Medical Assistance in Dying Committee on April 13th, 2022

[Abby Hoffman]

Thank you, Madam Chair. Thank you, Mr. Thériault.

Health Canada acts as the secretariat and supports the work of the panel. As required in the legislation, it is an entirely independent process. I think I can assure you that the panel's report will be available in the month of May; it may be in the latter half of that month.

I can also tell you that the panel and the process is pretty much at its end inasmuch as production, translation and fine tuning from the production standpoint are under way right now.

The panel is very conscious of this committee, its work and its anticipated interest in their report, so every effort is being made to make sure that the report will be tabled in a time frame that allows proper and thorough review by the committee.

I should also note, if I may, Madam Chair, that the tabling date is at the discretion of the two ministers, Minister Lametti and Minister Duclos, but they too are obviously aware of the importance of this committee and its review of the report.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Go ahead, Monsieur Thériault.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

Ms. Hoffman, back in June, you told us what the primary settings for the administration of MAID were in 2020: private residences accounted for 47%, hospitals accounted for 28%, palliative care facilities accounted for 17% and long-term care facilities accounted for 5.7%.

Today, you said in your opening statement that, despite the pandemic, the number of MAID cases rose by 30% in 2021, approaching 10,000 cases.

Do you know the breakdown for the administration of MAID by setting for 2021? Are those numbers available?

[Abby Hoffman]

Madam Chair and Mr. Thériault, no, we do not have that date yet. It will be published in the annual report for 2021, which, unfortunately, will likely be some few weeks after this committee completes its work.

I would say, based on our observation and reports from the provider community, that there is nothing to suggest that the profile of where these procedures have taken place is any different. We're not observing or aware of any significant difference from prior years, so I think that distribution that you cited would remain pretty much in place in 2021.

[The Joint Chair, Hon. Yonah Martin]

Monsieur Thériault, you have—

[Luc Thériault, Bloc, Montcalm, QC]

You're saying, then, that, despite the pandemic, you didn't necessarily observe any changes in how MAID cases were broken down amongst the various settings. That's helpful. Thank you for that answer.

Mr. Potter, as far as the regulatory framework is concerned, you said that territories and provinces could impose additional requirements. Can you give us examples of such requirements? Can you also tell us how much they could impact access to MAID?

[Jay Potter]

As I mentioned—

[The Joint Chair, Hon. Yonah Martin]

You have 30 seconds.

[Jay Potter]

—for health law, very quickly, provinces, as a matter of regulating their health professionals, could impose requirements about how they are to do the assessment of a patient, for instance, over and above what the criminal law safeguards do.

Recall that the criminal law safeguards effectively set a standard minimum floor across the country because a provider can only offer MAID and be exempt from criminal liability if they comply with all the federal requirements, but a province or a regulatory body, as a matter of health law or health practice, could impose additional and more specific requirements that exceed the criminal law, if that was their intent.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Our last speaker in this first round before the senators is Mr. MacGregor.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you very much, Madam Chair, and thank you to our witnesses for appearing before our committee and providing an update.

After Bill C-7 was passed, we're now faced with an impending deadline next year, when mental illness as an underlying condition will be removed.

Ms. Hoffman, you did say in your opening remarks that you anticipated the new regime would be difficult for practitioners, and I understand that's in the context of Bill C-7 coming into force. I also think you could use the future tense of that verb in that you anticipate that the new regime coming into effect in March of 2023 will also be quite difficult.

In the context of mental illness and the fact that it will now be considered to be an illness, disease or disability—and I understand that patients will also have to meet other requirements that they are in an advanced state of irreversible decline and that it also causes them enduring psychological suffering—given that Health Canada is working with this deadline in less than a year, what are your conversations like as a department with practitioners? What kinds of conversations are going on and how are they going to develop the guidelines to deal with this very fundamental change to Canadian law?

[Abby Hoffman]

There are just a couple of comments I could make.

One is that I think we have seen this same sort of situation play out in the early days of MAID. I think practitioners at the time were very concerned about their ability and their capacity and, frankly, whether they would have the legal protections they needed if they proceeded with their practice of MAID. I think we are now, for sure, encountering more challenging cases, such as cases in which natural death is not reasonably foreseeable and, as you indicated, cases of mental illness.

The conversations we've had with practitioners have absolutely pointed to concerns that they have. There are certainly some practitioners who have indicated that they may not wish to practise MAID in cases other than those in which a natural death is reasonably foreseeable. What we are hearing more often, particularly in our interactions with providers who are associated with this organization I mentioned, CAMAP, is that they want to have the tools and they want the education and they want the interaction with their colleagues. This will assist them to make the kinds of very complex clinical judgments that have to be made about whether or not a person actually qualifies in terms of the characteristics you enumerated of a grievous and irremediable medical condition. They also need support to apply the safeguards, particularly those safeguards that have to do with the offer of available supports and services that might alleviate the suffering of a person.

What I think we're observing, and we expect this will continue, is that while the number of providers involved in MAID is increasing, in fact the increase in the number of cases is being dealt with by fewer people; that is, more MAID practitioners are doing more cases. What we're seeing is the evolution of a specialty. That's why support for this accreditation training program is so vital: It's because it is going to require a level of expertise to address all of these standard concerns, which everybody agrees are legitimate concerns about mental illness, for example, and incurability and irreversibility.

