Justice Committee on Nov. 3rd, 2020

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

Thank you.

In terms of addressing what I feel is unfairness and not accurate information, the position was put by Dr. Coelho that an amendment needs to be made to this legislation to address conscience rights. In fact, Bill C-14 was amended at committee and validated in Parliament. Subsection 241.2(9) of the old Bill C-14, now in the Criminal Code, says, “For greater certainty, nothing in this section compels an individual to provide or assist in providing medical assistance in dying.” It is in the legislation now. It's also in the preamble. It's also in section 2 of the charter, and it's also in paragraph 132 of the Carter decision, where the court went to great lengths to indicate that no medical practitioner would be forced to provide a service they don't wish to.

In my mind, Dr. Coelho, it seems the concern is actually with the direct referral regime, which has been actually upheld in litigation in your own province of Ontario, where it was deemed to be held constitutional in the approach that is currently done. Direct referrals also occur with respect to any other provisions or treatments that doctors don't feel they want to provide themselves.

Perhaps you could respond to that in 45 seconds, and then give Dr. Daws the time to do the same. Thank you.

[Dr. Ramona Coelho]

Referral is not something that we pass on when we're not comfortable. It's a continuation of care for what we think is appropriate. I think that explains some ethics that I can't get to in 45 seconds. We do not actually make referrals for things that we think are bad for our patients. That is actually the standard of ethics and integrity in medicine. The World Medical Association, the CMA, the AMA, all support that position, as does the OMA.

The CPSO is actually the deviant here, in terms of the college policy. The fact that multiple religious organizations, like Hindu, Sikh and Muslim—

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

Could we allow Ms. Daws to answer the question, please?

[Dr. Tanja Daws]

I have a very different viewpoint.

In my experience as a MAID provider, especially for people with disabilities and even advanced illnesses, such as multiple sclerosis, the entire treatment team had been obstructing patients' access to care, and actually inducing traumatic stress in those patients and their families with their personal views that patients should keep on trying when they have really reached the end of the line, after years or decades of illness.

My patients with disabilities who qualify for MAID under Bill C-14 have told me multiple times that they abandoned health care because their practitioners continued to force upon them the concepts of continuing to struggle when they were done.

We found that, initially, providers of health care, including family physicians and specialists, would abandon patient care. That stopped after provincial regulations from colleges made it clear that this was not okay. We now actually find that patients abandon their health care workers and vote with their feet, and actually compromise their disability care and their palliative care. As MAID providers, we then pick that up, and work on that from scratch before we even start to make progress.

There are other unintended outcomes when people who think they're doing the right thing to protect their patient actually take it too far, and there are always two sides to a coin.

[The Chair, Liberal, Iqra Khalid]

Thank you very much, Dr. Daws, and thank you, Mr. Virani.

I'd like to address what you had noted earlier. I obviously wanted to ensure that our committee welcomes all witnesses. No matter how much we disagree on opinions, etc., we want to engage in a respectful and collaborative dialogue as we endeavour to make life-changing decisions for Canadians. Thank you all for fulfilling that respectful dialogue. I really appreciate that.

Mr. Thériault, you have six minutes. Go ahead.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

Allow me to repeat what you said. We aren't making life or death decisions for patients who are suffering. It is them—and only them—who will make those decisions. All we are doing is empowering them to make a choice. They have had no choice given that, for the past 50 years, accessing palliative care has been held up as the only way to die with dignity, as though receiving palliative care represented the full experience of what it is to die with dignity.

We aren't deciding for patients, on the contrary. The bill seeks to set aside medical paternalism so that patients can decide with freedom of conscience, and provide free and informed consent.

Dr. L'Espérance, you said your organization wanted the bill to go a bit further with respect to cognitive and neurodegenerative diseases. Can you tell us why? Can you describe what those diseases are and how they should be included in the bill?

[Dr. Georges L'Espérance]

I will answer very quickly.

In the past year in Quebec, 76% of patients who received medical assistance in dying had cancer. Cognitive and neurodegenerative diseases such as Alzheimer's are now the second leading reason why people seek medically assisted deaths.

