worst day they're not going to be offered something that is going to do that. Now, I think that there are there are folks who either because they're they're Catholic or because there's there's a big group of uh women now who don't want anything to do with anything hormonal, um, you know, because of stroke risk and some other things like that. There's a big group of folks that are out there that are kind of there, there's a funny little uh uh strange bedfellows of people doing natural family planning who are, you know, from the Catholic standpoint and then from the feminist standpoint too, who are doing that. But, you know, I I think that um I I I think that there one should be willing to provide information as to where a person can get help with this. Now, somebody who is uh there it's really not that hard to find contraceptives. You know, it's not like he's the only person in the entire world that can provide it.
SPEAKER_01Yes, but like in order to get oral contraceptives or an IUD, you need to get that from a physician.
SPEAKER_03Yeah, yeah. But there's still there's every walk-in clinic is gonna do that for you. Walk-in clinic? Oh yeah, you can get oral contraceptives at a walk-in clinic. In fact, there was a court case in Ontario that had some of these similar issues in it. And the the before it went to court, the it was before the um Ontario um board like our BC College, right? It went before the board, and the and the one member on that board who was an abortion provider, even, just said, look, there's not a 16-year-old girl in in the city of Toronto who doesn't know how to find find somebody who's going to help her get an abortion or give her get pills or an IUD or whatever. You know, there's there's lots of clinics, there's Planned Parenthood type clinics, there's all kinds of places that you can go to do that. It would be different if this were something like, let's say, you know, I I would I would agree with you in terms of something. Let's say you were doing uh you're a neurosurgeon and you do that fancy threading the the thing to get the clot out, you know, with the little cage, and you say, okay, I'm not ever gonna do that for anybody of a certain race. That's you know, I wouldn't put up with that, but that's something that's super specific and really hard to get, and special training. This is to me, it it's not as as big a deal. And to be honest, the the other people who are willing to provide that whole range of services, yeah. Okay, if I have a 13-year-old daughter who I'm not so sure that that's gonna be the best thing for her, I I would like to know that she's gonna go to see my Catholic physician friend who's not gonna be offering her that as a way out, but's gonna sit and talk with her about who is pressuring you at 13 years old to try to get contraception.
SPEAKER_01Well, I think like pressure, I mean, like that's a lot of assumptions. I think like the reality is that most kids in their teenage years these days, especially, are having sexual intercourse, and you know, like having being able to provide contraception, whether it's a barrier method through condoms or are contraceptive, is something that I think the individual should be able to make for themselves. It shouldn't be you like the my whole point is that the physician um should not use their own religious moral compass to put up these barriers to care uh for patients.
SPEAKER_03Yeah, it just depends on part of it depends on whether you you have come to the conclusion that this is it's it's another part of that beneficence thing. Like, is this really in the patient's best interest? Is it does does the literature show that it's in a 13-year-old girl's best interest to have sexual intercourse?
SPEAKER_01Well, I mean, like, I think it's fair to preach abstinence to 13-year-olds, but whether a 13-year-old girl or boy is going to listen to that and actually abstain from having sexual intercourse is like the research shows that most of them are going to be sexually active and therefore it's about half. Half is a lot. Half 50% is a lot.
SPEAKER_03But it's not everybody. Okay.
SPEAKER_01And but so for the people, the 50% of people that are going to be sexually active, you're saying that they shouldn't be offered any form of controversy.
SPEAKER_03I'm not saying that. I'm not saying that. I'm saying that if you have a physician who feels that it this is not part of his or her practice, that they should be able to have that. Um now, you know, this is not this is not my area of expertise, but I do know some of the folks who have have had that stand, that they taken that stand, and they try very hard to have really good discussions with the young people in their practice to help them understand, you know, what what are the risks and the benefits that are going on. It's not hard to find a condom. I mean, that's not hard to find. And you know, there are other barrier methods that are not that hard to find. There's clinics everywhere that can do that. And just to say that, well, you know, this we're not going to you're a you're a bad doctor because this this part of your of your belief for which you feel that you have really good evidence on your own, that it's it's not maybe it's it's participating in something that you don't feel is right for this this patient, okay, at a certain level. That's the way they see this.
