Physician-Assisted Dying Committee on Feb. 3rd, 2016

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

I'd like to thank you all for the comments you've shared. They're giving me much more to think about once again.

Cardinal Collins, you mentioned that you may not want to be involved in forming...or shaping, so I'll put this to the other two panellists.

Continuing on with the question of safeguards, we've heard from some presenters here that we should look at safeguards being medical. If somebody decides that they may be interested, there is a one-physician, perhaps two-physician, process with a wait time to be determined. We've heard from other witnesses that this should be taken away from the medical community and moved into a legal or quasi-legal kind of piece.

I'm wondering if you have thoughts on either of those options, or if there is another option on safeguards that we should be contemplating as we mull over how this may actually work out in terms of looking at protections for the vulnerable. How do we create the appropriate amount of time for reflection by both the patient and the care providers, and within what field? Is there something missing that we haven't considered in that legal or medical realm?

I throw that out to both of you for thoughts or comments.

[Laurence Worthen]

We've done studies looking at the various countries that have legalized this. Generally speaking, the problem you have is that when a patient comes to a doctor and they say that they want to die, many different factors could be contributing to that. Many of those could be dealt with. The problem is that if you are expecting a physician to be able to do the full evaluation required to ensure that the person is not being coerced, no other jurisdiction is willing to put the funding in place to be able to do that properly.

When you say that it's a safeguard to have two physicians.... In other jurisdictions, there is something called “doctor shopping”, where, if they don't get the answer they want from the first two physicians, they'll go on to a third, fourth, or fifth physician. Eventually they will find somebody in the jurisdiction who believes in patient autonomy to the extreme, where they will decide that because the person wants to die, they should be able to die.

The reality is that we have concerns even with the use of the term “safeguard”. It normally means that it's whatever we can put in place to be able to salve our conscience about how these vulnerable people will end up being put to death. The Carter criteria put together include disabled people.

It's so common for our physicians—it happens on a weekly basis—that patients will say they want to die: they've had a traumatic, emotional incident; they've just been diagnosed with a serious illness, or they've just become a paraplegic or a quadriplegic. Any number of factors can generate in a person's mind the desire to end their life. The question is, do we as a society have the compassion and concern to be able to put the resources in place to assist those people, or will we end up just euthanizing them and basically wash our hands of our responsibility for our fellow people?

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

I want to hear from our other panellist as well.

Ms. Ng, I'm wondering if you have any thoughts on this idea of safeguards.

[Vyda Ng]

The protection of vulnerable peoples is really important, and I think the assessment of competency is vital to this.

We're talking about two different things here: the protection of the vulnerable people and making sure the person seeking assisted dying is really sure this is what they want. That's where the careful assessment process comes in.

I think you made a good point that maybe someone doesn't want to die, that they just want to be out of the situation they're in. That's where the suicide assessment might come in. If there are other options to help someone deal with mental health issues in a more healthy way, then those should be available.

However, the difference is that when you're talking about someone with an irremediable illness, the road is bleak, right? So the careful and thorough assessment is really important. The assessment by two physicians is really important. The patient needs to completely understand the consequences of this decision on both themselves and their family. They need to know all the treatment options that are available. I think the key to this is that the patient must freely choose this option after considering all the treatment options, and the request for the physician-assisted death must be made by the patient and not another party. When you're talking about protecting the vulnerable, there is a fear here that someone else might request the death of this patient, and we want to make sure that doesn't happen, so the request for the medication must come from the patient and not another party.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you, Ms. Ng.

Mr. Cooper.

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

Mr. Chair, I will provide the balance of my time to Mr. Genuis.

[Garnett Genuis, Conservative, Sherwood Park—Fort Saskatchewan, AB]

Thank you very much, and thank you to the witnesses for being here today.

Cardinal Collins and Mr. Worthen, you bring a refreshing perspective. I would say respectfully that it's a perspective I wish we could have had an opportunity to hear more of at this committee.

I have two specific issues I'd like to raise. I'll raise them both at the same time, if that's okay, and then leave the balance of my time to you gentlemen to respond to them as you wish.

My understanding is that the idea of dignity, a word we hear often in this committee, is very important in the Catholic tradition as well, but I think sometimes we use words like “dignity” and “compassion” without a certain precision to them.

