Evidence of meeting #24 for Medical Assistance in Dying in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was children.
A video is available from Parliament.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you, Madam Chair.
Should access to medical assistance in dying for mature minors be limited to track one patients, in other words, patients at the end of life, whose death is reasonably foreseeable?
Clinical and Organizational Ethicist, As an Individual
My apologies, but I'm just hearing the translation. I'm having some trouble interpreting the question.
I interpret it as allowing for mature minors to access MAID under track one, and I think—
The Joint Chair Hon. Yonah Martin
Thank you, Dr. Morrison.
Unfortunately, with the time, we have to move on. You have my apologies for that.
I'm going to give the floor to Mr. MacGregor for five minutes.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you very much, Madam Joint Chair.
Thank you to our witnesses. It is a very difficult subject.
I appreciate this as a parent, first and foremost. I think the difficulty is that parents are driven by a desire to protect their children, but at the same time are juxtaposing that with a child who might be undergoing obvious suffering.
I guess we are lucky in a way, in that each of our provinces already have provincial laws in place, health care laws in place. In my home province of British Columbia, they state, “In general, parental consent for health care in BC is sought for children 12 years of age and younger. However, there is no legal age of consent”. Basically, “'Mature minor consent' is the consent a child or youth gives to receive health care after the child has been assessed by a healthcare provider as having the necessary understanding to give consent.”
Dr. Morrison, I know it's not so much tied to an age. It's tied to the general understanding that the child has.
Can you, first of all, give us an example? When a child comes in with their parents, how do you guide that relationship? Do you have a time when you sit down with the child alone? Can you give us an example of the types of questions that are asked to try to assess whether that child has an understanding of what's coming their way?
Clinical and Organizational Ethicist, As an Individual
Thank you for the question.
Unfortunately, I am not a physician and I'm not a frontline health care provider, so I do not do capacity assessments.
I would defer to the other witnesses on this question.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Dr. Gubitz, do you have anything to add that could help guide us on that?
Professor, Division of Neurology, Department of Medicine, Faculty of Graduate Studies at Dalhousie University, As an Individual
I can only reflect on what happens in a situation with adults.
We often will do interviews with the person seeking a MAID assessment and their supporters—their loved ones or whomever. We will often find a way to have a conversation separately with the person, just to ensure that they're not being coerced one way or the other into making a decision.
More often than not, when people are thinking about this, they've been thinking about it for a long time. Oftentimes when they come, they come with somebody who has been there with them on that journey. They understand the illness. They understand that this is going to be a difficult conversation. They're there to be supportive. Rarely, we have circumstances where people are not supportive, so clearly, they picked the wrong person.
I could see the same thing happening with parents and children, except ramp that up tenfold in terms of the concern and, as you mentioned, the idea about thinking of this as a parent.
Once again, it gets down to the degree of comprehension and the degree of support from the team around this group of people to work through this process together, recognizing that the decision is not going to be made just like that. The decision is going to be a process rather than just this immediate...and we're done.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Dr. Morrison, maybe I'll try to word this in a way that respects your expertise in clinical ethics. To what extent should the quality of end-of-life care be considered as a factor when we're assessing this?
I take Dr. Widger's comments about wanting to make sure that specialized palliative care is available so that every child who may potentially find themselves in this situation has at least had the opportunity to make that informed choice and to experience the full range of care options. Does your practice or your expertise in this field inform anything that you can say on that?
Clinical and Organizational Ethicist, As an Individual
Yes, because oftentimes clinical ethicists navigate very challenging situations regarding informed consent to treatment. I think Professor Widger's really important comment around the accessibility of palliative care is important: to inform mature minors around all of their options when it comes to end-of-life care. In some ways, it's very challenging to say that an informed decision has been made without full knowledge of and accessibility to all available options.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you for that.
That's it for me, Madam Chair.
The Joint Chair Hon. Yonah Martin
Thank you very much.
I will now turn this over to my joint chair for questions from senators.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Senator Martin.
Senator Mégie, you have three minutes.
November 1st, 2022 / 8:15 p.m.
Senator, Quebec (Rougemont), ISG
Thank you, Mr. Chair.
My question is for Mrs. Widger.
As a nurse, you work in the field with children with cancer or other terminal illnesses. How important do you think it is to promote the involvement of young people in discussions and decisions on this very important issue facing them? Is this something that should be discussed with children who are already sick or with healthy children?
Is there any research on that? If so, what were the findings?
Prof. Kimberley Widger
Yes. In terms of my experience as a nurse, I have not been at the bedside for quite a while, but I certainly have been involved with children and young adults—older teenagers, I guess—who are making decisions that impact their lives, very much so, and there's a range. No two 16-year-olds are the same.
