Evidence of meeting #28 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 disability.

A video is available from Parliament.

On the agenda

MPs speaking

Also speaking

Heidi Janz  Associate Adjunct Professor, As an Individual) (via text-to-speech software
Jessica Shaw  Associate Professor, University of Calgary, As an Individual
Tim Stainton  Director, Canadian Institute for Inclusion and Citizenship, University of British Columbia, As an Individual
Joint Chair  Hon. Yonah Martin (Senator, British Columbia, C)
Marie-Françoise Mégie  Senator, Quebec (Rougemont), ISG
Stanley Kutcher  Senator, Nova Scotia, ISG
Pierre Dalphond  Senator, Quebec (De Lorimier), PSG
Pamela Wallin  Senator, Saskatchewan, CSG
Liana Brittain  As an Individual
Karen Ethans  Associate Professor, Internal Medicine Section, Physical Medicine and Rehabilitation, University of Manitoba, As an Individual
David Shannon  Barrister and Solicitor, As an Individual

7:15 p.m.

The Joint Chair Hon. Yonah Martin

Thank you.

At this time, I will hand it back to my co-chair for the next round of questions.

7:15 p.m.

Liberal

The Joint Chair Liberal Marc Garneau

Thank you, Senator.

We will now go to questions from the senators.

Senator Mégie, you have the floor for three minutes.

November 22nd, 2022 / 7:15 p.m.

Marie-Françoise Mégie Senator, Quebec (Rougemont), ISG

Thank you, Mr. Chair.

My questions are for Dr. Shaw and are about prisoners.

I'm going to ask you several questions, and I ask that you take the time you need to answer them.

As we know, prisoners live in a closed and monitored environment. Does this affect the professional's assessment and the patient's choice? Does it affect the voluntary aspect of requesting medical assistance in dying?

How can a physician assess a patient in this monitored environment? Where does one draw the line in terms of confidentiality of medical information?

Which physicians assess detained patients and provide medical assistance in dying? In other words, are independent outside physicians used or do the correctional facility's physicians do it?

Please go ahead, Dr. Shaw.

7:15 p.m.

Associate Professor, University of Calgary, As an Individual

Dr. Jessica Shaw

The issue of voluntariness is an important one.

To answer your question, I've spoken with and interviewed physicians involved in each of the three known MAID cases. Certainly, the questioning by the assessors and the providers of the necessity of having guards, for example, or Correctional Services officers in the room did come up. I know that, in at least one case, a hospital ethics person was brought in to be present in the room to make sure that there was an extra level of eyes to ensure that the voluntariness was protected.

Similar to why we would keep people in prison if they can't hurt anyone anymore and they're dying, in the same vein, if someone is incapable of harming himself or someone else, probably those few moments of privacy are essential, and these have happened during assessments.

When I think about the three cases, assessments were done both within the prison system and after a transfer to community hospital. To answer your question, the process is that first the chief health services officer reviews the request for an assessment. The guidelines say that ideally a physician internal to CSC would be the first person to provide an assessment. If it has to be external, it goes external. The second, and sometimes the first and the second, is always external to Correctional Services.

Does that answer your question?

7:15 p.m.

Senator, Quebec (Rougemont), ISG

7:15 p.m.

Liberal

The Joint Chair Liberal Marc Garneau

Thank you, Senator Mégie.

We'll now go to Senator Kutcher for three minutes.

7:20 p.m.

Stanley Kutcher Senator, Nova Scotia, ISG

Thank you very much, Mr. Chair.

My question is first for Dr. Shaw and then Dr. Stainton.

I think that every member of this committee would agree that lack of appropriate housing and community supports should not be the determining factor to access MAID for anyone with a disability; however, not all people with a disability live in such circumstances, and their choice for MAID may be completely divorced from the need for any additional supports.