Other concerns are about how to assess competence and capacity, and what about suicidality? What about other vulnerable circumstances that play into the person's condition and therefore the assessment?

We're hearing...I don't know if I want to call it “concern”, but what we're hearing is the need for support. The MAID community has, in our view, really stepped up to work to try to address these issues. It's not to say there will not be some attrition among some providers who have concerns. I think that is natural and understandable.

[The Joint Chair, Hon. Yonah Martin]

There are 30 seconds remaining.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you, Chair. I'll donate that back to the committee so that I have more time in the next round.

[The Joint Chair, Hon. Yonah Martin]

Thank you, Mr. MacGregor.

We'll go to the senators next. We have Senator Mégie, followed by Senator Kutcher. Each senator will have three minutes.

[Marie-Françoise Mégie, Senator, Quebec (Rougemont), ISG]

Thank you, Madam Chair.

My question is for Ms. Hoffman.

You said in your opening statement that MAID providers were going to be required to collect information about the requester’s race, indigenous identity, disability and other characteristics, and that this would help establish the presence of any inequalities, including systemic inequality, in Canada’s MAID system.

Do you have any information thus far on systemic inequality in the MAID system?

[Abby Hoffman]

I cannot speak with absolute certainty, but the impression that one has talking to providers and looking at some of the data—and frankly, some of this is anecdotal data—is that the individuals who seek MAID are generally reasonably well educated. They may be middle-class professionals. They are people who appear to have had positive ongoing engagement with the health system, and this is a very important point. These are not people who are disenfranchised in terms of access to health care; they are people who have had a respectful and positive relationship with health care providers. We don't know, but we think they are largely white. Again, we don't have solid data on that. This is an impression.

The data we collect will help with some understanding, but that data has to be complemented by other research that involves actually dealing with people, speaking to people who are seeking MAID, for better understanding of the circumstances that are driving their requests and understanding the totality of their circumstances. We plan to support that type of research.

We're also using the data that we are collecting through the monitoring system to link it to health care utilization data, Statistics Canada data that is collected, and data collected and accessible through the Canada Revenue Agency. We will try to assemble all of these sources to have a better sense about access, and frankly about how MAID cases from people in different population groups are delivered, but more importantly how they are experienced by the people who enter that system or who choose not to enter it, because their motivations may be important as well.

[The Joint Chair, Hon. Yonah Martin]

Senator, there are only about 10 seconds left.

[Marie-Françoise Mégie]

Thank you for your answer, Ms. Hoffman.

I want to use my remaining 10 seconds to have you confirm something. You have no data on how many Black or racialized individuals have requested MAID. That is what I took your answer to mean. Is that right?

[Abby Hoffman]

That is correct at the present time, and that is absolutely something we need to fix. Bill C-7 directed the Minister of Health to develop regulations that would ensure that we would collect that kind of data. That is what we are doing.

[Marie-Françoise Mégie]

All right. Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Senator Kutcher is next.

[Stanley Kutcher, Senator, Nova Scotia, ISG]

Thank you very much, Madam Chair.

Thank you to all of the witnesses. I want to acknowledge your expertise on this incredibly challenging topic.

I have two questions together for Ms. Hoffman.

First, about 15% of Canadians have a mental disorder. What proportion of those receiving MAID currently would have a comorbid mental disorder?

Second, for those who've received MAID, what proportion would identify psychosocial factors, as opposed to physical factors such as pain, as the primary reason for requesting MAID?

[Abby Hoffman]

Thank you, Senator Kutcher.

Maybe one of my colleagues from Health Canada can, but off the top of my head I cannot give you an indication of the number of individuals who have a comorbid situation of a physical illness and a psychological or mental condition. If one of my colleagues can answer that, I will ask them to do so, but I think at this point we don't really have that data.

In terms of psychosocial factors, when you look at the explanations given by persons requesting MAID and documented by the providers who complete the reports that are required under the monitoring system, the things they say about what is causing their suffering.... If you have terminal cancer and a very short life expectancy, then the physical pain is clearly going to be very high. When people talk about the fact that they feel they no longer can do the things they formerly did and they need more assistance than they feel it is dignified to receive in order to carry out the normal activities of daily living, I would describe that as falling under the psychosocial dimension.

I think what we want to get at, particularly in the cases that are starting to come into the MAID system now of people whose death is not reasonably foreseeable, is whether those psychosocial circumstances can be alleviated in any way through supports. With people whose death is imminent, we generally see that they are, to be candid, sort of beyond the point where more income support or more social interaction would actually cause them to say that they're not going to proceed with their MAID request.

We are entering a new world in which documenting—and that's why the safeguards are so important—the kinds of support that are offered and then considered by people requesting MAID is going to tell us much more about how psychosocial circumstances and other forms of status in society play into a person's request for MAID. We don't see that now as such a critical factor in cases of MAID for people whose death is reasonably foreseeable.

[Stanley Kutcher]

Thank you very much for that.

Certainly what you said makes sense about this other group having.... We need the guidelines, the guardrails and the safeguards. Hopefully, we'll get that from the committee's reports.

Would it be fair to say that in this current situation, the majority of people seeking MAID do it primarily for psychosocial factors?