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https://doi.org/10.1177/2050312120913452
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Introduction
(A Physician’s Story) I just want to emphasize, as cliché as it
sounds, this work, being a provider, a prescriber for medical
assistance in dying, has been truly extraordinary work. I have
met extraordinary people—especially in the early days and
continuing today. The courage it took those people to step
forward, to ask for this care, these were independent, strong-
willed, long-lived, hard-core, independent people. These were
extraordinary people who led extraordinary lives. Their whole
lives had been like that. They had stories about what they’d
done in their lives that were mesmerising. To be able to do this
with them and give them this gift, and the reward I got personally
and professionally by doing that, was shockingly amazing. And
it continues to be, to this day. I find it the most extraordinary
work. I keep finding myself in the position of meeting people and
finding myself in situations I never would have dreamed of—like
holding someone’s hand you just met a week ago, who now
trusts you intimately and infinitely to do this most intimate act
with them and they’re thanking you as they’re dying. Like crazy
things that five years ago I never would have thought possible
and they keep coming up, these crazy situations keep coming up.
It’s amazing. It blows my mind still. I don’t think I take it for
granted yet. I don’t think I ever will. (Physician provider of
medical assistance in dying—Participant 5)
Rediscovering the art of medicine, rewards,
and risks: Physicians’ experience of providing
medical assistance in dying in Canada
Rosanne Beuthin1,2 , Anne Bruce2, Marie-clare Hopwood3,
W David Robertson4 and Katherine Bertoni5
Abstract
Background: Medical assistance in dying opens up uncharted professional territory for Canadian physicians extending their
practices to include assisting and hastening death for eligible patients.
Objectives: To understand physicians’ experience of participating in assisted dying and the emotional and professional
impact.
Methods: An interpretive descriptive methodology and thematic analysis were used for this research. We interviewed eight
physicians engaged in assessing and providing medical assistance in dying. Data were collected through audio taped, semi-
structured interviews in person or by phone.
Results: Three overarching themes included (1) rediscovering the art of medicine, (2) unexpected rewards, and (3)
negotiating risks and challenges. Each theme has accompanying sub-themes.
Conclusion: Medical assistance in dying is markedly different from other physicians’ practices in that it has an enriched
capacity for caring. The process brings deep satisfaction characterized by intimate, personalized contact with patients and
families. The professional rewards of providing medical assistance in dying outweigh the challenges, offering an alternative
narrative to more publicly accepted views of assisting someone to die.
Keywords
Death and dying, medical assistance in dying, physicians, art of medicine, end-of-life issues, stories, Canada, compassion
satisfaction
Date received: 6 November 2019; accepted: 7 February 2020
1 CNS End of Life Care, Vancouver Island Health Authority, Victoria, BC,
Canada
2School of Nursing, University of Victoria, Victoria, BC, Canada
3Oceanside Community, Royston, BC, Canada
4 Geography 3—Laboratory, Medical Imaging, and Pharmacy, Vancouver
Island Health Authority, Duncan, BC, Canada
5 Jack Petersen Health Clinic and School of Nursing, Faculty of Human &
Social Development, University of Victoria, Victoria, BC, Canada
Corresponding author:
Rosanne Beuthin, School of Nursing, University of Victoria, 6936 Shiner
Place, Brentwood Bay, Victoria, BC V8M 1E8, Canada.
Email: Rbeuthin@uvic.ca
913452SMO0010.1177/2050312120913452SAGE Open MedicineBeuthin et al.
research-article2020
Original Article
2 SAGE Open Medicine
Canadian physicians have been directly affected by 2016
legislation1 that set the stage for allowing assisted dying
under specific legal and regulatory circumstances. Because
of the sensitive nature and relative newness of assisted dying
in Canada, understanding the experiences of physicians par-
ticipating in medical assistance in dying (MAiD) is vital to
ensuring a smooth transition of assisted dying into health
care. This legislation is unique in that it includes voluntary
euthanasia (in which a medical practitioner administers a
lethal dose of medication to cause the death of a patient) and
assisted suicide (in which the medication is administered by
the patient). (Note: In the province of Quebec, only volun-
tary euthanasia is legal.) MAiD heralds an unprecedented
change for physicians who have been educated and trained to
support life. Physicians with expertise in providing end-of-
life care are also entering uncharted territory, personally and
professionally. All are being called to rethink their practice
by reorienting toward directly assisting eligible patients who
make this choice.
