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

[Prof. Kimberley Widger]

Yes. I had heard my name in the first round as well. I'm sorry.

At any rate, in terms of the safeguards, my safeguard is maybe obvious. Pediatric palliative care specialists need to be involved in assessing these children and making sure they truly have explored all options that are available. It's sort of “you don't know what you don't know” in some cases. Someone might feel they are doing a fabulous job of doing that exploration, but it really takes a team effort of specialists in the area. For me, that would be the minimum to have available.

COVID has made it better, in some ways, that some of this care can be done more so over long distance—

[Dominique Vien, Conservative, Bellechasse—Les Etchemins—Lévis, QC]

Since this is a very important issue, do you think that health care professionals could refuse to administer medical assistance in dying to young people simply on the basis of their age, when they would otherwise administer it to adults?

[The Joint Chair, Hon. Yonah Martin]

Madame Vien, we are over time.

Please answer very briefly, Professor Widger.

[Prof. Kimberley Widger]

I couldn't catch the end of that. I'm sorry.

[The Joint Chair, Hon. Yonah Martin]

Okay, we are over time, so we'll move on.

We'll go next to Monsieur Arseneault for five minutes.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Thank you, Madam Chair.

I'd like to thank all the witnesses for being with us. They're here this evening to discuss a very sensitive issue, the issue of mature minors.

My first question is for Dr. Gubitz.

Dr. Gubitz, you candidly admitted to us that you thought you were here to talk about advance requests. Ultimately, your work experience allows you to be part of the discussion.

You told us about a young girl who had suffered intensely for five years, before she reached the age of 19 and was able to apply for medical assistance in dying. You said that, in her case, it wasn't a question of age, but of ability to understand.

Can you tell us more about that, taking into account the framework of an application from a mature minor?

[Dr. Gordon Gubitz]

In this particular circumstance, I'll link back to something Dr. Morrison mentioned. It's the idea that capacity is a fluid thing. We can recognize that children might have capacity to make a decision about what they want to wear to go to school, what they want to do or how they want to do it based on the information that's available to them.

Obviously, Dr. Morrison's experience and research have demonstrated that children certainly do have capacity to make health care decisions, medical decisions, within the context of their understanding. I think it really does come down to ensuring that enough has been done to allow the child to explore the issues as best they can, to speak about it in a language that is common to them, that makes sense to them, and to reflectively respond to questions about their experience to get a sense of their understanding, the same as we do in the adult world: Do you understand what happened to you? Do you understand where you're at now? Do you understand what the future is likely to hold? What do you think about that? Do you understand what your options are?

We might have to do this in slightly different ways—

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

I'm sorry to interrupt, but my time is very short, and your comments lead me to my next question.

When it comes to analyzing a person's capacity, is there a difference between a mature minor, that is, a young person who, by your definition, has the intellectual capacity to reason and understand their situation, and an adult? Are there additional safeguards to consider?

[Dr. Gordon Gubitz]

I think it will be very situationally specific. It has to do with the child's development and their overall understanding. I'm not a pediatrician. I'm not a pediatric neurologist. I think, as Ms. Widger has said, making sure that we have the right people engaged with the children who are in the process of understanding their mortality, etc., is similar to what we do in track two for adults right now, where we need to have someone doing an assessment who has expertise in the condition.

If the people who are doing the assessments don't have expertise in that condition, I really need, as an assessor, to understand that all that can be done has been done to allow us to understand that the patient in front of us knows what's going on. It will probably be much more complex, but I agree with Ms. Widger that there will need to be very specific safeguards for these children, who, hopefully, are not going to be coming by the hundreds. That would be terrible. There will be very specific children who will meet the criteria and will be found by people doing the assessments to have capacity to make decisions about their health.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Dr. Morrison, after hearing Dr. Gubitz's testimony, can you tell us if you think there should be additional safeguards for mature minors? If so, what should those measures be?

[The Joint Chair, Hon. Yonah Martin]

Be very brief, please.

[Dr. Kathryn Morrison]

Thank you very much for that question.

I will endorse the testimony of the other two expert witnesses on the need for clinicians with expertise with this population.

I also want to emphasize that, when we think about decision-making, the alternatives to a decision are essential parts of informed consent. That's also true of mature minors. When we think about a decision, the alternatives need to be clearly laid out and as accessible as possible.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Next, we will have Monsieur Thériault.

You have the floor for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you very much, Madam Chair.

Dr. Gubitz and Dr. Morrison, in the case of mature minors between the ages of 14 and 17, should the legislation require parental consent, if not parental consultation?

[The Joint Chair, Hon. Yonah Martin]

Dr. Morrison can begin, followed by Dr. Gubitz.

Go ahead, Dr. Morrison.

[Dr. Kathryn Morrison]

I apologize. It felt as if we were in Zoom freeze.

That's a really important question to ask, because we know, in the Benelux countries where mature minors are able to access medical assistance in dying, parental consent is a requirement, at least in some cases.

It's a challenge because parental presence in medical decision-making is often seen as autonomy enhancing, in some respects. However, we encounter cases where there are deep concerns about how the role of the parents might impact autonomous decision-making for minors. As we see in the adult context, when it comes to MAID practice, the role of family members can be a dual challenge—autonomy supporting but also autonomy limiting.

One big challenge, when it comes to mature minors, is compatibility with our framework around treatment decisions. Oftentimes, when a patient—including minors—is capable, there is usually no role for family members to be making decisions on that patient's behalf. I think it would be a challenge to require parental consent.

Consultation is a bigger conversation.

[The Joint Chair, Hon. Yonah Martin]

Go ahead, Dr. Gubitz.

[Dr. Gordon Gubitz]

I would agree.

Once again, I'm not an expert on the legal definition of “mature minor”, so I think the committee may wish to have a look at that and get an opinion about what we are actually speaking about when we speak about a mature minor, as opposed to an emancipated minor, etc.

I agree that family is important. In the over-18 world, when we think about medical assistance in dying, we don't necessarily talk about family. We talk about those who are supporting them, because families come in all sorts of shapes and sizes. Some are very toxic and some are very supportive, so fortunately—

[Luc Thériault, Bloc, Montcalm, QC]

I'm sorry to interrupt. You said at the outset that you agreed. Do you agree with Dr. Morrison that there should be a legislative requirement for consultation, and not a legislative requirement for consent?

[Dr. Gordon Gubitz]

I think an assent approach would be more useful. It's really about the conversation, the nature of the relationship with the family and recognizing that, if this child is very ill and will die, the family is going to carry on afterwards. You would rather have a family that can carry on together, as a unified whole, than a family that is fractured into pieces and never speaks to each other again.

That can be the role of the team involved in doing the assessments and providing that level of support.

[Luc Thériault, Bloc, Montcalm, QC]

I imagine that these decisions, which are very rare, are made harmoniously in the majority of cases. Is that what you see in your practice, Dr. Gubitz? That's the first question.

Second, should access to medical assistance in dying for mature minors be limited to track one patients?

[Dr. Gordon Gubitz]

Unfortunately, sir, I'm not a pediatrician, so I can't really comment on that. It is not my practice. I deal with people who are able to give their own consent.

I would defer to the expertise of the other witnesses around that who study—

[Luc Thériault, Bloc, Montcalm, QC]

In this case, I'll ask Dr. Morrison to answer.

I'm sorry for interrupting you, Dr. Gubitz.

[The Joint Chair, Hon. Yonah Martin]

We need a very brief answer.

[Dr. Kathryn Morrison]

My apologies, but could the question be repeated? I also want to stay in my lane, as I am not a pediatrician either.