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

[John Aldag, Liberal, Cloverdale—Langley City, BC]

Thank you.

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

You mentioned that the hospices in Quebec had gathered together to opt out of Bill 52, but that when push came to shove, one of their own members wanted to die in hospice. I mean, we love hospices. That's the ideal place instead of dying at home unsupervised or on an emergency room gurney. People in a hospice are already receiving palliative care. Why wouldn't people have access to physician-hastened death in a hospice? It's a choice that they may not take, but if they want it, why wouldn't they have access to it in a hospice?

[Sharon Baxter]

It's a case that the hospice people believe in a philosophy of not hastening death, and this is something different. They do believe that their patient and patient-centred care have to be prominent. They're not saying they won't refer someone.

It is a difficult question. Every one of the hospice programs in this country is struggling right now with their boards of directors, their staff, and their volunteers. The one in Ottawa, the May Court hospice, has 400 volunteers. These people volunteer their time, their money, and their energy because they believe in the philosophy of hospice. Now they are saying, “You're going to allow somebody to die here?” They think they could send those patients to the Civic Hospital or whatever.

I'm not sure what the answer is. I don't have the answer. You guys are going to have to come up with some answers somewhere.

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

Thank you.

We're going to suspend for about three or four minutes as we prepare the next video conference.

I thank the witnesses, both in person and via video conference.

Thank you very much for your time with us today.

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

I will call us back to order for the second part of our evening.

Thank you to our witnesses for joining us. From the College of Physicians and Surgeons of Nova Scotia, we have Dr. Douglas Grant and Marjorie Hickey. From the Criminal Lawyers' Association, we have Leo Russomanno.

Joining us via video conference is Dr. Alika Lafontaine, in Grande Prairie tonight. I used to spend a lot of time in Grande Prairie.

We'll begin with you, Dr. Lafontaine, because of the video conferencing. If we have technical problems, it gives us a second chance to get you back if we need to.

You can hear and see us, and we can see and hear you as well. You have 10 minutes for your presentation.

[Dr. Alika Lafontaine, President, Indigenous Physicians Association of Canada]

Thank you very much.

My name is Alika Lafontaine, and I am an Oji-Cree anaesthesiologist practising in northern Alberta. I would like to acknowledge the Western Cree of Treaty 8, from where I'm video conferencing, as well as the Algonquin people, on whose territory these hearings are being held.

My thanks to the committee for the invitation to speak. I'd also like to extend thanks to the board members of the Indigenous Physicians Association of Canada, our past presidents, and IPAC membership for their input into this testimony, as well as the indigenous health advisory committee of the Royal College of Physicians and Surgeons and the staff of the college. In particular, I'd like to thank Dr. Tom Dignan, who has guided many indigenous physicians like me over the past few decades.

Senator Ted Quewezance, chair of the senate of the Federation of Saskatchewan Indian Nations, and Mr. Mike Cachagee, executive director of the National Residential School Survivors' Society, have both been extremely helpful. Senator Quewezance and Mr. Cachagee, also residential school survivors, are people who have helped me remember the responsibility of being Oji-Cree and that we should move forward with this work in a good way.

I am president of the Indigenous Physicians Association of Canada, the only national voice of first nations, Métis, and Inuit physicians. For almost two decades, national indigenous physician advocacy organizations have lobbied for improvements in indigenous health. Our organization has current and past members who represent every province and territory in our great Canadian federation. As one of the three founding nations of Canada, indigenous peoples have a critical perspective to add to all Canadian issues.

The Indigenous Physicians Association of Canada does not have an official position on medically assisted dying. It has not been identified, by our members or by the indigenous patients we serve, as a high priority. They are focused on other pressing issues within indigenous health. The comments I share are a reflection of the ongoing discussion we have on this issue and how it fits more broadly into indigenous heath. Some of these perspectives are my own.

In reviewing these hearings, I feel obliged to identify the absence of the major national indigenous organizations. I believe there has not been meaningful consultations with indigenous peoples, although meaningful mainstream Canadian consultations have been carried out by many other organizations that have presented here. You are all aware of the widening health disparities among indigenous peoples and the rest of Canada. When considering the overrepresentation of indigenous peoples in nearly every category who may qualify and pursue medically assisted dying, it should be strongly considered that you may be ignoring the largest proportional demographic that is eligible to pursue this service. I hope the apparent absence of indigenous consultation is remedied prior to any final decisions regarding indigenous patients and medically assisted dying.