I've cared for, at the same time, two 16-year-old girls. One made all the decisions, with her father with her, but he absolutely let her make all the decisions. I think she could have very much made this kind of decision. Another 16-year-old didn't want to be a part of any of the meetings and really didn't want to talk at all or make any decisions.
They're completely different children. They bring different experiences to the situation. Also, there's a big difference in terms of being diagnosed with something when they were three years old, are now 17 and have lived with and been involved in decision-making all the way through, versus someone who was diagnosed three months ago. It's hard. I can remember many children who could have made this decision, in my assessment, and many of the same age who could not have made this kind of decision.
Senator, Quebec (Rougemont), ISG
Do you think that the best way to have a debate on this would be to use research bases from countries that have already had this experience? There aren't many, but are you aware of their findings?
Prof. Kimberley Widger
No, there are not very many other jurisdictions, and in those that do have it in place, the numbers are very small. To be honest, I haven't looked up the numbers since we did the report on mature minors as part of the working group, so I don't know if their numbers have gotten bigger over the last few years. However, the numbers were small.
A study was done asking Canadian pediatricians how many times in their career they've been asked about it. It wasn't even called medical assistance in dying at the time. They talked about how over their careers there was a total of maybe 20 mature minors who had asked about MAID explicitly over the course of many pediatricians' entire careers.
I think—I hope—the number would be very small, but I think the number of adults who have taken advantage of MAID is much higher than what we thought it might be when Canada started down this path, so who can say?
Liberal
Senator, Nova Scotia, ISG
Thank you, Mr. Chair.
I have three questions. They are all for Dr. Gubitz.
In a slightly different area, I think you can help us in your role as chair of the MAID curriculum development process. I'll just ask the three questions and then ask you to respond.
The first question is this: Will this curriculum that the group is working on be of a similar standard to other curricula currently used in the training of physicians, family physicians or specialists for the royal college?
Second, will this curriculum provide an opportunity to standardize MAID assessment and delivery across Canada—so, to improve that standardization?
Third, will this curriculum assist professional and regulatory bodies to set standards of care for MAID similar to what we currently have in all other aspects of medicine in Canada?
Professor, Division of Neurology, Department of Medicine, Faculty of Graduate Studies at Dalhousie University, As an Individual
The first question has to do with the quality of the educational curriculum that we're developing. The curriculum will be accredited by all of the royal colleges—the Royal College of Physicians, the College of Family Physicians of Canada, and the Canadian Nurses Association—as they are actually partnering with us on the development of this. They have eyes on the project through all of its stages of development, but it will go through an accreditation process.
With respect to the second question about creating an educational standard across the country that's comparable to what one might see elsewhere, the reason this curriculum was developed is that there is no formal training for MAID in any form across the country. It arrived as a legislative change. Then it was “see one, do one, teach one”. Eventually, through the Senate request for CAMAP to develop the program, we now are developing a basic training program for clinicians who are interested in developing their skills around MAID assessment, MAID provision through a series of a more basic assessments through to more complex assessments, capacity and vulnerability, etc.
I think that, with respect to the third question, all of the provinces and territories presently have standards that we follow. In Nova Scotia, our college of physicians and surgeons has a standard that I must adhere to. We work with our college to ensure that they will have access to this information, and we would work hand in hand with them to improve the legislative standard as it would be required. I think there are only upsides to having a national standardized education process for MAID.
To anticipate the question that might come.... We don't have a standard at the present time for pediatrics or for mature minors only because it's not part of the law yet. I imagine that, as time goes by, that might be something that happens if this becomes part of the federal legislation.
Liberal
Senator, Quebec (De Lorimier), ISG
Thank you, Mr. Chair.
I'm going to follow up on.... My question was the one that Mr. Thériault tried to get an answer on. I will repeat it so that we will answer his question and mine.
I understand from the testimony of Dr. Morrison that she thinks there are two things that are important. We should look at maturity instead of age because this is not necessarily equivalent. The second thing is that, if access is provided to MAID for mature minors, it should be limited only to track one.
Would you, Dr. Gubitz and Professor Widger, agree with that?
Professor, Division of Neurology, Department of Medicine, Faculty of Graduate Studies at Dalhousie University, As an Individual
I'll go first.
I totally agree. I think that when MAID came about back in 2016, only track one existed. We learned over a period of time what that looked like. Through that and through gauging the Canadian response to this, we were eventually able to lead to track two and to Audrey's amendment and all of those sorts of things—the low-hanging fruit first, and then working and getting a sense of what makes sense and what our experience teaches us. I think to go immediately to track one and track two for mature minors might be more than the Canadian public is willing to handle. I think we need to approach this thoughtfully, cautiously, and in a stepped approach.
That's my opinion.