Evidence of meeting #25 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 minors.
A recording is available from Parliament.
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
All right.
Dr. Verhagen, I wanted to ask you a question about decision-making abilities, which seems to be the determining factor for going ahead with MAiD, but my time is up. Perhaps one of my colleagues will be asking you that very question.
Thank you very much.
Conservative
Michael Kram Conservative Regina—Wascana, SK
Thank you very much, Madam Chair.
Thank you to all the witnesses for being here today.
Mr. Belanger, you certainly had some very powerful testimony, so I'd like to follow up with you.
Can you think of any other federal government—
Bloc
Luc Thériault Bloc Montcalm, QC
Madam Chair, I'm sorry to interrupt my colleague, but I want to let him know that his mike is on mute.
Conservative
Michael Kram Conservative Regina—Wascana, SK
Let me just scooch over here to the microphone that does work.
Mr. Belanger, can you think of any other federal government policies that affect indigenous communities this significantly yet had little indigenous consultation?
Chief Executive Officer, Indigenous Disability Canada
I can't list them offhand, but I think Canada has a history of implementing laws and legislation without proper consultation with indigenous peoples. Historically we've seen that, which is why Canada implemented the UN Declaration on the Rights of Indigenous Peoples to compensate for that and to bring them in and speak with them.
We often see that indigenous peoples and communities are consulted after the fact with the mindset that we'll fix what's wrong later. This is no different with MAID.
We were involved in meetings in the beginning and very few indigenous organizations were at the table. We had commitments from the government that comprehensive engagement would happen, and it never did. It still hasn't to this day. This seems to be the rule we follow when it comes to indigenous people. Hopefully it will change in the future, and hopefully it will change now with MAID.
Conservative
Michael Kram Conservative Regina—Wascana, SK
Is it your view that the federal government should undertake a fulsome consultation with indigenous communities on the expansion of MAID before any expansion moves forward?
Chief Executive Officer, Indigenous Disability Canada
Yes, without a doubt.
As I said, with the Accessible Canada Act, which looks at accessibility on the federal side within first nations, Canada has exempted first nations until 2026 so they can do proper consultation and hear their voices.
With MAID and the significant impact it will have on our people and on our communities, why would it not be extended for the same priority? Why would it be pushed forward without proper consultation, without input and without their understanding? It makes no sense.
The Joint Chair Hon. Yonah Martin
Thank you, Mr. Kram.
Next we're going to have Monsieur Arseneault for five minutes.
Liberal
René Arseneault Liberal Madawaska—Restigouche, NB
Thank you, Madam Chair.
I'd like to thank all the witnesses for being here.
Dr. Beck, you said earlier that we continue to develop our cognitive abilities into our twenties. With respect to mature minors who want to receive medical assistance in dying, how can we ensure that their cognitive skills are sufficiently developed to understand the nature of MAiD?
Interim Psychiatrist-in-Chief and Chief of Staff, Clinical Director, Youth Psychiatry Program, Royal Ottawa Health Care Group, As an Individual
Thank you very much for your question.
I'm going to read a bit from the notes that I give to residents in psychiatry and child psychiatry to consider when they're addressing capacity, because capacity is not magic. It doesn't happen at one age or another; it happens over a continuum. It's based on a number of factors.
When we consider decision-making capacity in medical treatment decisions, we consider, first of all, whether the young person involved understands the relevant information of the condition, including around treatment and other measures that are being explained and provided. Secondly, we consider the degree to which they appreciate the situation and the circumstances. Finally, we consider their ability to communicate the decision.
I'll use a really brief example. Consider a young person who is, let's say, about 10 years old, because this would be consistent with their developmental level. They've broken a collarbone for the second time. It happens pretty regularly. They've had a broken collarbone before. They go to the emergency room, and while they're in the emergency room they sit with a hand on their shoulder. They sit like this because they've broken that collarbone before and they know that sitting like this it relieves the pain from that collarbone.
The pediatrician or doctor will come in and ask what they are here for. The child will say, “I broke my collarbone. I broke it once before and the doctor at the time said it might well happen again. I know that if I hold my hand like this, it won't hurt as badly.” This isn't an uncommon thing. I work in a pediatric emergency room. The doctor will then say, “We think you need an X-ray.” This has happened to this individual before, so they say, “Yes, I need an X-ray.”
I only use that particular example to explain that there can be a complexity of medical conditions. Clearly, when a young person is considering something more complicated, such as a mental health condition or a glioblastoma, and they're facing making decisions about dying and they're working with their parents around that, it's a much more complicated situation for the clinician.
Clinicians in child and adolescent psychiatry are very experienced in dealing with capacity, so they would—
Liberal
René Arseneault Liberal Madawaska—Restigouche, NB
I'm sorry, Ms. Beck, but I have so few seconds left. If you can provide us with more of this in writing, we would appreciate it.
I'll turn now to Dr. Verhagen.
Dr. Verhagen, welcome to Canada, even though you are attending the meeting virtually.
I'd like to know the social status of the seven mature minors who requested medical assistance in dying.
In our country, we're told that we must be cautious, since the poorest and most vulnerable Canadians are the ones requesting medical assistance in dying. However, statistics show that most people who have received MAiD but were not mature minors came from the middle class. They had a roof over their head and 85% to 87% of them had already begun receiving palliative care. However, they wanted to decide how they would die.
