Medical Assistance in Dying Committee on May 5th, 2022

[Marie-Françoise Mégie]

Thank you, Mr. Chair.

Before asking my question, I'd like to suggest that the report of the Select Committee on the Evolution of the Act respecting end-of-life care, tabled on December 8, 2021, and the other document from the Collège des médecins du Québec, entitled “Recommandation de positionnement du groupe de réflexion sur l'aide médicale à mourir et les soins de fin de vie”, tabled on December 10, 2021, be tabled to the committee for the purposes of its study.

Thank you.

My question is for Dr. Andrew.

Dr. Andrew, you work with and assist people suffering from dementia. You know that when there is discussion about broadening medical assistance for dying, people fear that they are on a slippery slope.

For this clientele, what kinds of slipups come to mind in connection with advance requests?

[Dr. Melissa Andrew]

Sorry; I was relying on my French. I'm mostly following.

You said les dérives. What do you mean by that?

[Marie-Françoise Mégie]

It's what's called being on a slippery slope.

[A voice]

A slippery slope.

[Marie-Françoise Mégie]

What kinds of slipups have you seen?

[Dr. Melissa Andrew]

In most of my discussions with people living with dementia, they're expressing indignation, essentially, that they are not taken seriously with regard to their own wishes, because perhaps a future self is valued more than their current self.

Of course, there could be slippery-slope arguments, such that if somebody makes a request, it could be taken too far, or that somebody who's thought to be a trusted decision-maker perhaps makes a decision that is in their own self-interest as opposed to the person's interest, or perhaps they are are constrained, despite what we hope, by economic or social circumstances. We know that a lot of people, particularly in their senior years, and especially those who have chronic medical conditions, have difficulties in terms of socio-economics and living situations and housing and whatnot. One can imagine, I suppose, different ways things could be taken too far in this slippery-slope type of argument.

However, maybe I'll bring it back. The other slippery slope is the uphill slope, when we don't allow people in their current state to exercise what they wish.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Dr. Andrew.

Do you have another question, Senator Mégie?

[Marie-Françoise Mégie]

No. Thank you, Mr. Chair.

We can give the rest of my speaking time to Senator Kutcher.

[The Joint Chair, Liberal, Marc Garneau]

Thank you very much, Senator Mégie.

Senator Kutcher, you have three minutes.

[Stanley Kutcher]

Thank you very much, Mr. Chair.

Before I ask my questions, I wonder, Mr. Chair, if you could request some information from Mr. Bach: a written note to this committee providing the data that documented the evidence to support the statement he made that stigma is driving advance requests instead of the need for autonomy. That has to be an evidence-based statement.

My question, to start with Dr. Andrew, is that I would expect that an individual who makes an advance request must be competent at the time they made that request: Is that correct?

[Dr. Melissa Andrew]

Yes.

[Stanley Kutcher]

Are you properly trained to make a capacity assessment of a person's ability to provide informed consent about acceptance of treatment and withdrawal of treatment?

[Dr. Melissa Andrew]

Yes.

[Stanley Kutcher]

Therefore, you are capable and competent enough to make a capacity assessment on someone who makes a request for MAID.

[Dr. Melissa Andrew]

Yes, I think so, not having done it yet. I do think so, because it would be based on the same principles of the person understanding the facts, applying those facts to their situation, reasoning pros and cons, manipulating that information and then considering alternatives and being able to communicate that choice, and making sure that it's being done without coercion.

I think it would be eminently possible to do, but I also think that if it were implemented, it would be important, as part of this, to include education for clinicians and for physicians and nurse practitioners who would be in these roles to ensure that they have the training to adapt their existing expertise on capacity assessments to an advance request.

[Stanley Kutcher]

The Royal College and the College of Family Physicians are now in the process of certifying such a program.

The last part of my question is for Dr. L'Espérance. It's always nice to meet a neurosurgeon, particularly at this distance.

[Voices]

Oh, oh!

[Stanley Kutcher]

I'd just like your comment on a comment we heard earlier: When a person feels they are a burden on the family, their “autonomy is gone”. Would you agree that because you feel a burden to your family, you lose your autonomy as a human being?

[Dr. Georges L'Espérance]

I don't think one can say that a patient had lost their autonomy. I'm not sure what basis one could use to say that.

On the other hand, I'd like to repeat the words used by Dr. Marcel Boisvert, a geriatrician and a compassionate doctor, who said that even if someone very old tells us that they no longer want to be a burden to their family, what's pathological about saying that?

It could very well be an altruistic, completely acceptable, and very interesting reaction. Of course, it's important to take into account the fact that such patients are treated over a very lengthy period. You don't decide from one day to the next when you get up in the morning that you're going to make an advance request for medical assistance in dying.

I trust that answers your question.

[The Joint Chair, Liberal, Marc Garneau]

Thank you.

Is that it, Senator Kutcher?

[Stanley Kutcher]

I think I'm out of time, Chair.

[The Joint Chair, Liberal, Marc Garneau]

Yes, you're just about there.

For Mr. Bach, this is just to note that Senator Kutcher made reference to something that you said about stigma being a driver, so we will follow up with you. He is asking for more corroboration and elaboration on that statement you made, but we'll follow up with you after this session.

We'll now turn to Senator Dalphond.

[Pierre Dalphond]

Thank you, Mr. Chair.

My question is for Dr. L'Espérance.

Unfortunately, we don't yet have access to your brief. However, I read the brief from your association, which you tabled in the National Assembly last month, and in which you had made a proposal to have criteria and requirements for advance directives. I presume that you are still of the same opinion that is mentioned in this brief.

And you added:

It is worth emphasizing once more that the availability of [medical assistance in dying] prior to advanced cognitive deterioration provides serenity and peace of mind, and enables these people to live life to the fullest and enjoy precious moments for a time, without the anguish of a lengthy period of suffering and loss of dignity as death approaches.

Is that based on your experience? If so, could you tell us about it?

Are there any statistical data to support this claim?

[Dr. Georges L'Espérance]

There are no statistics to my knowledge. Let's say that it's our joint experience, meaning the experience of virtually every doctor who provides medical assistance in dying.

The experience acquired is from being with patients who have received a diagnosis of a cognitive neurodegenerative disease, and with whom we proceed to medical assistance in dying after three months, six months or a year. They can obtain medical assistance in dying for as long as they are capable of deciding. When that point is reached, they lose months or years of life.

But the fact of knowing, particularly since March 2021, that they will not have to undergo this slow and painful process, gives them a form of serenity. I've seen patients arrive at the hospital to receive medical assistance in dying wearing a tie, holding flowers and smiling. All doctors who provide medical assistance in dying know about this experience with patients, by which I mean the knowledge that things will end calmly and serenely without any anxiety. There are also patients suffering from very recent illnesses, including cancer. As for Alzheimer's disease, we have all had this kind of experience.

[Pierre Dalphond]

As it stands, the wording of the act says that if a person cannot provide advanced directives, they choose medical assistance in dying and, in a sense, die prematurely.