Medical Assistance in Dying Committee on Oct. 18th, 2022

[Voices]

Oh, oh!

[Dr. David Henderson]

Unfortunately, many palliative care physicians who make any kind of seemingly negative comments towards MAID are quickly looked at as being overly religious or having other reasons for being concerned. I want to make it clear that I actually refer patients to colleagues of mine who provide MAID. I'm not against it from that perspective, but I do see a lot of concerns, as do some of the colleagues I work with who actually provide the service. I think it's really important that we look at these.

My theme tonight is that it's time for a reality check.

First of all, to me, health care in Canada is in the most fragile state we've ever experienced due to the lack of planning for the exponentially aging demographics we are currently living with. Not only are many Canadians reaching the age at which most need more health care, especially in hospital, but the health care workforce is also among this aging demographic. As we're seeing with that, new health care professionals no longer have the comfort of having seasoned colleagues to mentor them as they start their careers.

Many are feeling moral distress and feeling overwhelmed, and they are subsequently leaving health care in general. I'm sure you have all heard of that. The numbers are quite staggering, even among young health professionals, who are getting out of health care altogether, which is a terrible shame. It's putting this country in such a delicate, desperate situation.

Subsequently, this is leaving our patients with less-experienced providers, who are having to take on workloads they aren't used to without having had the opportunity to gain the knowledge and skills to meet the needs. This creates difficulties for all patients but especially for those who are dying or those in vulnerable positions, as we've talked about, given our poverty issues and the many other issues we face in our country.

I'm very concerned that this has opened the door for medically assisted death to be, potentially, a path of least resistance. As we see people getting more and more overworked, tired and exhausted, unfortunately this could become an easier pathway. Things tend to take the path of least resistance. I'm also concerned that the government has given health care professionals essentially a licence to kill without having significant checks in place to ensure that people are assessed properly and thoroughly. That comment was made up just minutes ago.

Canadians agreed that people living with a terminal illness with foreseeable death should be given an opportunity to seek voluntary euthanasia, and the laws were amended. Many people spoke up at that time about the worry of the slippery slope and they were quickly dismissed. Here we are a very short time later with MAID being available to virtually any person for any reason, and I ask, is that what the Canadian public actually wants?

If the majority of society feels that autonomy trumps all, as seems to be becoming the way, and that every person can end their life at their choosing, then so be it. However, we are still responsible for protecting the vulnerable and ensuring that people have a choice that includes access to palliative care, mental health and social supports, pain specialists and a health care system that allows for dignity for all, not just those who want to end their life.

I want to make reference to testimony that has come previously, again, from colleagues such as Dr. Leonie Herx and the Canadian Society of Palliative Care Physicians, who have outlined some of their concerns and ideas for how to remediate some of them. I know you've heard from—

[The Joint Chair, Hon. Yonah Martin]

I'm sorry, Dr. Henderson. Will you wrap up at this time?

[Dr. David Henderson]

I'll finish at this point. Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you. I'm sorry about that. I should have given you the one-minute warning, but I was listening to your speech.

Last we have Dr. Li.

You have the floor for five minutes.

[Dr. Madeline Li, Psychiatrist and Associate Professor, As an Individual]

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.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much to all of our witnesses in the second panel.

We'll now go into the first round of questions. As agreed, it will be four minutes for each MP.

We'll go to Mr. Barrett for four minutes.

[Michael Barrett, Conservative, Leeds—Grenville—Thousand Islands and Rideau Lakes, ON]

Thank you, Madam Chair.

Baroness Finlay, my question is for you. You are a member of the British House of Lords who has studied euthanasia regimes and has a professional background as a physician and a professor with attention to palliative medicine. How, in your view, is Canada being perceived from abroad regarding our MAID policies and practices?

[Baroness Finlay of Llandaff]

I think if I could put it very simply, it is being viewed with great concern because of the rapid expansion and the stories coming out in the press of people who are opting for MAID because they can't pay their bills. They're frightened financially. That isn't a valid medical reason to have doctors end lives.

There's also concern about extension into mental health because of suicidal ideation, which can fluctuate. People can go on to live very full lives if they're taken through their crisis and supported. It is viewed, I think, with great concern.

[Michael Barrett, Conservative, Leeds—Grenville—Thousand Islands and Rideau Lakes, ON]

This committee has recently heard testimony that Canada should consider expanding MAID to infants with a life-limiting prognosis in order to address the terrible suffering that those infants might undergo. I must note that I fundamentally disagree with this suggestion because I believe that it devalues persons with disabilities and that no child should have a question mark put over their life because society deems that life to be optional.

Can you tell us about the field of pediatric palliative medicine and whether MAID is the compassionate choice in those situations?

[Baroness Finlay of Llandaff]

I would say that it isn't a compassionate choice at all. It might be a convenience for people, and certainly the long-term care of a child with a lot of disabilities may be financially draining and emotionally draining on the family, but if you're going to focus on the child, you have to have evidence that the child is suffering. You have to have evidence that the child wants something different from their current existence, and you have to be careful that you're not reflecting disability phobia within society and a discordant view of disability.

