Good evening.
I'm a physician, an ethics researcher and geriatrician. I know Dr. Lussier well, but I don't agree with his position and I will explain why.
First of all, I must say that I am grateful to be taking part in the committee's work once again. In my last appearance, I discussed somewhat more philosophical and ethical contexts. Today I will be talking about a slightly more practical context.
I am aware that a physician is responsible for respecting a patient's autonomy. Of course, the principles of good treatment and non-maltreatment must be applied. The government must protect vulnerable people and protect people from themselves. Which is why it has established a legal age for alcohol consumption and requires people to wear seat belts in cars and helmets on motorcycles. Freedom of autonomy is therefore not absolute in Canada; it is regulated.
I have three arguments to advance and points to clarify. Time permitting, I will also make some recommendations.
My three arguments focus on the following elements: the error that individuals make when drafting their advance directives regarding medical assistance in dying, the error made by individuals who apply those directives, and the societal issues associated with medical assistance in dying by means of advance requests for people suffering from major neurocognitive disorders.
With respect to the error made in drafting advance requests, the problem stems from the fact that people don't have a crystal ball in which they can see the future absolutely clearly. Autonomy must apply in the present and cannot be anticipated. One must also consider with whom will those advance directives be made. Will it be with a specialist in dementia or major neurocognitive disorders, in this instance a geriatrician, a geriatric psychiatrist or a family physician who sees many such patients? It will be necessary to open medical assistance in dying clinics. Do we have the necessary resources? Is there a risk that the physician take a paternalistic approach to providing expertise to these patients? Autonomy would not be fully respected in that instance.
The changing self is another known argument, according to which significant moments in life, such as receiving a diagnosis of major neurocognitive disorder, alter an individual's personality. Families often tell us they no longer recognize a loved one who has received that kind of diagnosis. Those individuals aren't who they used to be. So a major change occurs. Is what a person said 20 years ago still valid today when he or she is proceeding with medical assistance in dying?
Furthermore, those who implement medical assistance in dying directives may make a number of errors. First of all, every written text requires interpretation. Whatever is written, whether texts of law, literary texts or even text messages, must always be interpreted, especially if the person concerned isn't around to tell us exactly what he or she meant. That interpretation may result in a number of errors. It may turn out that the advance directives are not at all applicable. In that case, they will not be applied, which is thus a lesser evil. That moreover is what often occurs in the Netherlands. On the other hand, there is the danger that they may be applied excessively as a result of conflicts of interest among the physicians or among members of the family, whether out of a desire to receive an inheritance, to free up beds or to remove patients with major neurocognitive disorders from emergency departments. When the medical team and family decide instead of the patient, it isn't autonomy that prevails, but rather a form of paternalistic expertise.
Does a lack of refusal really constitute consent? People who simply say yes without understanding exactly what that implies don't really give their consent. This is something we often hear in hospitals. If, for example, a woman says she wants her uterus removed, should we do it? Has she truly understood? Advance directives do not solve this problem. Assent, even implicit, is not consent.
The societal argument is perhaps slightly more philosophical. We are talking here about "dementiaphobia", the fear of people who are mentally ill. The stigmatization of major neurocognitive disorders, and of associated behavioural and psychological disabilities and symptoms, is what causes this fear and leads people to project into the future. As a result of this form of discrimination, they don't want to become those people who have been abandoned.
I would now like to clarify a few points. First of all, medical assistance in dying is not the same thing as advance medical directives. There is indeed a difference between requesting a form of care, such as medical assistance in dying, and refusing care one considers futile. Furthermore, medical assistance in dying is not like withdrawal of treatment. As in the distinction among first-degree murder, negligence causing death and an accident causing death, it is intentions that count, and intentions differ depending whether one is dealing with advance requests respecting medical assistance in dying or with withdrawal of treatment.
With respect to my recommendations, I believe that the government should protect the most vulnerable. It should also increase funding for work done to promote palliative, geriatric and geriatric psychiatric care. It should also improve access to that care by promoting essential jobs in those areas. Lastly, it should avoid "dementiaphobia" at all costs and avoid promoting it, contrary to what certain persons do who defend medical assistance in dying by means of advance directives.