Physician-Assisted Dying Committee on Feb. 2nd, 2016

[The Joint Chair (Mr. Robert Oliphant (Don Valley West, Lib.)), Liberal, Rob Oliphant]

I call to order this tenth meeting of the Special Joint Committee on Physician-Assisted Dying.

I welcome our guests, our witnesses.

What we have done in the last couple of meetings when we've had a teleconference is that we have chosen to go to the teleconference first, so we will hear first from Derryck Smith, the co-chair of the physicians advisory committee of Dying With Dignity.

You will have 10 minutes, Dr. Smith, and then we will go to Sharon Baxter and Carolyn Ells. Our process is to have that 30 minutes of input from our witnesses. Then committee members will be asking all of you questions and they may direct questions to any of you or all of you as they choose.

Dr. Smith, thank you for joining us. The floor is yours.

[Dr. Derryck Smith, Chair, Physicians Advisory Council, Dying With Dignity Canada]

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.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

Thank you very much, Dr. Smith.

I'm going to suggest that we move to Carolyn Ells, associate professor of medicine at McGill and, I believe, also at the Jewish General Hospital.

[Dr. Carolyn Ells, Associate Professor, Medicine, Biomedical Ethics Unit, McGill University, As an Individual]

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.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

I'm afraid you'll have to end it there. Thank you very much.

Ms. Baxter.

[Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association]

Good afternoon, everyone. I have a terrible cold, and I'm hoping I can get through this without coughing fits.

I'll be speaking mostly to hospice palliative care, the care that Canadians get at the end of life, and how it intersects with physician-hastened death, but not as much about the criteria for physician-hastened death. I'm the executive director of the Canadian Hospice Palliative Care Association. We work in and represent the hospice palliative care settings across the country, with over 600 registered programs and services and over 3,000 members.

We've just completed a three-year initiative, “The Way Forward”, around expanding what we think about as the specialist palliative care that about 35% of Canadians would need to use. About 65% of Canadians actually die in primary care and don't actually need the specialist palliative care teams and programs that we offer in hospitals. We talked about the palliative approach in primary care, so I can talk a little bit about that. That's to reach those Canadians who have dementia diagnoses and die over seven or eight years, as opposed to those who maybe have cancer and die in a profound dying stage. We can talk a little bit more about that.

While the recent Supreme Court decision on the issue of physician-hastened death has captured media attention, a relatively small number of Canadians are likely to meet the criteria for those services. Based on what we see in other jurisdictions around the world, we expect it to be about 2,500 to 3,000 Canadians in any given year, so it's not a huge number. However, of the 260,000 Canadians who will die this year, only 10% will die suddenly. The other 90% could use better hospice palliative care or a palliative approach to care.

We know that everyone has the potential to benefit from the growing willingness to acknowledge that dying is a part of living and that people deserve and should receive the integrated palliative approach to care at all stages of their illness trajectory and in all settings of care. It would be a shame if a Canadian chose physician-hastened death because their pain and symptoms were out of control and not managed well or because they had never been referred to hospice palliative care. I think we can all agree that we want to provide the best end-of-life care possible for all Canadians. We need to make sure that our government is focused on the delivery of quality hospice palliative care services along a full spectrum. All patients deserve access to information about options at the end of their lives, including physician-hastened death. It's something we all need to provide.

I am aware that this committee has asked us to keep our comments around eligibility, criteria, processes, and procedures. I'll say less about the physician-hastened death and more about the interface between the two. For further details, I refer the committee to the larger submission we made in the fall, which I believe you've all seen.

There is a dire need to educate Canadians around hospice palliative care options available to them at the end of their lives. I think Canadians don't want to talk about death and dying and don't necessarily understand what's available for them at the end of their lives until such time as they interface with the health care system in a moment of crisis. Comprehensive hospice palliative care can help alleviate many of the factors that may cause people to consider physician-hastened death, particularly the burden on their loved ones, depression, and inadequate pain and symptom management.