Cardinal Collins, could you talk to us a little bit about the understanding of dignity in the Catholic tradition, and give us a bit of a definition? Of course, we would all like to see people have dignity at the point of their death. Perhaps, then, we need to think a little bit about what dignity really means.

The second issue I want to hear more about is palliative care. I think all of us agree that palliative care is good, and we would like to see more palliative care. I think we need to go further than that and recognize that it is not just desirable but necessary to provide people with palliative care.

This was made clear by the report of the expert panel—and I'm quoting here—that a request for physician-assisted death cannot be truly voluntary if the option of proper palliative care is not available to alleviate a person's suffering. In other words, it isn't a genuinely autonomous choice at all if we continue to provide palliative care to such a tiny fraction of Canadians. In fact, if we proceed with this and don't respect conscience for institutions, I fear we'll see the closure of more faith-based palliative care services that aren't willing to provide this.

I wonder if you could comment both on the issue of what dignity means and also on the centrality of palliative care.

[Cardinal Thomas Collins]

Okay. Maybe I'll start with the very important point you raise concerning dignity. Everyone may have different opinions or different views on that.

I would say dignity comes from within the person himself or herself. I would think even a person without faith would see that in a purely human way, the dignity of the human person. It doesn't come from the circumstances around them. From the point of view of faith, it comes from the idea that we see a person as a child of God, as someone who has inherent dignity. Every person must be treated with reverence.

Did Jean Paul II have dignity? When he was a 58-year-old pope skiing down mountains, he had dignity. Did he have dignity when he was in the last years of his life when his body was breaking down? I would say he had dignity then and he had dignity at the other times as well. Dignity comes from within the human person. I would say dignity comes with a reverence we give to a person, and that's why we should surround them and care for them. Think of Mother Teresa. The people she served, did they have dignity? Yes, they did, and she tried to help them in their suffering and care. Dignity comes from within. Dignity, I would say, comes from God. What we are doing, and have been doing for hundreds, a couple of thousand, years is surrounding a person, reverencing their dignity. That's why we don't believe it's right to kill them. We think that's just not right. That is not the way to dignity.

On palliative care, I think not only do we need to talk about it but that it needs to be dealt with at the federal, provincial, and municipal levels, and certainly at the private level. I can tell you that in my own diocese—I can't speak for other religious groups—we have various initiatives. Just this afternoon I got a proposal for another palliative care place that we're thinking of putting in the centre of Toronto. We do this. We're on the ground. We're doing it. We're caring. But I do think it would help a lot if this was funded. I mean, what are we spending on in our country? I would think it should be on caring for those who have dignity inherent within them from the first moment of their life to the end of this life at the end of their earthly journey. I think we need to not just talk about it, but to do something about it.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you very much.

Senator Seidman.

[Judith G. Seidman, Senator, Quebec (De la Durantaye), C]

Thank you, Chair.

Ms. Ng, I'd like to ask you a little more about the point you made about a review after a death. We have heard, for example, that the review is very important. Data collection and oversight could then lead to a review of the legislation in an ongoing way to update or change it over time. We have heard that this could be a joint federal, provincial and territorial kind of oversight. You mentioned the importance of review. Would you be able to comment on this, please?

[Vyda Ng]

I think we learn from mistakes. Going out, we know very little about how it's going to play out in Canadian society. Opinions are very dichotomized around this. I think a review would serve all sides in this situation. If we proceed without a review, we won't know what we've done well and we won't know what can be improved. We won't know if palliative care actually may take care of a lot of the issues that people who are irremediably ill face. A review process, if it's a joint federal, provincial, and municipal venture, will provide answers to a lot of the questions we're asking now in this situation and will help us make sure that, one, processes that are working well will be improved upon and shared, and two, processes that aren't working so well will be improved upon, especially in the cases where areas are more remote, in cases where physicians are acting on their conscience, and in cases where maybe not enough education or information is being shared with health care practitioners. We cannot afford to assume that the rollout of this will be smooth.

[Judith G. Seidman]

What kind of information could you see being collected under this approach, in terms of monitoring oversight and then having a feedback loop into the legislative process?