SPEAKER_05Yeah.
SPEAKER_03I'm not saying that that's the way I see it, okay? Okay. I'm just saying that I I think that we there's enough of us around as physicians that we shouldn't be focusing in on these little flashpoints and and and um causing more rifts within the medical community over something where somebody else can easily pick up the slack on that. That's the same thing with MAID. If there are those of us who do not want to refer, who do not want to do any assessments, who don't want to be involved at all, if if we're even if we're up to five or ten percent, that means 90% of the patients don't want anything to do with it. So why do we need to have everybody on board who's who's willing to do this?
SPEAKER_01Yeah, okay. I I hear that perspective that there's enough other doctors to pick up the slack, but I think it really comes down to like just as we were talking about before, the the relationship between a patient and a physician is special, right? Like you're you're given a special amount of.
SPEAKER_03I understand what you're saying. You're saying that I should, I should, but but see, here's here's what we were talking about before, too. That who I am as a person is part of what goes into that therapeutic relationship. And if I really believe that something is wrong, like there, I I personally don't believe that contraception is wrong, okay. But the people who are not providing it, they're not n they're not declining to provide it because they think it's a good that they're withholding. They're declining to provide it because they think it's it's it's it's a moral evil.
SPEAKER_01I think like an analogous situation is like, well, this is truly a form of harm reduction, right? Like uh preventing uh unplanned pregnancies in young teenagers. That would be a good idea. It's the exact same it's the same, it's the same kind of approach for people with addictions using opioid agonist therapy to get them out of that vicious cycle of intoxication, withdrawal, craving, so on and so forth.
SPEAKER_03I agree with those things too, but I think there are people who say that we're just we're and I think some of the contraceptive people would say the same kind of thing, that we're putting a band-aid on a big wound, and that what we need to be doing, and at the and they feel like they're participating in the harmful part of the culture that is signaling to young people that it's okay to go ahead. So, you know, I'm I'm probably not the best person to do this because I'm not I'm not in their shoes completely, but I know enough folks who feel that way that I can I can say that it's it's not it's not something that is done without thinking about it, it's not something that's done in a punitive way, and it's not something that's done with without really due consideration and real strong convictions about things. And I think um there may be people from other cultures who who come to our country and who are part of our medical system who have similar things from their own cultures that um and we understand that we need to um kind of uh accommodate to a certain extent those things, not to the point of you know, general mutilation or anything like that, but we do we do understand about some of these things, and I think that that's something that just because our Catholic colleagues are people who have been here for a long time, doesn't mean that we can't offer one another some understanding and understand why they feel that way and you know help each other out. You know, you you may actually have patients who who don't understand why you believe that a certain way, and you say, Well, I've got this other this other colleague, and I can send you to that person and we can help we can help out.
SPEAKER_01Okay. So maybe we'll just talk, I mean, like we were just talking about uh contraception, which obviously segues into abortion. So obviously you are anti-abortion. Do you agree that a therapeutic abortion would be necessary and ethical for uh any conditions where a mother's life is at stake? Ectopic, uh ectopic or tubal pregnancies, septic uh pregnancies, molar pregnancies, that's not even uh pre-eclampsia.
SPEAKER_03Well, it would depend on uh I I suppose it depends on um whether what what the definition is. I think that they're certainly for the the molar pregnancy and for the ectopic, you know, where there's the not gonna live, you know, anyway. But the some of the other ones like the preeclampsia or other things like that, um the I think there's a difference between saying, okay, we're going say for preeclampsia, we're gonna have to deliver this baby early, and the baby's gonna have to take its chances, versus we want a dead baby.
SPEAKER_06Yep.
