Medical Assistance in Dying Committee on April 13th, 2022

[Abby Hoffman]

I think it's hard to tease out the difference between the suffering, the pain, the lack of capacity, lack of mobility, difficulties communicating, and particularly the intense pain associated with a very serious medical condition and all of those kinds of things. It's very hard to separate those from the person's anxiety and their existential questioning.

When you speak—and I hope you will—to some MAID providers, I think they can probably give you a stronger sense—a more “at the bedside” sense, shall we say—of what the mentality is of individuals who seek MAID.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Senator Dalphond, you'll have four minutes. I will make sure I add more to Senator Mégie in the next round, because there are only four senators now. I will have three minutes following you.

Go ahead, Senator Dalphond.

[Pierre Dalphond, Senator, Quebec (De Lorimier, PSG]

Thank you, Madam Chair.

My question is for both the health and justice officials. It's about policy.

In Canada, there is significant support for allowing advance directives for medical assistance in dying. In fact, it was a recommendation made by the Senate, as well as a previous joint committee in 2016.

Policy-wise, do you anticipate moving towards a more comprehensive system that includes the regulation of advanced directives? Conversely, do you expect the possibility to be provided for in the Criminal Code, leaving it up to the provinces to determine the rules around recording and preserving consent, verifying witnesses and so forth?

[The Joint Chair, Hon. Yonah Martin]

I'm sorry, Senator Dalphond. The interpreters are having difficulty hearing. Could you move your microphone up?

Thank you.

[Pierre Dalphond]

I was actually done asking my question.

[The Joint Chair, Hon. Yonah Martin]

I paused the time, so....

[The Joint Chair, Conservative, Michael Barrett]

Senator Dalphond, could you start your question from the beginning, now that we have your microphone adjusted?

We'll restart the clock for you.

[Pierre Dalphond]

Thank you, Mr. Chair.

My question is about advance directives. Surveys show that Canadians are strongly in favour of allowing advance directives, a measure recommended by the Senate as well as the 2016 joint committee.

I am wondering whether the officials here today can tell us whether they anticipate moving towards a comprehensive regulatory system from a policy standpoint, or a system whereby advance directives would simply be allowed under the Criminal Code? In that case, it would be up to the provinces to regulate the preservation and periodic review of advance directives, witness requirements and so on.

[Jay Potter]

I can perhaps start with a response to the senator's question.

The scope of a federal regime for advance requests, if that's the will of Parliament, is one issue that this committee should certainly consider. Some of the features, as I mentioned earlier, are if it is desirable for Parliament or if there is interest in putting in frameworks on both of the points in time I mentioned.

On the area of the time when the request is made, without federal safeguards or procedures for that period of time, then for the practitioner who actually administers MAID, perhaps years later, there wouldn't necessarily be a guaranteed standard in place for them to know why they can have confidence in the integrity of that request or in the information the patient was given, for example, and why that request can be said to be truly representative of what their wishes were in the past.

That's one point in time that is, as I mentioned, more typically dealt with as a matter of health law but where Parliament may wish to give consideration if there's a desire for standardization. Otherwise, there is a possibility that if provinces do not occupy the field, there could be variance across Canada in how advance requests are created, stored and documented, and then how they would ultimately be used.

I think we would all agree that for that second practitioner who is going to administer MAID to be very confident in that original request is an important consideration in ensuring that it's voluntary. I think you're right to point to the issues of how that gets constructed. It's certainly a very important issue.

[The Joint Chair, Hon. Yonah Martin]

Go ahead, Ms. Hoffman.

[Abby Hoffman]

I will only add to what Mr. Potter has said.

Even today, when it comes to advance directives, which in many cases are much less significant in their consequences, they are mainly distinguished from an advance request because they are only about the withdrawal of treatment.

The systems within provinces and territories, within institutions and across the country are not only diverse, but they are frankly not all that functional. A request that may be MAID, or a directive that a person may file in the context of their interaction with a family physician, a visit to a hospital or whatever, may or may not surface again on some future occasion. There would be an enormous amount of work to be done, not just at the level of the legislation and the permissibility of such a regime in the Criminal Code, but in the actual implementation within the health care system.

I'm not offering an opinion about whether or not advance requests should be permitted. I'm just commenting on the infrastructure that would be needed, including, for example, periodic renewal of the request, so that any last request that is made is as proximal as possible to the point in time when the person has identified that they would like that advance request to be acted on.

[Pierre Dalphond]

Thank you.

[The Joint Chair, Conservative, Michael Barrett]

Thank you, Ms. Hoffman. Thank you, Senator Dalphond.

Next we'll turn to Senator Martin for four minutes.

Go ahead, Senator Martin.