Why should the bill include the diseases? The reason is that more and more people are going to contract them. As you know, after the age of 60, the older a person is, the more at risk they are. As people age, the more common cognitive and neurodegenerative diseases become.

When patients reach the later stages of disease, which, for Alzheimer's, generally coincides with stage four, they are no longer really capable of making their own decisions. Patients in stage four and beyond spend the last two or three years of their lives living without dignity—at least, in the estimation they held when they were capable.

In Quebec, a committee studied the issue of advance medical directives and released its report in late January. Except from a religious standpoint, a broad consensus exists over the ability to obtain medical assistance in dying through advance medical directives. It is up to the person to decide when they would receive medical assistance in dying. They might decide that it is when they no longer recognize their children, for instance. The person decides on their own beforehand, of course, in the presence of witnesses.

That is a very short answer to a complex question.

[Luc Thériault, Bloc, Montcalm, QC]

Do you think advanced requests should be allowed because these types of diseases follow a predictable course?

[Dr. Georges L'Espérance]

In the case of Alzheimer's, we know that, once a patient receives their initial diagnosis—say, at stage two—they die within eight to 10 years. Patients who do not die from the disease directly tend to die from complications such as pneumonia, sores and undernutrition. Once a patient reaches stage four, statistics show that their life expectancy is usually three to five years. Obviously, it varies, but that is the average. That's what the literature and clinical practice has taught us.

[Luc Thériault, Bloc, Montcalm, QC]

In other words, the whole problem lies in the fact that the advance request has to be pursued at the right time and a tremendous number of precautions must be taken. For example, it's important to take the time to explain things clearly to the patient, so they fully understand that they will no longer be able to give their consent afterwards.

[Dr. Georges L'Espérance]

Precisely. A whole mechanism is in place to ensure the process is followed rigorously. That is what the majority of those in the very elderly population want, however, because they do not want to see themselves go downhill cognitively. I think that is entirely reasonable and valid.

[Luc Thériault, Bloc, Montcalm, QC]

I see.

Dr. Coelho, I think it's a very good thing for a doctor to care about their patients and want to do right by them.

When patients are suicidal, the condition can be reversed. Patients who receive proper treatment will no longer be suicidal. Why would a suicidal patient request medical assistance in dying if being suicidal is a reversible condition? Would that happen in a case where you weren't able to provide the patient with the proper care?

Suicide has been decriminalized in Canada. Why? Being suicidal is a reversible condition.

When patients request medical assistance in dying, their condition is irreversible and their pain is intolerable.

[The Chair, Liberal, Iqra Khalid]

My sincerest apologies, Monsieur Thériault, but you hit that six-minute mark with the end of your question. Perhaps the witnesses can answer your question in other formats.

Before we go to Mr. Garrison, may I have the consent of the committee to continue past the one o'clock mark, at least to get through Mr. Garrison's question time?

[Some hon. members]

Agreed.

[The Chair, Liberal, Iqra Khalid]

Thank you.

Mr. Garrison, please go ahead for six minutes.

[Randall Garrison, NDP, Esquimalt—Saanich—Sooke, BC]

Thank you very much, Madam Chair.

I want to direct my question to Dr. Daws, but first I want to thank her, along with a number of other MAID practitioners who shared precious time with me in getting me to understand the reality of dealing with patients who are facing end-of-life issues or other related, but also serious, medical conditions.

Dr. Daws, you're one of the few witnesses we'll probably have before us who are practitioners working in rural and remote communities. Could you talk to us a little bit about the challenges of providing medical assistance in dying in those situations? In particular, what would be the impact of denial of referrals in rural and remote areas?

[Dr. Tanja Daws]

I can say, from four years of experience, that it is much more difficult in rural areas, because there are limited alternatives for patients. In simple terms of travel for sick people, using two ferries just to come to Vancouver Island would be a challenge. They might have just one physician on the small remote island, or a physician who might fly in and fly out every two weeks.