SPEAKER_03Okay, so I would draw a line there and say, yes, if the mother's life is on the line, we go ahead, we deliver the baby, and we do whatever we can to resuscitate the baby. Um in terms of um other things, like for example, with a fetal anomaly.
SPEAKER_00Yeah, like uh enencephaly, for example.
SPEAKER_03Okay, so this is kind of an interesting thing. One of my colleagues was um uh Brian Byron Calhoun, OBGYN in the US, and he developed the concept of neonatal hospice, okay, where when there was a diagnosis like that, where that where the baby seemed to be incompatible with life, that they would support the family. And he even, he actually worked in the U.S. Army at the time, and he even got permission that if as the baby got determined, it looked like the child was going to die, that he could do a cesarean section so the mother could hold a child, living child, well, before the child died. And so they put together a whole bunch of things like the the photographers, the now I lay me down to sleep folks, and um helping them with little kits that they would have to take footprints and and handprints and and uh telling helping them to figure out what kind of subscriptions that they needed to cancel, like the new baby things that people welcome wagon stuff, things like that that would come and get counseling and all of that sort of thing after. And they they did studies on this and they found out that the families that had that kind of support and were able to carry the baby as far as they could and then grieve it did better than the ones who went for an early termination. And it was so compelling that insurance companies in the United States, who are all in it for the money, actually started funding the neonatal hospice because they realized that if they funded that, they had less to fund in the um in the mental health stuff for the family afterward. So it's it's another way of just saying that we're all members of the human family and we honor and support you. Um it doesn't mean that I am nasty to women who have made a different choice. Um I do think it's sad when you look at um the number of Down syndrome children that are aborted. Uh many, many people living with Down syndrome uh live great lives and have have good things. And and what are what kind of are the standards that we're measuring? It's a little bit again like the end of life. Like what are our standards that we're measuring where we say this life is worth living, this one is not worth living? And um, you know, there was a study, you know, there's even you know, there's talk now of having infant euthanasia here in Canada. And um in they have it in Belgium and the Netherlands, and there was a study way back, um, gosh, I can't remember the year, but it was in a journal called Acta Pediatrica. And in Belgium they found that um in that only 81% of the neonatal uh euthanasias that were carried out were were the parents consulted. So that one in five of those babies that the the healthcare team decided that they didn't deserve to live, they never even asked the parents.
SPEAKER_01This is a published study?
SPEAKER_03Yeah, acta pediatrica if you if you have pediatrica.
SPEAKER_01I need to see that because I'm not a therapy and one. I find that really hard to believe.
SPEAKER_03Well it's it's it's published. I can you you send me, you got my email, send me an email and I'll I'll get you the reference. But it was a long time ago, but they found that that there were like they they talked to the parents 80 81% of the time. And so there was there wasn't a question of whether the family would like to take the baby home and love the baby for as long as possible or do what they could. It was the team that decided that it was this baby wasn't worth resuscitating or caring for, and or you know, they actually did an intentional termination of this baby's life. So, you know, I think that once we decide as a culture that death of any sort of any member of our human family is quote unquote an answer to a problem, then we have trouble. Abortion or euthanasia. There's there's a violence to it. We are taking a life. Um I was on a task force with our national uh palliative care group before the legislature came down, and I made a statement, I said, I'm not sure that in this little task force, and I'm not so sure that very many doctors are gonna really feel like killing their patients. And he came back at one of the people came back at me and said, Whoa, that's very inflammatory language. And I said, Well, okay, you know, I want to play nice in the sandbox here. What should I have said? And he said, Well, you can say take the life of a patient.
SPEAKER_00Okay, yeah, like the censorship of like just using the case.