What advice would you give this committee to ensure that we have safeguards for people with disabilities who require additional supports so that they don't seek MAID as an alternative, but, at the same time, not deny those people with a disability who wish to choose MAID as an choice and who are not deciding to do so because of a lack of resources?

7:20 p.m.

Liberal

The Joint Chair Liberal Marc Garneau

We'll start with Dr. Shaw and then Dr. Stainton.

7:20 p.m.

Associate Professor, University of Calgary, As an Individual

Dr. Jessica Shaw

Perhaps this is quite a bold response, but who are any of us in this room to decide how long someone has to suffer and how much their suffering has to be before they're granted the right to access an assisted death? I worry about having additional measures imposed on to people that then affect their ability to exercise their health care rights.

I want to reiterate that I think it's clear, and everyone has said it's clear, that no one wants to see someone die because of a lack of access to social and medical supports. If that ends up being a determining factor in why they're seeking death, who am I and who are we to prevent that?

I suppose that is where I would push the envelope a little bit in our thinking, meaning that, if we don't live in a country where people are supported—and this is not specific to people with disabilities—it still comes down to who decides how long and how much suffering is enough, and I think that rests with the person.

7:20 p.m.

Liberal

The Joint Chair Liberal Marc Garneau

Go ahead, Dr. Stainton.

7:20 p.m.

Director, Canadian Institute for Inclusion and Citizenship, University of British Columbia, As an Individual

Dr. Tim Stainton

I'm going to disagree a little bit with Jessica. The premise has always been balancing the protection of the vulnerable and autonomy. On one level, yes, who are we to decide for anyone else? The trouble is—

7:20 p.m.

Senator, Nova Scotia, ISG

Stanley Kutcher

Excuse me for a second. I don't want you to get into a philosophical debate with the witness. I want you to answer the question. We need your advice, so could you answer the question, please? Thank you.

7:20 p.m.

Director, Canadian Institute for Inclusion and Citizenship, University of British Columbia, As an Individual

Dr. Tim Stainton

Sure, and I thank you for the question.

As I've said, I struggle to see what safeguards there could be, beyond restoring the reasonably foreseeable death criteria. There are some things that could be done.

In the past it's been recommended that for track two there be an independent panel that reviews in detail a detailed psychosocial assessment similar to what we would do in child placement or in sentencing. It could look at all of those factors and at whether there are things like housing and alternatives. That would need to step out of the doctor-patient and into a somewhat removed panel with a broader set of expertise.

The problem, which the senator will be more than aware of, I'm sure, is that with our jurisdictional division of provincial and federal responsibilities, the MAID law can't order the provinces to meet people's disability or housing needs—not without a very long and torturous fight.

That's one thing I think could improve the situation. It's that kind of independent review, psychosocial assessment and ordering. Perhaps if those supports aren't forthcoming, then approval for MAID wouldn't be given until they are.

From a policy perspective, that's really hard to pull off.

7:20 p.m.

Liberal

The Joint Chair Liberal Marc Garneau

Thank you, Doctor.

Senator Dalphond, you have three minutes.

7:20 p.m.

Pierre Dalphond Senator, Quebec (De Lorimier), PSG

Thank you, Mr. Chair.

Since I have only three minutes I would like first to thank the witnesses.

I will address my questions to Dr. Shaw.

I understand that you have done a lot of research with vulnerable people. You wrote an article called “Perceptions and Experiences of Medical Assistance in Dying Among Illicit Substance Users and People Living in Poverty”.

Can you comment on that? I think you commented in your article about the lack of knowledge about the end-of-life care options.

Also, did you find that it was a slippery slope with vulnerable people being coerced or pressured to end their lives?

7:25 p.m.

Associate Professor, University of Calgary, As an Individual

Dr. Jessica Shaw

Thank you for that question.

The short answer is no, we did not find that there is a slippery slope of people being pressured to end their lives.

