Medical Assistance in Dying Committee on April 13th, 2022

[Abby Hoffman]

Okay.

[The Joint Chair, Hon. Yonah Martin]

We will go to Dr. Fry next.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Chairs.

Thank you again to Ms. Hoffman and Mr. Potter for coming in and sharing your information with us.

I must say that I'm impressed by Ms. Hoffman's ability to answer these very complex questions with her own complex knowledge of the issues. She has been really following up on everything.

I have two quick things I want to ask about. One of them goes back to the issue of advance directives. Before MAID and before the Carter decision, etc., physicians were providing advance directives with their patients for ages. They were doing it under the guideline of the colleges to talk about ethical decision-making with a patient who feels they want to have an advance directive, and it's been done under those jurisdictions.

I want to know why, and whether, there is intent by the Government of Canada to decide that it will enter into the College of Physicians and Surgeons' ethical and knowledgeable decision-making by which it guides physicians and suddenly impose some sort of heavy-handed legislation on how physicians should practise with regard to things like advance directives, which are very physician-patient-related and therefore involve privileged decision-making. That is the first question.

This is the second question, and then I'll let you guys go after it.

We know that on the question of social vulnerabilities and other vulnerabilities, many countries have had a long-standing practice of MAID. There are Luxembourg, Belgium and Switzerland, as well as the states of Washington and Oregon, and so on. We know that in fact two—the Netherlands and Oregon— stand out with regard to looking at the issue of how to protect vulnerable persons in terms of how MAID is done, and they now have a good evidence-based decision with respect to how that worked and whether or not it worked.

Have you guys been looking at what the evidence from those jurisdictions is now telling us?

Thank you.

[The Joint Chair, Hon. Yonah Martin]

There's only one minute remaining, so we'll hear from Mr. Potter first, or Ms. Hoffman, and you'll both have to be very brief.

[Jay Potter]

I might answer very briefly on the first question.

I would just note that advance directives and MAID are very different things, and that advance directives as they currently exist are for refusal of care, which people have always had a right to do, whereas MAID legally is an act that requires a criminal exemption because it actively ends a person's life. There is an important distinction there, at least from a legal perspective.

I'll let my colleague Ms. Hoffman add on.

[The Joint Chair, Hon. Yonah Martin]

You have 30 seconds.

[Abby Hoffman]

We'll have to come back to these issues that Dr. Fry has raised, because they are very important ones.

On vulnerability, I have just two quick points. One is that the new safeguards, for cases in which people are not dying, do try to ensure that the provider gets at the totality of the person's circumstances to look at anything that could relieve those features of the person's vulnerability beyond their medical condition, and that there is an opportunity to address those.

The other thing I want to say about vulnerability, in the experience with these other countries and within the plan in Canada, is that it has to be assessed in the context of each person. We cannot say that because someone is a member of a group, they are therefore vulnerable and therefore they cannot get MAID. That is absolutely—

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you.

[The Joint Chair, Hon. Yonah Martin]

We will return to this hopefully in the next round.

We will go back to the five-minute time slots, and the questioner will be Mr. Barrett, actually, or did you want to go back to Mr. Cooper? It's a five-minute round.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

I'm prepared to go, but I thought it was Madam Vien.

[The Joint Chair, Conservative, Michael Barrett]

That's correct.

[The Joint Chair, Hon. Yonah Martin]

Okay, thank you very much.

Go ahead, Madame Vien.

[Dominique Vien, Conservative, Bellechasse—Les Etchemins—Lévis, QC]

Thank you very much, Madam Chair.

Good afternoon, everyone.

Thank you to our witnesses for being with us this afternoon.

Ms. Hoffman, perhaps I misunderstood, but you can let me know. In your opening remarks earlier today, you said that, according to 2020 data, the proportion of deaths by MAID procedures, as a proportion of the total number of deaths, will probably stabilize at around 4%.

First of all, how do you estimate that it will be 4%? Why do you estimate that the proportion of MAID cases will stabilize at 4%, when we know that access to MAID will be extended to other situations, particularly with regard to mental health? How did you arrive at that percentage, given the changing situation?

[Abby Hoffman]

The reason we're saying that involves two things. One, we're looking at other what we'll call “progressive regimes” of MAID in other countries—the Netherlands, as an example— and over time it rose and eventually reached the point of approximately 4% of all deaths, and we think that is likely in Canada, but there's no more science to it than that kind of international comparability. We will have to see how this plays out.