SPEAKER_03Just like that. And and and you know, I'm I don't want some poor lady to suffer on her own and do this. I've been on the board for um these pregnancy care centers now for over 40 years. So I work on this at both ends of life. And we have uh the one here in in Vancouver in Burnaby and Richmond, we have pregnancy care centers where women can come and get counseling. We don't we don't refer for abortion, but we also we don't shame people, we don't show nasty pictures, we don't do any of that. We give them options counseling. We have a maternity home where people who were who are would be homeless without it are able to come and live there for up to a year after they have their baby. We have a safe house for women who um are fleeing domestic violence where they can come with their children and live there. That's you know, all of these kinds of things. So I'm I put my money where my mouth is and my time where it is. And I I have no interest in having, and everybody thinks, oh, it's these little teenage girls. No, most of the people we serve in this are people who are refugees, who are students from foreign countries, who don't have English as their first language, who have nowhere else to go, who have been working in entry-level jobs and now they're pregnant, and what are they going to be able to do? So we we have a real uh a real calling to care.
SPEAKER_01Yeah.
SPEAKER_03That's that's what I feel about these things. And that's really nice to hear.
SPEAKER_01Like I think um I was if I'm being honest, I was a little bit nervous um before having this interview with you, especially on the topic of abortion, because you know, as you may have seen, I recently posted about a patient that was treated for ectopic pregnancy, and uh, you know, it would I was really taken aback at uh how aggressive some of the comments were uh from like the pro-life people saying, you know, that's not an abortion, but like by strict medical terms, that is an abortion, you know.
SPEAKER_03Yeah, I know, I know. It's the part of the problem is is that um the language that has been used against pro-life people is is so extreme that people get touchy about it, you know. Um our our pregnancy care center here at one of the ones here in the one here in Vancouver has been vandalized three or four times with red paint splashed on it, poured through the letter slot. You know, the graffiti company has taken it off um carefully because they know that we're actually there to to support women and to care for them. Nobody's forced to do anything, nobody's forced to come through our door. We we don't do if we show pictures of normal fetal development, we don't show any, you know, torn-up babies or anything. And you know, I've had people that have, sorry, I'm just gonna turn off my phone here. Um, I've had people that have uh said to me, Well, you shouldn't be showing them pictures of normal fetal development. I said, Look, I thought we were talking about informed consent. If somebody's going to change her mind after she sees what's normally going on in her body, then maybe maybe abortion wasn't the right choice for her. She's gonna find this out sooner or later. So I I just have a real a real concern and that and we we do have a uh a group of and um sort of a counseling part for if people have had an abortion in the past and they're regretting that, that they can come and talk to our, we have licensed counselors they can come and talk to. We're part of the rape relief victims network, so if somebody's had that, they can come and talk to us and get get some support. So we we really do, we care, we care about the women. We can we have all kinds of baby clothes, maternity clothes, and diapers and all that kind of stuff that we do, and maternity classes and and doulas that'll go with them when they're in labor, and all these kinds of things. It's it's comprehensive how they're cared for.
SPEAKER_01Yeah, like that sounds really compassionate and great. Actually, the the reason that I actually posted that was actually um speaking about the same classmate in medical school because he had very, very extreme views even about abortion uh provided in these kind of extreme cases, like ectopic pregnancies and and stuff like that. And maybe it was because he wasn't that informed at that time.
SPEAKER_03Like, I hope I hope that was what it was. You know, it's just you know, I don't my own sister had an ectopic pregnancy as her first pregnancy, yeah. You know, and I I there there's there's not a way around that, I don't think. And you know, of course a molar pregnancy, well, that's not even really there's no fetus or anything involved. But you know, I think I think those those things are really the those are the minority things. Like I'm not I'm not putting uh people who you're you're being very reasonable, but reasonable about this. There are there are people who are really extreme on the other side about this too. You know, we have we have zero abortion law in Canada. So technically, if you if you had a baby that was crowning and the mother said, I I just want this baby dead, if you could find somebody to do it, you know, it's it's legal. Yeah, but you know, so what is I I think that um I'm I'm not wanting to to um what what I would like to see is a world where we care enough about each other that somebody who has an unintended pregnancy would get the support that she needs.