[Vyda Ng]

Some examples are: how assessment of competency is done; how physicians have the conversation with their patients; whether or not the patients feel comfortable enough to broach the subject knowing that there are going to be physicians who are not comfortable providing that kind of care; whether the institution has enough resources to support both the patient and its own medical personnel when these conversations are going on; whether two physicians are present, if that makes a difference in terms of the request from the patient; what kind of medication is used; and whether there are requests from the patient to self-terminate or whether the medication is going to be administered by a physician. Whether or not the family members are involved I think is important. That also speaks to matters of coercion and protecting the vulnerable. Patients might feel subtle pressure from family members to act either one way or another way. I think these intangibles are also important for the review process to pick up on.

One of the important things—I've talked about the equitable access—is how patients in the remote areas access this care. His Eminence has talked about having a third party referral process. In principle we don't object to that, but if it puts more barriers and roadblocks in the way of the patients requesting this care, and if it doesn't work very well, then a better mechanism needs to be produced.

[Judith G. Seidman]

We have heard that nurse practitioners and other medical professionals could be involved in actually administering the process, the death for the patient. Could you see that as well?

[Vyda Ng]

We could see that happening as long as the proper information, education, training, and support were provided to the health care professionals involved in administering that. We don't say that physicians should be the only ones, because we know that circumstances are different around the country, especially in more remote areas. So yes, we are open to the option of other health care professionals being involved both in administering the medication and in support.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you, witnesses, for being here with us today, and colleagues, for your questions.

We need to turn this around in two or three minutes for the next session.

With that, I suspend the meeting.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

I'm calling the meeting back into session.

In this session we have three panels.

We have, from the Canadian Council of Imams, Sikander Hashmi, who will be speaking on their behalf.

We have two panels appearing by video conference. The Centre for Addiction and Mental Health is represented by Dr. Tarek Rajji, chief, geriatric psychiatry; and Kristin Taylor, vice-president of legal services. From the Canadian Paediatric Society, we have Dr. Dawn Davies, chair, bioethics committee, and Mary Shariff, associate professor of law and associate dean academic at the University of Manitoba.

Once again, for the benefit of the witness groups, I will indicate that each group has 10 minutes in total and our committee members have five minutes for questions and answers.

Mr. Genuis.

[Garnett Genuis, Conservative, Sherwood Park—Fort Saskatchewan, AB]

I have a very brief point of order.

Another member and I were timing during my speaking time and I think I was about 45 seconds short in terms of when you stopped the time. I'm sure there was no ill intention there, but I just wonder if maybe that time could be applied to another member on our side.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

According to the clerk, I said 20 seconds to Mark, but it was 22 seconds, and on mine it was 25. I have been routinely cutting them off at that point. If it's 30 seconds or more and they don't get the answer in, I ask the witness to provide a written answer afterwards.

Thank you very much.

With that I will also continue the process that we invite the groups by video conference to appear first, just in case there is a technological glitch. I will go in the order they're listed on the paper in front of me. That means I'm going to invite the Centre for Addiction and Mental Health to present first, please.

[Dr. Tarek Rajji, Chief, Geriatric Psychiatry, Centre for Addiction and Mental Health]

Thank you.

Members of the Special Joint Committee on Physician-Assisted Dying, thank you for the opportunity to appear before you today to share our perspectives on this extremely important topic.

My name is Tarek Rajji. I'm the chief of geriatric psychiatry at the Centre for Addiction and Mental Health, CAMH, and I am joined by my colleague, Kristin Taylor, vice-president of legal services.

CAMH is one of Canada's largest mental health and addictions academic health science centres. We combine clinical care, research, and education to transform the lives of people affected by mental illness or addiction. We have over 500 in-patient beds, 3,000 staff, over 300 physicians, and over 100 scientists. We treat over 30,000 patients each year.

PAD, physician-assisted dying, as it relates to mental illness is an extremely complex topic. The Supreme Court did not explicitly define specific medical conditions that would be eligible for PAD, but ruled that the “competent adult person” must have “a grievous and irremediable medical condition (including an illness, disease, or disability), that causes enduring” physical or psychological “suffering that is intolerable to the individual in the circumstances of his or her condition”. This means that mental illness may be eligible for PAD.

But should mental illness be eligible for PAD? If so, how should we address it within a therapeutic clinical relationship? How do we ensure that safeguards are in place to protect those whose mental illnesses make them vulnerable to suicidal ideation?

We do not have the answers to these questions yet. These are issues that we continue to struggle with at CAMH. We have convened a working group of clinical, legal, ethics, and policy experts from across our organization, who are attempting to answer these questions and determine the impact that PAD will have on our patients, clinicians, and organization. Kristin joins me today as the co-chair of this committee.