The College of Physicians and Surgeons of BC Standards2
states that a physician must “provide patients with enough
information and assistance to allow them to make informed
choices for themselves” about medically assisted death. The
scope of practice extends from performing patient assess-
ments and/or to performing MAiD. Although physicians
may conscientiously object to assessing a patient for or per-
forming MAiD and may choose to not be involved, they are
required “to provide an effective transfer of care for their
patients by advising patients that other physicians may be
available to see them” (p. 6). As with other health care pro-
fessionals, physicians have a duty of care that must be con-
tinuous and nondiscriminatory. Although national data are
slowly being compiled,3 and a body of literature is rapidly
evolving, to date limited research is available on how physi-
cians are engaging in assisted dying in the Canadian
context.
Literature review
The number of jurisdictions across the world where some
type of legislation related to assisted dying/suicide and volun-
tary euthanasia are in place continues to grow since it was
first introduced in Switzerland in 1942. Currently, euthanasia
is legal in the Netherlands, Belgium, Columbia, Luxembourg,
and Canada. Assisted suicide is legal in Switzerland,
Germany, the Netherlands, the state of Victoria in Australia,
and in the US states of Washington, Oregon, Colorado,
Hawaii, Vermont, Montana, Maine, New Jersey, California,
and the District of Columbia.
Amendments made to the Canadian Criminal Code on 17
June 2016 mean that Canadians can now legally access
MAiD. The spirit of the law is that this new service be pro-
vided compassionately and ethically, that all involved are
supported, and that harm is not caused to patients or staff.
The path to physician involvement in MAiD has been fraught
with tension.4,5 Initially, some physicians struggled to recon-
cile themselves to this major practice change, but general
sentiment is slowly changing. From 2013 to 2015, the num-
ber of Canadian physicians supporting MAiD rose from 34%
to 45%, with 83% of those surveyed in 2017 supporting the
idea of advance requests.6 A recent survey of medical stu-
dents showed that among Canada’s new generation of doc-
tors, 71% would offer MAiD.7 Although provisions are in
place to ensure physicians can decline to help on moral or
religious grounds, researchers in Quebec found that the
majority of physicians who refused to participate did not
oppose MAiD. Rather, their expressed concern was “the
emotional burden related to this act and the fear of psycho-
logical repercussions.”8
Notwithstanding that what is known about physicians’
experiences in the Canadian context remains scant, a grow-
ing body of research from other countries is available. In a
recent scoping review, Fujioka et al.9 examined the roles of
physicians and other health care professionals in decision-
making related to MAiD and the professional challenges
that arise when they are confronted with patient requests.
Key challenges reported by physicians included tensions
caused by colleagues conscientiously objecting to MAiD.
In a qualitative study from the Netherlands, some palliative
care physicians felt pressured to comply with patients’
requests for euthanasia, despite their own discomfort.10
Other challenges included the emotional tensions experi-
enced by palliative care physicians in the Netherlands and
United States, including feelings of strain, loneliness, and
being conflicted.11
Similarly, Brooks12 conducted a scoping review of qual-
itative literature and called for further investigation into the
experiences of diverse MAiD providers in the Canadian
setting. Reported findings specific to Dutch physician pro-
viders include studies that underline stressful, negative
experiences of providing assisted dying.10,13 According to
another study, physicians in Oregon faced ethical complex-
ities and a negative emotional impact,14 and yet they did not
express major regrets over their decision to participate. The
findings showed how requests for assisted dying prompted
discussion of important issues and increased physicians’
confidence and assertiveness in discussing end-of-life
issues with other patients. Mixed findings regarding physi-
cians’ experience have been thrown up by, among others, a
quantitative study whose authors reported that euthanasia
was seen as burdensome and emotional for 42% of all cases
of hastening death that they investigated, and 52% of the
physicians reported feelings of satisfaction and relief.15
Although the body of research is growing regarding physi-
cians’ roles, attitudes, and opinions on assisted dying in
Europe and, to some extent, the United States, we aimed to
understand better the direct physician-provider experience
in the Canadian context.
