Good morning, honourable chairs and committee members. Thank you for the privilege of appearing before the committee today. I commend the committee for taking on the formidable tasks that are before you.
I'm a professor in the department of family and community medicine at the Dalla Lana School of Public Health at the University of Toronto, where I am also the Dalla Lana chair in clinical public health and division head of clinical public health. Additionally, I'm the associate director of the Lunenfeld-Tanenbaum Research Institute, scientific director of the Bridgepoint Collaboratory for Research and Innovation, and a staff physician at Hennick Bridgepoint Hospital, Sinai Health, in Toronto.
I've been in clinical practice for over 30 years, with a particular clinical and research interest in the care of older adults. I served on the Royal Society of Canada's expert panel on end-of-life decision-making in 2011. I was also a member of the working group on the Council of Canadian Academies' expert panel on advance requests for MAID. I'm a past chair of the Royal College of Physicians and Surgeons of Canada's ethics committee. I'm the current chair of the College of Family Physicians of Canada's ethics committee. From 2006 to 2011, I was the director of the University of Toronto's joint centre for bioethics.
The comments made today reflect my views alone and not those of any of the organizations in which I am employed or provide service for.
I recognize that public opinion polls and survey data indicate strong support for advance requests in medical assistance in dying. However, I wish to raise the following points.
As noted, I was a member of the CCA working group for advance requests in MAID. I'd like to commend the CCA and its chief executive officer and president, Dr. Eric Meslin, and the chair of our committee, Dr. Jennifer Gibson, and the members for their exemplary work. It was an illuminating experience. The process was carried out with immense rigour and thoroughness, and was as inclusive as possible in soliciting views and collecting and reviewing the evidence. It is, to my knowledge, the most comprehensive examination of the issue in existence. I do hope that members of this committee have read this report with care. As I am a signatory to the report, most of what I think is the case on the topic is in the report.
The working group represented the continuum of perspectives on the acceptability of MAID itself, let alone advance requests. There was, however, unanimity on the following points. The issues involved in advance requests for MAID are immensely complex, they are of profound importance and significance, and there are large knowledge gaps and uncertainties.
I'd like to quote from the concluding section of the report, which says, “the main issue with [advance directives] for MAID is the uncertainty faced by those responsible for following the request when it comes to gauging...whether the patient desires an assisted death.” The responsibility for this decision will fall upon a third party, most likely a family member who has been designated as the proxy or substitute decision-maker, and not the physician. It's very distinct from the regime that is in place in the Netherlands.
If this becomes the case, then it is essential that the knowledge gaps identified in our report be filled as expeditiously as possible in order for there to be evidence-informed supports for substitute decision-makers, clinicians and others, because the circle of individuals around MAID is quite extensive. However, we must do this recognizing the inadequacy of current support for substitute decision-makers and the lack of uptake of advance directives and advance care planning in day-to-day practice outside the context of MAID. Much work remains to be done.
There is also considerable uncertainty around our understanding of such commonly employed concepts as suffering, and extensive clinical uncertainty as to how this is best assessed in even competent populations. This also raises questions of allocation of resources and whether sufficient resources will be devoted to ensuring that the necessary supports for substitute decision-makers and clinicians are provided, that safeguards are in place, and that there is a continuous monitoring and evaluation of any regimen put in place for advance requests for medical assistance in dying. The question of whether new resources should be brought to bear on this particular dimension of MAID when we have large extant gaps in end-of-life care is one I cannot answer but believe requires close scrutiny and debate.
Regardless of how we proceed, tough choices must be made. To paraphrase 19th century philosopher Georg Hegel, tragedy does not consist in choices between right and wrong, but between two rights.
I thank you again for the opportunity to appear before the committee. I look forward to answering your questions to the best of my ability.
Thank you.