There's still a lack of understanding and conversation taking place between physicians and patients around options at the end of life. Doctors are often not well trained to engage in end-of-life conversations, resulting in unclear goals of care, the burden of stress and anxiety being placed upon caregivers, and an overall lack in fulfilling the wishes of how patients would like to live in their final days.

The Canadian Hospice Palliative Care Association believes we need national leadership and coordination of a fully funded national strategy to ensure universal access to hospice palliative care. That includes an awareness campaign around hospice palliative care generally, including advance care planning. We now have resources and tools for advance care planning, but we're not using them to the maximum. They're just coming out now.

Over the last few years, our initiative, “The Way Forward”, developed practical and implementable tools and resources to help policy-makers, health planners, and service providers across the country. Some of the provinces are taking on this new national framework now, but we're in early days. This initiative is now over, but the information needs to be pushed out further across all of the provinces and territories.

The federal government is responsible for health care provisions for certain groups of people, including veterans, military personnel, prisoners, and our indigenous peoples. All of these groups should be afforded the same coverage in hospice palliative care, but that is currently not the case. Access to hospice palliative care is not an essential service for our first nations people on reserve. Home care is an essential service, but palliative care isn't. This must be rectified. This is a clear opportunity for the federal government to improve the treatment of first nations people.

We must engage Canadians and patient groups to be champions, to talk about death and dying. We must also disseminate information to the hospice palliative care community to educate both patients and physicians. It's time to normalize this conversation.

Palliative care and physician-hastened and physician-assisted death are philosophically and clinically separate. Conflating them could result in confusion, making people who are already frightened of palliative care even more reticent to avail themselves of this vital and effective means of addressing suffering. We'll need to be careful with that.

We must educate and support health care providers to help them overcome their own fear of loss, dying, and death. An integrated palliative approach to care should be part of all health care providers' education. We must ensure that our future physicians and allied health providers are well versed in these conversations and are ready to have them with their patients. Only when conversations about death and dying are fully transparent and when options at the end of one's life are fully understood and discussed will we be able to properly manage requests for physician-hastened death.

The Canadian Hospice Palliative Care Association believes hospice palliative care does not include physician-hastened death. Hospice palliative care does not hasten or prolong death. Hospice palliative care strives to end suffering, not life. Canadians need universal access to hospice palliative care, including good pain symptom management. All patients deserve access to information around end-of-life options, including physician-hastened death. We need to be part of that.

The separation between palliative care and physician-hastened death must not impede a smooth, compassionate, and effective transition between both, and we need to work on that. How do patients go from one area to the other, and who will be doing that?

Physician-hastened death will greatly impact the illness trajectory of elderly and sick Canadians and their caregivers. We must ensure that this new development is introduced in an appropriate way that does not impinge on the programs and services already available. Moreover, a structured and unified action plan must be presented to the Canadian public, including those working within the hospice palliative care field, explicitly establishing norms of practice and standards of care that should be followed when carrying out physician-hastened death.

The following factors should be considered. Allied health care professionals, including physicians and nurses and other allied professionals, must be protected in such a way that their decisions are respected and alternative options presented should they choose not to administer a physician-assisted death. All institutions and physicians should be given the option to opt out of providing physician-hastened death, granted they are willing to provide a referral to this service. I echo some of the comments that Carolyn made about the transfer or transition to another setting.

In the palliative care units in hospitals, there will be physician-hastened death. They may not have those people do it; maybe somebody else will come in to do it. In home-based programs, I can see it happening quite easily. The process in our residential hospices, of which there are 80 in this country, is not around hastening death. They're asking for a site exemption.

Keep in mind that most of them don't receive much government funding. They are charitably funded, for the most part, and they want to make sure that they are actually following the wishes of the community that raises the money for residential hospices. We'll see where that all goes.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

You have one minute left.