As a physician, I recognize that medically assisted dying must be provided in a thoughtful and patient-centred manner. I applaud the members of this committee for their commitment to explore an issue that could be divisive and emotionally exhausting. I am thankful that so many organizations have taken the time to provide meaningful advice to the committee, and preface my comments as specifically pertaining to indigenous patients. Whether the issues I raise are dealt with, they will remain issues nonetheless.

My personal experience with indigenous patients and their concerns regarding medically assisted dying are very different from my experience with mainstream Canadian patients. One reason is that medically assisted dying has existed in our communities for more than a century.

When residential schools exposed children to nutritional deprivation and medical experimentation, that was medically assisted dying. When traditional medicines and cultural practices were made illegal, driving traditional healing underground, that was medically assisted dying. When traditional medicine is appropriated, depleted, and patented by private industry, so-called discoveries that have been known by indigenous peoples for generations, thereby removing access to our own ways of healing, that is medically assisted dying. When traditional medicine is treated with hostility by mainstream health professionals, despite being requested specifically by patients, that is medically assisted dying.

When child and family services apprehend indigenous children at an alarmingly high rate—if not the highest rate of all demographics—with medical decisions made by the crown, and an inconsistent quality of standards that contribute to children dying in care or going missing, that is medically assisted dying. When the trauma of residential schools is perpetuated intergenerationally and we do nothing to stem the tide of abuse, addiction, and suicide that overwhelms our indigenous communities through insufficient mental health intervention, except in crisis, that is medically assisted dying.

When indigenous peoples have programs designed without their input, then are chastised for poor engagement in mainstream health care, that is medically assisted dying. When Health Canada provides 40 programs that do not provide comprehensive primary health care on reserve and neglects to provide a seamless transition between federal and provincial health jurisdictions, that is medically assisted dying.

When the health system prescribes benzodiazepines, opioids, stimulants, and other prescription substances without considering the high risk of addiction and overdose, that is medically assisted dying. When health professionals request services for indigenous patients and their requests are denied by bureaucrats at Health Canada who ignore clinical recommendations, that is medically assisted dying.

When nursing stations employ health professionals that lack a skill set to provide emergency and urgent care or when nursing stations lack basic life-saving equipment and medication that does not meet the minimum standard of every other health facility, that is medically assisted dying.

When there is no monitoring, tracking, or enforcement of standard practice that every other Canadian can expect when receiving medical care, that is medically assisted dying. If an indigenous person dies and no one tracks it, does anyone care?

What we are pleading for in indigenous communities is not medically assisted dying. That already exists in more ways that can be counted. What we are pleading for is medically assisted life.

It is in this background that I make the following nine recommendations.

One, consult indigenous peoples regarding their opinions on medically assisted dying and whether it is a priority. You can do this during the submission of each first nation's health strategy, a requirement of funding for health programs on reserve, and through national consultations with those off-reserve, first nations, Métis, and Inuit. Continue to engage the national indigenous organizations and weigh their opinion with the same weight as those who testify through this current process.

Two, implement the truth and reconciliation recommendations for health. Change the culture of medically assisted dying towards indigenous peoples by the health care system. Confront bias, discrimination, and racism in indigenous health.

Three, reprofile existing funding with Health Canada towards primary care services, with a lower focus on public health programming. You do not build a health system around public health. You build it around primary care services. Public health cannot exist in isolation and should not exist to the detriment of primary care services.

Four, implement the recommendations of the Naylor report on health care transformation, including the creation of an indigenous health quality council so we can independently track indigenous health outcomes and provide support to indigenous communities. Health quality councils are a central support of provincial health systems. The Naylor report goes into more detail about this.

Five, create a national indigenous health strategy that seamlessly integrates medically assisted dying. This deserves to be a stand-alone national priority in health, not a subcategory below other health priorities. Dealing with the crisis should be at the same level as pharmacare, the opioid crisis, and medically assisted dying.

Six, pass an indigenous patient bill of rights that ensures seamless transitions in care between federal and provincial systems and puts patient need before policy and procedure within Health Canada. Design it to minimize jurisdictional ambiguity and emphasize jurisdictional responsibility.

Seven, do not create a program for medically assisted dying unless you speak directly to the community who may access it. In a system where everyone is already dying, the effects of creating a literal program where patients intentionally die within the medical system will further disengage and disenfranchise indigenous patients and families.