What we would like to share with the special joint committee today are two key insights from our expert working group that we hope will assist in developing a federal framework on physician-assisted dying.

Our first insight is, should mental illness be considered irremediable? Mental illness is typically chronic and episodic. Following the natural history of mental illness, some individuals have persistent symptoms, some experience worsening symptoms, and some even recover from illnesses, even illnesses like schizophrenia. To date, we cannot predict who will be on what trajectory. Further, we have some effective treatments for mental illness and some knowledge to guide us with respect to personalizing treatments; however, we are still far from predicting what treatments would work for a particular person.

The symptoms of mental illness that persist, worsen, or remit include thoughts of suicide. However, a minority of patients with mental illness die from suicide. Again, while we have good knowledge about risk factors for suicide and some interventions that have been shown to reduce suicidality, we still cannot predict when a suicide will happen. This natural history is in contrast with terminal illnesses and some chronic physical illnesses, which are irremediable in that a proximal death is an eventual outcome.

Thus, mental illness may be grievous to an individual. Symptoms can cause enduring psychological and sometimes physical suffering. However, suffering should not be equated with irremediableness, and the lack of an inevitable or predictable death by natural history provides us with an opportunity to deliver recovery-based treatment.

A recovery-based approach to mental health care, which we provide at CAMH, focuses on hope and on developing the skills that are needed to live with a mental illness and its symptoms. We do not just focus on treating or curing the illness. Similarly, people with mental illness may be vulnerable to the impact of the social determinants of health. They may live in poverty, have poor housing, and lack social support. These circumstances may exacerbate suffering and a person's perception that their illness is irremediable.

Again, part of recovery-based care is for mental health professionals to work with people to help them cope and address these reversible causes of suffering. Therefore, within a clinical recovery-based environment, there is always the potential for mental illness to be remediable.

I would like to use a clinical example to illustrate the points I've talked about: a 73-year-old woman with a lifelong history of bipolar disorder, recurrent, and a persistent desire to die driven by a sense of futility and of being limited by her illness and the cognitive deficits, the attention problems, and the planning deficits that are due to this illness. The patient was married once and now she has an adult daughter and a granddaughter. She also has a neighbour with whom she has limited contact. Her bipolar illness is responsive to medications. However, despite good response, she has a persistent wish to die.

During her treatment, my discussions with her around death were focused on acknowledging her wish, respecting it, but also confining it. I focused on exploring with her the possibility of strengthening her relationship with her daughter through regular visits and meals together. This evolved to regular babysitting that her daughter and her son-in-law depended on. This new form of her relationship provided her with an unexpected sense of satisfaction and meaningfulness. These new feelings and experiences did not eliminate her wish to die, but ran in parallel and competed with it during her daily life.

We also explored her ability to consolidate her relationship with her neighbour who ended up having a stroke, and the patient became part of his network of caregivers.

This therapeutic work with her took about three years. The lack of inevitable and proximal death allowed this work to happen. Further, throughout the three years, what deterred her from committing suicide was the possibility of pain or a medical sequel if suicide was not successful and the shame she would have left her daughter with.

Would the availability of a painless death option and the sanction by a physician have eliminated the obstacles of pain and shame and interfered with the completion of this therapeutic work?

The second point I want to present to you is there must be safeguards in place to ensure people with mental illness truly have the capacity to consent to PAD.

In addition to the points I made previously about the natural course of the mental illness and its social determinants, individuals with mental illness experience distorted perceptions due to the illness and its consequences.

When a person is experiencing an acute episode of their illness such as a major depressive episode, or an acute psychotic episode, or a manic episode, it's not uncommon for them to have severely distorted beliefs about themselves, the world, and their future. Sometimes the sense of helplessness, and worthlessness, and hopelessness continues even when the symptoms of the mental illness are better controlled.

Thus these distortions raise questions about the capacity to make PAD requests during both the acute and less acute phases of the illness. In addition it is during the phases of relative wellness that recovery-based approaches to care are critical to change these distorted beliefs that have often been reinforced by lifelong experiences with a recurrent mental illness, associated stigma, and sometimes abuse or neglect due to this illness.