[The Joint Chair, Hon. Yonah Martin]

Thank you, Mr. Co-Chair.

This is a question for Abby Hoffman.

You mentioned that the federal government was funding some training for MAID providers. Health is provincially directed, and whether it's training or whatnot, it would be done at the provincial level.

I'm just wondering what you meant by funding. Is it with specific provinces? We know there are different advancements of the MAID practice, depending on the province. Can you clarify the role of the federal government in doing such funding?

[Abby Hoffman]

Sure. This is not untypical of the sorts of things that the federal government takes on, whether it's in large quantities of money through the Canada health transfer or through smaller projects. Obviously, the federal government plays a role in various aspects of health care.

What we're specifically speaking about here is what emanated from the practice community of MAID. That led to the creation of the Canadian Association of MAID Assessors and Providers. They were the ones, through the interaction with their communities, who said that we need to regularize practice, and a good way to do that is through an accredited training program.

I will also note that across the board in the health care system, specialist training is accredited by the Royal College of Physicians and Surgeons. The expectation here is that MAID training would be accredited through that same system. It would be up to individual provinces and territories to decide whether or not to make this training and this accreditation mandatory for a provider in order to practice MAID in that province.

As well, a lot of these things work through collaboration among national bodies and provincial bodies and the provincial regulatory bodies for physicians and nurse practitioners. They too would be part of this discussion, but this is a normal kind of approach.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Naturally, there will be differences. I'm concerned about those challenges that are faced between rural and urban providers. Who is addressing these differences in how things are administered? How will we achieve consistency?

[Abby Hoffman]

In quite a few provinces, there are MAID coordination networks so that somebody, regardless of where they live, can actually enter the system through this coordination network. The resources that are needed—I'm not talking about the financial resources, but mainly about the human and professional resources—are then allocated to the individual in question. As far as the training is concerned, it will be delivered both online and in person. Hopefully, that will help with providers from smaller communities.

Look, I'm not going to misrepresent the situation. In the new cases of access to MAID for people whose death is not reasonably foreseeable, it is a much more complex assessment process. There needs to be an expert in the person's condition.

[The Joint Chair, Conservative, Michael Barrett]

You have 30 seconds.

[Abby Hoffman]

If one of the two assessors or providers does not have that information, it is very challenging. A lot of efforts are going to have to be made to make sure that access is equitable for people who are living in smaller communities, because it is a much more complex process.

[The Joint Chair, Hon. Yonah Martin]

Thank you. In my second round, I'll ask again about the complexity of that.

Thank you, Mr. Barrett.

We'll now go to the second round for the House members. We'll begin with Mr. Barrett for three minutes, followed by Dr. Fry for three minutes.

Go ahead, Mr. Barrett.

[The Joint Chair, Conservative, Michael Barrett]

Thank you, Madam Chair.

For my first question, I'm looking to see if the government acknowledges the contention made by the World Health Organization, the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians that MAID and palliative care are separate and distinct practices.

[Abby Hoffman]

I would say that the actions of the palliative care community would suggest that they are not completely separate and distinct. I think Senator Kutcher, or perhaps one of the other members who spoke, mentioned that a significant number of MAID procedures actually take place in palliative care units. When it comes to the providers who are involved in MAID processes, a significant proportion of those providers actually are physicians with a palliative care specialty.

I think it was the case in the early days of MAID and in the lead-up to the original framework in the Criminal Code that there was a bit of a standoff between the palliative care community and palliative care providers versus the MAID community, but I think over time there has been an inclination to look at end-of-life care in all of its facets and components and for many palliative care providers to see that MAID is not a testament to the failure of palliative care. It is a reality that sometimes palliative care will not believe in individual suffering, so we don't see this kind of antagonism, shall we say, between MAID and palliative care.

[The Joint Chair, Conservative, Michael Barrett]

Thank you, Ms. Hoffman.

The two leading Canadian palliative care associations have called for “prioritization of, adequate investment in, and enhancement of palliative care services as a separate service from MAiD”. How has the Government of Canada responded to these calls and requests?

[Abby Hoffman]

I'll start with a response to that.

First of all, although we have provided to the provinces some very significant amounts of money through the recent health accords for home and community care, including palliative care, we cannot and we do not direct provinces in terms of exactly what they should do and how much of their resources they should direct to palliative care. We know they are making improvements and we also know that the palliative care system is not as strong as it should be.

If you are a person who is suffering grievously with cancer, the continuity of care system that works in the cancer world will likely ensure that you get access to the palliative care you need, but in the case of many other diseases, that may not be the case at all.

The other thing—

[The Joint Chair, Hon. Yonah Martin]

Thank you, Ms. Hoffman. I apologize, but we're past three minutes.