Justice Committee on May 4th, 2016

[Dr. Jeff Blackmer]

I would say probably the best analogy is therapeutic abortion. This is a matter over which the medical profession has certainly struggled collectively and individually. There's often a question around conscience rights and a right to objection and whether or not physicians may have an obligation to refer to another practitioner there. That's probably the closest analogous situation.

[Chris Bittle, Liberal, St. Catharines, ON]

Are physicians required to conduct a therapeutic abortion?

[Dr. Jeff Blackmer]

No. There's no requirement for them to do that, and there's only one province that currently requires them to refer someone to a colleague, which is Ontario. Ontario is actually the only jurisdiction in the entire world with that requirement.

[Chris Bittle, Liberal, St. Catharines, ON]

Do the colleges across the country, the colleges of physicians of the various provinces, fiercely safeguard the conscience rights of physicians through their own professional regulations?

[Dr. Jeff Blackmer]

That's correct. I would say that particularly on the point of assistance in dying, we've seen the nine provinces, those outside of Quebec, come forward with regulations. All of them, save Ontario, have wording that very clearly protects the conscience rights of physicians, but we have certainly seen some discrepancies in terms of the exact wording. As I say, Ontario is an outlier in terms of its regulations in that regard.

[Chris Bittle, Liberal, St. Catharines, ON]

Perhaps you could speak for a moment about the importance of self-regulation in terms of your membership.

[Dr. Jeff Blackmer]

Self-regulation is very much a privilege and not a right of the medical profession. It is something we constantly must strive to uphold through our actions, collectively and individually.

As you know, there are members of the public now on these regulatory bodies, and we look to them for guidance as well. This is critical to what it means to be a medical professional—the ability to self-regulate and to hold our members to a high standard.

On issues such as conscientious objection, we often look to the colleges for guidance. This has been a difficult issue, again, because of some of the inconsistencies in the guidance that has come forward.

[Chris Bittle, Liberal, St. Catharines, ON]

Perhaps I could direct my next question to Dr. Forbes. You mentioned that you are a family physician. I expect that, in the course of your practice, you have had a number of patients who have gone through suffering at the end of life.

My concern relates to the 15-day waiting period. I know the legislation provides that this period can be abridged, but for the sake of argument, we would say that the average person accessing medical assistance in dying will have to wait 15 clear days. Is there a cruelty in that? We have declared that someone suffering at the end of life must wait over two weeks, in an average case.

[Dr. Cindy Forbes]

That is certainly a question that has been asked. It does say at least 15 clear days, which allows for a longer period of time, if that is appropriate. However, there is some wording around the fact that if the prognosis is felt to be shorter than that, there would be some special arrangements there.

Do you have the wording?

[Chris Bittle, Liberal, St. Catharines, ON]

I was wondering if you could speak more to the patient-centred approach to things rather than the legal—what the patients go through in their last days, the suffering they must endure, and waiting an additional two weeks.

[Dr. Cindy Forbes]

The whole issue around assisting a patient to die is an issue of compassion, for society to be compassionate to people in this situation, and certainly for any physician willing to participate. It is of highest concern that patients not be unduly suffering. However, this is being weighed against safeguards to make sure there is sufficient time for sober second thought. I think you have to look at it as a balance.

The wording in the bill is that if the two medical practitioners

are both of the opinion that the person’s death, or the loss of their capacity to provide informed consent, is imminent—any shorter period that the first medical practitioner or nurse practitioner considers appropriate in the circumstances

There is a provision there. I think it would be an exceptional circumstance, but at least it does give that leeway. As I said, these are complex issues. We would want to make sure that the safeguards are protecting people at this very vulnerable time in their lives.

[Chris Bittle, Liberal, St. Catharines, ON]

This is understandable.

Would the CMA support a shorter time frame, given the balances of which you are speaking?

[Dr. Cindy Forbes]

I think that as long as there is a provision.... Our original document did suggest two weeks, but we also suggested that in the case where the prognosis was much graver, much shorter, there be some flexibility. I think Bill C-14 actually does provide that.

[Chris Bittle, Liberal, St. Catharines, ON]

Thank you.

Ms. Morris, you talked about this bill not being workable medically. I was wondering if you could elaborate on that and explain that comment, again, from a patient-centred approach.

[Wanda Morris]

Absolutely.

I think of our members, individuals who are dealing with multiple chronic illnesses, often in great pain. To tell them that they can have assistance to die only if death is reasonably foreseeable is to leave many of them without the compassionate support they are looking for.

