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

[James S. Cowan]

Sure. That's right. If a physician in our current system is in any doubt about capacity or competence—and I agree with you that it depends on the severity of the procedure that's involved—they might ask for a second opinion, or indeed the opinion of a specialist. The nature of the doubt would inform their decision as to the kind of second opinion that would be required.

[Dr. Derryck Smith]

Absolutely. I'm asked to do capacity assessments by lawyers for various individuals. There are people like me who have expertise in that area.

I think that having a panel of experts available to assist our colleagues on difficult questions of competence and capacity is very sensible. It probably could be done informally, in the same way that medical consultations are arranged now.

[James S. Cowan]

Could I shift for a moment to the issue of access? Again, I think we have to make sure that the system that is designed and the service that is available will be available, as best as it can be accomplished, for Canadians from coast to coast to coast, regardless of where they live. I'd like you to comment on the need for the involvement in that of non-physicians, of other health professionals, in order to guarantee the kind of access that is so necessary.

[Dr. Derryck Smith]

I think doctors are fairly well distributed across the country. It would be ideal if all Canadians had a family doctor, which is not the case now, unfortunately. I'm concerned about rural and remote communities, where there may not be a doctor living in the community. We may have to look at the role for nurse practitioners or telemedicine. A good deal of medical services, at least in my province, are done over a telemedicine link. I think the recommendation I've read that makes the most sense is that one of the two doctors must assess the patient in person, but the other one could be done by a telehealth link.

Finally, I think we have to recall that doctors, whether administering intravenous medications or prescribing medications, have these medications supplied by pharmacists. I think we need to give some thought as to whether there is a particular role for pharmacy here. What about pharmacists who don't want to dispense medication that they know is going to be used to hasten death? We need more thought in those areas.

[James S. Cowan]

Thank you.

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

Thank you.

We're going to go to round two. Just before we do, I want to use the chair's prerogative to ask Dr. Ells a question.

From your past life as a practising ethicist, can you tell us if you see a role for a hospital ethics committee? The Supreme Court has said that we are going to have physician-assisted death and we're going to have it in a variety of places and a variety of venues. The venues that have the most developed ethics programs are hospitals.

You have been a practising ethicist, not just a theoretical one. Can you give us any comment that could help us in understanding what that role could be and what it should be?

[Dr. Carolyn Ells]

I don't think there should be a requirement for an ethics consult by a single consultant or a committee on every occasion. These resources ought to be available, to be sought when things are particularly difficult, but I would not want it to gum up the process by being added in.

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

Would it have a role at the beginning, as a policy body, and then on availability later, on an unusual case?

[Dr. Carolyn Ells]

Yes. Absolutely.

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

Thank you.

We'll begin our second round with Monsieur Arseneault.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Thank you, Mr. Joint Chair.

Thank you, Dr. Smith, Professor Ells and Ms. Baxter. I know your time is valuable, but this evening, you're really helping to shed light on issues that the members of this committee need to consider in order to come up with a bill.

My first questions are for Ms. Baxter.

I read the briefing note your association submitted. Your association acknowledges the need to respond to the Carter decision through a bill that amends the Criminal Code, while ensuring the promotion of palliative care. I understand the dynamic behind your association's position.

I also appreciate the fact that your association suggested responses to the criteria or parameters set out by the Supreme Court of Canada, in keeping with the Carter decision. I am assuming, then, Ms. Baxter, that you read the Carter decision.

Paragraph 127 of the decision summarizes the court's thinking, if you will, or decision. Without quoting the entire paragraph, I'll cite some of it as a reminder for you. The Carter decision states that “a competent adult person who (1) clearly consents to the termination of life; and (2) has a grievous and irremediable medical condition...that causes enduring suffering that is intolerable to the individual” may seek physician-assisted dying.

In Carter, that suffering is perceived by the patient. I'm trying to figure out how to reconcile the court's position in Carter with your or, rather, your association's position. Specifically, I'm referring to your stance whereby a request for physician-assisted dying should be granted only when the health care professionals are in agreement that no other options are available to ease the patient's suffering. Then, and only then, should access to physician-assisted dying be provided.

How do you reconcile that with the Carter decision?

[Sharon Baxter]

We know that there will be Canadians who want physician-hastened death. We know that Canadians need physician-hastened death in some situations. I'm not sure this will answer your question in the way you worded it, but one thing we want is for Canadians to have the best options and the best care possible up to the point where they decide on physician-hastened death.