It has caused difficulty in the past to get witnesses. That's why we are eternally grateful for the amendments proposed in Bill C-7. It has been difficult for patients with disabilities and with end of life, even from cancer, to get adequate supports, although the work that has been done for that has always been exemplary and commendable. We always feel that as MAID providers we have added another layer of that into it and actually enhanced the reach of palliative care and disability support, and not just done MAID work.

In terms of concerns, it is harder for patients to get alternatives if they feel that they are being blocked or are not receiving information or access, and that has led to significant delays and stress to families. We've also seen that people who did not know about the alternatives often actually had suicide plans in place, and the moment they learned of all the supports....

We actually have a MAID consultation and those things are brought forward. We play devil's advocate to really make sure those things have been adequately addressed and provided, and the suicide plans disappear. Those people may actually end up having natural deaths and not MAID, because they were kept comfortable and had good care and it enhanced their quality of life. However, those who did have MAID had good access, because we made it work.

[Randall Garrison, NDP, Esquimalt—Saanich—Sooke, BC]

Thank you, Dr. Daws.

Can you make a comment on the concept of transient suicidal thoughts that some people are introducing in this debate? Do you find that's a real factor in those facing end of life?

[Dr. Tanja Daws]

We know from our experience that patients are not sick for just a week. They learn that they have cancer for months or years. People with disabilities have told me that they are often insulted by the thought that they have made sudden and urgent decisions after having lived brave and courageous lives dealing with those disabilities. In most cases, they are very well aware of their own vulnerability and they do not take it lightly that other people speak for them. They have told me, “Tell them that I am the real disabled, but I am being trampled on by this pretend concern for my own ability to be autonomous.”

[Randall Garrison, NDP, Esquimalt—Saanich—Sooke, BC]

Thank you.

I probably have one minute left here.

[The Chair, Liberal, Iqra Khalid]

Yes.

[Randall Garrison, NDP, Esquimalt—Saanich—Sooke, BC]

Can we give that to Senator Cowan to make any final comments, if he can deal with his technical challenges?

[The Chair, Liberal, Iqra Khalid]

Senator Cowan, go ahead, sir.

[James S. Cowan]

Thank you very much for the opportunity, Madam Chair and Mr. Garrison. Sorry for the technical difficulties.

Perhaps I could just conclude on a couple of points.

Dying with Dignity Canada is concerned about the express exclusion from Bill C-7 of those with mental illness and believes this exclusion to be stigmatizing, discriminatory and likely unconstitutional.

It's worth recalling the words of Justice Baudouin in the Truchon decision. She said:

The vulnerability of a person requesting medical assistance in dying must be assessed exclusively on a case-by-case basis, according to the characteristics of the person and not based on a reference group of so-called “vulnerable persons”.

She went on to say that “the patient’s ability to understand and to consent is ultimately the decisive factor, in addition to the other legal criteria”.

I have one other point, if I may. We strongly believe that the five-year parliamentary review of the MAID legislation and the state of palliative care in Canada, which was scheduled to begin in June 2020, should commence as quickly as possible following the disposition of Bill C-7. More specifically, we expect that the three areas identified for further study in Bill C-14 and addressed in the Council of Canadian Academies report, namely advance requests, mental illness and mature minors, will be considered during that review.

From our perspective, the most pressing of those three areas is the area of advance requests, something that 85% of Canadians support, as confirmed both by our own research and by the government’s consultation. Today, over half a million Canadians live with dementia, and there's no place for them in our current legislation.

[The Chair, Liberal, Iqra Khalid]

Thank you very much for that, Senator Cowan.

Thank you, Mr. Garrison, for allowing Senator Cowan to finish his remarks. That really helps me out a lot, and I really appreciate it.

With that, and understanding the time limitations as well, I would like to thank our witnesses for their time today and for their testimony. If you feel there are things you were not able to clarify or further things that you are able to address based on the questions you have been asked, please send in written submissions to the clerk so that we can further include your expertise on the subject matter.

Thank you very much.

We're confirmed to meet on November 5 from 11 a.m. to 1 p.m. The committee will also meet next week, on November 10 and November 12 from 11:00 to 1:00 to complete our hearings on Bill C-7.

I'll confirm with—