SPEAKER_01Yeah, I guess the counter-argument though is that you know, as you know, because you're a mother, right? How many children do you have? I have two. Two, okay. So I have one. And um as a physician, I mean, like I theoretically knew that the woman's body changes during pregnancy. But like when you actually see it yourself, you're like, oh my god, this is crazy, you know, like just like everything changes while they're pregnant. And um, you know, as a physician, you know that that doesn't come without risk. There is risk, it is uh known as the ultimate stress test for a woman, right? Going through pregnancy. And so um, you know, like my general thoughts have been that it's uh a young woman who's going who unintentionally became pregnant, they have this big, big journey ahead of them that is, you know, not going to be like totally easy. And you know, I guess there's a lot of debate on like where life begins, whether it begins at conception or whether it begins at 22 weeks when you have a true viable fetus or whether it begins when they actually exit the uterus, right?
SPEAKER_03And well, I don't think there's a debate about when when it's alive, it's where where do you assign personhood? Because personhood is what the law protects.
SPEAKER_01Yeah, okay. Yeah, sure.
SPEAKER_03So personhood, if you say viability, that just as one one of the people said who actually was an abortion advocate said to me one time, well, that just means how much money do you want to spend? Yeah, you know, you can you push it back farther every every year to and there might even be a time where you could have an artificial womb, you know. Um and so we're I don't think there's any debate that when you have a fertilized ovum, you have a unique human individual who is growing, and the only things that you're ever gonna add to that person for the rest of his his or her life is oxygen and food. You know, you're you're not gonna add any more genetic material unless there's some kind of gene therapy. But for the most part, you're not you're not really doing much. You're just if you leave it alone, it's gonna be a baby. And and so I think all this other stuff is really dancing on the head of a pen. And yes, a woman is taking on a lot if you say, you say, oh, I'm asking her to take on a lot. But like like one of my colleagues once said, you know, we're saying now that women can handle corporations and be in battle and everything, but they can't do the nine months that that their body was designed to do. You know, what does that say? Does that that's a low view of women to say that she can't she can't handle the stress of a pregnancy?
SPEAKER_01Is that a feminist view or an anti-feminist view? I can't even really pick place.
SPEAKER_03You know, but the the the feminist view is that we can handle, we can handle, we can be doctors, we can be lawyers, we can be corporate executives, we can do this. And then somehow, but somehow we're we're going to, but we we can't handle giving nine months of our life so another being can come come into the world.
SPEAKER_01But I think the feminist view is that they should have autonomy and and be able to make decisions for themselves, right?
SPEAKER_03Yeah, except that you're not just making a decision for yourself, you're making a decision for the child that you're carrying within you. And most of the time, most of the time, you you knew that when you had intercourse with somebody that you had the up that there was a chance that you would get pregnant.
SPEAKER_01I mean, most people are just thinking about getting laid at that point.
SPEAKER_03Yeah, well, I don't I don't care, but we don't we don't say that with somebody who drinks and drives. We don't say, oh well, and kill somebody. We don't say, oh well, the person was just was just thinking about getting home after being drunk. We say you're responsible for what what came out of that that encounter that you had. And and to me, there's there's something that, you know, the the other thing I've heard is, well, you know, it's a parasite. It's not a parasite, it's it's a it's a human being. And how how can we how can we come alongside people? So I I worked in student health for a few years when I was first out of uh medical school. And I had quite a few young women who came in to to talk to me. I was the only woman on the on at the student health service where I was. And what I actually said to them, they'd come in and they'd say to me, Dr. Coddle, I have a problem. I'm pregnant. And what I said, going back to something I said earlier, is I said, you know what? You don't have a problem, you have a tragedy. Because finding out you're pregnant should be one of the most wonderful w moments in a woman's life. But you and you don't, we can't, there's there's not a solution to this. There's absolutely nothing we can do right now to make you never pregnant again. So you need to decide what you're gonna do about this. So let's say you're engaged to be married. Well, if you get married a little bit early, um, there have been many people who have done that before. If you decide you're gonna be a single parent, there's lots of people that have done that and been, it's not that it's gonna be easy. If you decide that you're going to give a child up for adoption, that's not easy either. But there's lots of different ways that one can go about doing that these days. And if you decide to have an abortion, at this point in time, it is going to be the quietest thing, it's going to be the thing that not as many people know about.