You know, even within the hospice palliative care community, a small number of palliative care physicians have said they'd be interested in performing physician-hastened death. Most of them aren't interested, but what all of them are saying is that they want to give the best care possible and see if we can manage the pain and symptoms. Then we will refer them on to find the best person or the best program to provide physician-hastened death.

There's not a conflict between the two. We just want to make sure that the best care is offered and the best options are offered at the start, before they go to physician-hastened death. I think there are some concerns about having somebody who has had uncontrolled pain, because a lot of Canadians aren't getting the right care they need at the end of their lives. They're living in isolation, they're showing up in hospital emergency rooms without having the proper care or ever being referred to palliative care programs. These people arrive in drastic circumstances. We're saying we want to get them the best care possible, and then if they want to have a physician-hastened death, we will refer them and they will get that.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Very well. I see what you're saying.

I have a question about age. I was listening to what you said earlier in response to the question—

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

You have a minute left.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Okay.

In your brief, it says that the patient should be 21 in order to make such a request but that careful precautions need to be taken with those in young adulthood. Do you mean those who are 21 years of age or those who are younger than 21?

[Sharon Baxter]

As I said earlier, it's not based on a whole pile of science. We hadn't even referred a lot with our pediatric palliative care community. They are coming here tomorrow. I was speaking to their lawyer, who's presenting tomorrow. I'm sure the Canadian Paediatric Society will give you a better reflection.

The pediatric palliative care community is a small percentage of our community. There are seven residential pediatric hospices in this country. They are concerned about where they lie. We picked the age of 21 for no other reason than it is that last barrier to add on. If people have a better sense of that, I'm sure you'll hear it tomorrow.

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

I need to move on to Monsieur Deltell.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Thank you very much, Mr. Joint Chair.

Welcome to your Parliament, ladies and gentlemen.

My question is very simple. We are here not to determine whether we support allowing people to die with dignity through physician-assisted dying but, rather, to decide how to go about it.

The Supreme Court was quite clear in telling us that we needed to amend the Criminal Code. Given, however, that the Criminal Code is the responsibility of the federal government while health care falls in the provincial domain, we need to figure out how to harmonize the two.

In the committee's recommendations to the government, should we suggest that the legislation set out very clear direction for the provinces or give them free reign, in your view? I'd like to hear what all three of you think. For the sake of comprehension, I'll ask Mr. Smith, from Vancouver, to go first.

[Dr. Derryck Smith]

I'm happy to address that, but again, you won't get a lot of wisdom from me out of this. I'm well aware of the balance of powers between the federal government and the provinces. Hopefully working together in the best interest of Canadians will result in a national program, but we may have to end up with a patchwork of regulations.

I think it's important that we have a national reporting mechanism, even if the provinces go their separate ways on some of the specifics. For example, I cannot imagine that Quebec will move its current legislation to allow for the prescribing of oral medications without a great deal of thought. I don't think we'll get national agreement on some things, but I've not heard anyone argue against a national reporting system so that Canadians, on an annual basis, will get some idea of how the system is working and be assured that the vulnerable are protected, that there's ready access, and that things are being done properly.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Ms. Baxter?

[Sharon Baxter]

I agree with the idea of national reporting, and we've come out and said that we would prefer national legislation as a guiding principle. I know Quebec does its own thing and has already done its own thing, but in regard to the rest of the provinces, we understand that implementation of the process will depend on where the community is at and what the needs of the population are. We've already been talking to rural Manitoba, and they're talking about a mobile unit. There are all sorts of different ideas coming out of the provinces on how they would try to satisfy their needs, particularly rural needs.

I think we need national legislation and national reporting. Within those guidelines, implementation will fall to the provinces to figure out what meets the needs of their population and their own health systems. No two provinces' health systems are set up the same way. We're not starting from the same point every time.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Ms. Ells?

[Dr. Carolyn Ells]

The system ought to provide it. If it's the right of Canadians to receive access to physician-assisted dying, then I would like the federal legislation to require provinces and territories to make it available where people live in each province and territory. I think we have to compromise in the struggle of competing values so that some institutions are responsible to provide it. Whether others can opt out, particularly if a conscience-based deep core value is the reason to opt out, the system nonetheless ought to provide it.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

I think we all recognize that it will be a very difficult task. We're talking about provincial power and a federal obligation, but if we let all the provinces decide by themselves, don't you think we'll see tourism in Canada? People from Alberta will want to go to Quebec, and what else?

[Dr. Carolyn Ells]

Exactly. That's why I think we shouldn't allow that. This helps to justify the federal government taking a stand to help ensure access all the way across. Canadians who are eligible in the public health care system ought to be able to receive it where they live.