Evidence of meeting #11 for Medical Assistance in Dying in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was minors.
A video is available from Parliament.
Liberal
Brendan Hanley Liberal Yukon, YT
Yes, maybe I'll rephrase it.
In some of our deliberations—for instance, on adolescence and drug or cannabis use—we often consider the maturity of the adolescent. In fact, science tells us that maturity of the frontal lobes is not achieved until age 25. At some point, we have to make decisions about relative maturity. There is, obviously, no black and white cut-off.
I'm wondering where you apply that cut-off in your own experience and practice.
Clinical Associate Professor of Pediatrics, Memorial University, As an Individual
I can't give you a number based on years. Obviously, as you said, it's early adulthood. It's outside of my area of expertise. I can't comment outside of age 18, because I only take care of children up to age 18. Therefore, my argument is that we should not have it for children aged 0 to 18. There should be complete prohibition.
Above that age, it's out of my scope of expertise, so I cannot comment.
Liberal
Brendan Hanley Liberal Yukon, YT
The point I'm trying to make is that these things are relational. To the point of the previous witnesses, decisional capacity is relative, and the severity of a situation has to be considered in the context of the condition and maturity of that individual.
Mr. Carnevale, I wonder if you can comment.
When you say we need the youth voice, what have we neglected and where can we do better in bringing the voice of young people into decision-making?
Professor and Clinical Ethicist, As an Individual
Well, these comments are against the backdrop of a very large body of literature and evidence highlighting being excluded from discussions in clinical care as well as in policy-making. In clinical care, it is many times very humiliating and distressing for young people to be excluded from discussions about their diagnosis and prognosis.
With children with various types of end-stage illnesses, there's legal recognition, through the mature minor doctrine, that they should be principle decision-makers in making decisions that sometimes would even result in their death, declining certain trials in terms of cancer treatment and other neurodegenerative, neuromuscular degenerative conditions. That's been very well documented.
There is an increasing view, and some of this really.... This is why I worked with Holland Bloorview in preparing evidence for the CCA panel that I worked on. Holland Bloorview has probably the longest-standing youth advisory council. They have, through their youth advisory council, programs for developing youth leadership. These are youth who are living with various forms of disability, and therefore can be quite sophisticated in demonstrating their insights on the implications of different types of treatments and policies. It is within the institutional mandate of Holland Bloorview to incorporate youth on various committees to weigh in on decisions on the ways in which policies are made.
The UN Convention on the Rights of the Child, article 12, highlights that young people should be heard and that their voices should be attributed due weight in matters that affect them. It's fairly wide scale.
Dr. Hanley, I'd like to maybe ride on one of your comments, on the recognition that decisional capacity is a relational phenomenon. One of the areas where I work as a clinical ethicist is in a child and youth mental health centre. It is very clear that the way in which we present information, the way in which we create a trustworthy, safe, relational environment, can bolster or thwart a young person's capacity to participate in decisions.
The Joint Chair Hon. Yonah Martin
Thank you.
Thank you, Mr. Hanley.
Monsieur Thériault, you have five minutes.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you very much, Madam Chair.
I'd like to thank the witnesses for their testimony, which has been fascinating and enlightening.
Ms. Montes, you talked a lot about minors having access to medical assistance in dying when mental health disorders are their only medical conditions. I assume that you're aware of the expert report that was tabled recently.
Where does it say in that report that mature minors can obtain medical assistance in dying when they are in a crisis or a suicidal ideation situation?
Clinical Associate Professor of Pediatrics, Memorial University, As an Individual
I'm so sorry. Do you think you could repeat that question, because the translation was not.... Could you just repeat the question?
Bloc
Luc Thériault Bloc Montcalm, QC
I was saying that the report tabled by the experts talks about access to medical assistance in dying when mental health disorders are the only medical conditions involved.
You put a lot of emphasis on mental health disorders and you talked about crisis and suicidal ideation.
Where in the report would one find the recommendation to move forward on mature minors who are suffering from a mental health disorder or are in a state of crisis?
Where in the report did you see that?