SPEAKER_05Yeah.
SPEAKER_03But you are the one that has to live with this the rest of your life. And I'm not telling you not to do that, I'm just saying don't pay a lot of attention to what your parents are saying, what your boyfriend says. You are the one who has to live with the decisions that you make. And you don't have, we don't have a way. Abortion doesn't make you never pregnant. It doesn't do that. You have you have a tragedy, you have an opportunity to choose how you respond to that tragedy in your life and what you're going to learn, what you're going, what the trajectory of your life is going to be. It will be different if you're a single parent than if you get married and have, you know, have this relationship, or if you give the child for adoption, whatever. You have all of these different options. But you you need to think about them really carefully because there, despite what it says in the media, there are quite a number of people who regret having had an abortion. And you need to decide whether that is something that would be would be hard for you. And the other thing you need to decide is if you need somebody to help you talk to your loved ones about this, because oftentimes what you fear they're going to say is way different from what they do say. And so we don't want you to, you know, we don't want you to be alone in the midst of this or do whatever. But this idea that somehow abortion is something that fixes this is that's just not true. It doesn't fix it. You can never be never pregnant again. You know, you you have to think about these things. And that's kind of what we do at the Crisis Pregnancy Centers is we we help them, we give that, we say, this is not an emergency. You have time to think about this. I mean, you know, not forever, but you have you have at least a few days to think about this, talk to people, and think about what what you're gonna be glad you did 10 years from now.
SPEAKER_01Yeah. Okay. I mean, that sounds quite reasonable. I I'm all for supporting people, especially like uh during such a critical period in their life, right?
SPEAKER_06Yeah.
SPEAKER_01Um, yeah, I guess my views still always come back to um supporting a patient based on their own values. And I just feel like I mean, I've been thinking about this throughout our entire conversation. Like you uh your views and the way that you practice medicine is so clearly guided by your Christian faith, right? And for me, like I abandoned my Christian faith and now I subscribe to just like straight patient patient-centered care, which what what I believe is patient-centered care, right? And I I just wonder, like, there's it seems to be quite a big divide and a big difference between, you know, quote unquote old school doctors who are in the older generation compared to doctors that are in my generation who have graduated and are practicing in the last 15 15 or so years. And like, have you noticed that yourself?
SPEAKER_03Um I I would say I still have quite a bit in common with my Christian colleagues. Okay. You know, that they um I have quite a number who I'm still in touch with and that um would believe the way that I believe about a lot of these issues. Um I think um I I don't think it's fair to say that the old school people are not concerned about patient-centered care. And I think I think we were, we we have been. Um I think about the people in my class, and many of them, you know, did the best they could with the resources that they had. And um we we didn't have like um we we didn't have the internet available to us just at that moment to do a search on different things. You had to go to conferences and read the magazines and do all those things. So there probably was less um there were less informed uh studies, you know, that people would do and they would likely have relied on on pattern recognition within their own practice to say, well, usually this has been helpful to people that have this particular thing and you know, would do that. Um but I I think people who have a real heart for caring for their patients have been the same for a long time. And I think, you know, going right back to Hippocrates with uh who was not Christian, obviously, from BC, about talking about not giving to deadly medicine to anyone if asked, not giving a pessary to cause an abortion, you know, just respecting life at a certain level and understanding that life was a good in and of itself if we talk about uh the societal goods and that protecting it was really important, and that they he wouldn't train anybody until it wasn't something you did at the end of his training, you had to affirm the Hippocratic oath before he would train you, and he would his group of physicians would train you. So it's that that idea, and before Hippocrates, the person who was the healer was the person who also had the drugs that could kill you. And if the guy down the street paid more money to the the witch doctor or whatever, then you never knew what you were getting. But Hippocrates' followers had said they weren't going to do that, and there were other things within the Hippocratic oath about uh not taking advantage of people and not doing things that you weren't trained to do, and and all of those kinds of things that that showed that there was there was a deep respect for one's the fellow members of the human family. And I I like that terminology better than the sanctity of life.
