Evidence of meeting #5 for Medical Assistance in Dying in the 45th Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was access.
A recording is available from Parliament.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you very much, Dr. Crawford.
Now we'll go to Dr. Grant, who is also a representative of the Federation of Medical Regulatory Authorities of Canada.
Douglas Grant Registrar and Chief Executive Officer, College of Physicians and Surgeons of Nova Scotia
Thank you.
I'm the registrar of the College of Physicians of Nova Scotia. I have been since 2011. Before that, I practised law and family medicine for many years. It's a privilege to make these submissions.
The committee has had read into its record a letter from the Federation of Medical Regulatory Authorities of Canada. I was one of the signatories to that letter. To summarize its essence, wherever the law lands on medical assistance in dying, the regulatory colleges will be ready.
My submission—and I'm here on behalf of my own college—is that the college in Nova Scotia will be ready because it's our legal duty to be ready.
As a medical regulator, our college must keep pace with change in medicine. Otherwise put, medical regulators can't be the rate-limiting step for medical progress. We haven't been for MAID, and we won't be if MAID changes. Recent history supports that.
When the world changed with the pandemic, the regulators were the enablers of medical change. I think of the hours spent on vaccine mandates, on public health orders, on virtual medicine and on remote prescribing. On all of the things that were required in the moment to make medicine work, the regulators were at the front.
For MAID, additional time won't help us. Additional time in and of itself will not materially advance the regulation of MAID in Nova Scotia. If the law changes, we'll make the necessary regulatory changes, which will involve changing professional standards, communicating with the public and communicating with the profession. We'll respond to questions from the public. We'll investigate complaints to hold physicians accountable. We'll do what's necessary.
On the surface, Nova Scotia's regulatory experience with MAID has been smooth, as has been the country's as a whole. At each punctuation mark, we've made the necessary changes in standards and communicated with the profession. We've kept step with the law. We've kept step with practice.
Since it was introduced, since MAID became part of clinical medicine in Nova Scotia, our college has investigated around 4,000 complaints. Three of them have involved MAID, and all three involved cases where family members were unable to access an assessment for MAID by a conscientiously objecting physician. These complaints were resolved through advice and education, not through discipline.
Most regulation takes place behind the scenes. I appreciate Dr. Close's comment about regulation at the coal face. For me and for MAID, there have been lots of meetings to provide advice, there's been engagement with advocacy and faith-based groups with conscientious objections and there have been discussions with institutions seeking to assert policies inconsistent with the law. Some of these meetings have been difficult, but overall, the regulatory burden associated with MAID has been less than this chamber might anticipate.
When I spoke to this committee—and I think I've given evidence two or three times to this committee or predecessor committees—the questions of regulatory readiness were raised at each significant juncture, each significant punctuation mark with MAID. They were raised following the Carter decision. They were raised in the debates about Bill C-14 and Bill C-7. They were raised in contemplation of Audrey’s amendment.
At least in my experience, each time I was asked questions about regulatory readiness, they came from voices known to be opposed to MAID for other reasons. I urge this committee to examine the question of readiness as readiness per se and not as a proxy for other reasons.
I see four domains of readiness. The first is legal, and the Carter decision is your foundation.
The second is political. By the way, I'm grateful for the service of the people sitting in these chairs who work on questions of political and legal readiness.
The third is regulatory readiness. I really appreciate Dr. Close's analysis of the matrix, the filters and the various levels of regulation, but from the purely medical regulatory authorities' perspective, I'd submit that that shouldn't be a determinant of your deliberations.
The fourth, of course, is clinical readiness. You're clearly hearing significant evidence about that. I would submit that Nova Scotia's clinical approach is extraordinarily robust, and I have tremendous confidence in it, but that's your decision to make.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you, Dr. Grant.
We're ready for questions now. The first questions will be from Ms. Jansen.
You have four minutes and 15 seconds.
Conservative
Tamara Jansen Conservative Cloverdale—Langley City, BC
Dr. Crawford, you said that up to 7% of calls to Canada's suicide crisis line have people mentioning MAID as an option. The majority of those callers had thoughts of suicide in just the previous two days. If I understand that right, when MAID comes up in those 988 calls, you're talking to people who are much more likely to be in an acute suicidal state compared to the ones who don't mention it. Is that a fair understanding of what your data is showing?