Beuthin et al. 3
Study purpose and design
The purpose of this study was to enhance the general under-
standing of Canadian physicians’ experience of directly pro-
viding MAiD (referred to as “providers”).
Methodology
We used a qualitative design drawing on thematic inquiry16
to identify themes, as well as interpretive description17 to
work interpretively with participants’ narratives.
Participants
Eight physicians volunteered from urban and rural areas who
were providers of MAiD. Participants were recruited from
across the local health authority via a poster sent to medical
divisions and physicians who had completed MAiD assess-
ments. Participants included general practitioners (GPs) and
nonspecialist physicians from urban and rural communities
working in acute and palliative care. Ages ranged from 33 to
62 years (average age 49), with an equal number of men and
women. The majority identified no active religious affilia-
tion, and ethnicity was withheld to protect anonymity. Years
of experience ranged from 6 to 38 years (average of 23), and
experience with MAiD provision ranged from 12 to 113
assisted deaths. Only one physician was dedicated to full-
time provision.
Data collection
Data were collected using semi-structured interviews last-
ing 40–70 min. Interviews were audio-recorded and con-
ducted in person or by telephone by coinvestigators (Ab,
MH). The majority of interviews were conducted via tele-
phone to facilitate participation throughout the large geo-
graphic region. Interviews were guided by questions
including: (1) Please tell me about your experience of
being asked to participate in a medically assisted death and
how you came to your decision; (2) Tell me about your
MAiD experience. What has been most challenging? (3)
What concerns did you have, if any? and (4) How are you
(or are you) reconciling your personal and professional
beliefs? What challenges do you foresee in moving for-
ward with MAiD?
Analysis
We followed a layered approach informed by Thorne’s17
interpretive description and Braun and Clarke’s16 thematic
analysis. Analysis began with identifying individual and col-
lective narratives via preliminary questioning of the data:
What narratives surprised us, what was missing, and what
patterns were we beginning to see? A second layer of analy-
sis included identifying categories and preliminary coding.
Transcripts were systematically coded and recoded using
Atlas-ti™, collapsing codes into overarching themes and
sub-themes.
As with any qualitative research, we focused on attaining
not a high quantity but rather a high quality of participant
experiences; interviews that had a depth and richness of
detail and nuance. After analysis of eight interviews, we
noted that the amount of variation had leveled off and thus
felt confident with the data set.
Ethics and rigor
We received approval from the Human Research Ethics
Board as per Tri-Council Policy Statement.18 This included
approval from Island Health and the University of Victoria.
Findings
Physicians’ experiences of providing MAiD were conceptu-
alized into three overarching themes of rediscovering the art
of medicine, gaining unexpected rewards, and negotiating
risks and challenges. Each theme was accompanied by
descriptive sub-themes (Table 1).
Table 1. Overarching themes, sub themes.
Themes Description Sub-themes
Rediscovering the art
of medicine
Providing assisted dying is a process that calls physicians
into embodied awareness and relationships of intimacy
and grace.
Remembering whole-person care
Practicing differently
Intimate, emotional engagement
Embodied awareness
Gaining unexpected
rewards
Personal and professional well-being is gained from
satisfaction and appreciation of living core values.
Compassion satisfaction
Aligning values and beliefs
Conviction of doing the right
thing
Outpouring of gratitude
Negotiating risks and
challenges
Legal, collegial, and institutional barriers must be
navigated. Individuals have concerns over sustainability
of workloads.