SPEAKER_01So, what would you say about your physician colleagues who don't subscribe to the same ideology? The say the palliative care doctors who do actually administer MAID or the physicians who do administer abortions or DNCs just uh for How do I feel about them?
SPEAKER_03Well, to be honest, I probably have uh a better feeling about them than they have about me in some ways, although that's maybe not fair to give uh my palliative care colleagues.
SPEAKER_00You think that they would they would really dislike you?
SPEAKER_03No, I think they might uh I think some of the people who uh the palliative care colleagues would not, would not. I think some of the people who are more militant on the pro-abortion side of things would be very upset about um me being on the board for a crisis pregnancy center, which they call fake clinics when you know we don't we do pregnancy tests and that's it, you know, we're not doing anything and and and uh that there I I think there are there's a lot of uh um kind of misunderstanding about me being judgmental. I'm not judging them. You know, I understand, like I said to you before, I understand how people could think that that it was a good thing for that poor woman to have made when she came in. I just think that there are better ways of dealing with suffering than eliminating the sufferer. I think there are better ways of dealing with an unplanned pregnancy than eliminating the baby or fetus or embryo, whatever you want to call it at that stage. Um, if if you go in at 13 weeks with a pregnancy that you want, and they put the Doppler on and they say, This is your baby's heart. But you know, I'm not allowed to say that that it's a baby until later. So I think that they're censorship is crazy.
SPEAKER_00Yeah, yeah.
SPEAKER_03You know, I I I think that I think we can be better than than just saying, go your way and be warmed, to use a biblical thing.
SPEAKER_01I think we can we can learn to care for each other. How do you broach the conversations though with like uh physicians who disagree with you? Like part particularly physicians, uh palliative care doctors who do administer may because there are some Yeah, there are.
SPEAKER_03Yeah, there are there are some who do, and I uh I've been on committees with them and everything, and it's um I I just uh I have commended them for the good work that they have done, but I can't go on that part of the journey with them. Some of the some of them have done some very good work in palliative care and have done um uh you know worked with people that are uh living on the margins and doing other things like that. But I I I can't go along with that. Now, interestingly, when Maid first came in, one of my colleagues who's been a big proponent of this in the past, I said to him, I said, what if the per reason the person is coming to you is because uh he's poor and he's living on the street and he just doesn't want to live anymore. And he said to me, Well, that's just not that wouldn't qualify. So I wouldn't I wouldn't uh I wouldn't assess it, I wouldn't do it. So of course that started happening. And I said, Well, what what about this?
SPEAKER_01Is that uh I I can't believe that's happening. People are getting made for homelessness?
SPEAKER_03Well not complete homelessness, but for example, there was a woman here in in BC in Vancouver who could not who had multiple um had she had multiple chemical sensitivities and she couldn't get um she couldn't get um uh supportive housing where she was gonna be free of the chemicals and everything, and they said, well, you could have maid, so she got maid instead of getting supportive housing. And there was a man in Toronto who he, you know, a lot of people who are homeless qualify just fine for maid because they've got all these other you've seen them, you know the cool morbidities they have, and nobody's gonna sue that.
SPEAKER_01Those would be like typically track two.