Pediatrician and Head of the Beatrix Children's Hospital, As an Individual
The social situation wasn't described in much detail, but generally I can say that they were all well insured, they were all from middle-class or higher-class families and they purposely chose death knowing about the suffering they had gone through and having heard their prognosis of certain death. Also, both parents in all those situations agreed. There was no conflict.
From the medical point of view, there was full understanding and consensus that the suffering could not be ameliorated in another way, so there was no discussion there.
The Joint Chair Hon. Yonah Martin
Thank you very much.
We'll move on to Monsieur Thériault for five minutes.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you, Madam Chair.
Dr. Beck, surely you've read the expert panel report on mental disorders, which says that it's good medical practice to exhaust all available treatments and means to achieving a cure and then establish beyond the shadow of a doubt how chronic the disorder is.
Dr. Verhagen, I'm going to include you even though you're not a psychiatrist, because this also applies more broadly.
If a mature minor ends up in this situation, it's because nothing else can be done, and that's mostly the case for track one patients in the end-of-life phase who are already in the process of dying. A mature minor patient in the palliative care continuum could suddenly decide to request MAiD.
If this committee were to recommend that only track one mature minors be allowed to access MAiD, don't you think we would be hitting the nail squarely on the head?
Interim Psychiatrist-in-Chief and Chief of Staff, Clinical Director, Youth Psychiatry Program, Royal Ottawa Health Care Group, As an Individual
In the case of mature minors, one question that arose on the expert panel was about mental disorders very specifically. As a child psychiatrist—and I've been in practice many years—I could not say for a mental health disorder that by the age of majority, someone would reach the stage that all treatments had been tried, specifically because some treatments that we would use to treat certain conditions would only be used once a person became older.
I think that answers part of your question, but it's one thing that I think people probably consider. In terms of some of the other illnesses, this is the only place where my scope of practice really allows me to comment.
Pediatrician and Head of the Beatrix Children's Hospital, As an Individual
From how I understand it, track one is for children or people who have a disease they are dying from, and that would allow them a yes or no for medical aid in dying. Our euthanasia law requires hopeless and unbearable suffering, which means that there's no good outcome possible and that there is certainty of the diagnosis.
Those seven cases I described were all somatically ill children who were dying, and it was a shortening of the death process they had asked for and received. I would say that without a track one condition, it would be more difficult to envision a good regulation.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you.
Dr. Verhagen and Dr. Beck, I'm going to circle back to decision-making abilities.
Some practitioners tell us that when a mature minor experiences illness, a synergy or symbiosis starts to develop within their family. So when the minor claims to want medical assistance in dying and wishes to go through with it, very rarely do the parents oppose it and attempt to impose their wishes, even if they are suffering over it.
At the end of the day, is it fair to say parents should be consulted, but obtaining their consent should not be mandatory?
Pediatrician and Head of the Beatrix Children's Hospital, As an Individual
No. Consent is not necessary, so we follow the child.
We know that children and parents are often on the same page, but not always. Conflicts have been described frequently. Very importantly, the doctor will only go ahead in providing what is asked if he or she is convinced that this is in line with what is the real and genuine opinion of the child.
If there is any doubt on the side of the doctor, whether he or she is listening to the child or the parents' opinion, he or she will not go ahead and provide it. There needs to be a firm conviction on the side of the doctor.
The Joint Chair Hon. Yonah Martin
Thank you very much.
Lastly, we'll have Mr. MacGregor for five minutes.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you, Madam Chair.
Thank you to our witnesses for appearing today.
Mr. Belanger, I'd like to start with you. I take note of your comments about the lack of consultation. I understand the Canadian government and provincial governments have a very sorry track record on that front.
This special joint committee was entrusted to look at five major themes. Mental disorders as sole underlying conditions have already been passed in the previous law. That's going to come into effect in March of next year. However, on the other themes—mature minors, the state of palliative care, the protection of persons with disabilities and advance requests—not only is this committee going to make recommendations on how law and policy might go forward, but it's going to make recommendations on things like consultation with various groups on funding gaps that may exist. I don't want to presuppose what kind of recommendations our report will have, but they might end up being quite varied.
This is your opportunity, sir, to inform this committee about the kinds of recommendations you would like to see in our final report on how the federal government could step up its game on consultation, especially when it comes to indigenous children who are living with disabilities.
Very briefly, in about a minute, can you inform us of what kinds of strong recommendations you'd like to see in our report on that theme?
Chief Executive Officer, Indigenous Disability Canada
The recommendation that I would make is to pause the expansion of MAID. Making recommendations to consult indigenous people after the fact and after the changes are in place doesn't make any sense.
We know, historically, that there's underfunding. We know that there's a lack of critical mental health services. We know the effects of poverty, as we have 80% of first nations in Canada living under the poverty line.
Recommendations to consult after you change the law are not good recommendations. Put a pause on it. Engage the people who you are making recommendations for. Get their input. Get their insight.
I can't make recommendations for the expansion of MAID to go forward when you haven't consulted the very people that these laws will be applied to. It would be impossible.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
That's very well taken.
We've been discussing provincial laws that allow children below the age of 18 to consent to medical procedures if the medical professional is convinced that they have the capacity to understand the treatment and what it may mean. Some of these could be very serious medical interventions.
I take note of your point about the lack of supports that exist. Those have been very well documented. However, if we were to arrive at a situation where a child has, in fact, had access to the full range of supports and is in a state of intolerable suffering with an incurable disease, what's your understanding of a child's ability to give that kind of consent when it is already an established right under provincial law for medical interventions?