Being vulnerable
Collegial discord
Risk of reprisals
Workload and financial impact
4 SAGE Open Medicine
Rediscovering the art of medicine
Providers acknowledged how MAiD offered a personal
engagement rarely experienced with patients in the hubbub
of daily work. They described a sense of slowing down and
practicing medicine differently, and they remembered simi-
lar experiences back in medical school. One physician
described the need for “keeping the grace central” in order to
intimately listen to their patients’ suffering (#3). Another
described the process as “very meditative and contemplative
in a different sense than I do in my other practice” (#8). One
foregrounded the mutuality with patients:
There just seems to be more of an intimate contact . . . maybe
because I spend a longer time with them? There’s often a home
visit and there’s, I don’t know, a sort of mutuality about it. It’s
different than general practice—I find that I invest more
emotionally but that doesn’t mean I’m upset, it just means I’m
using more of an emotional side of myself than I do in an
ordinary general practice consult. (#4)
The science and art of medicine were central, with “the
art piece really coming full strength now with MAiD.”
Tremendous consideration went into ensuring practical (and
vital) details such as the need for administering of medica-
tions not to take center stage. One participant experimented
with multiple inches of IV tubing so she could stand behind
the patient and family and “be one layer back, sort of in the
second row seat. Which I really feel is good.” She explained,
I needed to figure out how to let the family be the main people
that the [patient] is seeing . . . I needed to feel fluid enough with
my drugs and syringes that I could just focus on the patient. [I
use] eye contact and demonstrate where people should focus
because sometimes they just look at me and the needle. (#8)
Another skillful aspect of the “art” involved an embodied
self-awareness, “paying attention to my syringes,” while
concurrently attuning to both people and the quality of space
in the room:
[I try to] focus on what else is going on in that room. What else
is going on with the patient? Am I picking up any undercurrents
and am I tuning into any undercurrents of tension, hostility,
sadness, that I should address? So it’s a very different type of
attentiveness, I feel like all of my skin is on edge watching . . .
the vibe in the room. It’s a different type of attentiveness, and in
a different way tiring—It’s not so much the technical part, that
part is easy. The difficult part is being on alert for what’s
happening in the room. (#8)
Unexpected rewards
An overarching theme was how unexpected and “extraordi-
narily rewarding” the work had become. We have conceptu-
alized this as “compassion satisfaction,” and as one
participant shared, “it feels like the most important medicine
I do.”
Compassion satisfaction. Participants also described MAiD as
a process that included expressions of “deep empathy” and
“love” and as “amazing.” Some used this type of animated
language, while others grappled with how challenging the
experience was to articulate. Nevertheless, other descriptors
included “gratifying,” “it feels good,” and “I hadn’t expected
this.” Some physicians compared the almost inexplicable
experience of honoring and assisting death to the joy of
attending a birth, and all prescribers valued the unique nature
of the work:
It’s a very positive experience and difficult to put into words
how it makes me feel. It makes me feel really kind . . . I feel like
I’m doing a good thing . . . heart-warming. It’s quite loving.
(#4)
Participants often expressed these views softly, as if hesi-
tant to describe the experience in such an affirming way,
which may run counter to what other physicians or the public
might imagine the experience of assisting death to be like.
The unanticipated and high levels of satisfaction were illus-
trated by one participant who stopped providing MAiD as a
result of his workload, but who later returned (after a few
months), stating how much he “missed it.” Several partici-
pants likened the experience to being joyous, an end-of-life
experience that left them feeling high. Many spoke of their
love of the work, even after providing many deaths: “It’s
amazing. It blows my mind still.”
Aligning with deeply held values and interests. Reasons under-
pinning such satisfaction may include how closely MAiD
aligned with deeply held values and interests, participants’
conviction of doing the right thing, and the outpouring of
gratitude from patients and families. We will now discuss
each in turn.
