Justice Committee on Nov. 3rd, 2020

[Dr. Tanja Daws, Family Physician, As an Individual]

Thank you for allowing me to speak.

I'm a family physician from Vancouver Island, servicing rural communities. I have been a physician for 20 years in total and have done MAID since 2016.

I want to thank Parliament for the time it has given to study Bill C-7, because I know that for some it will seem to never be safe enough. From reading House of Commons Debates notes, I could see that for many there were specific fears relating to disability, vulnerability and slippery slopes, and frustration by other members that the bill never seems to go far enough.

I want to specifically focus on two issues, but in my brief I did provide more information specifically addressing the MAID process as to how we assess patients and the nuance and detail involved. I share the same practice profile as my colleague and can state that in the four years of doing MAID I have never seen vulnerable patients being abused. That is something that we are specifically looking for in MAID assessment. We spend much more time than we spend with regular patients—over months, if needed—to come to eligibility decisions, even if there was just a 10-day wait period in the past.

As MAID providers, we bring an added level in that many are palliative care physicians and many work with disabled patients to start with, and we feel that our moral grit is strong enough to ensure that we are another layer of comfort and care for those patients, more so than just being MAID assessors.

I want to take the time to spend some attention on two separate issues that I think will flow forward on a practical level in MAID from Bill C-7. The first is around the clarification of expertise.

In this brief, I wanted to focus on the fact that family physicians and nurse practitioners provide the majority of the backbone of Canadian health care by doing primary care and also by being co-pilots with our specialty colleagues. Where “expertise” is mentioned in the bill, we realize with appreciation that it's not to change the equitable access to MAID, but rather to ensure that people are more in place to assess these patients thoroughly, especially when we talk about vulnerability and disability.

I do, however, feel that most family physicians, specifically those who deal with these people for decades of knowing them, for decades as their primary caregivers, are probably in the best position to help them. Most MAID providers come from this field, the same as nurse practitioners. In medicine, when you feel you are not equipped medically or knowledge-wise, or you feel you're missing something, that's when you always phone a friend and refer to a specialist or another colleague.

I don't think that in MAID assessments that process will be different. We have shown that in the MAID community more MAID providers have done palliative care courses, and we are all looking at courses to help us with cultural sensitivity as well as with vulnerability and sensitivity. We are all willing to do training to ensure that we will have enhanced skills to make it safer.

I do think the one thing that will be very difficult with how expertise is defined in Bill C-7 is that it may be very difficult in some illnesses to have a MAID assessor feel that they are an expert. It may be impossible, for instance, to find a neurologist who is willing to be an expert and be a MAID assessor.

I would like to propose the idea to the committee that perhaps the two MAID assessors, if they feel they are at the expert level, could continue in that role, but where they feel that none of them could be expert enough, they could perhaps refer to a third expert, such as an addiction specialist or a pain specialist. They are not actual specialities per se, like surgery, but they can ask for a consultant opinion, which is pretty much what we are doing at the moment with Bill C-14, when we refer patients for a formal capacity assessment. Their assessors, who are usually psychiatrists or geriatric psychiatrists, are not comfortable being MAID assessors or providers, but they're happy to be consultants.

Third, I would just like to address, in terms of the final waiver, that the specified day as a choice for patients can provoke unintended harm by causing anxiety. It's very hard to write down a day, but patients may be more comfortable writing down a period that they would give for that advance consent. This should also be transferable to other providers, as we do have holidays and conferences, or we may be in COVID quarantine, and another provider may have to act on that waiver.

Finally, we are concerned with obstruction from third parties, as in the recent Nova Scotia case. If we deem that the patient is not suffering and the family agrees, then we can stand back.

[The Chair, Liberal, Iqra Khalid]

Thank you very much, Dr. Daws. I appreciate your time.

We will go on to Dying With Dignity Canada, with Senator James Cowan and Ms. Helen Long.

Please go ahead. Your time starts now.

[Helen Long, Chief Executive Officer, Dying With Dignity Canada]

Good afternoon and thank you for the opportunity. Senator Cowan and I will be splitting our time.

For 40 years, Dying With Dignity Canada has been committed to advancing end-of-life rights and helping Canadians avoid unwanted suffering. Our role is to represent the 86% of Canadians who support the 2015 decision in Carter v. Canada, which struck down the prohibition on physician-assisted dying. We've done a number of studies and surveys over the years around end of life, and our results are largely consistent with those of the federal government in the spring consultation.

In our view, the experience of Canadians within the MAID regime has been overwhelmingly positive. However, experience and research would demonstrate that there is a need for some improvement.

