Medical Assistance in Dying Committee on April 25th, 2022

[Dr. Stefanie Green]

I'm comfortable saying that I'm comfortable to provide MAID to mental health patients who fulfill the criteria of the law, absolutely. I would not withdraw my services there.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Okay.

Here's my concern when it comes to mental health. I have some experience dealing with doctors. If you showed 10 doctors an X-ray or a CAT scan of somebody who has cancer, all of them will agree the person has cancer. If you have 10 people examining somebody with a mental health problem, there's a chance that two or three of them will reach the conclusion that the person does not have a mental health problem.

Does that analysis cause you concern or should it cause me concern, in your opinion?

[Dr. Stefanie Green]

To be honest, I think when mental health patients start to step forward for this care, we're going to have to be very careful with how we assess them.

I think it's valid to think we're going to need more expertise. We're going to need more consultations. We're going to need to be very careful, and maybe it'll be different from what we're doing right now.

I do actually have faith in the physician and nurse practitioner community to do their jobs properly. I think we can assess capacity. I think we can assess whether they have a diagnosis or not. I think we can assess suffering. We've done that before there was MAID. We do that now that there is assisted dying. I think we'll be able to do that in that population. I'm confident we'll be able to do so.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

I have faith in the profession as well, but on the off chance that somebody is wrong, we're talking about the most dire of consequences here.

Let me move on to mature minors, because I have the same concern there. It requires a subjective assessment by a doctor or doctors to determine whether somebody is in fact mature enough to make a decision. You used the example of making decisions on reproductive health. Do you agree that you run into the same problem making an assessment about whether somebody is mature enough to make that decision?

[The Joint Chair, Hon. Yonah Martin]

You have 30 seconds.

[Dr. Stefanie Green]

No, I would disagree with that. I think we have lots of experience determining whether minors have or do not have capacity to make their own decisions. We've been doing that for decades.

We certainly have experience in reproductive health choices, in blood products and in lots of different circumstances. Although it's always tricky, I think we have experience and have shown that it can be done safely and carefully. I think that can absolutely be done. I don't think it's subjective. I think it can be objectively determined.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Thank you, Doctor. Your comfort gives me some comfort, so I appreciate your answers.

I'm out of time. Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Monsieur Thériault, you have five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

First, to facilitate the committee's work, we should agree on the use of terms. At present, we are using advance medical directives, or AMD, to refer to an advance request for medical aid in dying. Advance medical directives do not present a problem. They are part of agreed medical practices of refusing and stopping treatment. If we constantly confuse advance requests for medical assistance in dying and advance medical directives, it won't work, conceptually. We need to agree on this.

Dr. Pageau, in your defence, you didn't have a lot of time to explain your thinking. I understand there is an obligation to be very careful about various pitfalls such as ageism, for example. You seem to think that in its desire to facilitate access to medical assistance in dying or to extend it to certain situations, the state is operating on reasoning based in malice.

But when we violate a person's autonomy, their free will, their capacity to make their own decisions, their free choice, then, in my opinion, we are offending their dignity, as Kant meant it. You point out in other texts that death is not beautiful, it stinks. That has nothing to do with incontinence.

By definition, the health care system, the medical profession and health care workers must be benevolent. If they are malicious or harmful, they have to be got rid of, period. That is provided in the Criminal Code. We can't be benevolent, as a state, if we violate a person's autonomy. When a person is suffering from fatal dementia, in the name of what would the state have the right to define its threshold of what is tolerable? In your opinion, how is it more honourable and ethical?

[Dr. Félix Pageau]

You are correct that Kant based autonomy on the concept of dignity and human value. They are two slightly different concepts. Autonomy is the rational capacity to make one's own decisions, but benevolence is not necessarily aligned with autonomy. Some authors do say that it is malevolent not to respect autonomy and benevolent to respect it. In their classical sense, these two principles are very different: a person's autonomy can be infringed while doing good.

Instead, I want to point out here that in dementia, autonomy is lost. The autonomy exercised in advance medical directives or in everything that is a previous guide is a way of representing autonomy in the future. That autonomy cannot be fully exercised because the person is not aware of what is happening. At that point, we are in the register of benevolence.

The state does not prevent people from being well by preventing them from having access to medical assistance in dying; the opposite is true, in fact. My argument is, rather, that if we permit medical assistance in dying, we run the risk of encouraging people to believe they no longer have value, they are bad, they stink—that's the word you used—when they suffer from advanced dementia and are sometimes lying in their own excrement, unfortunately. We clean them, we look after them, we care for them. That care is beneficial because the previous autonomy no longer exists...

[Luc Thériault, Bloc, Montcalm, QC]

Forgive me for interrupting you.

