Evidence of meeting #7 for Justice and Human Rights in the 43rd Parliament, 2nd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was maid.
A recording is available from Parliament.
Liberal
The Chair Liberal Iqra Khalid
I call this meeting to order.
Welcome to meeting number seven of the House of Commons Standing Committee on Justice and Human Rights. We are studying Bill C-7.
First and foremost, I understand that Mr. Manly from the Green Party is requesting to join our meeting today.
Mr. Clerk, is Mr. Manly with us right now?
The Clerk of the Committee Mr. Marc-Olivier Girard
He's actually asking to be admitted. I can grant the access right now.
Liberal
The Chair Liberal Iqra Khalid
Thank you.
I seek unanimous consent from the committee to allow him to be part of this committee if that's okay. Please give a thumbs-up to show your consent.
Go ahead, Mr. Clerk, and allow him in. Thank you.
To ensure an orderly meeting, I would like to outline the following rules. Members and witnesses may speak in the official language of their choice. Interpretation services are available for this meeting. You have the choice, at the bottom of your screen, of floor, English or French for your own interpretation needs.
I remind members and witnesses that all comments should be addressed through the chair. When speaking, please wait until I recognize you. Unmute yourself and speak slowly and clearly for the sake of interpretation. When you are not speaking, your microphone should be on mute.
With regard to the speakers list, the clerk and I will do our best to maintain a consolidated order of speaking for all members. I have time cards. I have a one-minute card and a 30-second card to give you advance notice of how much time you have remaining for your remarks and for your questions.
Mr. Manly has also asked if he can be allowed some time to ask questions. I ask whether there is unanimous consent of the committee to allow Mr. Manly two and a half minutes for the first panel and two and a half minutes for the second panel to ask his questions. You can indicate this by showing me a thumbs-up, or a thumbs-down if you don't agree.
We do not have unanimous consent, but please note that members are able to share their time with Mr. Manly if they should choose to do so. Mr. Manly is welcome to visit and to participate in the committee.
At this time, I'd like to welcome our witnesses. We have before us, appearing as an individual, Dr. Jennifer Gibson, director and Sun Life Financial chair in bioethics at the University of Toronto Joint Centre for Bioethics. We also have Dr. Alain Naud, family physician and clinical professor at the department of family and emergency medicine at Laval University. We also have the Honourable André Rochon, retired justice of the Québec Court of Appeal, and we have David Roberge from the Canadian Bar Association.
Each witness will have five minutes to make their opening remarks. We'll go ahead and start with Dr. Jennifer Gibson.
Please go ahead, Doctor. You have five minutes.
Liberal
Arif Virani Liberal Parkdale—High Park, ON
Madam Chair, I'm sorry, but just before we commence, I find it a bit less than parliamentary that we're allowing Mr. Manly to participate but not allowing him to ask questions for 2.5 minutes in each of the next two hours. I would ask for a recorded vote on that point.
Thank you.
Conservative
Rob Moore Conservative Fundy Royal, NB
I would give my consent for two and a half minutes for each panel. I thought you said two and a half minutes per round, which would be five minutes.
Liberal
The Chair Liberal Iqra Khalid
No, sir, I said two and a half minutes per hour: two and a half minutes for the first panel, and two and a half minutes for the second panel.
Liberal
The Chair Liberal Iqra Khalid
Can I ask again for unanimous consent for two and a half minutes for Mr. Manly? Can I see thumbs-up from everybody? Just to confirm, I see thumbs-up from every single member who is permanent on this committee.
Thank you, Mr. Virani, for raising that. It's greatly appreciated. I will add Mr. Manly to the speakers list at the bottom of each hour.
With that, Dr. Gibson, please go ahead. You have five minutes.
Bloc
Luc Thériault Bloc Montcalm, QC
Madam Chair, the witnesses should be reminded to speak slowly and clearly, even if they have very little time to make their presentations. This will prevent us from interrupting them, and the interpreters will be able to do their job well.
Liberal
The Chair Liberal Iqra Khalid
Thank you, Mr. Thériault.
I made that remark when the meeting opened, but I will remind the witnesses to please speak slowly and clearly so that the interpreters can do their work.
Go ahead, Dr. Gibson. You have five minutes.