Clinical Associate Professor of Pediatrics, Memorial University, As an Individual
Are you referring to the CCA report? Which report are you referring to?
Bloc
Luc Thériault Bloc Montcalm, QC
I'm talking about the report the minister commissioned from the expert panel that was to look into whether or not to include in Bill C‑7 the sunset clause designating March 17, 2023, about when mental health disorders are the only medical conditions claimed.
That's okay, I will move on to another question.
Mr. Carnevale, you talked about additional safeguards for mature minors. You also stated that mature minors should not be granted medical assistance in dying if they are suffering from mental health disorders. I did understand what you said.
In your opinion, what should the additional safeguards be?
Professor and Clinical Ethicist, As an Individual
It's really a work in progress. We need a lot more information to gain a solid grasp of what safeguards are needed.
We can draw inspiration from what's done in the Netherlands and Belgium, which have safeguards. In certain situations, parental consent is required based on the child's age. We already have that in Canada in certain situations. it depends on the province. In Quebec, for example, if a minor refuses necessary treatment, it's possible to challenge the decision in the minor's best interest.
There are safeguards in place for the few minors who make a decision that is not in their best interest. For example, we need to make sure they're not under any pressure and that they have been well informed. This measure is also described in the report I filed with the committee. Parents must also be considered another decision-making authority.
Bloc
Luc Thériault Bloc Montcalm, QC
I'm eager to read the report.
You have extensive clinical experience. Do you often come across situations where the parents and child disagree on what is in the child's best interests given the progression of the illness? Making those decisions is definitely a process because measures can't be put in place overnight.
In your extensive clinical experience, do you come across many disagreements, or does the decision-making process tend to be healthy, such that the parents and child are in sync regarding the child's best interests?
Professor and Clinical Ethicist, As an Individual
In my experience, disagreements over what the child wants and what is in their best interests are the exception, not the norm.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you, Madam Chair.
Dr. Montes, I would like to start with you.
I'm from B.C., and you're practising in Newfoundland, is that correct?
Clinical Associate Professor of Pediatrics, Memorial University, As an Individual
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
I know that provinces all have laws in place to govern, like British Columbia, mature minor consent. It basically puts in place the ability of medical professionals to accept consent from a child if they understand that the child is informed of the risks.
For you as a pediatrician, what are your guidelines when you're treating a child and it's related to medical procedures only? How do you understand that concept of informed consent on medical procedures for minors who may be under your care?
Clinical Associate Professor of Pediatrics, Memorial University, As an Individual
It's a very complex issue, obviously, and there are many voices that need to be heard. Pediatrics is not as straightforward as adult medicine. It's not just talking to the adult. First and foremost, we talk to the child. When I go into any sort of consultation room, the first person I greet and try to establish a rapport with is the child, and hear what the child has to say.
Obviously, I try to get a sense if the child understands the medical procedure, and is the child able to say back to me the risks and benefits? It's not just that. It's a very complex thing, because children are part of a wider social network. They're part of a family, and there are many other voices that you have to balance along with protecting them, because we look at their developmental stage. Having a special interest in their development, we have to look at that, as well.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
What if, for example, you were treating a child who had an incurable disease, an irremediable medical condition, and you were having this discussion with the parents and the child about end of life care. And then, in the confines of your office, just you and the child, the child was expressing an interest to go into palliative care, would you consider that to be consent, assuming the child understood the circumstances? Would you feel the need to go to the parents, or would you accept that child's desire to go into palliative care?
Clinical Associate Professor of Pediatrics, Memorial University, As an Individual
It's context specific, but obviously, as I've said, there's not just one voice. I would have to talk to the parents as well. You have to think about the decision the child is making and how this is going to affect the parents. That's one thing we haven't really discussed, especially with MAID. The death of a child, as I've seen in my practice, is literally one of the most heart-wrenching things, and some parents never recover. I've actually personally gone through this in losing a nine-month-old—
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
I fully believe you there. I'm a parent of three children.
Clinical Associate Professor of Pediatrics, Memorial University, As an Individual