I'd like to thank the joint chairs and committee members for the opportunity to participate in this study.
I am a psychiatrist at the Princess Margaret Cancer Centre, an associate professor at the University of Toronto and a scientist with a research focus on emotional distress and suicide in cancer, and this includes MAID research. I led the development of the MAID program for the University Health Network, served as an expert witness on the Lamb case and am currently the scientific lead for CAMAP's MAID curriculum development project. However, I am speaking today as an individual, so all opinions expressed are exclusively my own.
I am also a MAID assessor and provider, and what I'd like to tell you today is that I have significant concerns about the pace and process of the expanding MAID legislation.
I'd like to begin by recognizing that practitioners all have values that sit on a continuum of whether they prioritize patient autonomy or the protection of vulnerable persons. I personally lean more towards the duty to protect, largely reflecting my belief that MAID for those with a reasonably foreseeable natural death, or RFND, is literally assistance in dying, while MAID for those without an RFND is technically assisted suicide. This opinion underlies the four points I'd like to make.
My first point is that there has been insufficient attention given to the psychological dimensions of palliative care. Although psychological suffering has clearly been shown to be the primary driver of the desire for MAID, we have not adequately captured data on access to psychosocial care or emphasized the need for targeted research and funding in this area.
Second, as was just said, I've yet to see a public opinion poll on whether the Canadian populace is in favour of MAID for all forms of life suffering, and in particular for psychosocial or structural vulnerability. It's an important question, because I believe the Canadian populace—and maybe even legislators—are not aware of who has been qualifying for MAID. I suspect it may come as a surprise to learn that what are essentially “completed life” cases have been happening in Canada since even before Bill C-7, because no one reaches older age without some form of qualifying chronic illness like arthritis, COPD or diabetes, and psychosocial vulnerability often underlies these requests.
Conceptually, MAID and palliative care are arguably distinct, but I believe that clinically speaking there needs to be better integration to ensure high-quality end-of-life care, with attention to vulnerability. The thing is that everything about MAID except for the five minutes of the lethal injection is palliative care. All the initial conversations with a patient about whether to apply for MAID, optimal symptom management until they do, guidance about choosing when to go ahead with it once they're approved and support for the family after they've received it are really most safely done via palliative care. However, to engage the palliative care community, we need to demonstrate that we're practising MAID carefully, consistently and for palliation, but the legislation hobbles us in this. I've certainly had cases in which I felt compelled to provide MAID against my better clinical judgment because the law did not adequately protect. I'd be happy to describe such a case, if asked.
This leads to my third point: The current legislation leaves too much responsibility in the hands of clinicians, whose application of the eligibility criteria according to their own values can render the legislative safeguards impotent. As said earlier, this is because incurability can include treatment refusal; an advanced state of decline may not need to be progressive; suffering is determined only subjectively; and “reasonably foreseeable” is not legally defined at all. The absence of a definition of RFND is crucial in light of Bill C-7, as patients with prognoses of several years or those who refuse preventive care or who voluntarily stop eating and drinking can be placed on the supposedly palliative track one, in which there is no longer even the mandatory safeguard of a 10-day reflection period.
This brings me to my final point, which has also been made: Canada needs some standard mechanism of oversight to review cases. This has been proposed for mental illness as the sole underlying medical condition, but I believe it's required for many MAID cases or at least for all track two cases.
In sum, I'd like to see four things: increased attention on the psychological dimension of MAID, a determination of whether there is a public mandate for MAID for any form of suffering, a legal definition of RFND and some form of federal oversight. Under what circumstances a person should receive MAID cannot be left to the variable opinions of individual practitioners, because that is the responsibility of the government, which really should reflect the will of the Canadian people.
Thank you.