Dr. Jennifer Gibson Director and Sun Life Financial Chair in Bioethics, University of Toronto Joint Centre for Bioethics, As an Individual
Thank you so much for the invitation to join you today. As noted, I'm affiliated with the University of Toronto, but in 2015 I co-chaired the provincial-territorial expert advisory group on physician-assisted dying. In 2017-18, I was co-chair of the Council of Canadian Academies' expert panel on medical assistance in dying, and chaired the working group on advance requests for MAID. Today I am speaking as an individual drawing from these experiences and my disciplinary background in ethics and health policy.
I had the privilege to meet with this committee in spring 2016 in relation to Bill C-14. Over the last few weeks, I've been reflecting on how much has changed in four and a half years and how better prepared we are to contemplate amendments to the legislative framework for MAID in Canada with some confidence. In 2016, we did not have any Canadian experience to draw from, and relied on experience from other jurisdictions. We did not yet have systems and care processes in place to offer MAID to eligible persons and needed to build these. We did not know what actual effect the introduction of MAID would have on Canadians. Would it displace palliative care? Would it make people more vulnerable and not less?
Today, with the benefit of almost five years' experience, we have learned that MAID can be provided safely and compassionately to Canadians. We have Canadian evidence to draw from. We have the lived experience of Canadian families, caregivers and clinicians to shed light on its practice. We have heard from community groups and individual citizens about how, and to what extent, MAID fits within a continuum of supports for persons who are suffering.
Bill C-14 sought to outline a legislative framework, including eligibility criteria and procedural safeguards, but sought ultimately, to the greatest extent possible, to respond to Canadians' suffering whilst balancing the autonomy of persons seeking MAID on the one hand and the interests of vulnerable persons in need of protection and those of society on the other. The project of striking the right balance of these values-based commitments continues today.
Many of the comments from witnesses and organizations who have appeared before this committee have drawn attention to the suitability and appropriateness of key safeguards, both those that are in the current legislative framework and those that are being contemplated in Bill C-7. Such current safeguards, such as the 10-day reflection period and the requirement of final consent, were introduced in order to ensure that only those Canadians who wished MAID actually received it and to protect and promote their autonomy.
Experience of the last four and a half years has shown that the effect of the safeguard may not have been what was originally intended. On the one hand, we have heard from clinicians about some patients who have forgone pain medication and endured preventable suffering in order to sustain their capacity to provide final consent. On the other hand, we have also learned from clinicians, families and caregivers that persons seeking MAID are most often not ambivalent about their choice. In the words of a member of the public who emailed me in December 2015 and who was facing a life-limiting illness, “no patient is going to reach such a decision and request lightly”. Hence, the removal of the 10 clear days and final consent seemed to be a good step forward toward striking a new, appropriate balance in safeguarding Canadians who have already been found eligible for MAID.
There is little doubt about the importance of safeguards to protect vulnerable persons who might, as per the original preamble to Bill C-14, be induced in moments of weakness to end their lives. A lesson we may draw from our experience of the last four and half years is that in developing safeguards, we must be especially attentive to the potential impact of the safeguards, notwithstanding their intent to protect. We must be especially wary of a safeguard if it may reasonably have the effect of rendering some persons more vulnerable. The protection of vulnerable persons turns on safeguarding competence, voluntariness and consent. Exclusion of otherwise competent persons may be justifiable in limited circumstances if there is a strong case to be made from the perspective of justice. Failing this, though, these exclusions violate the autonomy of competent persons of such groups and unjustly force these individuals to remain in a state of enduring and intolerable suffering.
For these reasons, we may wish to consider whether the 90-day reflection period will, in fact, be protective or may instead contribute toward enduring suffering of persons who are already found to be eligible for medical assistance in dying.
Liberal
The Chair Liberal Iqra Khalid
Thank you, Dr. Gibson. I'm going to have to stop you there. We are at the five-minute mark, and I'm hoping that the rest of your testimony can come out in questions.
Director and Sun Life Financial Chair in Bioethics, University of Toronto Joint Centre for Bioethics, As an Individual
Thank you.
Liberal
The Chair Liberal Iqra Khalid
Thank you very much, Dr. Gibson.