We're here today to speak in support of the legislative amendments that have been put forward in Bill C-7, although we will briefly address concerns. The changes do address the need for personal autonomy and also importantly demonstrate compassion for individuals.

We were pleased to see the removal of the reasonably foreseeable natural death eligibility requirement, which infringes “life, liberty and security of the person” guaranteed by section 7 of the charter. Removing this clause ensures constitutionality for the individual and also their choice to end their life at the time they choose.

Jean Truchon and Nicole Gladu spoke for hundreds of Canadians who have been excluded from existing MAID until this point because they are not imminently dying, although they are still experiencing constant physical pain and suffering that is intolerable to them, and they have carefully considered their decision.

We commend the government on the inclusion of Audrey's amendment, allowing the waiver of the requirement for final consent for those who are assessed and approved for MAID but who may lose capacity in advance of their date. This is something that 85% of Canadians support. We believe that this waiver of final consent should also be extended to those whose death is not reasonably foreseeable.

Many of you will be familiar with Audrey's story. Sadly, it's one we hear every day. We are forever grateful to her for her advocacy, and we appreciate the acknowledgement of the pain caused to individuals like her in this amendment.

Senator.

[The Chair, Liberal, Iqra Khalid]

Go ahead, Senator.

Do we have him on the line?

Senator Cowan, can you hear us? I can see you, but we can't hear you.

[Helen Long]

Shall I finish the statement, Madam Chair?

[The Chair, Liberal, Iqra Khalid]

Maybe we can come back to Senator Cowan.

We'll move on to the Quebec Association for the Right to Die with Dignity, with Dr. Georges L'Espérance. Perhaps I can, in the meantime, have somebody from IT give Senator Cowan a call to fix his issues.

Go ahead, Dr. L'Espérance.

[Dr. Georges L'Espérance, President, Quebec Association for the Right to Die with Dignity]

Good afternoon, ladies and gentlemen. Thank you for this invitation.

My name is Georges L'Espérance, and I am president of the Quebec Association for the Right to Die with Dignity.

As a retired neurosurgeon, I provide medical assistance in dying and am part of a private discussion group in Quebec. The group consists solely of physicians who provide that last compassionate and ethical care. This enables highly judicious and educational exchanges. The following remarks enjoy a strong consensus among us and inform the association's reflections for our fellow citizens.

I use this opportunity to thank Minister Lametti and his team for listening to patients and practicians in the development of this latest bill.

The bill proposes highly relevant adjustments, more specifically for people who are alone. First, the bill allows there to be a request for medical assistance in dying in writing with a single independent witness. In addition, someone whose job is to provide health care or professional care now has the ability to act as an independent witness. What is more, the 10-day reflection period has been shortened, and this adjustment is the fruit of simple clinical logic. Finally, the waiver of final consent immediately prior to care is, once again, a response in line with the clinical reality we are all experiencing.

We completely agree with the previously drafted opt-out provision, as well as with proposed new sections (3.3) and (3.4) concerning manifestations through words, sounds or actions of refusal for the substance to be administered. However, we suggest this last safeguard measure, in section (3.4), must be revised in two years. Based on experience acquired, it could eventually be shortened.

We feel there are still three major points to Bill C-7 that should be improved.

First, we are asking that the concept of “reasonably foreseeable natural death” as a safeguard measure be pulled from Bill C-7. The other criteria set out in Bill C-7 have proved in Canada that the most vulnerable individuals don't need any other protection to guarantee their fair and safe access to medical assistance in dying. Otherwise, our patients and us, the physicians on the ground, will once again remain stuck with a vague and non-medical concept. Life expectancy is actually a notion that affects the average, and not specific individuals.

If, despite everything, the legislator wants to hold on to this measure, they should at least remove the 90-day minimum assessment period for the same reasons as those mentioned regarding the 10-day period. That so-called period of reflection is an insult to our patients' intelligence and suffering.

The removal of that criterion will also make more seamless access across Canada possible, since the decision in terms of medical assistance in dying will be subject to a strict objective medical process.

As far as mental illness goes, with all due respect for those Canadians and because those issues are complex, we suggest removing that exclusion provision and keeping a 12-month legal non-application period, during which the regulatory colleges within each province will have to work together and be under the legal obligation to define a common clinical framework.

Finally, any capable individual who has been diagnosed with a cognitive neurodegenerative disorder of the Alzheimer type should be able to indicate in their advance medical directives, with a supporting witness, that they wish to obtain medical assistance in dying at a time they deem appropriate, according to their values and regardless of their cognitive state at the time.

