Thank you.
My name is Derryck Smith. I'm a practising psychiatrist in Vancouver. I was head of psychiatry at BC Children's Hospital for 30 years, but currently I work mostly with adults. I'm a board member of Dying With Dignity Canada and the chair of the physician advisory committee. I'm also a board member of the World Federation of Right to Die Societies, which is meeting in Amsterdam this year in May. Your committee may wish to attend.
I became committed to this issue not because of anything to do with my patients but from watching my father and mother-in-law die horrible deaths, mostly from dementia.
In terms of the issues you wanted me to address, on the issue of eligibility I have no argument with the words and language used by the Supreme Court. Incidentally, I was an expert witness on the Carter case as well. The one concern I have with the Supreme Court language is limiting this measure to “competent adults”. I would much prefer that it be limited to “competent individuals”, because many teenagers are quite competent to make medical decisions. That of course leaves us with the conundrum of what to do about children suffering from terminal illnesses, in pain. Typically we let children's parents make decisions on all other medical matters. I know it's hard to lobby for extending physician-assisted dying to children, but I think we need to wrap our minds around how to deal with suffering children at some point as well.
The last question, which is of particular interest to me given my history with my two relatives, is what to do with individuals who at one time were competent and now are not because they are either in a coma or demented. I know there is legislation in British Columbia to link advance directives to medical intervention at the end of life. I think we need to give some thought to how we will allow people to make decisions when they're competent about what's going to happen to them when they are not competent. I don't have advice for the committee on that, but I think you need to wrap your heads around what to do with that, if anything.
In terms of the next issue, the processes and procedures, I don't have much argument with the general ideas that are out there currently involving requests to two different physicians, with a reasonable time period. For someone who is close to death, “reasonable” may be a matter of days. For someone who is not that close to death, it may be a month. I think making sure that people have had time to understand the decision they're making, reflect on it, discuss it with their friends and relatives, and then reaffirm their decision is an important safeguard.
In terms of the oversight, I would suggest that for the best oversight there is a good model in Oregon. They have an annual report about all things concerning physician-assisted dying. This would give us a tracking mechanism over time. I'm hoping that this would be done federally rather than provincially.
The last one has to do with privacy considerations. I think what has happened in Quebec is maybe an ideal model. I've been given to understand that at least one patient, and maybe more, has had physician-assisted dying, and yet I've seen nothing in the press about it. That's good, because we do not want the privacy of individuals compromised. The privacy of patients and doctors needs to be protected, with one exception: I think I'm compelled by the argument that the certificate of death for people who die from physician-assisted dying should state both the diagnosis of the illness that they were suffering from and the fact that it was physician-assisted dying in order to make statistical reference to these easier.
In terms of the roles and regulations of health care practitioners, I think most of the discussions to date have focused on the doctors, on the two licensed physicians, making decisions on this. I wonder what we're going to do for people in remote communities. I know in B.C. there is some thought being given to using telemedicine for at least one of the opinions. Thought needs to be given to the role, if any, of the nurse practitioners and the pharmacists who have to be involved with providing the medications that will be prescribed by physicians.
To my way of thinking, the way we conduct physician-assisted dying should be built around the needs of the patient. Some patients are incapable of swallowing medication. In that situation, administering medication intravenously, such as in Quebec, seems to me to be the way to go, but I suspect that the vast majority of patients—and probably doctors—would prefer to have oral medications prescribed, which is the model that is used in Oregon.
In terms of the rights of conscience, I don't think any physician should be forced into performing a medical act that they do not believe in. In fact, doctors already have a wide range of flexibility in their practice. In theory, I could be out doing surgery, according to my license, but I'm obviously choosing not to do that. You don't even have to evoke conscience to have doctors refusing to participate in certain medical acts, including this. If doctors, because of religious or other beliefs, don't want to participate, I think we should allow them not to have to be involved, but they should have to make an effective referral, because it's the rights of the patient, the autonomy of the patient, that's of primary concern with these issues.
I have a grave concern, however, about discussions allowing institutions, health authorities, or hospitals to opt out based on a so-called objection of conscience. If we allow health authorities to opt out, for example, it may be that the entire north of British Columbia would be without these services, or the entire province of Alberta, or Prince Edward Island. There is a history with this, in that abortion services are still not available on Prince Edward Island; women have to go off-island.
I think this is a national program. It should be available nationally. I do not believe that institutions that receive public funding, such as hospitals or palliative care facilities, should be able to opt out. If they are private, that is one thing, but public funding should allow the institution to provide this service.
I know that battles are already forming up in B.C. between Catholic-based institutions and the medical staff. I'm told by a medical colleague that at St. Joseph's hospital in Comox, the medical staff have voted in favour of providing physician-assisted dying, but I suspect that the institution, the hospital, may not be in favour of it.
That's an issue I would like to see addressed to make sure that this is widely available to all members of the Canadian public.
In terms of the roles and regulations for health care practitioners, I think it's fairly straightforward. The role for doctors is evident in the discussions that have been forwarded to your committee from the various medical associations and licensing bodies. I don't have anything much more to say about that.
In terms of discipline and penalties, the easiest way would be to leave that to the licensing bodies and each of the provincial jurisdictions, because that's what they do now. I can't see a federal body looking after the disciplining of physicians when there's already a mechanism in place in the provinces to do that. I would leave discipline and penalties to the licensing authorities.
I believe I'm going to finish my comments there. I again thank you for inviting me to testify in front of your committee. I look forward to hearing my fellow witnesses and dealing with any questions as they arise.