We will now move on to Dr. Alain Naud.
Sir, you have five minutes. Please go ahead.
Dr. Alain Naud Family Physician and Clinical Professor, Department of Family and Emergency Medicine, Laval University, As an Individual
Thank you very much, Madam Chair.
First of all, I would like to thank the committee for its invitation to share my experience with its members.
I have been a family and palliative care physician for 35 years, and I'm a clinical professor. I also acted as a medical expert in medical assistance in dying and palliative care in the trial of Ms. Gladu and Mr. Truchon.
I have personal experience with supporting more than a hundred patients who have received medical assistance in dying and their loved ones. After five years of concrete experience in Quebec and almost everywhere else in Canada, I think it's important to anchor our reflections and decisions in the reality of the field, as well as to listen to the testimonies of patients, their loved ones and the caregivers involved.
Let me give you a few observations.
Medical assistance in dying is compassionate care that is provided by a whole team. The choice for a person to resort to it is never impulsive, but rather the result of a long reflection lasting weeks, months and sometimes years, anchored in the flesh and suffering. To realize this, you have to have met these patients, supported them and their loved ones, and been with them to the end.
There is no opposition between palliative care and medical assistance in dying. They are legitimate and legal end-of-life options that are interrelated and complement each other. In all of our palliative care units, physician-assisted dying is fully integrated as a possible choice and option.
For the past five years in Quebec, medical assistance in dying—or MAID—has been administered very rigorously and with full respect for rights. The problems that have been observed have all be in the obstruction by certain caregivers and certain institutions of legitimate access to MAID. This is where we find the real vulnerable patients who are not protected. In Quebec, this affects 33% of requests, or one patient out of three.
The following elements of the bill should be retained. It contains major improvements that are important to patients. The first improvement is the need for only one witness at the signing, who can be a caregiver. The second is the repeal of the mandatory 10-day waiting period, which for most patients was sheer cruelty. The third improvement is the possibility of waiving in advance the obligation to still be fit at the time of the procedure.
Now the following are the elements of the bill that need to be changed. The phrase “reasonably foreseeable natural death” is the biggest stumbling block to this bill for several reasons that I address in the document you have already received. The term does not meet any medical concept or definition. It doesn't exist in any medical textbook. Yet it is the responsibility of physicians to assess the eligibility of patients.
Removing this term from the eligibility criteria as a safeguard doesn't give it any more meaning or a recognized standard medical definition. Maintaining this term will continue to place an intolerable and unacceptable burden on the shoulders of medical evaluators to interpret a criterion that has no medical meaning and for which there will never be a consensus. The term should be removed. Other measures are largely sufficient to ensure the protection of vulnerable patients.
If Parliament wishes to maintain different safeguards for two distinct categories, I suggest replacing this expression with the introduction of a “prognosis of death of less than 12 months” or “of more than 12 months”, which would avoid the randomness and subjectivity of the answer to be given. The concept of prognosis is very clear, well-defined and used daily in the medical world.
With respect to mental health and psychiatric illness, I have detailed my observations in the document. I believe it is appropriate for the bill to include indications that would allow these patients to see the light at the end of the tunnel, thereby avoiding further legal challenges to the law and suicides.
I think the term “assisted suicide” should be replaced by “medical assistance in dying by oral medication”, which is what it really means.
Items not covered in the bill include advance medical directives allowing access to medical assistance in dying after a diagnosis of Alzheimer's disease or other dementia. In the document, I propose simple and clear guidelines that would provide a clear framework for this care.
Lastly, with respect to the review of applications for denied or non-administered medical assistance in dying, the bill should provide much more explicit and rigorous mechanisms for systematically documenting and reviewing denials and non-administration of MAID. As I mentioned, this where the problems are and where the real vulnerable patients who have not been protected for five years in Quebec and for four and a half years in Canada are.
A summary of my recommendations are on the last page of the document.
Thank you, Madam Chair.
Liberal
The Chair Liberal Iqra Khalid
Thank you very much, Dr. Naud, for staying within those five minutes on the dot.
We’ll now turn to the Honourable André Rochon for five minutes.
Go ahead, sir.
