Medical Assistance in Dying Committee on May 5th, 2022

[Hedy Fry, Liberal, Vancouver Centre, BC]

I understand that, Monsieur Deschamps, and I'm not being rude, but I would like to hear from Dr. Cohen-Almagor.

[The Joint Chair, Hon. Yonah Martin]

Dr. Cohen-Almagor, you have 30 seconds.

[Dr. Raphael Cohen-Almagor]

I'll make two very short comments. One is that any advance directive should be restricted by time. When I assisted the legislation of the Israeli law, we set up a framework whereby people could renew the living will or advance directive every five years. That's the first comment.

Second, Dr. Fry, you have put a lot of emphasis on the autonomy of the patient, as do I. The question that we have to ask ourselves is, what happens when autonomy ceases? My answer is that if autonomy ceases, there's no euthanasia, because there's no autonomy. That's a very simple sort of a border that we have to draw.

[The Joint Chair, Hon. Yonah Martin]

Okay. Our next—

[Hedy Fry, Liberal, Vancouver Centre, BC]

I disagree with that.

[The Joint Chair, Hon. Yonah Martin]

—questioner is Monsieur Thériault, for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

To avoid interrupting a discussion with a witness, I will first introduce the following notice of motion:

That, given the importance of the Special Committee on Physician-Assisted Dying's work with regard to the provisions of the Criminal Code and the application thereof, the Committee allocate time as follows to hear witness testimony for each of the components of this study: (a) 12 hours for testimony related to mature minors; (b) 12 hours for testimony related to advance requests; (c) 12 hours for testimony related to mental health; (d) 8 hours for testimony related to palliative care; and (e) 5 hours for testimony related to persons with disabilities; it being understood that the time already allocated to hear from witnesses at the Committee meetings of April 25 and 28 is taken into account when calculating the number of hours allocated per component.

I'll go to Mr. Deschamps first.

First of all, welcome, Mr. Deschamps, and thank you for being with us today.

I'm sure you'll agree with me that medical paternalism has had its day. First it was overtreatment; then they tried to provide better palliative care. Many practices are being considered, such as refusal of treatment, discontinuation of treatment and so on.

The government's role is not to be paternalistic or to decide what's good for the patient, but rather to provide patients with conditions in which they can exercise free choice, choice made by free and informed consent. I imagine you agree on that principle.

Don't you?

[Pierre Deschamps]

Yes, I absolutely agree on that principle.

What I'd like to tell you is that, if you, as federal legislators, decide to make it legal to use advance directives respecting medical assistance in dying, you must consider the situation of the individual who, when the time comes, will ask us to apply or not to apply those directives. Safeguards must be put in place. They may include a double or triple assessment, for example.

You also have to consider the fact that, when we talk about executing the request—

[Luc Thériault, Bloc, Montcalm, QC]

I apologize for interrupting, Mr. Deschamps. My speaking time is unfortunately limited. So I'll clarify my question so I can better direct your answer.

Let's consider safeguards, since you raised the point. I noticed you emphasized robust safeguards in your opening statement.

What do you think those measures might be?

[Pierre Deschamps]

Two of them come to mind.

First, currently, an assessment by two physicians is generally requested for medical assistance in dying. We should perhaps be able to request a third opinion from a physician with specialized knowledge of the person's medical condition. I'm not thinking of family physicians, although I don't doubt their competence. Sometimes in these cases you need the opinion of a physician who has specific knowledge of, for example, Alzheimer's disease.

Second, a certain assessment period should be provided for. Here's an example. Consider the case of a woman who has signed advance directives or an advance request for medical assistance in dying. Her son begins the process at some point, believing that his mother has reached the stage where action should be taken on her request. At that point, time should be taken to evaluate the case and assess once again whether it's necessary to activate that request before providing medical assistance in dying. All other existing conditions should also be protected.

Those are two measures that I think Parliament should bear in mind if it wants slightly more robust safeguards to accommodate to the person's vulnerability at that point.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Merci.

Next, we will have Mr. MacGregor for five minutes.

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

Thank you, Madam Joint Chair. Senator Cowan, it's good to see you. Welcome, Ms. Long, from Dying with Dignity.

I want to give you a chance to respond to what we've heard so far in this session.