Chief Medical Officer, 9-8-8: Suicide Crisis Helpline
Yes. We're still analyzing this as we go. As you know, 988 is a relatively new service, but we've had almost 900,000 calls and texts to the service. Seven per cent represents almost 70,000 interactions.
What we're finding is that when people reference MAID, they have a much higher degree of suicidality than callers and texters who don't reference MAID. The key point here is that people make a lot about being able to distinguish suicidality from a wish to die due to MAID, and we are seeing a great deal of overlap in those populations. They're clearly suffering, but it's suffering that overlaps.
Conservative
Tamara Jansen Conservative Cloverdale—Langley City, BC
Dr. Crawford, with the way MAID is talked about in the media, it seems that they are completely unaware of the danger of suicide contagion. We hear and see portrayals of MAID in serene and dreamy surroundings, with the idea that this kind of death is heroic and self-sacrificing, which is, of course, very opposite to the suicide prevention messaging.
Normally, we don't amplify or glorify the actions of, say, a shooter, for example, in order to avoid copycat behaviour. How real is the risk of suicide contagion with our media reporting and messaging, and what immediate communication safeguards should be in place to prevent that kind of effect?
Chief Medical Officer, 9-8-8: Suicide Crisis Helpline
In Canada and internationally, we've made great strides in responsible media practices when media mentions suicide, but when we looked at articles that mention both MAID and suicide, we found that the safe and responsible reporting practices were not followed. There was a glorification of death. There was a lot of stigmatizing language in a vast majority of articles.
We know that that has very real effects. Certainly in the suicide prevention world, there is a demonstrable effect, called the Werther effect, that results in many deaths. This does apply to MAID. We've already seen that in the Netherlands. When there are media cases with a lot of attention, we see increasing requests for MAID. It's a very real effect, and we should be very concerned about contagion.
Conservative
Tamara Jansen Conservative Cloverdale—Langley City, BC
When the Simons advertisement came out, which definitely glorified MAID for somebody, could you see in the calls to 988 that there was an impact?
Chief Medical Officer, 9-8-8: Suicide Crisis Helpline
We didn't look at that specific ad campaign, but we have looked at different legislative time points and can definitely see an impact.
I'm sorry; that's in media reporting, not to 988. We have not looked at that in terms of calls to 988.
Conservative
Tamara Jansen Conservative Cloverdale—Langley City, BC
What specific evidence gaps did your literature review identify about distinguishing MAID requests from suicidal intent? What would be required to fill those gaps?
Chief Medical Officer, 9-8-8: Suicide Crisis Helpline
We just completed a systematic review of the literature and found a lot of overlap and inconsistency in how research—the published peer-reviewed literature—was talking about and defining suicide in relation to MAID.
In many of these debates, they're treated as very distinguishable, but in the scientific literature, that distinction is not clear. We also found no standardized tools that could reliably distinguish between suicide and an interest in dying from MAID.
I'm not sure we can get there such that we are able to distinguish between them. They are overlapping concepts. They're both an intention or an interest in dying. They're both signs of despair or thoughts of despair.
Conservative
Tamara Jansen Conservative Cloverdale—Langley City, BC
Where does the Canadian Psychiatric Association guidance fall short in practice?
Chief Medical Officer, 9-8-8: Suicide Crisis Helpline
Primarily the concern is that it tries to say that a gap has been filled that has not been filled. It tries to advance that we are closer to making differentiations around irremediability and suicide.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you very much.
The next round of questions will be from Dr. Powlowski.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
I have to say, Mr. Vice-Chair, as a greenhorn in this business, you're doing really well. For those who don't know, you were a Quebec Court of Appeal judge before you came here. You're going to hit me with the hammer next.
The question is whether we should expand MAID for mental illness. Certainly, we've heard from Professor Close about the comprehensive oversight available in Canada. Dr. Green talked about the robust professional oversight. Dr. Grant talked about being ready. There would be professional oversight.
It's hard for me to believe this, given the kind of oversight of MAID we've currently been seeing and the lack of cases that have come before the colleges of physicians and surgeons across Canada. For example, Professor Close talked about a coroner's MAID review team. According to them, there have been 14 cases referred by the Ontario coroner's office to the CPSO. To my knowledge, there has been no disciplinary action.
I've been a member of the College of Physicians and Surgeons of Ontario for 40 years. I know the College of Physicians and Surgeons. If they got a medical complaint about my practice, there would certainly be a review. It would be sent to all members of the College of Physicians and Surgeons. This doesn't seem to be the case with MAID.