There is a real difficulty there: Where would you put the line anyway?

[Michael Barrett, Conservative, Leeds—Grenville—Thousand Islands and Rideau Lakes, ON]

Thank you very much.

Dr. Henderson, how have palliative care resources been impacted by the implementation of MAID legislation in Nova Scotia and elsewhere in Canada?

[Dr. David Henderson]

Ultimately, we haven't seen a significant increase in human resources at all. I know that a colleague of mine talked about things being a lot better in one spot here in Ottawa, but that's very few and far between. We're struggling. We have wait times for patients for access to palliative care in Nova Scotia.

I mentioned the challenges now faced by the palliative care teams, partially because we are part of the aging demographic, so we're not even keeping up with those in the palliative care specialty teams who are retiring. We're not producing new specialists quickly enough. There aren't enough positions open for training in Canada, and that's something we've been talking about for quite a while with the universities to try to increase that.

Also, there's a lack of primary care. News on that just came out yesterday in Nova Scotia. Ultimately, we have a population of about a million people, so respectively it's not that large compared to other places in the country. However, about 120,000 people now don't have a primary care provider. That's like one in 10 people in our province.

As those people don't even have access to primary care, the only way they receive palliative care is that they end up in the emergency department and subsequently get referred. Our palliative care teams see these people and virtually have to hang on to them because there's nobody else to care for them. That's creating another load on our palliative care teams, and that's becoming more and more challenging.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much, Dr. Henderson.

We'll next go to Dr. Fry.

You have the floor for four minutes.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Chairs.

I am listening to two panels, the one an hour ago and this one, and I must say that some of the things I hear concern me. First and foremost, I buy and I accept the idea that we need to have palliative care accessible across the board. We know that provinces are responsible for that, so we need to look at some kind of universal accessibility, regardless of where you live in Canada, to good palliative care.

I hear that we don't have enough human resources to deliver palliative care, especially specialists. I'm hearing that and I buy all that. I accept all that, but what I am a little concerned with is, does anyone on this panel believe that palliative care and MAID are actually interchangeable, or that they're separate and you might have one or the other, and not that it's a continuum of care? If palliative care does not work, if a person's existential suffering becomes so great, then who are we to say that somebody is not suffering existentially?

How do we know that? Especially adults.... I accept the question that small children don't know and can't articulate, but for many adults, existential suffering is exactly what that is. We know that it sometimes can.... We heard it from one of the panellists in the last hour, who said that some people get great palliative care, yet they just don't want to continue because whatever they're feeling, whatever they're suffering, is just too much.

If, all things being likely, we have great palliative care, we get money put into it, it is universally accessible and we have enough human resources to train and deliver good palliative care, my question is this: Could a person who was undergoing all that, with the ability to get it without any problem about the ability to pay—as we know, in Canada medical care means you shouldn't have to worry about the ability to pay.... Do any of you believe that a person should be forced to stay in palliative care and not be offered MAID if they so choose?

I notice that Dr. Li is shaking her head, so perhaps, Dr. Li, I'll direct that question to you first.

[Dr. Madeline Li]

I absolutely take your point. I support the availability of MAID for end-of-life patients, and I certainly agree that I don't think the minority of patients who want MAID and go ahead with it are doing so because of a lack of access to palliative care.

I think the question was asked in the last panel about what proportion of patients who receive MAID have accessed palliative care. The last federal report tells us that: 82% of people who have received MAID have also been in receipt of palliative care. Also, the criticism of that was that it was clinician-reported. At UHN, my hospital, we have looked at actual receipt of palliative care services, and it's closer to 100% of our oncology population who accessed and received MAID and have also received good palliative care.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you, Dr. Li.

How many more minutes do I have, Chair?

[The Joint Chair, Hon. Yonah Martin]

You have 30 seconds.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I'm probably going to make a statement and not ask a question.

I think we've had a lot of people asking what other people think about the Canadian system, what society thinks, etc. At the end of the day, the Supreme Court ruled that it has to be section 7 of the charter, with “the right to life, liberty, and security of the person”, and that means it doesn't really matter what other people think. People, and society in general, should not be judging whether you or whether one should choose palliative care. It's the clinician—

[The Joint Chair, Hon. Yonah Martin]

Thank you, Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

It's the clinician who should work with the patient to do this.

[The Joint Chair, Hon. Yonah Martin]

Thank you, Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thanks, Chair.

[The Joint Chair, Hon. Yonah Martin]

Next we'll have Mr. Thériault for four minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

Dr. Henderson, what we're hearing from you this evening is that we need to wake up. I fully agree with your call for better health care.

I'd like you to explain to me what you mean when you say “autonomy trumps all” in advocating for, say, medical assistance in dying as opposed to palliative care.

As far as I know, individual self-determination is enshrined in law, and in matters of health, no one can intervene with a patient without their free and informed consent. That's what autonomy and self-determination trump all means, even in emergency situations.