For many participants, the decision to become a MAiD
prescriber was based on core values and beliefs such as “a
fundamental value of patients’ autonomy” (#7). Other beliefs
referenced undercurrents of social justice and a history of
activist engagement on many fronts, be it with women’s
reproductive rights, animal rights, HIV/AIDS work, debates
on end-of-life care, and palliative care at a time when its
merits were also being debated. Although only some partici-
pants were interested in assisted death as a social movement,
they all expressed personal interests beyond professional
obligation; as one participant stated, “I would personally ask
a physician to do the same for me.” Several had a long-stand-
ing interest in medically assisted dying and were preparing
in advance of the legislation so as to be ready as soon as it
became legally available:
I’ve always been interested in the intersections of medicine,
ethics, and law my entire career and . . . I always followed along
the national discussion and debate about end-of-life care since
the Sue Rodriguez case, which was going on actively when I
was in medical school. So it’s always been at the back of my
mind. . . I went to a conference in Amsterdam and it was
Beuthin et al. 5
extraordinary, and basically the conference convinced me that I
wanted to work in this area—it was something I really, really
wanted to do. (#8)
Participants were unequivocal in believing they were
doing the right thing. As one physician quipped, “You could
perhaps describe me as a conscientious provider . . . ” (#3).
Like others, he contrasted against those who refuse to par-
ticipate in MAiD on moral or religious grounds (conscien-
tious objection) with his own strongly held belief that
providing assisted dying is the right action. As another pro-
vider advised, “you have to be 100% sure that you believe in
this and that you are happy with the law and the rules” (#2).
Most participants expressed this certainty and were commit-
ted to providing assisted dying as soon as the legislation was
passed:
Well the first year . . . there was a certain number of people who
stepped forward—and I think we were taken advantage of, quite
honestly. But we didn’t care, because we were going to show
that it could be done [MAiD], and we were going to show that it
could be done well, and we were going to spread the word, and
recruit people, and change the world kind of thing. So we did
that. (#5)
Although most participants wanted to provide MAiD
once it was legal, this was not unanimous. One participant
shared her initial indecision. Although she agreed with the
legislation, she needed more time to do some “soul search-
ing.” She questioned, “Will I be able to cope?,” “Will the
deaths haunt me?,” and “Will it be too great a burden?”:
I thought about it for six months before I decided that I could do
it. I discussed it with my partner, talked it over, and just dwelled
on it a bit really. [I wondered] whether the ways I’ve dealt with
death before, whether it would bring back any bad memories of
my own parents’ death. I just mulled it over. I did quite a lot of
soul searching to see would I be emotionally resilient [enough]
to do it. (#4)
Finally, providing individuals with an assisted death also
generated an intimate outpouring of gratitude by patients and
families, and the extent of this landed on the prescribers in an
overwhelming and significant way. Patients’ gratitude
seemed to buoy, empower, and affirm participants’ convic-
tions about patient choice and their role in reducing patient
suffering.
Negotiating risks and challenges
Participants were also frank about fears and challenges asso-
ciated with being a provider, especially in the early days after
the legislation was passed. These included concerns about
what their families might think and worries for their personal
safety. They acknowledged feeling vulnerable by stepping
up to offer this service when others would not and opting to
make their names public as MAiD providers. As one
physician stated, “So emotionally, I was fearful but not so
much of the work as I was of the backlash of the work” (#5):
I was worried that it would be like abortion, meaning providers
would be at risk of shootings and stabbings and having their
offices blown up and that has not happened with MAiD . . . it
has not elicited the same level of anger. (#7)
Fear of reprisal from oversight bodies such as the coro-
ner’s office was particularly present in the early days. A
heightened sense of risk related to what seemed for some to
be disproportionate surveillance: “We’re being scrutinized a
lot more” and “I’ve never once been called by the coroner,
but for a MAiD death I’ve been called two or three times.”
Concerns over repercussions led to time-consuming and
meticulous consultation notes for their personal records.