André Rochon Retired Justice of the Québec Court of Appeal, As an Individual
Ladies and gentlemen, thank you for your invitation and for this opportunity to share with you our committee's thoughts on advance requests for medical assistance in dying.
In the name of a strong consensus in the country and in order to protect the autonomy and dignity of the person, I propose that the bill before you be amended immediately to give any person suffering from a major neurocognitive disorder such as Alzheimer's the right to MAID. The urgency of the matter is clear to me. In this regard, allow me to provide a brief reminder of the elements that led us here.
In 2015, the Carter decision set out the cardinal rule that, in exercising an individual's right to life, liberty and security of the person, every person must be free to make his or her own fundamental decisions without interference by the state.
Bill C-14 was passed in 2016. It provides for the formation of an expert panel to study three situations, including that of advance requests for MAID.
In 2018, this expert panel stated the following regarding advance requests:
Having some assurance that their request for MAID would be honoured could provide comfort and relieve anxiety and distress at end of life for those who make this choice.
…
Allowing ARs for MAID might have an impact on the way society values people with capacity loss, increasing stigma and signalling that it is acceptable to consider a life with capacity loss as one not worth living.
In the face of the suffering and distress of all those who receive such a diagnosis, the question is no longer whether the compassion of Canadian society should grant us MAID. The time has come to define the parameters for the granting of this assistance and to put in place guidelines both to ensure the protection of potentially vulnerable people and to respect the clearly expressed will of the person affected.
So when a person receives such a diagnosis, which is likely to progress to severe dementia, they must be allowed to give an advance directive to request MAID when their situation has reached a serious and irreversible stage, provided that the person meets the following criteria: a) they are eligible for government health care; b) they are at least 18 years of age; c) they must be able to express their will freely, without external coercion or undue influence, and must not suffer from a mental condition that affects their judgment; d) a physician must certify that the person meets the above criteria when signing the advance directive.
To be valid, this directive must be renewed in writing after a six-month waiting period from the signature of the initial directive, ensuring that the four previous conditions are still met. This period is an important guideline, which provides a sufficient period of reflection for the person affected and ensures that the decision was not made impulsively or without sufficient reflection.
It goes without saying that this directive may be revoked at any time in writing, as long as the person is capable of doing so. The representative may ask the multidisciplinary team to begin the evaluation process as soon as it has reason to believe that the advanced stage of the disease is reached.
As an added precaution, the directive should be written in a prescribed form. I have appended to my presentation synopsis a template of this directive.
What you are being asked to do today is to provide a choice for anyone diagnosed with an Alzheimer's-type neurocognitive disorder. It isn't a matter of imposing a course of action, but rather of putting in place the necessary guidelines for exercising this choice.
Inspired by our values, this citizen is asking the government to come to their aid and provide them with the necessary care to relieve their suffering, preserve their dignity and respect their decision.
Thank you.
Liberal
The Chair Liberal Iqra Khalid
Thank you very much, Mr. Rochon, for staying within the five minutes.
Last but not least, we will go to the Canadian Bar Association, represented by David Roberge.
Please go ahead, sir. You have five minutes.
David E. Roberge
Good morning, Madam Chair and honourable members of the committee.
My name is David Roberge, and I am a member of the Canadian Bar Association's end-of-life working group. Thank you for inviting the CBA to discuss Bill C-7 today.
The Canadian Bar Association, or CBA, is a national association of 36,000 lawyers across Canada, with a mandate to promote improvements in the law and the administration of justice.
Our brief was prepared by the CBA end-of-life working group. This working group comprises a cross-section of members drawn from diverse areas of expertise, including constitutional and human rights law, health law, criminal law, wills, estates and trusts law, elder law, children's law, and privacy and access-to-information law.
While we applaud the government's efforts to clarify the law about MAID following the Quebec Superior Court's decision in Truchon, we have several concerns with Bill C-7. I would like to use my opening remarks to outline some of them.
Eligibility for MAID should be aligned with the criteria established by the Supreme Court of Canada in Carter, taking into account the protection of vulnerable people. The CBA supports the Quebec judgment in Truchon and highlights its interpretation of Carter, namely, that the essence of the Supreme Court decision is not proximity of death, but rather the prevention of intolerable suffering, as well as dignity and the autonomy of the person, for those who are capable to clearly consent to the termination of their life. We also support a patient-centric approach for capacity and consent, as adopted by the Quebec court in Truchon.