Eight, provide access to a culturally safe educational organization that will provide education on a patient's right to live, a patient's right to die, and the legal mechanisms that protect each. Empower patients with information.

Finally, nine, ensure that complaints from patients and patients' families about bias, discrimination, and racism of health care providers and/or administrators that push patients or patients' families to choose medically assisted death in a way that is not patient- and family-centred are transparently addressed. The complaint process should outline the various ways that complaints can be pursued, including through health regions, regulatory bodies, and civil actions.

I want to emphasize that I believe no individual in our health care system deliberately causes harm to indigenous patients. Through historical trauma, mainstream attitudes, and system design, however, we do cause ongoing harm, whether intentional or not.

Thank you for the opportunity to participate in these hearings. Medically assisted dying is an important issue for Canadian and indigenous patients. Meegwetch.

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

Thank you very much, Dr. Lafontaine.

I think we'll keep in that medical vein before we switch to the legal vein again, so we'll turn to Dr. Grant and Ms. Hickey.

[Dr. Douglas Grant, Registrar and Chief Executive Officer, College of Physicians and Surgeons of Nova Scotia]

Thank you, honourable Chairs and committee members.

My name is Dr. Gus Grant. I am the president of the Federation of Medical Regulatory Authorities of Canada, but speak today in my role as registrar of the College of Physicians and Surgeons of Nova Scotia. I'm accompanied by our legal counsel, Marjorie Hickey.

Our college has jurisdiction over the regulation of the medical profession in Nova Scotia. The college's objects, which are defined by a provincial statute, are to serve and protect the public interest in the practice of medicine, preserve the integrity of the medical profession, and maintain the confidence of the public and the profession in the regulation of medicine. I would respectfully submit that any legislation regarding physician-assisted death, PAD, be directed to complement the work of the colleges toward these objects.

The legislative component of the framework must provide clarity and certainty for patients and physicians without confining the medical judgment of physicians or limiting access for the patients. Those aspects of PAD that are fundamentally medical and touch on the exercise of professional judgment, the delivery of clinical skill, or the essence of the patient-doctor relationship should remain regulated by the colleges. As with any aspects of medicine, the clinical means by which PAD is delivered will change over time. Legislation cannot confine progress of this sort, and the college is mindful of the adage that to define is to limit.

The ultimate combination of legislation and regulation must result in a framework that is seen with confidence to appropriately protect vulnerable patients; promote a patient's right to life, liberty, and security of the person; and give consideration to the physician's freedom of conscience. To that end, the college makes the following submissions regarding certain discreet aspects of PAD that are already before the committee.

With respect to eligibility criteria and the question of mature minors, the college asks that legislative amendments specifically address whether PAD is available only to competent adults or also to competent mature minors. The college takes no position on this issue, apart from encouraging explicit legislative direction. The college supports the definition tabled to this committee by Professor Downie earlier this week.

Another item is the place for the now famous language in Carter of “grievous and irremediable medical condition”. These famous words and the interpretation of these words will evolve. The college does not feel that this evolution should be limited by legislation, but if legislation does address these words, the college urges that the spirit of Carter be maintained. The primary lens through which to assess eligibility must remain that of the patient's illness experience. Eligibility is to be determined primarily based on the subject of experience of the patient.

However, protection of vulnerable patients, together with the public's confidence in the framework, will be served if the assessment of eligibility includes an objective component. The college supports an interpretation of the word “grievous” to mean a very serious condition and, thus, requires an objective assessment of severity by physicians.

On this, I'd say one more thing. Please avoid lists. With advances in medicine, that which is grievous today may be imminently curable tomorrow.

I'd like to talk about the timing of the eligibility criteria for Carter. To effectively regulate our college and colleges, we need specific legislative direction on the question of when each of the eligibility criteria must be met. The Carter decision, unfortunately, does not give clear guidance on these questions, and the colleges, our college, would prefer to have direction from legislation, rather than to be left to extrapolate from Carter.

We must consider the arc of the deteriorating patient. If all criteria are to apply at the point of either prescription of medication or administration of medication, patients who lose their competence or who become unable to express their experience of intolerable suffering will be unable to avail themselves of the physician-assisted death they may have requested earlier while competent.

To avoid this dilemma, legislation may also be needed to address the role of advance directives. On this, the college makes no submission beyond recognizing that a myriad of new issues are associated with the expansion of PAD to include patients who are no longer competent.