Some worried whether their notes would be sufficiently thor-
ough and defensible. The range of patient diagnoses neces-
sitated significant background work if providers were not
familiar with particular diseases. This added layers of appre-
hension when conducting an assessment:
Your heart sort of sinks when you get this letter from the coroner
because I guess they have great powers to request anything so
you kind of think, oh God, what’s going to happen? It is pretty
intense making sure you get all the pieces in order because you
can’t be wrong from a procedural aspect. There is this kind of
fear in the background that there could be legal repercussions,
so I suppose that’s part of the emotions. (#1)
In contrast, participants described strong prescriber sup-
port received via a web-based physician list-serve. Some
spoke cautiously about their national organization that pro-
vided legal advice. The thornier ethical and legal issues were
the most worrisome, and as one physician explained, support
from legal advisors was often limited: “As lawyers [they] are
very conservative and so with any sort of grey area—they’re
going to say don’t do it.” This was perceived as frustrating:
I can understand why they’re super conservative about their
advice but at the same time because they do that, it makes me less
likely to actually seek their advice because I already know what
they’re going to say. Whereas if they’re more, I guess,
understanding of the situation and able or willing to put—I think
it’s important for our peace of mind that they put it in writing
because when they give us an opinion in writing that’s something
I keep always in my documents—if they were willing to say in
writing that they were able to sanction or recommend, or say that
it seems reasonable, I’d be much more likely to seek their advice
in the future. And I think I’m actually less and less inclined to
seek their advice because of that, which is not good. I should be
wanting to get an opinion from them. But then others argue that
we should be consulting with other physicians, not with lawyers
because the decision lies with us, not with lawyers. (#6)
Collegial challenges also included tensions with physi-
cians related to poor communication when patients
requested MAiD without informing their attending
6 SAGE Open Medicine
physician or palliative care team. Participants described
trying to protect professional courtesy:
It is sort of a passive relationship with the personal physician.
I’m never too sure where I stand on that. I try and give them a
bit of [a] heads up if they haven’t already been aware that this is
happening if the patient hasn’t communicated. (#1)
Feeling unsupported, especially in smaller communities,
was another issue identified by some providers. Early in
2016, participants spoke of resistance from individuals or
faith-based institutions disagreeing with the legislation:
One thing I should add so you understand what’s difficult—
what has been the biggest thing in our town—because the
hospital was Catholic, we had limited supports, so we could not
get patients to get an IV. We had to do a lot of undercover,
underground work. We had to visit patients afterhours, pretend
to just be visiting them, close the door and do an assessment
whispering behind the closed door, or ask other colleagues to
just quickly come to a patient’s room to quickly sign a request
form and then all scatter so no one knows a request form was
signed. These things were hard because we had to manage all of
this on top of managing the family’s grief, the patient’s process,
the legal process, and having to find a place to do this in a
community that was otherwise not very supportive. The hardest
thing was witnessing patients suffer because the hospital would
not allow certain things to happen. (#2)
Another challenge considered part of the process was turn-
ing down a patient who was not eligible. A further challenge
arose on hearing the patient say they would “end it them-
selves” if they were not deemed eligible. Other difficulties
were having to cancel a planned MAiD because of a patient’s
loss of capacity and facing a devastated family. Although
most families reportedly accepted these often unforeseeable
situations, participants shared infrequent stories of facing
loud or threatening families or when a patient wanted MAiD
and his or her partner did not support the decision.
Finally, concerns about insufficient remuneration and a
growing workload were widely shared. Most GPs had no
administrative assistant who could complete the required
paperwork; the volume and process of reporting were per-
ceived as burdensome. As one participant shared, “There’s
no other aspect of medicine that I practice where I’m shuf-
fling that much paperwork and I’m personally responsible
for getting it done” (#6).
Fears of burnout and the unsustainability of workload
were pervasive. One provider shared, “There were times
when I was getting five or six referrals in a week and it was
completely overwhelming.” With the exception of a few,
most physicians conducted MAiD on top of their regular
workload, with many doing so in the evenings or on week-
ends. One participant shared, “The future of providing access
and quality end-of-life care for those who cho[o]se MAiD is
not sustainable with the lack of physicians or nurse practi-
tioners” and the current system. Others shared hard-won
lessons of putting boundaries on this work by designating
particular days and times for providing MAiD. Some
described limiting their role as consultant on MAiD to help
with the workload, recognizing: “I’m not the expert in those
other alternatives, especially complex palliative medicine or
whatever else; I’ll get those folks involved.”