On the contrary, the folks who I spoke with—roughly 50 people who were quite impoverished and there were some substance users as well, in Alberta and in British Columbia, primarily in Vancouver and Calgary—rather than being worried about being pressured to end their lives, were concerned about being prevented and not knowing where to go to access end-of-life care. That's what you raised about not knowing the resources.

There was a concern that, like all other aspects of their health care, they would be prevented from accessing this. It's very difficult when you're living on the street to access any health care. End-of-life care and MAID in particular was seen as an extension of that. Rather than feeling pressured, there was a fear of being prevented from accessing it.

If I can add a comment to that as well, I will never forget this one gentleman who said to me that not every overdose is unintentional. He reminded me that people have the ability to end their lives quite readily available to them.

I think the question we have to grapple with in this committee and as a society is that the state doesn't owe anyone a dignified death, but if we can provide one to someone who is suffering grievously, why would we withhold that from them?

7:25 p.m.

Senator, Quebec (De Lorimier), PSG

Pierre Dalphond

Do I gather that for vulnerable people, you don't feel there is a need for additional safeguards?

7:25 p.m.

Associate Professor, University of Calgary, As an Individual

Dr. Jessica Shaw

There is a need for additional social supports. Vulnerable people, in many different experiences, are asking for more support, but the folks—I'm talking about people experiencing homelessness—are fighters. They're fighting to survive every day. They need more support to survive, but they certainly don't need additional supports on whether or not they can die.

7:25 p.m.

Senator, Quebec (De Lorimier), PSG

7:25 p.m.

Liberal

The Joint Chair Liberal Marc Garneau

Thank you, Senator Dalphond.

Senator Wallin, you have three minutes.

7:25 p.m.

Pamela Wallin Senator, Saskatchewan, CSG

Thank you.

My question, too, is for Professor Shaw.

It is my understanding that, given the Charter of Rights and Freedoms, human rights law and even common decency, to put it that way, disabled people cannot be denied or excluded from access to medical assistance in dying. I think that was the point you were trying to make.

There will be many in the disabled community and in the communities you have done specific work on who will understand that and believe that they should not be excluded from access to MAID.

How do you assess where we are on that issue of accessing this right they have to make this choice, which is what you've just been discussing a little bit with Senator Dalphond?

7:25 p.m.

Associate Professor, University of Calgary, As an Individual

Dr. Jessica Shaw

For me, it is how we frame vulnerability, too. What I was trying to say in my opening statement is not to shift away from thinking about vulnerability in the ways that people are personally experiencing it. It's thinking about who is vulnerable to having their rights to make that rights link, who is vulnerable to having their rights infringed upon because of policies and, potentially, extra safeguards that are not necessary, which then prevent our having further steps and hoops for people to jump through, when it's already incredibly difficult for some of these folks to access health care, end-of-life care, of which MAID is a part.

Putting it into a human rights perspective and making that link about vulnerability, not based on life circumstances alone, but vulnerability to policy and procedure, is where my thinking is right now. I think that's where your opportunity as a committee is, to really get this right when you are thinking about expanding eligibility criteria to do so, as you have done in a very intentional way, without adding unnecessary additional levels that will actually harm people who do need support.

7:30 p.m.

Senator, Saskatchewan, CSG

Pamela Wallin

I raised it in part, because even provinces like my own have taken the information about MAID off the 811 system. Are you finding that it is more difficult for vulnerable people, people who are disabled, perhaps the communities in prison, to even get basic information about the choice that is their constitutional right?

7:30 p.m.

Associate Professor, University of Calgary, As an Individual

Dr. Jessica Shaw

Yes, and when we think about access to any health care information.... My fellow witnesses spoke about systemic ableism. We have systemic racism. We have all kinds of reasons why people are discouraged from accessing services and feel that they're not safe. Health care is one of those systems that feels very unsafe for people to access. Basic health care information, and MAID in particular, is an issue.

7:30 p.m.

Senator, Saskatchewan, CSG

Pamela Wallin

Thank you very much.