With respect to the clinical process, I make the following submissions. Most provinces have developed professional standards that have been informed by the work of FMRAC and by the Canadian Medical Association, and have been built through extensive consultation. Contrary to the submission of Professor Downie earlier this week, these standards are largely harmonious.

I submit that the clinical process is best left to the regulator. There are issues specifically addressed in these standards that are before your committee. Specifically, should there be legislated and defined waiting periods? The college does not support legislated waiting periods. The goal should be for physicians to make a determination of eligibility free from ambivalence, and to take whatever time is needed and reasonably required to do so without unduly limiting patient access. Prescribed time limits would encroach on this critical exercise of professional judgment.

How many physicians should be involved in the process and who should they be? This is a question that our college does not feel requires legislative address. The college currently takes the position that eligibility should be provided by two physicians, or determined by two. In these early days, I think public confidence will be served by the involvement of more than one physician.

We also take the position that when the grievous and irremediable condition is primarily a mental illness, the determination of eligibility should be informed by a psychiatric opinion. In the course of our consultations, there has been concern that mental health patients who seek PAD are among the most vulnerable. The public, in my submission, will be comforted by the involvement of a psychiatrist.

Medicine is increasingly delivered through a team-based approach. The allied health professionals, working with or under the direction of physicians—think nurses, counsellors, dispensing pharmacists—require clear legislative comfort that their involvement with PAD will not be considered illegal or criminal.

The next question is perhaps the most contentious: what are the responsibilities of physicians conflicted by conscience, and by whom should these responsibilities be mandated? We have a history to confront. I refer to our country's experience with abortion and access to contraception, where conscientiously objecting physicians faced, and continue to face, the same question. On many occasions, whether through silence or obfuscation, physicians chose, and continue to choose, not to assist women to access a legal and medical service that runs counter to their personal beliefs.

I respectfully disagree with the submission of Dr. Jeffrey Blackmer of the CMA to this committee. As a regulator, I submit that it is naive to think that access to physician-assisted death will not be an issue, whether for reasons of conscience or geography. The provincial colleges are not in unanimous agreement on the question of conscience. Whereas it's unfortunate there is not a unified pan-Canadian approach, this alone should not invite federal legislation. The professional and ethical obligations of a physician in this difficult situation are clearly within the objects of provincial legislation. The colleges, through FMRAC, should work toward consistency, both to establish the physician's obligations and to establish the disciplinary consequences that might flow from a breach of those obligations.

With respect to oversight and program structure, I make the following and final two submissions. Should there be a formalized oversight process? Medicine is driven by data. A formal oversight process will allow medicine to develop evidence as to which conditions give rise to the request for assistance in death. Track the timelines of the request and the death, and in so doing identify opportunities for research and for intervention.

Most importantly, I submit that the process must be retrospective. The medical profession is well capable of assessing eligibility and delivering care. This inherently medical process should not be interrupted. We cannot place an administrative panel between a physician and a suffering patient.

My final submission pertains to the oversight of the medication itself. The experience in permissive jurisdictions is clear. The majority of patients prescribed medication to end life do not take the medication.

According to The New England Journal of Medicine, we are in an epidemic of deaths from opioid overdoses, and I appreciate the reference to this by Dr. Lafontaine. We now face the situation where our family medicine cabinets will contain medications for the purpose of ending life. These medicine cabinets are the targets of addicts and of experimenting teenagers. There needs to be a robust system for the return of unused medication. The college would welcome that this system be mandated through legislation.

I thank you for the great privilege of making these submissions and welcome your questions.

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

Thank you very much, Dr. Grant.

Mr. Russomanno, you have 10 minutes.

[Leo Russomanno, Member and Criminal Defence Counsel, Criminal Lawyers' Association]

Good evening. On behalf of the Criminal Lawyers' Association, I thank you for inviting our organization to give you our thoughts on this very important topic. Having seen the transcript of the remarks of previous witnesses, I truly feel honoured to be a member of this group of individuals and part of this debate.

The Criminal Lawyers' Association represents more than 1,500 members, primarily criminal defence lawyers in the province of Ontario. A large portion of our efforts relates to ensuring access to justice in criminal law and protecting the civil liberties of Canadians.

The majority of our members' clients are part of vulnerable groups in one way or another. Our organization's members routinely assist individuals with mental health issues, marginalized groups, the impoverished, and the uneducated. Our position here really reflects what is the constitutionally minimal standard that's set out in Carter, and what the role is of Parliament and the federal sphere in how to deal with the issue of section 7 compliance.

