Medical Assistance in Dying Committee on Nov. 18th, 2022

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

Thank you very much.

I'll now move on to Dr. Gaudreault and Dr. Luyet.

For people with a disability who request medical assistance in dying, how is it possible to clearly determine that the circumstances might be precarious and that there may not be resources to help with mental suffering? How can we clearly see and make sure that people are truly aware when they request medical assistance in dying?

[Dr. André Luyet, Executive Director, Collège des médecins du Québec]

I'll let my colleague handle this one.

[Dr. Mauril Gaudreault]

I'll answer that. Then Dr. Luyet, who is a psychiatrist, can take it from there.

The important thing in a situation like this is the relationship between doctor and patient. That's also true for the Duncan sisters, who spoke earlier. There must be an established relationship between a doctor and the doctor's patient, particularly when this doctor has been treating the person for 20 years. I believe that the most important thing is the relationship between the patient and the doctor, and the understanding and empathy the doctor shows towards the patient.

Dr. Luyet, It's over to you now.

[The Joint Chair, Hon. Yonah Martin]

Please answer very briefly, Dr. Luyet.

[Dr. André Luyet]

We further feel that there can evidently also be a great deal of suffering in connection with a mental health disorder. It's very important to acknowledge this.

However, there are conditions on access to medical assistance in dying. The decision should never be made because of a lack of access to services. Nor should it be seen as a way of putting an end to suffering when the more promising, effective and recognized alternatives were not on offer.

We have had the opportunity to reflect on this issue and have developed five criteria for assessing a request for medical assistance in dying linked to mental health. I know that time is short, but I think it's important to summarize them for you.

To begin with, it's a decision that is made at the end…

[The Joint Chair, Hon. Yonah Martin]

I'm sorry, Dr. Luyet—

[Dr. André Luyet]

... of a fair and comprehensive assessment of the situation by the applicant, and not as a result of a single care episode.

[The Joint Chair, Hon. Yonah Martin]

I apologize. We are one minute over the time. Would you submit to the committee those five points that you were about to articulate?

Merci.

Next we'll go to Monsieur Thériault for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

My questions are going to be for the representatives of the Collège des médecins du Québec. Thank you for being here in person.

First of all, I'd like to say that although I heard what you were saying about 0 to 1 year-old patients, the committee is not considering that particular issue.

You mentioned the problem of harmonizing the two acts in the event that no additional guidelines are developed with respect to discussions of illness, disease or disability.

What caused all the turmoil in Quebec? What was the problem? For Mr. Truchon and Ms. Gladu, the court said that they had infringed upon their right to life. These were severely disabled people. Where there is no illness, or, to give another example, a car accident, people would have been upset immediately. People said that they should not be given access to medical assistance in dying, and that there had been no debate on the matter in Quebec.

What's your position on this? Could you clarify what created the issue in question and what led the health minister to back down?

[Dr. Mauril Gaudreault]

In Quebec, the discussion is still only about illness, and neither disease nor disability has come into it. So we have the Canadian act and the Quebec act. The doctors and other members of the order I am privileged to preside over may find themselves in difficult situations with respect to patient requests of this kind. In Quebec, the Quebec act takes precedence over the Canadian act. That's why I say that there ought not to be two acts for the same condition.

Doctors are often in contact with patients who deserve medical assistance in dying and whose requests ought to be accepted, but the Quebec act does not allow it.

[Luc Thériault, Bloc, Montcalm, QC]

Why did people say there was no debate on it in Quebec when the Truchon decision allowed someone with a disability to receive medical assistance in dying?

What was the problem?

[Dr. Mauril Gaudreault]

I think that the Quebec government will be revisiting this issue in a new bill that would include it. The problem is that a doctor in Quebec cannot currently administer medical assistance in dying to someone with a disability in the province, but could do so if a patient in the same condition were in another province. That's why the acts need to be harmonized. I believe that the Barreau du Québec said the same thing here this morning.

[Luc Thériault, Bloc, Montcalm, QC]

In my view, the Criminal Code takes precedence in matters of medical treatment. Who in Quebec would sanction behaviour that complies with the Criminal Code?

[Dr. Mauril Gaudreault]

To be honest, it has never happened. Doctors and the Collège said that doctors could choose to follow one or other of the two acts, but we were upbraided for having said so. Our opinion has not changed, and there have not been any problems in this regard.

Doctors nevertheless find themselves in difficult circumstances that generate unnecessary anxiety.