In closing, I would like to reiterate that the Quebec Association for the Right to Die with Dignity firmly and unwaveringly defends the absolute prohibition on using medical assistance in dying, under threat of criminal penalties, in the case of individuals who have always been incapacitated—here we are talking about mental deficiency—or individuals who became incapacitated before providing advance medical directives.

Thank you for your attention.

[The Chair, Liberal, Iqra Khalid]

Thank you very much for that, Dr. L'Espérance. It is much appreciated.

We will go to Senator Cowan if he is able to communicate at this time. We will do a check.

No, we still don't hear you. Can you check on your mute button and just ensure that it is your headset that is selected for your microphone? You're on mute now, so even if we could hear you, we can't hear you.

Unfortunately, we still don't hear you, Senator. As we are running very short on time, what I will do is ask if you can provide some written submissions, which I know you may have done already, with respect to your comments today.

Could I please have IT call the Senator so he can at the very least participate through the question and answer period?

We will go to six-minute rounds now. We will start with Madame Findlay. We will go on to Mr. Virani, then Mr. Thériault and Mr. Garrison.

Go ahead, Madame Findlay. The floor is yours for six minutes.

[Kerry-Lynne Findlay, Conservative, South Surrey—White Rock, BC]

Thank you, Madam Chair.

My questions are primarily for Dr. Coelho, whom I found to be a very compelling witness.

Doctor, in 2017 you expressed concerns about the duty that doctors who don't wish to participate in MAID have to refer patients to another physician who is willing to give the patient the end-of-life procedure.

Could you speak to this referral issue and how the expansion of MAID to those whose death is not imminent would affect doctors who are not willing to participate?

[Dr. Ramona Coelho]

Thank you very much.

The preamble of Bill C-14 did speak to conscience protection, but that is not an enforceable part of the bill. Unfortunately, in Ontario the CPS still has a policy whereby doctors have to arrange for and facilitate medical aid in dying, and what will now be an assisted death, for those who are not dying.

At that time, Hindu, Sikh, Muslim, Jewish and Christian groups, which are part of this submission, all reached out to the government saying that they needed further conscience protection for their adherent physicians.

Regardless of that, everybody has a line, and this is something people feel very strongly about, which I understand. I hear Dr. Daws express how this is, for her, something through which she feels she is being very merciful and compassionate.

I, who take care of very vulnerable people, have come to the opposite conclusion. I feel that they come to me and I try to offer them safety and protection, and when they are in a safe space and express their death wishes, I can try to work on creative solutions for them. I will not deny them information. I will not obstruct them, but my job is to be in their corner and fight for them to want to live again. That's because I've had many patients who have done just that.

It would be very good in Bill C-7 if we had an amendment that spoke to conscience protection, not just in the preamble.

[Kerry-Lynne Findlay, Conservative, South Surrey—White Rock, BC]

I appreciate that, Doctor, and also your comments regarding transient suicidal ideations and the need to apply a good standard of medical care and time for specialty consultations, which, as you pointed out, and I think we all know, take some time.

[Dr. Ramona Coelho]

It's not only that. This will make us the most permissive euthanasia regime in the world, in the sense that usually euthanasia is a last resort, once we've tried to help people want to live again. But with the way the bill is written—and again, I want to acknowledge that Dr. Daws said she spends months, so she acknowledges that it takes more time sometimes—having that kind of protection written into a life-ending bill—when other doctors might not be as conscientious as Dr. Daws—I think is very important.

[Kerry-Lynne Findlay, Conservative, South Surrey—White Rock, BC]

Thank you.

In a recent op-ed you co-wrote for the National Post, you said:

Instead of using our resources to increase health-care personnel, improve our quality of care, enhance our palliative care options and ensure quicker access to psychiatric care, our federal government seems more interested in fast-tracking death on demand and dismantling the MAID safeguards that were put in place [a short time ago] to protect the vulnerable.

Do you have any examples from your practice where MAID was considered by the patient because the resources for treatment they were receiving were insufficient?

[Dr. Ramona Coelho]

Yes, I have had many such death wishes by patients who have had strokes, and during COVID there was not enough help to come to the home and open containers so they could eat. I take care of very marginalized patients, those who are constantly fighting for things like housing, resources in the home, social supports, pain control, and access to medications that they can't afford. There are many barriers that lead patients to have death wishes every day, and it is a conscientious doctor on both ends who is going to spend that time with them, but we need that written in the bill.