The Criminal Lawyers' Association is against the duplication or the addition of unnecessary complications into an already unwieldy Criminal Code. We're skeptical of any attempt to import what is essentially a medical regulation into the Criminal Code. We're also skeptical about the federal government's jurisdictional competence to regulate assisted suicide comprehensively within the Criminal Code. The Criminal Code, as we know, is a very blunt tool, and it ought to be used sparingly. You have to ask yourself if the federal role will be a criminal one, because that's the anchor for the jurisdictional authority. What does that look like?

What is the continued relevance of criminal law and the regulation of physician-assisted death post-Carter? That is the question I'm here to address on behalf of the Criminal Lawyers' Association.

Having gone through some of the testimony in earlier hearings and having gone through Carter several times now, I must say that Carter sets out fairly clearly what is the constitutionally minimum standard. It starts at paragraph 1 of the decision. Paragraph 1 of the decision couldn't be more clear as to what the issue is with section 7 compliance.

The prohibition in the Criminal Code with respect to counselling suicide created a net that was cast too wide and went beyond the legislative objective. That's what section 7 principles of fundamental justice are about—looking at the legislative objective and then looking at the effects of trying to meet that legislative objective. Overbreadth is really about casting a net that's too wide.

What Carter was about and what the Supreme Court was saying is that there are individuals who unfortunately are faced with a “cruel” choice as a result of this blanket prohibition. Those were the words of the Supreme Court in paragraph 1 of Carter. A person who is able to consent and has a grievous and irremediable illness or medical condition and intolerable suffering faces this cruel choice of ending their life early, before the onset of this intolerable suffering or pain, or waiting for a natural death. The Supreme Court found this to be an unconstitutional choice that individuals were faced with.

If we're going to accept that this counselling suicide provision is going to remain in the Criminal Code—and for the purposes of these hearings, I take it as a given that we are leaving it in place—the role of the federal government in terms of a constitutionally minimal standard is to really create an exception that meets those constitutionally minimum standards. Outside of that, subject to the comments I made earlier, getting into comprehensive regulation would just be encroaching upon the powers of the provincial governments to regulate health care.

Subject to questions, of course, those are my comments at this time.

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

Thank you very much for a very clear presentation.

Ms. Dabrusin.

[Julie Dabrusin, Liberal, Toronto—Danforth, ON]

Thank you to everyone for coming tonight and for speaking with us.

Dr. Lafontaine, you mentioned, as number two in your list of recommendations, that we take into account the application of the Truth and Reconciliation Commission recommendations. I'm wondering if you might be able to give us some guidance on those.

In particular, I was looking at the health section. Recommendation 22 calls upon the Canadian health care system “to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients.” When we're looking at the application of Carter, which is what we're tasked to do, can you give us some guidance on how that might look and what we should be considering?

[Dr. Alika Lafontaine]

Thank you for your question.

I'll touch on a couple of comments from Dr. Grant and Mr. Russomanno. Dr. Grant mentioned that you should not put administrative oversight between the patient and the physician. As I mentioned in my preamble, we've created a system design that absolutely does this. When we're looking at the application of physician-assisted dying in particular, and we're looking at it through the context of the Truth and Reconciliation Commission's calls to action for health, the goal is to become patient-centred. It's to make sure that the objective of the law is achieved, just as Mr. Russomanno mentioned.

When you're looking at objective 22, it's not just respect for traditional healing practices; the outcome is to ensure that patients receive access to those services in a way that's patient- and family-centred, keeping in consideration the realities of our health care system. I think with the application of physician-assisted dying in the framework of the provinces, indigenous patients will fall between the cracks, because they exist in federal jurisdictions. Health Canada is supposed to provide those programs to ensure that we have primary care on reserve and for our off-reserve indigenous peoples, but time and time again you get this jurisdictional ambiguity going back and forth.

When we're writing up the rules of physician-assisted dying in the context of indigenous patients, it's important to always go back to what those outcomes are: ensuring that the patient-physician relationship is respected, ensuring that there's transparency, and ensuring that the outcome of the law is achieved regardless of what policy and procedure might currently be in place.

[Julie Dabrusin, Liberal, Toronto—Danforth, ON]

Thank you for that.