Similarly, a freedom of information request in B.C., in 2023, found that there were two dozen cases referred to police, colleges of physicians and surgeons or colleges of nurses regarding MAID practitioners. Again, there are seemingly no cases, yet there have been some egregious cases. One example is the case involving Dr. Wiebe, which is currently in the courts. There was a patient hospitalized for suicidal ideation. While out on leave, they saw a MAID practitioner and received MAID.
Dr. Maher, an ACT team doctor in southern Ontario, talked about a patient of his with chronic schizophrenia. I might add that he was asked to appear here but has so far said no. He didn't want to appear. Both he and the family physician said that this patient clearly did not meet any of the requirements to get MAID, but he'd seen two doctors and had been approved. When Dr. Maher went to the College of Physicians and Surgeons of Ontario, they said, “Well, you'll have to wait until he has actually died before you can....”
I know, Dr. Grant. You're looking.... That's the way I feel.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
I've talked enough, Dr. Grant.
It's hard for me, given what we're seeing with MAID, to really believe there will be oversight. Maybe you haven't seen the cases. Tell me what you can to reassure me there will be oversight.
Registrar and Chief Executive Officer, College of Physicians and Surgeons of Nova Scotia
The first thing is that the decisions of colleges are only made public and circulated to members when there's been a disciplinary finding. In the case of your example, a concern about clinical practice would only be circulated if there was a disciplinary finding.
In the brief amount of time allotted to me, I'll say that this speaks well of the many layers of regulation Dr. Close described. If you look at examples of medical assistance in dying in Nova Scotia, involved in that process would be nurses, nurse practitioners, social workers and two physicians of different disciplines. As employees of a health authority, each of those professionals would have responsibilities if they saw something amiss. They would have professional responsibilities, as physicians do under the CMA's code of ethics. They would have the professional standards of their regulatory body, or of other regulated health professions, to report it themselves if they witnessed something unprofessional. They would have duties as citizens: “When you see something, say something.” There are many layers of—
The Joint Vice-Chair Hon. Pierre Dalphond
The question was very long, but unfortunately time is running out.
Registrar and Chief Executive Officer, College of Physicians and Surgeons of Nova Scotia
That's fair enough.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you.
We now go to Mrs. DeBellefeuille for four minutes and 15 seconds.
Bloc
Claude DeBellefeuille Bloc Beauharnois—Salaberry—Soulanges—Huntingdon, QC
Thank you, Mr. Chair.
Ms. Close, your remarks were very compelling. You said that the job of lawmakers is to set legislative guidelines, but also to take a more holistic view. That means talking about the suffering people with mental illnesses are experiencing.
I'll never forget a schizophrenia client I had. They would come to see me and ask whether they could receive MAID. They experienced visual and auditory hallucinations and paranoid thoughts, and despite 25 years of treatment and medication, they couldn't live without suffering. For a variety of reasons, they couldn't see a future for themselves. They genuinely wanted to consent to an assisted death, but that isn't possible yet.
Don't you think it is also up to those practising the profession to examine and define suffering? Work in Canada to establish those guidelines is advancing slowly, but here, around the table, we aren't talking much about suffering. Even with professional support, some people continue to suffer and just can't do it anymore. Do you think we aren't focusing enough on the suffering dimension in this evening's debate?
Senior Research Fellow, Australian Centre for Health Law Research, Queensland University of Technology, As an Individual
I think suffering is important. Of course, it's part of our Criminal Code and of our law. I'm obviously not a clinician, but the law tells us that individuals need to tell us that they're suffering.
While my research hasn't looked at the normative questions around MAID for mental illness as a sole underlying disorder, I know that the notion of suffering and the notion that some people who are suffering from a mental disorder may have intractable suffering and may still want an autonomous choice are rooted in our charter. That is why our court has decided that this is part of the law.
Bloc
Claude DeBellefeuille Bloc Beauharnois—Salaberry—Soulanges—Huntingdon, QC
Dr. Grant, where do you stand on a case where the patient has an incurable mental illness, will suffer all their life and has tried everything, from therapy and drugs to professional treatment?
Should that patient be able to choose MAID to end their life after years of suffering?
Registrar and Chief Executive Officer, College of Physicians and Surgeons of Nova Scotia
I should probably limit my answer. My personal answer is yes, but my answer as a representative of the College of Physicians and Surgeons is that I have confidence in the medical profession's ability to discern whether that patient can provide informed consent for this.