Two, I mentioned that there were 200 MAID deaths associated with people whose death was not reasonably foreseeable. This is a small number, understandably, in the first year after the new legislation. We'll see, but we are not anticipating right now that vast numbers of people whose natural death is not foreseeable will be seeking a MAID death, or people whose principal underlying condition is a mental illness. We may be proven wrong, but that is what we see at the present time.

I'll just say that we know the rates in some parts of the country are higher—in Quebec, for example, and on Vancouver Island. Whether that will be the case across the country remains to be seen. It's a combination of the will of individuals and the receptivity and preparedness of the health system. Both need to be place to influence the rate of MAID procedures.

[Dominique Vien, Conservative, Bellechasse—Les Etchemins—Lévis, QC]

Ms. Hoffman, you've opened a door for me.

As you said earlier in your presentation and in response to my colleague Mr. Thériault, the use of MAID has increased by 30%, which seems quite high to us.

That 30% increase in Canada is huge, but from what you're seeing across the country, I understand it's variable. The situation isn't the same across the country. What is the situation in each province?

[Abby Hoffman]

Some of you may have observed this, but I will just note, for example, that there was recently some television coverage of access to MAID on Vancouver Island. One thing that the physician who is in charge of MAID services in that part of the country said is that they are open, and they help ensure that every health care institution on Vancouver Island knows about and is prepared to accept and to deal with MAID requests. That is not the situation everywhere. Attitudes are different in different parts of the country. The rates in those parts of the country where citizens were less inclined to pursue MAID are starting to increase.

I don't want to be held to this 4%. I will just note that there are differences. Some of those differences will persist; but 4% is the number in a system in which MAID can be provided both by a practitioner and through self-administration. In those societies where MAID is.... At least in Canada—

[The Joint Chair, Hon. Yonah Martin]

You have 30 seconds.

[Abby Hoffman]

—where almost all of the cases are actually administered by a provider, not by the individual who wishes to see their life come to an end, this approximate 4% is in place. What we hope is that there will not be institutional or other barriers so that someone, for example, who's living in long-term care or is living out their life in a hospice is told, “Sorry; you cannot have access to MAID in this institution.” That's a barrier we're concerned about.

[The Joint Chair, Conservative, Michael Barrett]

Madam Co-Chair, just on procedure, I just would like clarification on the round that just concluded. We had three minutes for the Conservatives and three minutes for the Liberals. Should there have been time allotted in two-minute increments for both—

[The Joint Chair, Hon. Yonah Martin]

To the Bloc and the NDP, yes. I'm doing that next, and then we will.... Oh, you're saying that I skipped them by mistake. You're right, Mr. Barrett.

[The Joint Chair, Conservative, Michael Barrett]

Yes, we would need to go back and do two minutes for Mr. Thériault and two minutes for Mr. MacGregor and then go back to the Liberals.

[The Joint Chair, Hon. Yonah Martin]

Yes. I apologize. I have all of this listed in front of me, but my eyes have played tricks on me. Thank you for that, Mr. Barrett.

In round two there should have been two minutes for the Bloc speaker and two minutes for the NDP, so I will return to that and then come back to these five-minute slots.

We have Mr. Thériault for two minutes, followed by Mr. MacGregor. My apologies.

[Luc Thériault, Bloc, Montcalm, QC]

I thank my colleague Mr. Barrett for raising this point.

We look forward to receiving the expert report on the fact that mental illness alone could be enough for a person to have access to MAID. In the meantime, there are things you can tell us about that to give us some direction.

Some countries do provide MAID to people with mental illness. Could you tell us about the protective measures put in place in those countries and tell us what we can learn from these experiences, which are rather few?

I'd like to hear what Ms. Hoffman, Ms. Klineberg or Mr. Potter has to say about this.

[Jay Potter]

I might begin by just saying that one significant difference between, say, Belgium and the Netherlands and Canada in terms of our MAID frameworks is that Belgium and the Netherlands have a criterion that effectively requires the other treatments or alternative means of alleviating the suffering to have been tried and failed, whereas in the Canadian MAID legal framework it's for the individual, the person seeking MAID, to determine whether any particular treatment is acceptable to them, or not, as a means of alleviating suffering. That's one important difference between the regimes that you might look at.

As a broader comment on lessons learned, while those jurisdictions certainly do have a longer experience with MAID outside of a very end-of-life context compared to Canada, these cases remain controversial and difficult even over there. There are also important differences in not just the legal framework but also in our health system and in our society that the committee may wish to consider as well in looking at this issue—the geography of Canada, the shared responsibility between the provinces and territories, and so on.

[Abby Hoffman]

Just very quickly, Madam Chair, if I could add, just apropos of—