[Luc Thériault, Bloc, Montcalm, QC]

I understand your point of view. But what's the problem? I was very surprised to hear parliamentarians tell us that the debate had not taken place.

People often refer to the example of a young person who might become quadriplegic after a car accident. That person would be denied medical assistance in dying.

From the clinical standpoint, what would happen if you had a request for medical assistance in dying further to an accident that occurred two months ago?

Do you think that a young quadriplegic, should, after two months, have access to medical assistance in dying under Canada's current act?

How do you view that from a clinical standpoint?

[The Joint Chair, Hon. Yonah Martin]

Be very brief. You have 30 seconds.

[Dr. Mauril Gaudreault]

What we think, and we explained this earlier, is that there is no age attached to the request. It all depends on the specifics of each case, and every request needs to be individualized. Medical assistance in dying is care. We see it all from the standpoint of care.

Medical assistance in dying needs to be considered one of the care options available.

[Luc Thériault, Bloc, Montcalm, QC]

Are you telling us that after two months, this young person should have access to medical assistance in dying?

The clinical situation means that all of the options available to this young person have been attempted and exhausted, and that there has been confirmation that the patient is not suicidal or depressive, and as for time, it would involve a continuum that would greatly exceed two months.

That's the clinical reality…

[Dr. Mauril Gaudreault]

That's not what I'm saying. What I'm saying is that there is a range of care to which the patient is entitled and that perhaps, if the problem deteriorates over a certain number of years, medical assistance in dying might be one of these care options.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Lastly, we'll go to Mr. MacGregor. You have the floor for five minutes.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you very much, Madam Joint Chair.

Thank you to all of our witnesses for joining us today.

I'll start with the ARCH Disability Law Centre and Ms. Joffe.

I was listening to your opening statement and taking down a number of notes. Because, of course, you're involved in law, perhaps you could provide us with an informed opinion.

On the safeguards part for a natural death that is not foreseeable, in the Criminal Code the person has to be “informed of the means available to relieve their suffering, including...counselling services, mental health and disability support services, community services”, etc. I know that in many parts of the country this is lacking.

In your experience with the clients you are serving, how is it that physicians are meeting that criterion? Do they have to identify specific services? I'm wondering what kind of feedback you're getting from your clients in how that part of the Criminal Code, that requirement, is being met.

[Kerri Joffe]

Thank you for the question.

I can't say that I've had in-depth conversations with my clients about all of the steps that physicians are taking to inform them of services that might be available to alleviate their suffering, but I can tell you, from a broader perspective, the concern of the clients I've worked with is not so much that they're not being informed of what's available, but it's that they have, for years or months or really extended periods of time, tried to avail themselves of the services that are in fact available to them, and either they have encountered extensive barriers in not being able to access those services or the supports they needed were simply not available.

This goes to the example I was talking to in my opening remarks about a person who has high support needs, needs attendant services, and has been told by the state, by the provincial authorities, that we're not going to provide you with that level of care in the community, and if you want that level of care, you need to institutionalize yourself.

While I can't speak specifically to the steps that physicians are taking, I would imagine that physicians are put into a very difficult position. They are required to inform people of what's available, but what's available often does not meet people's needs. That's the crux of the issue that we're talking about here when we talk about whether people are truly able to make a real decision.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Yes, I think I understand you. This safeguard is triggered only after our request for MAID is made, and that's usually at the end of a very long road where a person has gone through with a lack of services. Your point is very well taken.

To the Duncan sisters, I think, Alicia, you had made some recommendations at the end there. There was the need for clearer definitions, mandatory access to health care, clear safeguards, and so on. On that same point, for track two—this is when death is not naturally foreseeable—there is a requirement that the person who is assessing has to make sure the person is aware of all of these different services. Do you have any comments on this? It's the same sort of thematic question.

[Alicia Duncan]

I do have some comments on that.

Mainly, our mother was fully aware that she had these options. Her condition had deteriorated so far at that point that she had suicidal ideation. Because she couldn't access the care she needed in a timely manner—I think that's an important part to put in there—it had gone so far that even though she knew there was access to all of these clinics, it seemed like such a daunting thing to her that it was just easier to end her life at that point.

I think it speaks again to what Kerri was just saying: that doctors are put in a hard position. They can ask, “Do you understand that there are these treatments available?” Then the MAID assessor goes, “Check.”

I asked them if they know about these—not asking “What were the steps that you took?” but “Were you able to access this?” and “Why?”, looking into it more as opposed to just ticking check marks on a box. There's no in-depth assessment.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

I will turn this over to you, Mr. Joint Chair.