[Kerry-Lynne Findlay, Conservative, South Surrey—White Rock, BC]

Thank you.

Advocates for persons with disabilities in my riding are extremely concerned about the specific expansions of MAID under Bill C-7, especially the elimination of any reflection period, and signalling by the Liberal government of a desire to expand it even further through the unnecessarily delayed statutory review.

I wonder if you have a comment on how you see that there could be better safeguards for vulnerable people.

[Dr. Ramona Coelho]

I think this consultation was supposed to be extensive, and I'm really hoping that it goes forward that way. It is very interesting that most of the people who are here are MAID lobbyists.

The Council of Canadians with Disabilities and the Canadian Association for Community Living have actually said that this bill is very bad. There are 70 signatories, different advocacy groups for people with disabilities.

You guys need disability experts to speak to you about what they consider to be dangerous in this bill. You guys need expert physicians like neurologists, physiatrists, stroke specialists, and psychiatrists to weigh in on safeguards. We're talking about ending someone's life. I understand that some people perceive that as a merciful act, but I think everyone still agrees that there is no problem with trying to make sure that people who have transient suicidal ideation are not killed and that everything is offered to them so that they can go forward.

I strongly suggest to the committee that you have witnesses who are content experts in medicine.

[Kerry-Lynne Findlay, Conservative, South Surrey—White Rock, BC]

I understand that 70% of Canadian citizens do not have access to palliative care. I also took note of—

[The Chair, Liberal, Iqra Khalid]

I'm so sorry, Madame Findlay, but we're out of time. Hopefully we can get to a second round to ask any further questions.

[Kerry-Lynne Findlay, Conservative, South Surrey—White Rock, BC]

Thank you, Madam Chair.

[The Chair, Liberal, Iqra Khalid]

Thank you so much for your patience.

We'll move on to Mr. Virani for six minutes.

Go ahead, Mr. Virani.

[Arif Virani, Liberal, Parkdale—High Park, ON]

Thank you.

In my six minutes, just let me say at the outset that I think when witnesses refer to other witnesses on the panel as “lobbyists”, in a derogatory manner, I don't think that's very respectful and perhaps the chair should make some remarks in that regard.

I'm going to ask three questions to three different parties.

The first is for Dying With Dignity and Ms. Long and Senator Cowan. We've heard from others during the course of today's discussions about the fact that the Truchon decision should have been appealed to a higher court, rather than acted upon immediately in terms of alleviating people's suffering. I wonder if Dying With Dignity has any views on that. Minister Lametti was quite clear that it was acted upon immediately in order to address the suffering that was identified in the decision.

Could you answer that in 90 seconds, please, Senator Cowan or Ms. Long?

[The Chair, Liberal, Iqra Khalid]

Please go ahead, Senator Cowan.

[James S. Cowan, Former Senator and Chair, Board of Directors, Dying With Dignity Canada]

Yes, sorry for the technical difficulties.

We very much believe that the Government of Canada and the Government of Quebec took the appropriate action not to appeal the Truchon decision. We believe, as Ms. Long has said, that the response contained in Bill C-7 is the appropriate response, and we strongly support it.

We do have one reservation with respect to the express exclusion of mental illness. I'd be pleased to address that if I have time, but I know, Madam Chair, that you're short of time, so I'll wait for your invitation. Otherwise, that's covered in our written brief, which we have filed with the committee.

[Arif Virani, Liberal, Parkdale—High Park, ON]

Thank you.

I will now turn to Dr. L'Espérance.

Dr. L'Espérance, I'd like to talk about the situation as it relates to people with disabilities. The issue has been brought up repeatedly today as well as in the House.

In 90 seconds, I would like to hear your thoughts on Mr. Truchon and Ms. Gladu's case. Beyond their disabilities, it was necessary to recognize their access, autonomy and dignity, while taking into account their suffering. Could you please comment on their autonomy and decision-making power as persons with disabilities?

[Dr. Georges L'Espérance]

You touched on a big part of the answer in your question.

Both of them testified before Justice Baudouin. I was there for all the testimony, and what emerged was how carefully they had considered the issue for so many years. Like other people with disabilities, the two of them had access to all the necessary supports. Mr. Truchon constantly pointed out that, as a person with a disability, he had all the help he needed on a daily basis. That was not at all the reason why he was seeking assistance in dying. The same is true of Ms. Gladu, but she has not yet followed through with a medically assisted death.

Overall, patients with disabilities are very familiar with their conditions, and they are the ones requesting medical assistance in dying. Neither doctors nor anyone else is forcing them to obtain a medically assisted death.