Returning to Bill C-7, in our view mental illness should not be excluded from the scope of the legislation, especially given the full MAID review initially planned for June 2020, and now pending. This exclusion forecloses a thorough review of the issue and suggests a conclusion that has not been debated or recommended. In Truchon, the court stated that vulnerability must be assessed from an individual perspective through informed consent. In our view, the general exclusion of all persons suffering from mental illness is likely to be constitutionally challenged.
Bill C-7 proposes two different sets of safeguards for MAID, the application of which depends on whether the person's natural death is reasonably foreseeable or not. The criterion of reasonably foreseeable death, which was declared unconstitutional in Truchon, has caused significant uncertainty in practice, and Bill C-7 does not give any guidance on how to apply it. Should the government maintain different sets of safeguards, we recommend that guidance be given to avoid confusion on which safeguards apply and to ensure appropriate access to MAID.
On another topic, the CBA has reservations about the requirement that one of the two assessors must have specific expertise in the condition causing the person's suffering. Appointments with specialists can take several months, and in some communities are not available. There is currently no requirement that individuals seek specialists when applying for MAID. It is up to the practitioners to determine their own level of expertise when assessing informed consent and to make an appropriate referral if need be. While some situations could justify seeking the opinion of a practitioner with specific expertise, a blanket requirement could have a disproportionate impact on some individuals and create a significant barrier to MAID.
Lastly, Bill C-7 provides that the final consent waiver to MAID applies only if death is reasonably foreseeable. It is our view that waiver of final consent should also be possible if death is not reasonably foreseeable, since it is possible to lose capacity to consent in both situations.
On behalf of the CBA, thank you again for the opportunity to present today. I look forward to answering any questions you may have during today's session.
Liberal
The Chair Liberal Iqra Khalid
Thank you very much for that. I really appreciate it.
We will now go into our first round of questioning, for six minutes, starting with Mr. Lewis.
Go ahead, Mr. Lewis. You have six minutes.
Conservative
Chris Lewis Conservative Essex, ON
Thank you very much, Madam Chair.
Thank you to all the witnesses today. It's so vital that we continue to hear from across the country and have these discussions and open dialogue, and we certainly could use a lot more of them.
Dr. Catherine Frazee, a renowned academic with a disability herself and leader of Vulnerable Persons Standard, presented on Tuesday to our committee. She asked the question, why us? Why not indigenous or suicidal healthy young men or other marginalized persons on the fringes? What is it about persons with disabilities that makes it okay to target this character of protected group for a special track to get suicidal completion, and other groups get help, protection and resources?
She went on to point out that a majority of the Canadian population wanting MAID for those living with disabilities don't mean that they should be put in danger and that their minority voice be silenced and ignored.
In our last meeting, Liberal member Marcus Powlowski, in his question to Dr. Ewan Goligher, said that, if his son suffered a spinal cord injury and felt he wanted to end his life, he would support his son. He said this to an able-bodied witness among three other witnesses who live with disabilities. I have to believe that this was interpreted by these brilliant women as an instance of ableism, and this is exactly the kind of discrimination that makes disabled Canadians fear for their lives when Parliament is considering a bill like Bill C-7. It sends them a message that their lives are not worth living.
The impact of allowing MAID, which is an extremely inexpensive and fast-tracked option, in the absence of other options, such as financial support, pain specialists, good housing, and well-trained and sufficient home care, will lead to coercion, as evident already by many witnesses on Tuesday, such as Roger Foley and Taylor Hyatt.
A recent release in the Netherlands shows that there is growing interest in euthanasia from vulnerable people, those less educated, poor, isolated and lonely, and the findings suggest that many of those people would not ask for euthanasia if good social measures were in place.
My question for Dr. Naud is this: What do you think about disability groups unanimously asking for protections and not a suicide completion track in Bill C-7?
Director and Sun Life Financial Chair in Bioethics, University of Toronto Joint Centre for Bioethics, As an Individual
My apologies, Madam Chair. I thought the question was directed to Dr. Naud.
Liberal