How would intervention or prohibition by the state be more honourable and more ethical? In the name of what could the state tell someone who is of sound mind and has received a firm diagnosis not to make that choice? Supported by a caring and benevolent team, the person says that when they have reached a particular condition, they have crossed the threshold of what is tolerable and they are longer capable of acting, they will want to be given medical assistance in dying. In fact, suicide has been decriminalized, I would note in passing.

How is that ethically blameworthy?

[Dr. Félix Pageau]

There is a logical problem in what you're saying. When a person gets to the point of requesting medical assistance in dying, autonomy is no longer being exercised. Even if they made a previous guide, the benevolence and choice of other people is all that applies for us, unfortunately or fortunately. Unfortunately, if we believe that dementia is a condition of terminal decline for which care should not be given...

[Luc Thériault, Bloc, Montcalm, QC]

In the name of what could the state...

[The Joint Chair, Hon. Yonah Martin]

Thank you.

I'm going to go on to Mr. MacGregor for five minutes.

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

Thank you very much, Madam Co-Chair.

Dr. Green, I'd like to start with you.

In the motion that the House passed authorizing this committee to start its work, one of our main topics is going to be the protection of Canadians with disabilities. I was furiously scribbling notes as you were making your opening statement, and I do know that you made reference to the necessity of disability supports.

I have heard concerns, and I'm sure many of my colleagues have, from commentators who've said that MAID could be requested by vulnerable populations because of a lack of supports to ensure an adequate quality of life for individuals who may be sick or may have a disability. With those concerns that have been expressed in mind, I'd like to ask you if you can talk about any encounters in your practice or in that of any of your colleagues with individuals who have sought MAID and whose requests seemed to be based on a lack of supports. If so, how did you or your colleagues advise those individuals?

[Dr. Stefanie Green]

I won't talk about any particular cases, because there are still very low numbers of people from the track two coming forward, and even less in the circumstance you describe, though I'm sure it's not zero.

I think what we are starting to see, as I mentioned, are people coming forward who have expressed that their suffering is extreme and intolerable and the feeling of the clinician involved is that perhaps improved resources might alter that and improve and lessen their suffering if the resources were available.

That's not necessarily coming from the patient. It may be, and it may be that they've expressed that they haven't been able to access something, but it's coming from the people who are doing the work and the assessments and who are noticing that maybe this patient hasn't had access to a pain specialist, we'll say, because they live somewhere rural where there is no pain specialist.

The interesting dilemma is, what do we do in a situation when someone truly meets the criteria of eligibility for MAID but the clinician believes that maybe something more could be offered that's not actually reasonably available to that patient? That's causing distress in some of my colleagues, and we are not moving those cases forward, but we do ask that the government, federally and provincially, help to fix that situation and help make more robust the resources that can be made available.

We can't fix the health care system as clinicians, necessarily, and we certainly do not suggest that we curtail MAID in general, but we do think that you cannot hold individuals hostage to society's failings and the health care system's failings. That's just not fair. That is why we support the parallel development of resources—and adequate resources—at the same time that MAID is being developed and supported.

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

Thank you.

Do you think the trend could increase? In your mind, what kind of a gap do you think the federal and provincial governments are looking at trying to properly address, so that you and your colleagues no longer need to worry about those additional situations in a person's life and you can focus solely on the clinical aspects of a person's case?

[Dr. Stefanie Green]

I wouldn't presume to be able to answer that.

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

No.

[Dr. Stefanie Green]

It's been just a year since we've had these patients coming forward, and very few of them. Ideologically, I can tell you that I've been in the health care system for several decades, and there are many gaps in our health care system. I don't think we need MAID to point that out. I imagine the gaps are substantial in some areas and minimal in others. I think it's too soon for me to be able to answer that from the perspective that you'd like.

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

I appreciate that. Thank you.

In the final minute that I have, I'll turn to you, Mr. Guest.

From the perspective of the Canadian Nurses Association, if you wanted to add a little more about your experiences with the issues of accessing MAID in rural, remote and northern communities and, in your mind, how that access can be improved, is there anything you wanted to add in your testimony to the committee?

[The Joint Chair, Hon. Yonah Martin]

You have about 35 seconds.

[Tim Guest]

Thank you for the question.

Based on our consultation with nurses, some of what is concerning is that there's a lack of equity in accessing assessors or providers for those services.

The other thing we've also run into when we've had conversations with nurses who work in those areas is the concern that individuals may choose to access those services sooner than normal because they're unable to access other services that would enable them to delay those decisions.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

We'll go to questions for senators.

Mr. Co-Chair, I will turn this back to you.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Senator.

We will now move on to the period for questions from senators.

We will start with Senator Mégie.

Senator, you have the floor for three minutes.