Medical Assistance in Dying Committee on April 25th, 2022

[Dr. Leonie Herx]

Yes, I would just say that unfortunately not everyone in Canada has access to palliative care, and you mentioned that everyone in Quebec should have access as well. It is not available. I explained the statistics of only 30%-50% of patients having access to palliative care, and they don't have it early enough in their disease trajectory to make a difference in reducing irremediable suffering. It's not about whether MAID is right or wrong; it's that people do not have access to palliative care. Then they have unnecessary suffering that leads to MAID requests, and this is something that can lead to wrongful death, and that's not okay.

[Luc Thériault, Bloc, Montcalm, QC]

So again you have a mindset that sees them as being in conflict. Essentially, in your opinion, if someone requests medical assistance in dying, it's because they haven't received good palliative care, and palliative care is the only solution for dying with dignity. We understand.

Dr. Naud, the committee will have to decide whether or not to recommend a change to the Criminal Code to expand access to medical assistance in dying. However, before authorizing it for persons with dementia, for example, Parliament would have to be satisfied that it is possible to establish guidelines to ensure that the patient's freedom of choice is respected.

Could you talk to us about these guidelines?

[Dr. Alain Naud]

Thank you for the question.

In my brief, I propose very clear guidelines, that have an objective basis and adhere to the principle of self-determination and the choice made by the patient when they are still competent to make it. I can describe the process, very briefly. After meeting with their physician, the patient would give the physician a signed request form. In the request, which would have to be renewed after a certain period of time, the patient would determine, in their own judgment, the objective criteria stating the point at which, having become incompetent, they would be in a state of indignity. The patient should also designate a third party whose mandate would be, not to determine that the time had come, but to call on the treatment team, quite simply, to have them do the assessment to see whether the time, as predefined by the patient, had come. I think that is something we are capable of putting in place very easily.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Next we have Mr. MacGregor for five minutes.

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

Thank you, Madam Co-Chair.

Dr. Herx, maybe I'll start with you. I was a member of Parliament in the 42nd Parliament when the original debate on Bill C-14 was going on in 2016. I remember the very passionate debates in the House during that time. Opinions voiced by members spanned the entire spectrum. Concurrently with that debate, there was also an acknowledgement that we as a country needed to do better in terms of giving patients palliative care options. In my own community in the Cowichan Valley on Vancouver Island, Cowichan Hospice has benefited tremendously from the building of a new palliative care centre, which has expanded the number of beds that are available.

I want to take a little walk down memory lane with you over the last number of years.

The original Bill C-14 was passed in 2016. We had all-party support in 2017 for the palliative care framework. Dr. Herx, when you saw that renewed focus on palliative care in Canada that came first in 2016 with the debate on Bill C-14 and then with the passing of the palliative care framework, did you see an improvement in 2017, 2018, and 2019, and then did it just ebb? Have we just lost the plot a bit, and do we need to refocus the attention a bit? I want to get a sense from you of what those previous years were like.

[Dr. Leonie Herx]

Certainly there is renewed attention, as you said, on the importance of palliative care, and it was indeed positioned, by both the Supreme Court and in the Bill C-14 legislation, as something that could alleviate suffering that might lead to a request for hastened death. We were so fortunate to have supported, through the Canadian Society of Palliative Care Physicians, Bill C-277, which created the national framework for palliative care. What that really allowed us to do was to put together all the good work that's been done across the country, informed by international standards, to solidify what we need to achieve in Canada to make palliative care a reality.

Unfortunately, we haven't really done anything further than to put a framework on paper. What we need is the money and the infrastructure to get the boots on the ground. We now have clearly defined national competencies for all professionals who provide a palliative approach to care for their patients and for the specialist training that is needed, but they are not embedded into curricula across the country. We do not have quality standards to evaluate what palliative care is happening across the country. That goes back to the Health Canada data. We just don't know what's happening and who's providing the care, although now we have these credentialing programs.

We need a national system that's linked to Accreditation Canada's standards and that's administered so that provinces collect data on outcomes for patients that is patient-reported. We also need the quality standards to make sure that provinces are accountable for improving both the quality of palliative care and the access to it. Achieving that will take a sustained investment of resources over time to get those trainings embedded, to get the standards up and to hold the provinces accountable through accreditation standards. That's absolutely needed, and we haven't seen any of that. There was no money in the last federal budget, and that needs to change. At least 95% of Canadians don't want to die via an assisted death, so let's put some money into supporting the needs of all those people who don't want MAID.

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

Yes, that's a fair point. I think we will struggle as policy-makers to always try to respect the agency of the patient. We want them to have the best available care so they can make the best decisions for themselves.

Maybe, Dr. Naud, I can get you to chime in on the same theme. When you look back over the last number of years, since 2016 and 2017, do you have any thoughts on how the national intention regarding palliative care has ebbed and flowed and what more needs to be done?

[Dr. Alain Naud]

We are all in agreement that palliative care must be offered everywhere and to everyone who needs it. No one is opposed to that.

In my position, here in Quebec City, I hear the argument that medical assistance in dying has resulted in a reduction in funding allocated to palliative care. But I have never seen any proof of that. I am still waiting for the evidence, very simply. I think that palliative care is underfunded in general, and has been for a very long time. That has nothing to do with the advent of medical assistance in dying.