Discussion
The themes of rediscovering the art of medicine, gaining
unexpected rewards, and negotiating risks and challenges
might be expected with a medical change of this magnitude.
Personal passion and conviction, followed by intense satis-
faction, provided a foundation for participants’ willingness
and commitment to provide assisted dying. We are seeing
similar perspectives in editorials and personal narratives
across Canada. To name a few, eminent palliative care physi-
cian and MAiD provider Sandy Buchman19,20 and three phy-
sicians featured by Evans21 share similar commitments.
Family physician Tony Reid22 described his experience of
providing MAiD as “an extension of palliative care”; “pro-
found” and “astonishingly rewarding,” “it combines so many
of the skills and art that make family medicine so fulfilling”
(p. 640). Many participants also saw MAiD work as an
extension of palliative care and, while facing resistance from
some palliative care providers, they appreciated deeper con-
nections and the recent goal of coexistence23 with palliative
care teams in their communities.
Rediscovering the art of medicine
A key finding of this study was how providing an assisted
death felt like rediscovering what participants once knew
and valued—practicing the art of medicine. This contrasts
starkly with recent claims that intimate, personalized medi-
cal practice has become “an unfortunate causality in a health-
care system that values volume, numbers and data over
caring [for] the whole person.”24 Study participants reported
how providing MAiD is remarkably different from their
other clinical work, in part because of the intimacy and care
required in opening oneself up to and understanding the
grievous and irremediable suffering of another. It is this
capacity for caring that Gillespie et al.25 defined as the art of
medicine. Furthermore, this kind of medical attention and
“relationship-centered care” are said to enhance personal
growth and physicians’ well-being.26,27 Participants seemed
to support this assertion, describing MAiD as highly satisfy-
ing, and for some it has become the culmination of their
career. Medicine as an art has long been recognized as “resid-
ing in the interpersonal aspects of [the] patient–physician
relationship,”28 and participants also go beyond the interper-
sonal to include larger goals of social change and service to
society. This is reminiscent of Hippocrates, who reportedly
said, “Wherever the art of medicine is lived, there is also a
love of humanity.”29
Beuthin et al. 7
The findings from this study support Peabody’s claim that
“the art and science of medicine are not antagonistic but
complementary.”25 Participants reported the beauty of being
able to see and hold both the technical and the human, to be
invisible and visible to families in the process, to be clini-
cally concise and have grace, to feel meditative and fatigued
from the high level of alertness. The ability to hold opposites
at the same time, to be deeply passionate and yet cautiously
reluctant, builds on current hallmarks in understanding the
art and science of medicine.
Compassion satisfaction
Another key finding of compassion satisfaction offers an
emerging narrative that counters more publicly accepted
views (and cultural norms) that assisting someone to die will
be emotionally distressing. Piemonte went so far as to claim,
“a broader look at the research surrounding physicians’ psy-
chological responses to suffering and death suggests that phy-
sicians are more fearful of death than either patients or persons
in good health” (in Frank, 2018, p. 43).30 The finding that
MAiD evoked a sense of deep satisfaction is critical when
considering that an alarming number of Canadian doctors (one
in four) report burnout.31 An irony is that in current general
practice, many physicians refer their patients to palliative spe-
cialists and in essence “give away” what could be one of the
most rewarding aspects of care. Further research is needed to
understand why family physicians may not lean into end-of-
life conversations and care; we wonder about potential dis-
comfort or a perceived lack of skill.
Our study participants were drawn to MAiD: holding the
conviction of doing the right thing and having values and
beliefs that align. Although the emotional challenges of end-
of-life care are reported,32,33 there is also a growing interest
in the potential positive effects for clinicians working in dif-
ficult situations including end of life and trauma.32 The find-
ings from our study add to this growing body of knowledge
by illustrating participants’ experiences of compassion satis-
faction through providing assisted dying.