When we look at the history of the issue of the right to die in Canada, we see people with ALS, Parkinson's, MS, Huntington's disease—diseases that can cause great suffering but where death is certainly not imminent and, perhaps a doctor may say, not reasonably foreseeable. I think of individuals with multiple chronic degenerative diseases who are suffering greatly and want access to assistance to die. For us to deny them is to thwart the spirit of the Supreme Court's decision.

[The Chair, Liberal, Anthony Housefather]

Thank you.

Mr. Rankin, go ahead.

[Murray Rankin, NDP, Victoria, BC]

Thank you, Chair, and thank you to all the witnesses for coming and for your patience today.

Dr. Forbes, I first of all wanted to thank you for referencing the pan-Canadian end-of-life and palliative care commitment. When we had Minister Philpott here a couple of days ago, she asked me to keep hammering away at this, and so thank you for giving me that opportunity to once again plug that important thing.

[Dr. Cindy Forbes]

Thank you.

[Murray Rankin, NDP, Victoria, BC]

Dr. Blackmer, we had the benefit of testimony from Dr. Stern of the Canadian Medical Protective Association yesterday. I want to read you a couple of things and ask your comment. Presumably, if I'm right, the CMPA insures doctors from coast to coast to coast so I would have thought these were important to your members as well.

They say this when talking about seeking clarity and the eligibility criteria: “The eligibility criteria for "grievous and irremediable medical condition" in subsection 241.2(2), and the requirement for practitioners to be "independent" in subsection 241.2(6), must be more clearly defined to ensure appropriate access to MAID and to protect vulnerable patients. Bill C-14 should state unequivocally whether or not a patient must be at the end of life to be eligible to receive MAID.”

I suppose I'm asking you to comment on that given that your insurer is so concerned about the bill as drafted. You seemed to say you were content with the bill as drafted.

[Dr. Jeff Blackmer]

I think it's important to recognize that although we are both medical organizations, we come at this bill with slightly different perspectives and slightly different filters in terms of the way we interpret some of this. I have had a chance to read Dr. Stern's comments.

What I would say is that there has been a lot of discussion around clause (d) and the issue of natural death becoming reasonably foreseeable. We see this as an immeasurable improvement over the alternative, which is to leave it at grievous and irremediable, which has no meaning to physicians whatsoever, and it would essentially leave anyone with any medical condition the ability to request assisted dying.

What the wording in Bill C-14 does is it allows us to understand how grievous this condition has to be. So we would say while it may not be perfect from a physician standpoint—and I've heard colleagues who have said it provides clear guidance, and I've heard colleagues who say I'm not quite sure how to interpret that—it's certainly much improved.

If the committee felt there was additional language that could be added to further improve that, to further clarify that for physicians, we would welcome that.

We also recognize, though, that in a piece of federal legislation you cannot capture all eventualities.

[Murray Rankin, NDP, Victoria, BC]

Right.

People who insure you are seeking greater clarity, and I think that needs to be acknowledged.

The other question they, your insurer, have in the bill is that protection in one of the sections should be extended to include civil and disciplinary proceedings for practitioners acting in good faith. The provision provides protection from criminal sanctions, but does not with the rest, and they call for that change.

You're obviously content with leaving it as it is.

[Dr. Jeff Blackmer]

I think it's important to recognize that these are comments that have been made in front of the committee that we haven't had a chance to vet internally or with our membership. We feel the bill as it stands is sufficient. We certainly respect the opinion of our colleagues within that sphere.

We haven't had a chance to consult with our membership on those changes.

[Murray Rankin, NDP, Victoria, BC]

They are your lawyers, though. I point that out to you, sir.

[Dr. Jeff Blackmer]

They have an important voice.

[Murray Rankin, NDP, Victoria, BC]

Ms. Morris, thank you very much for your testimony.

Yesterday, we had the benefit of Dr. Derryck Smith testifying. You may know him. He's a leading child psychiatrist in our jurisdiction of British Columbia and former head of the B.C. Medical Association.

He spoke passionately about advance directives and said the last change he would recommend is inclusion of an advance directive such that individuals with dementia can, when they are still competent, agree to medical assistance in dying at some point down the line.

I'd like you to elaborate. You heard one of your colleagues say this was not something that should be sought in this bill. I've heard you say the opposite. I'd like you to comment on Dr. Smith.