I was there until recently. I'm full time at McGill now.
Thank you. The committee asked us to provide very concrete recommendations, specifically on the areas, as Derryck Smith mentioned, of eligibility criteria, processes, and rules and regulations for health care professionals, so that's how I've structured what I have to say.
As a bit of a preamble and so you understand where I'm coming from, the analysis and recommendations that I'm going to present in this statement take into account the current legal context, including that in Canada, of course, and in particular the Supreme Court Carter decision; the context of health care delivery in Canada; the experience of Quebec in addressing physician-assisted dying, which I have followed closely and, to various degrees, have been involved with; the important and competing values and voices of Canadians, which I've heard and read through academic, public, and other media reports, such as that of the External Panel on Options for a Legislative Response to Carter v. Canada and similar types of reports that have come before this group and in Quebec; and the philosophy, bioethics, and medical literatures and debates on these topics.
Regarding my experience as a health care professional, I was a respiratory therapist for about 10 years. After I studied philosophy and focused my career as an academic on bioethics, I was a hospital ethics consultant for about 10 years. Both of these areas required me to be involved in many different ways regarding end-of-life care, and they informed my views.
For the purposes of this statement, I'm going to understand physician-assisted dying as encompassing both physician-assisted suicide and voluntary euthanasia. I'm referring to assistance in dying whereby the physician or a designated, regulated health professional administers the means of death under certain circumstances and with the voluntary consent of the patient. That would be voluntary euthanasia. In physician-assisted suicide, a physician or delegated, regulated health professional prescribes the means of death under certain circumstances and with the voluntary consent of the patient, and the patient self-administers the means of death.
From a bioethics perspective and often in the literature, we don't see a great distinction as far as the values are concerned, but as you know, some jurisdictions allow one or the other, and some allow both. Certainly, they feel different for the people involved.
To the extent that the recommendations and rationales of the provincial-territorial expert advisory group on physician-assisted dying in its final report of November, 2015, bear on the federal-level collaboration and legislation, I recommend that those recommendations be followed in the response of the committee. Many of the recommendations that I'll mention now actually come from that report and are informed by it.
Regarding eligibility, according to the court in the Carter decision, a person who meets the following eligibility criteria is eligible for physician-assisted dying: a competent adult who clearly consents to termination of life and who has a grievous and irremediable medical condition that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition. That's how the Carter decision characterized eligibility.
I understand that the Carter case was a specific case responding to the specific situation of those who initiated it. It seems to me, from my experience, that we should allow a broader range of criteria, and consider Carter to be the minimum criteria, so in my opinion additional scope consistent with, but not considered in, Carter should be included in the response of the committee.
That said, the federal government, I believe, should amend the Criminal Code such that physician-assisted dying is limited only to those people who are eligible for publicly funded health care services in the province or territory where the request is made.
The federal government should amend the Criminal Code such that the eligibility for physician-assisted suicide is based on the person's capacity to make a decision, rather than on the person's age.
Current legal and professional standards and processes with respect to determining capacity to consent to care, and what consent to care is to consist of, should be followed.
The federal government should amend the Criminal Code such that the eligibility for physician-assisted dying is limited to only those persons who clearly consent to termination of life.
The federal government should amend the Criminal Code such that the eligibility for physician-assisted dying is limited to only those persons who have a “grievous and irremediable” illness, disease, or disability that cannot be alleviated by a means that is acceptable to that individual. In this case, “grievous and irremediable” should be defined as “very severe or serious”. I note that this criterion provides a more objective criterion for eligibility than the Carter decision.
Mental illness should not preclude eligibility for physician-assisted suicide. Legislative or regulatory safeguards will be warranted, though, where grievous and irremediable illness, disease, or disability is primarily of a mental nature, as opposed to a physical nature. Respectfully, I don't feel that I have expertise to go further in my recommendation there, but of course I realize that safeguards will be a concern in expanding the scope to mental illness or persons with mental illness.
Regarding processes and procedures, I believe the federal government should amend the Criminal Code to allow that at any time following the diagnosis of a grievous or irremediable condition, an eligible request for physician-assisted dying, made through a valid patient declaration form, may be fulfilled when suffering becomes intolerable. This speaks a little bit to the issue of someone who is no longer competent but does make a competent decision before losing competence.
The federal government should encourage the development and implementation of a pan-Canadian strategy for physician-assisted dying. No doubt this is a challenge, but I feel strongly that we need continuity of care and continuity of procedures and access across the country. The federal government should encourage that and also should collaborate with the other governments, health professions, and others towards that end.
Regarding roles and regulations of health professionals, I'm uncertain, to be honest, where the federal government jurisdiction over rules and regulations of health care practitioners lies. My assumption is that a lot of these matters should be addressed at either the provincial level or the health professions' own regulations bodies. However, to the extent that the federal government does have a role in setting high-level parameters regarding roles and regulations of health professionals, I offer the recommendations that follow.
The federal government should amend the Criminal Code to explicitly protect properly regulated health professionals who provide supporting services during the provision of physician-assisted dying. That's not just for the physicians, but for all those health professionals who are providing supporting services.
The federal government should amend the Criminal Code to allow the provision of physician-assisted dying by a regulated health professional, such as a registered nurse, who is acting under the direction of a physician. In selecting the regulated health professions to qualify for this role, consideration should be given to enabling access to physician-assisted dying in communities where Canadians live or receive health care services.
I will move to the issue of conscientious objection, which was a huge concern in Quebec and no doubt still is. For the last few years when Bill 52 was in the pipe, and then after it was passed by the National Assembly, both the health professionals and the institutions were very concerned about conscientious objection and what they were allowed and not allowed to do. I coordinate activities with ethics consultants at McGill-affiliated institutions, and this was for sure an abiding concern.
My view on this issue is similar to that of our colleague: an individual health professional should be allowed to make a conscientious objection to providing physician-assisted suicide; however, the duty to care for the patient and the duty to inform the patient of all end-of-life options continue.
Some institutions, notably some faith-based institutions, may also make a conscientious objection to providing end-of-life care. This is natural when the core values of the institution are in conflict with providing such services. However, like health professionals, institutions in the public sector also have social contracts. To some extent, we should require non-faith-based institutions to allow physician-assisted dying or to at least not prevent it from taking place in their institution. Those who are objecting should transfer, or offer transfer, or provide people to come in and provide those services there.
To the extent possible, I think the provision of physician-assisted dying should be required of certain health care institutions, probably the regional hospitals and the big referral hospitals, as a matter of providing access to Canadians.