Again, we have to stop looking at the possibility of receiving medical assistance in dying as something that is the opposite of quality palliative care. We need to have both and respect the patient's free and informed choice. It comes down to the principle of self-determination again.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Mr. Co-Chair, I will turn it back to you for the senators' questions.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Madam Chair.

We will now move on to the senators, starting again with Senator Mégie.

Senator Mégie, you have the floor for three minutes.

[Marie-Françoise Mégie]

Thank you, Mr. Chair.

My question is for Dr. Naud.

What would your answer be to the argument we often hear, that there would be fewer requests for medical assistance in dying if there were better palliative care?

[Dr. Alain Naud]

Thank you for the question, senator.

This was an argument used by opponents of medical assistance in dying. In Quebec, we started talking about medical assistance in dying in 2009, when the government set up the Select Committee on Dying with Dignity, and continued until the Act respecting end-of-life care was enacted in June 2014. It is an argument we heard constantly. But we knew it was wrong, and our experience for almost six and a half years has shown it to have been wrong. No patient receives medical assistance in dying because they don't have access to quality palliative care.

In Quebec, we compile excellent statistics on this, unlike some other places in Canada. The Commission sur les soins de fin de vie, which was established under Quebec's Act respecting end-of-life care, compiles rigorous statistics. As I said in my presentation, 80 per cent of patients in Quebec who receive medical assistance in dying were already receiving palliative care; the others, who represent 20 per cent, voluntarily declined to receive palliative care. When we meet with a patient who is requesting medical assistance in dying, we have an obligation to talk to them about treatment and pain relief possibilities still available to them. We have an obligation to talk to them about the possibility of getting palliative care if they have not already had it. Nonetheless, 20 per cent of people who receive medical assistance in dying voluntarily declined to receive palliative care.

I also talked about the experience of hospices, which initially refused to offer medical assistance in dying. That didn't mean that there were no requests in all those facilities. When those patients were two or three days from death and were in horrendous condition, they were transferred to a hospital so they could receive medical assistance in dying. Now, more than half of those hospices offer medical assistance in dying without providing any worse palliative care. It is a matter of time. When Quebec's Act respecting end-of-life care is amended, I am sure that the exemption enjoyed by hospices will be removed.

So that argument is wrong, and we can prove it and provide the evidence that the argument was wrong from the start.

[Marie-Françoise Mégie]

Do I have time to ask another question?

[The Joint Chair, Liberal, Marc Garneau]

You have 30 seconds left.

[Marie-Françoise Mégie]

In your brief, Dr. Naud, you propose protective measures in the event that medical assistance in dying were expanded to mature minors and persons whose only diagnosis is a mental health problem. Do you foresee safeguarding measures?

[Dr. Alain Naud]

Certainly, senator. In my brief, I refer to the position taken by the Collège des médecins du Québec, the experience of Belgium and the Netherlands, and the reports of experts in psychiatry who are proposing measures. I am thinking of the Association des médecins psychiatres du Québec, which has produced a voluminous document talking about the measures to be put in place, among others. I think the experts have to be involved in this.

On the question of minors, in the Netherlands and Belgium, for example, in addition to the two physicians, there is a requirement to have an opinion from a pediatric psychiatrist or a psychiatrist on the minor's maturity. You have to understand that adolescents aged 14 to 18 years are not immature. On the contrary, these young people, who have been very sick, are often possessed of a maturity that most young people their age do not have. It is therefore wrong to think that because they are under 18, they are not competent to consent to medical assistance in dying. As physicians or specialists, we are capable of properly assessing that competence to consent to medical assistance in dying.

These are in fact clienteles for whom we have to have additional safeguarding measures, in addition to those we already have.

[The Joint Chair, Liberal, Marc Garneau]

Thank you.

Senator Kutcher, you have three minutes.

[Stanley Kutcher]

Thank you, Mr. Chair.

I have three short questions for Dr. Herx.

What proportion of Canadian palliative care physicians currently also provide MAID?

[Dr. Leonie Herx]

Thank you for the question.

We don't have any recent statistics on that, Senator Kutcher. Our most recent survey from the Canadian Society of Palliative Care Physicians shows that 92% of palliative care physicians did not provide MAID, but we haven't resurveyed recently.

[Stanley Kutcher]

Thank you.

When MAID became available in Canada, was there a consensus among palliative care physicians that MAID should be provided?

[Dr. Leonie Herx]

Sorry; what do you mean by “should be provided”?

[Stanley Kutcher]

If people wanted MAID instead of palliative care, was there consensus among palliative care physicians that it should happen?

[Dr. Leonie Herx]

The consensus among palliative care physicians was that hastening death and ending someone's life is not part of the practice of palliative care.

Certainly there are some individual palliative care clinicians who choose to make MAID part of their medical practice, as you can in any specialty—you can build a MAID practice—but it was very clear and consistent in the palliative care community that MAID is not part of the philosophy of palliative care.

[Stanley Kutcher]

So it would be correct to say that there was no consensus.

[Dr. Leonie Herx]

No, we did not discuss anything to do with whether MAID was right or wrong. We don't make legal decisions. As medical professionals, we discuss what is a competency within our medical discipline, and ending someone's life is not part of that.