Medical Assistance in Dying Committee on Nov. 1st, 2022

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Very good. That's understood, sir.

I guess the—

[The Joint Chair, Hon. Yonah Martin]

I'm sorry, Dr. Ellis. You're out of time. Thank you very much.

Next, we'll have Mr. Maloney.

You have the floor for five minutes.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Thanks, Madam Chair.

Thank you to all of our witnesses for their comments so far. It's very helpful.

Professor Reiner, I want to start with you.

Of your five points, I'll go to your fifth point, which was about asking the requester to deal with unforeseen scenarios, or the third party objections or obstacles that might arise at the end, when you're not in a position, or don't have the capacity yourself, to respond to them.

To get right to the point, can you flesh that out a bit for me?

[Prof. Peter Reiner]

Yes. It's entirely possible that you, as an individual—particularly as a dementing patient—might behave in a fashion where you might resist at the time of provision. You might be resisting all kinds of treatment at that point. That is a very difficult situation for a MAID provider to deal with. That's what they have told us. Those sorts of situations are extremely stressful. They're trying to figure out what the right thing to do is.

If it's explained to you, as an individual, that this sort of thing happens from time to time, you can say, “If I am resisting, I want you to go ahead.” That provides a degree of comfort. I don't think it provides 100% assurance that everything will go as you wish, but it provides a degree of comfort to the MAID provider—that they are doing the right thing, at the right time, in the right circumstance. There are a number of these kinds of things that go south, regularly, as people's dementia progresses. Families intervene in various ways that are problematic. There is even the situation discussed, here in the committee, of the happy demented patient.

If you delineate what you want done in those situations, you give clearer instructions to the MAID provider.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

You're never going to get a situation where you can cover off every scenario. Is that fair?

[Prof. Peter Reiner]

Yes.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

What you're talking about is trying to anticipate as many of the challenges as you can. That goes to your fourth point, which is discussing the issue with family and close contacts.

[Prof. Peter Reiner]

That's correct.

I think you already heard from some MAID providers who have suggested that nothing will be foolproof and guaranteed. What we want to do is set up the situation so it is likely you get the outcome you want, with the kinds of constraints that are important to you. If your situation is that you don't want MAID if you're a happy demented person, that's what you also need to put forward. For many people, that might be the way they want to go.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

This goes back to your premise that it's not as simple as filling out a form. Doctors want to make sure the instructions are clear and there's informed consent, so that, when the time comes, they know they are acting in accordance with the instructions of the individual.

If I understood you correctly, your point was that, if you add this clarity, the number of doctors willing to comply with those instructions increases. Did I misunderstand you?

[Prof. Peter Reiner]

That's what we anticipate, yes. Of course, we don't have advance requests for MAID. All we have is the hypothetical we presented to those MAID providers.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Informed consent is the biggest part of this. Informed consent means that the person providing instructions to a medical practitioner understands as many of the scenarios, risks and problems as can be anticipated at the time. If I'm in a situation where I'm coming to a doctor and making an advance request, I understand that I might be in a position where I don't have the capacity, physically or mentally, to change my mind or convey a different message at the time.

Isn't that informed consent? I'm giving you consent, being fully informed of the risks that are in place at the time.

[The Joint Chair, Hon. Yonah Martin]

We need a brief answer, Professor.

[Prof. Peter Reiner]

Yes. That seems to satisfy what I would consider to be informed consent.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Thank you very much.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Next we'll have Monsieur Thériault for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

I'd like to thank all the witnesses for their enlightening testimony.

I'll start with Prof. Reiner.

You were talking about periodic reaffirmation. We've heard from several witnesses that, in all cases of degenerative neurocognitive disease, the prerequisite is to make the diagnosis. I imagine you agree that the first thing that's needed is a diagnosis and that there is no question of an advance request without a diagnosis. For example, there couldn't be an advance request that would be valid for 20 years. From what we've heard, a neurodegenerative disease can worsen over a 10-year period, but it rarely takes 20 years. Do you agree with that?

[Prof. Peter Reiner]

I can speak for myself that I generally agree, but what I'm trying to represent for you are the perspectives of the MAID providers. We didn't discuss that, so I'm hesitant to comment.

[Luc Thériault, Bloc, Montcalm, QC]

So you're not sure that there has to be a diagnosis first before an advance request is accepted in the case of a degenerative neurocognitive disease. Is that correct?

[Prof. Peter Reiner]

It's not that I'm not certain. It's that it was outside of the domain of our study. It wasn't something that we looked at.

[Luc Thériault, Bloc, Montcalm, QC]

Okay.

If I summarize the fourth and fifth possible solutions that you proposed in your opening remarks, you say that there must be a discussion with the family. We've had several witnesses tell us that, in preparing for the advance request, in addition to establishing the diagnosis, it is absolutely essential to designate a third party, that is, the person who, when the time comes and according to the patient's wishes, would initiate the medical team's assessment process.

Do you support that? In other words, this responsibility would fall to this third party much more than to the family.

[Prof. Peter Reiner]

Yes. I think that's an extremely excellent suggestion. The more people you confer with, the more people you lodge your autonomous wishes with, the more likely you are to have them expressed at the right time, when provision of MAID should be delivered.

[Luc Thériault, Bloc, Montcalm, QC]

Treatment for degenerative neurocognitive diseases is usually a process that takes place over time. A health care team is involved in this process, and the person's wishes are known to all.

Do you think legislation should be created to open up this possibility, while leaving it up to the regulatory authorities to decide on all the procedures for applying advance requests, given that they are the ones with the necessary expertise?

[Prof. Peter Reiner]

I'm not sure I understand the question.

[Luc Thériault, Bloc, Montcalm, QC]

Actually, what I'm saying is that it's the people working in this area and the colleges of physicians, for example, that have the clinical expertise required. Instead of putting everything in fine detail in a piece of legislation, we could have a minimalist piece of legislation that, in practice, would leave it to the regulatory authorities to set the guidelines.

[The Joint Chair, Hon. Yonah Martin]

We need a very brief answer, Professor.