As you're very well aware, there are several dimensions to advance requests. There is the status of the patient, the clarity of communication, the strength of relationships, but there are also a lot of challenges. Intolerable suffering is a very subjective thing, and in the case of someone who is unable to communicate, it can be hard for an outsider to determine what their level of intolerable suffering is or whether it's meeting the definitions placed in their advance request. Also, there's informed consent, the role of third party decision-makers, the potential conflict between anticipated and present circumstances.

From of both of your viewpoints, I want to give you a chance to respond on how we could set up a system that takes into account those very real concerns that exist out there.

[James S. Cowan]

Helen, do you want to go first?

[Helen Long]

Sure.

Yes, there are concerns and there are things we would need to do. In terms of informed consent, the individual should obviously know the disease state, the trajectory of their diagnosis and how things are going to go so that when they're describing, in their advance request, that point at which they would like MAID, it's a clear description. I think the description needs to go beyond “when my family can't recognize me”. Perhaps it's a specific state or stage in a dementia diagnosis, and very detailed.

I think it's also important to note the use of language. This is an advance request; it's not an advance directive. The request is made. We believe that all of the eligibility requirements that exist for MAID, as outlined in the current legislation, should still be met—so the two assessments and all of those pieces. Then the clinician never has to go ahead with the procedure if they don't feel the individual meets the bar that's been set. It is a request, not a directive, and I think it's important we remember that language.

[James S. Cowan]

It's good to see you again, Mr. MacGregor.

I only add that we go back to this being about the patient and about the individual. It's a clinical assessment by a medical professional as to competence. Medical professionals make these kinds of assessments every day in their practices. They're well versed and well trained in assessing competence, and if there is any doubt, then obviously they don't certify the compliance with the strict criteria that are set forth in legislation.

The legislation, as originally in Bill C-14 and then as modified by Bill C-7, has very strict criteria, very strict safeguards. I think there was significant improvement in Bill C-7, because some of the safeguards that we thought about or that Parliament put in place back when we began this journey turned out to be burdens or barriers rather than safeguards, so they were properly modified last year.

I think that as we learn more about the evolution of MAID in Canada, we have lots of experience here in Canada and, as I said in my remarks, there is simply no evidence of abuse, of coercion, and it is, as I said, about the individual's decision. It's not about what other people might think that decision ought to be.

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

Thank you for that.

I have just over a minute left.

Do you have any comments on how advance directives for care that currently exist under provincial jurisdiction and a possible future federally permitted advance request for medical assistance in dying would interact?

[Helen Long]

I don't believe they necessarily would.

I think an advance directive is direction around treatment you would like to receive in your health care. An advance request is a request for MAID to be carried out when you reach a state that you have identified and described and you meet the eligibility criteria.

I don't know that there is necessarily any connection between the two pieces.

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

Thank you.

That's all for me, Madam Joint Chair.

[The Joint Chair, Hon. Yonah Martin]

Thank you, Mr. MacGregor, and thank you to the witnesses.

We now go into the first round of questions, or the second round. It's for senators. I will turn it back to my joint chair.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Senator Martin.

We will begin with Senator Mégie.

Senator Mégie, you have the floor for three minutes.

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

Thank you, Mr. Chair.

My question is for the Honourable James Cowan and Ms. Long, if she also wishes to respond.

Do you agree with Mr. Deschamps on safeguards, or do you think the current safeguards are adequate in cases of dementia and advance requests for medical assistance in dying?

Do you have any other suggestions on this point?

[James S. Cowan]

In the brief that we'll be filing in the next few days, we go into our recommended safeguards in some detail. We recommend for advance requests both when there is a diagnosis and when there is no diagnosis, in this case with more strict safeguards. The main difference is that we recognize that without a diagnosis, the request ought to be time-limited. I think one of our colleagues on the panel mentioned that specifically. We would agree. We would suggest a five-year period and suggest that such a request would need to be renewed every five years in order to be considered at a later stage.

The safeguards that in place now in Bill C-14, as modified by Bill C-7, are very strict and I think are perfectly fine.

[Marie-Françoise Mégie]

Thank you.

[The Joint Chair, Liberal, Marc Garneau]

Is that your only question, Senator Mégie? You have a little more than a minute left.

That's it? All right.

We will now go to Senator Kutcher.

Senator Kutcher, you have three minutes.