[Sharon Baxter]

Legislation must be put in place to ensure that the specific requirements are met for a patient to be granted physician-hastened death. More than one person should be conducting the competency assessment. We must ensure that trained professionals are used during these consultations and that they are able to adeptly analyze a patient's illness trajectory and make sure this is the only option to alleviate a patient's suffering.

The federal government will need to be responsible for developing universal legislation with regard to physician-hastened death that provincial governments can follow. There needs to be one set of regulations and norms of practice that should be followed nationwide.

Clear information and readily available guidelines must be available to all Canadians in order for them to be informed about their options. These resources should be led by an awareness campaign funded by the federal government and distributed among the provinces.

In closing, I have a few bullets.

The CHPCA is calling on the federal government to consider a national federal strategy or framework for hospice palliative care that would work toward the following: ensuring universal access for all Canadians; a national awareness campaign for hospice palliative care, including advance care planning, which would inform Canadians on the options available to them at the end of their lives, including physician-hastened death; the protection of Canadian health care workers in the hospice palliative care field, including the option for them to opt out of providing physician-hastened death should they choose to, although they would then refer a patient to the appropriate place; clear and informed legislation regarding physician-hastened death, developed federally, to be enacted provincially and through institutions; and readily available information and resources for physicians, families, caregivers, and patients regarding their end-of-life options and physician-hastened death.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

For questioning, we begin with Mr. Lemieux.

Ms. Shanahan will also be speaking.

[Denis Lemieux, Liberal, Chicoutimi—Le Fjord, QC]

Thank you, Mr. Chair.

My question is for Ms. Ells, from McGill University.

Witnesses representing palliative care physicians told us that they regularly engaged in physician-assisted dying, since one of the final steps in palliative care is palliative or continuous sedation. It consists of rendering a suffering patient unconscious such that death occurs naturally without causing any conscious distress.

In your view, ethically speaking, how does the practice of palliative sedation differ from the practice of physician-assisted dying?

[Dr. Carolyn Ells]

Of course, in some ways they seem equivalent in principle; however, no, they're different.

Palliative sedation or continuous sedation till death—there are various terms that talk about it—is an accepted practice within the standard of care in certain circumstances.

Basically, it's the idea of sedating someone deeply—almost like you would during surgery—until death. Death doesn't happen quickly in those cases; Sharon might speak well about that too. It takes a long time to accompany someone through that, and one needs to titrate that very carefully, but yet it is an option out there. In Quebec law, they allow that for people who cannot consent on their own behalf. In a sense, they're allowing for something that's already allowed within medical practice. To be honest, I saw it more as political, you know, that we'd still allow for something.

The greater issue, I think, is the importance of consent. In regard to giving a substance that ends one's life very quickly, health professionals, health institutions, and, I believe, many patients, families, and individuals prefer someone to consent to that for themselves. I think that palliative sedation, or continuous palliative sedation, is a very good treatment modality among the varieties of treatment modalities that would not be used as a first or second line of treatment, but only when the suffering was really quite terrible. Some pain is really awful to see and very, very difficult to manage. I can imagine that it would be much easier for some people simply to be asleep, in a sense, rather than conscious.

I don't see a huge ethical difference. I see it more of an emotional difference. However, it requires resources.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

Madam Shanahan.

[Brenda Shanahan, Liberal, Châteauguay—Lacolle, QC]

In fact, I'd like to continue on that line and explore either with you, Professor Ells, or with Dr. Smith, what the criteria are to access palliative care as we have it now. Just so we can understand, what are the actual medical interventions that take place, or what is given and what is withdrawn? Then you could talk a little more about the continuous sedation.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

There's just one minute.

[Dr. Derryck Smith]

Maybe I could lead off that discussion. I'm very much in agreement. We need better palliative care in Canada. The biggest problem now is accessing it, because mostly it's available only in the major centres.

However, I think that if you look at the experience in Oregon, you will see that there are more people accessing palliative care who want to have physician-assisted dying than there are people who die from natural causes, so it's not one or the other. In spite of the best palliative care, we are all going to die, so it's probably not one or the other. It's both.