These findings support research describing compassion
satisfaction as stemming from emotional rewards when pro-
viding meaningful care to another,34,35 resulting in feelings
of positivity and pleasure.36 Stamm34 suggested that compas-
sion satisfaction can be an antidote to clinician burnout. In a
recent study, Khoshnood et al.37 found that MAiD providers
also experienced the work as highly rewarding and believed
that other physicians and the public were not ready to hear it.
The findings from this study support this attitude of reticence
alongside the view that MAiD provision is satisfying and
personally sustaining.
Negotiating risks and challenges
Findings regarding the risk of physician vulnerability, fear of
reprisals, and workload concerns are similar in the literature.27,37
Khoshnood et al.37 reported physicians’ commitment to provide
assisted dying despite the collegial, financial, and scheduling
limitations they were facing. A recent Canadian study by Shaw
et al.27 identified similar challenges and pointed to a growing
need to support physicians working in small communities and
facing disapproval of MAiD from colleagues and faith-based
institutions. In addition, nuanced support for physicians fac-
ing ethical-legal dilemmas that goes beyond “standard”
advice from formal sources, such as the National Protective
Society for Physicians, is needed. Findings point to percep-
tions of legal advice as conservative, risk averse, and often
unhelpful when navigating complex cases. Consequently,
physicians created networks among themselves to support
their decision-making and practice, with similar findings
shared by Shaw et al.27 The clinical judgment required in
determining eligibility for MAiD can be nuanced and has led
to wide variability in opinions about when a person becomes
eligible.38 More research is needed into what resources would
be helpful when facing complex cases rooted in unclear legal,
moral, and ethical considerations. For example, if suffering
was believed to be what the patient says it is,39 and assessing
“reasonably foreseeable death” was ambiguous, physicians
must work through the risks of legal challenges alongside
what they can personally live with.40 A greater understanding
of effective supports for physicians interested in becoming
MAiD providers is essential. Without resources and supports,
the pool of physicians willing to provide assisted dying will
not keep pace with patient demand, and the risk of provider
burnout may be inevitable.
Limitations
Interviews occurred in the first 2 years of assisted dying leg-
islation being enacted (March–June 2018) and provided an
early account of physicians’ experiences as MAiD providers.
The study was limited in its diversity of perspectives; we
sought to recruit physicians who held objections to or moral
conflicts with assisted dying but were unsuccessful in our
efforts. Participants came from a single health authority
where GPs provide assisted dying as sole practitioners.
Consequently, we excluded nurse practitioners who were not
serving in a provider role at that time in the health authority.
Finally, sampling was purposive, and participants self-
selected, which should be considered when interpreting
these findings.
Closing thoughts
In this study, we addressed existing gaps in knowledge of
how providers are making sense of and being affected by
MAiD. Such evidence is vital for ensuring responsive, sus-
tainable, and effective implementation of assisted dying.
Overwhelmingly, the physician participants shared stories
that conveyed how the rewards of the practice outweighed
the risks and burdens. Participants related to the experience
8 SAGE Open Medicine
as rediscovering the art of medicine in a way that was unex-
pectedly satisfying and meaningful, both professionally and
personally.
Acknowledgements
To the participants who spoke to us with honesty and openness, we
found their trust humbling. Our gratitude to all we have had the
privilege of encountering in this work.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Ethical approval
Ethical approval for this study was obtained from Island Health,
Health Research Ethics Board (HREB) (Certificate of Ethical
Approval for Harmonized Minimal Risk Health Study, #J2017-
102. Physicians Experiences of Assisted Dying) and also reviewed
and approved by University of Victoria, in accordance with the
Tri-Council Policy Statement.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was supported by a collaborative grant from the Vancouver
Island Health Authority.
Informed consent
Written informed consent was obtained from most subjects before
the study. Written consent was not possible for participants inter-
viewed by phone. In this instance, verbal consent was obtained. The
researcher conducting the interview reviewed the consent form and
asked for verbal consent verbally, and this was recorded.
ORCID iD
Rosanne Beuthin https://orcid.org/0000-0002-8186-6548
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