There are two parts I want to jump into. You raised the jurisdictional question. That's something I have been wondering about quite a bit. What we see as a possibility, if the provinces choose to draft inclusion regulations or legislation that says you must be provincially insured to access care, then.... I don't know and maybe you can clarify this for me. If indigenous people living on reserves are federally insured, is there a possibility that they then would be carved out of provincial legislation?

[Dr. Alika Lafontaine]

I think that possibility does exist. Dr. Grant can probably speak to the ability of any of the regulatory colleges to actually enforce their standards on reserve.

A good example would be any of the multiple news stories you've seen of patients who have died in northern communities that existed under federally provided Health Canada clinics. We know that they don't meet standards. When you look at a family medicine clinic that exists in, let's say, northern Alberta—Fort Vermilion is under Alberta Health Services—they're required to have certain things available. If they don't have those things available, that clinic gets shut down and all the patients get re-streamed to another place where they can receive care until those standards are met again. When the same thing happens in a federal jurisdiction, that does not happen.

Now, as to whether or not that's legal, I don't think we've actually had a court case that outlines it. We talk about jurisdictional ambiguity, but in the case of child and family welfare services, where we found there was discrimination between children under federal care and children under provincial care, it took a lawsuit for people to actually say whether or not this was the right thing to do.

There are two ways in which this whole system is sustained. The first is by maintaining ambiguity and encouraging patients that, you know, this is just how it is; there's nothing you can do about it. But I think there will be a court case coming, whether it's with physician-assisted dying or something else in health, in order to clarify that responsibility and the responsibility for seamless transition of care, which has already been outlined in Jordan's principle. Second is ensuring that the programs are uniform across the provinces.

Do they have to be carved out? I don't think they do. Are they currently carved out? Absolutely.

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

That's time.

Mr. Cooper.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Dr. Grant, is my understanding of your testimony correct such that the College of Physicians and Surgeons of Nova Scotia takes no position with respect to whether euthanasia should be available simply to adults or whether it should be extended to, for instance, mature minors?

[Dr. Douglas Grant]

Our position is simply that explicit direction is required on this question.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

I have before me “Standard of Practice: Physician-Assisted Death” from the College of Physicians and Surgeons of Nova Scotia. At section 5, which contains the eligibility criteria, it says the patient must be an adult. When I turn to section 11, which contains definitions, it defines adult as “a person who is 19 years or older”.

It would seem that the College of Physicians and Surgeons of Nova Scotia does have a position. Could you explain that?

[Dr. Douglas Grant]

Certainly. In the absence of a response from Carter, the position of our college, and of most colleges, was that standards that most loyally adopted that which was expressed in Carter should be developed . However, we as a college did not feel that it was up to us to extrapolate from Carter. We felt from the specific language of Carter that an adult patient meant just that. We, however, recognized that there are legal precedents and the legal question of a mature minor, so we come making the submission today that this is a question that requires addressing.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Thanks for that clarification.

Moving on to just the issue of medical practitioners, as a physician, could you perhaps comment on what the ability, for example, of a family physician would be to identify and diagnose a psychiatric condition?

[Dr. Douglas Grant]

In my experience of over 15 years as a practising family physician, I would say that the majority of cases presenting to my office had a component, if not a dominant component, of mental illness. It is, sadly, a very common presentation to family physicians, and I would think that it's very much within the scope of practice of almost all general practitioners to deal with mental illness.

Of course, family physicians, when they get into a spot where it feels as though the presentation of the patient is beyond their scope, turn to consultants for further assistance.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

That's why, for example, in the standards that have been set out, it is recommended that for a mental condition, a psychiatrist conduct the second evaluation. Why would that be necessary if a family physician could diagnose?

[Dr. Douglas Grant]

There are a number of questions within that. The standard puts forward the requirement that when a grievous and irremediable condition is primarily that of mental health, the opinion of eligibility should be informed by a psychiatrist, so that the physician making the determination of eligibility can rely on the opinion of a psychiatrist who may already be present. I believe it was in the last session—and the physician's name escapes me now—that the witness who was video conferencing pointed out that involving psychiatrists for all such cases may create a problem of access.

I think we also have to recognize that in these early days of this new medical service and this new right of patients, as the profession itself grows increasingly accustomed to making decisions on questions of this sort, all would be comforted by the presence of a psychiatric opinion.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

You're suggesting then that a psychiatric opinion in these sorts of matters would be appropriate in all instances, at least as a good safeguard, or, as you said, a comfort.