I think the other model we have to keep in mind, particularly with the model of continuous sedation, is that the vast majority of Canadians want to die at home, surrounded by their friends and family. If you look at the statistics from Oregon, you see that more than 70% of people who have physician-assisted dying die at home. That's one of the great advantages. Because no one is going to get continuous sedation in their home, we should make options available for Canadians to die at home where they wish to, at a time of their choosing, and surrounded by their friends and family.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

Thank you, Dr. Smith.

Mr. Warawa.

[Mark Warawa, Conservative, Langley—Aldergrove, BC]

Thank you, Chair.

Thank you to the witnesses.

Dr. Ells, are you representing and bringing recommendations from McGill, or are these your personal recommendations?

[Dr. Carolyn Ells]

These are my personal recommendations.

[Mark Warawa, Conservative, Langley—Aldergrove, BC]

Thank you.

Dr. Smith in beautiful British Columbia, I love your tie. My question for you is whether the positions you've shared tonight are the same as those of Dying With Dignity or whether they are your own.

[Dr. Derryck Smith]

In large part, my positions represent the views of Dying With Dignity Canada and the physician council. The one position I outlined that has not been fully debated or adopted by Dying With Dignity Canada is the issue of what to do with the children who are suffering irremediable illnesses, but who are obviously never going to be competent to give consent themselves. That position I brought forward, because I've spent most of my life working with children and teenagers, and I think we really need to give more thought to that.

[Mark Warawa, Conservative, Langley—Aldergrove, BC]

Thank you, Dr. Smith.

We have heard from Dying With Dignity, last week from Linda Jarrett, last night from Wanda Morris, and now from you. We have had lots of opportunities to hear from Dying With Dignity, and what you've shared is very consistent with what we heard the previous two times.

I have a question for the Canadian Hospice Palliative Care Association.

Ms. Baxter, do you represent the position of your association, or are these your own views?

[Sharon Baxter]

These views are from our association. Since last summer we've gone through a long process to develop our statement. In the fall we had a large conference of 650 hospice palliative care professionals and caregivers, and we came to a consensus on our key messages. I didn't get into all of the key messages, but they'll be in the bigger submission.

[Mark Warawa, Conservative, Langley—Aldergrove, BC]

Right. Thank you.

You've used the term “physician-hastened death”. Member of Parliament John Aldag and I hosted a town hall meeting last Saturday, and that was the term that people seemed to like using. In your brief, which we have here, you suggested that a consenting adult should be somebody over 21 years of age.

Just for interest, for members of the committee, with regard to asking about the age, 96.6% of the people who responded to this survey said that it should be 18 or over. That's right in line with what you're saying. Could you comment on that?

[Sharon Baxter]

When I presented to the panel in the fall, I actually told them that when we talked about when we leap over and become an adult and that sort of thing, that wasn't based on any great science. Our pediatric palliative community said that you can drive at 16, you can drink at 19, you can join the military, and 21 was that last point across the threshold of adulthood. It wasn't based on anything other than feeling that it was the age of consent.

There's a lot of debate and discussion about the younger terms. I do think that we would have a problem with young teenagers grappling with what they have to grapple with, but that's what we put in our submission. It's not based on any huge science.

With regard to the term “physician-hastened death”, one of our colleagues, the Canadian Society of Palliative Care Physicians, which is one of our partner organizations, as well as most of their members and my members, felt that the term “physician-hastened death” played into the idea that palliative care does not hasten death. It sort of signifies that. People who work in palliative care do assist in death and dying, but they're not actively ending somebody's life, so they felt that the term was interesting.

We've been very hesitant. You may notice that our submission said “physician-assisted” death and we're using the term “hastened” right now. We're waiting to see what the legislation says, because I think whatever the legislation decides in June will be what we all have to call it. Right now we're in this period of transition, but the hastened death piece resonated with the palliative care community.

[Mark Warawa, Conservative, Langley—Aldergrove, BC]

Do I have any time left, Chair?