SPEAKER_03Yeah, some of them, but some of them are have been deemed by By some of the people who have been more aggressive about this, of saying, Oh, well, you know, you've got, I know of one specific case where a colleague of mine was asked by the wife of this patient to go to see this gentleman who was living in a not so great care home. He had um he had cerebral palsy, I think, and he was um he was living in this care home because he needed the the care, but it was a double room and he just wanted to die. And uh one of the more aggressive palliative care, well, not one of the more aggressive maid doctors went to see him, and his wife called my friend and said, you know, can you go and see my husband? I think he's gonna get this. So I went to see him and he said, Well, you're not you're not dying, you know, you're just here. And he said, Well, this doctor told him that he was in bed all the time, and there was potential for him to get bed sores. He didn't have them yet. And the bed sores could get infected. And if he got infected bed sores, then his if and he didn't take treatment, his death would be reasonably foreseeable. So this doctor was willing to do MAID on the basis of that, and actually ended up doing it.
SPEAKER_01So I mean, like I yeah, I I feel like uh the gray track two is definitely like a really, really big gray zone. And like I get that. Yeah, I think my personal perspective is like it needs to be evaluated on a case-to-case basis, and like I I with these kinds of cases that you're telling me about, I don't have all the facts, so I wouldn't be able to weigh in on it.
SPEAKER_03But yeah, like well, anyway, I went I so I I went to this colleague afterwards and I said, Look, this is what's been happening. And his response, I said, you know, some of these people, the main reason they're asking for this is not because of the underlying disease, it's because they're homeless, it's because they're lonely, whatever. And he said, That's not my job. He says, I'm just there too, I'm just there to see whether they qualify. And now it's gone one step further. So now those of us who are saying, if people are having made because mainly because of the social determinants of disease that are happening, that and we say that that's that's not good enough for us as a culture, that just because you're you're underhoused or all these other things that you should be getting made. I've been we're being told by these same folks, well, you're the paternalistic one. Who who are you to say that just because somebody's living on the street and that's part of the reason that he wants to have made and he qualifies, that he shouldn't be able to have it. So, you know, to me it's it's it's completely gone upside down from that. But it there's something that makes me very sad about that kind of um rationalization that well, if you qualify, it's okay. That that I want us to be better than that. I want us to be a place where you know, if if you if you end up pregnant, we come alongside you and we help you. If you are at the end of your life and you're feeling like your life isn't worth anything, you've got all this stuff going on, that we come alongside, we come alongside your family. We're we're there to tell you that you don't have to be beautiful or wonderful or any or or physically able to help us or mentally, even even with us to do this, that we are going to care for you because you are a member of our human family and you matter to us. And so that's that's where I come down on these things, and I I I understand to be honest, Jeff, this is one place where my Christian faith comes in. I was a person in high school who was very passionate about social justice. Okay, and I could see myself being really passionate about these these issues because I would see them maybe as social justice. So I graduated from high school in 1970, which was right at the end of the Vietnam War, right at the end of all the civil rights things, you know, all of that going on, so which shaped who I was really as a person. So I was I was passionate about this. You can probably tell I'm a bit of a little terrier. So I was passionate about those things. But when I became a Christian and the Holy Spirit got a hold of me. I'm I mean, this is personal for me. I'm not saying it has to be for everybody. I began to see things through the lens of how Jesus would see them, and to see, to be to have the same kind of lens that Mother Teresa has. When she sees a dying person, it's not like a piece of trash. This is somebody that is a member of my family. I need to care for them. This is somebody made in the image of God, I need to care for them. And these colleagues of mine are the same. And and I realized that I could be those other people without the intervention of the spirit. I could be the people who are pushing for these things because I think that there's a social justice element to it. But I have um had the spirit come alongside me and say, look, yeah, there's a justice element in this, but the love is bigger, love is better, love is greater.
SPEAKER_01Great. Well, I think we'll call it there. Okay. Thanks so much for the great conversation. I learned a lot. It was very insightful, but uh, thanks so much. Okay, you're welcome. You're welcome.
SPEAKER_03Thanks for inviting me and not just blowing me off. This interesting young man, I'm gonna DM him.
SPEAKER_01Great.