Again, I would like to use a clinical example to illustrate these points: a 55-year-old man with a long history of chronic schizophrenia with onset that occurred when he was 18 years old. Even before the full manifestation of the illness, this man was considered as awkward and bizarre at school, bullied by classmates, and was unable to excel in several academic or social activities. He continued to experience some failures since the full break of his first episode, including failure to maintain a job, failure to have a romantic relationship, and a failure to maintain the relationships he had before the illness.

It is not hard to see the lack of capacity when this person is experiencing an acute psychotic episode, but what about when he is not experiencing an acute episode? Wouldn't these repeated failures and maltreatment be contributing to a sense of worthlessness and hopelessness?

This distorted and learned view of self can potentially change in response to a recovery-based treatment and not only treatment that addresses the acute psychosis.

In both examples we recognize there will be some individuals with mental illness who will persistently perceive that they have suffering from an irremediable illness. These individuals may also argue that they are capable of making this decision. We believe that in these situations an objective decision of the irremediable nature of a persons's illness must be made by a board versed in these issues, such as the Consent and Capacity Board in Ontario.

Members of the special joint committee, thank you again for the opportunity to speak with you today. There are no easy answers when looking at PAD and mental illness.

Today I have attempted to lay out the very real challenges and concerns that affect us at CAMH as a recovery-based organization that aims to transform the lives of people with mental illness. We hope that sharing our thoughts and recommendations will assist you as you move forward with your work.

Kristin and I would be happy to take any questions.

Thank you.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you very much.

I will now turn to the Canadian Paediatric Society and invite them to make their presentation.

[Dr. Mary Shariff, Associate Professor of Law and Associate Dean Academic, University of Manitoba, Canadian Paediatric Society]

Thank you for inviting us to speak with you today. I am very grateful for this opportunity.

I am a law professor who has been researching issues around physician-assisted suicide and palliative care since approximately 2008, and I was an expert witness on comparative laws for jurisdictions at past termination-of-life legislation for the Carter case.

In terms of legislative response, one possibility would be to construe Carter, of course, as narrowly as possible, which would be to construe it to the specific facts of the case. But of course you could always use Carter as a legislative entry point to include individuals and medical conditions not deliberated or decided upon by the Supreme Court.

Today I am here to speak to the matter of children, and with respect to children, I would argue that you should not go beyond the Supreme Court's pronouncement.

In termination-of-life legislation there are two main organizing streams when it comes to deciding whose request for physician-assisted dying can be legally granted.

First there are the substantive criteria, which we understand are the patient qualifiers, what criteria qualify a patient's request to be entertained by a physician. Then there are also the procedural due-care criteria, meaning what procedures you put in place to make sure that the patient has actually met the substantive criteria.

As we know, in cracking open the Criminal Code to allow willing physicians to provide termination-of-life services without prosecution, the Supreme Court only expressly identified the substantive criteria, namely, competent adult, grievous and irremediable condition, enduring suffering that is intolerable to the individual, and clear consent to termination of life. The court did not expressly articulate procedural due-care criteria, meaning that it didn't articulate the safeguards to be implemented to make sure the patient satisfies those four to six qualifying criteria.

As we know, the Supreme Court provided the substantive criteria of “adult” but did not define “adult”, but again, if we go back to the facts of the case, the court was making and could only make a pronouncement on those facts. Non-adults were simply not part of the equation.

First, I would argue that it's not arbitrary to exclude non-adults from qualifying criteria in any first iteration of Canadian termination-of-life legislation. Again, there is no evidence before the court on the issue of children or adolescents. But also note the evidentiary finding by the trial judge, as articulated by the Supreme Court, that while there is no clear societal consensus on physician-assisted dying, there is a strong consensus that it would be ethical only with respect to adults who are competent, informed, and grievously and irremediably ill who voluntarily chose it.

Second, there is a massive ethical question as to whether children and adolescents should be able to qualify in the first instance for lethal injection. This ethical question was not considered in Carter, and to the best of my knowledge, it has not been fully considered by Canadians. There is no ethical data on minors to inform the Canadian legal analysis. Dr. Davies will speak more to the issue of data.

Third, the argument is being made that the law has already allowed mature minors to make medical decisions even if doing so would result in their death. But let's think about that a little more closely. In those death cases, the decision is about rejection of treatment whereby if the child rejects treatment, the child runs the risk of dying. This is an entirely different consideration for children than is children being expected to consent to lethal injection.

Fourth, we also see from those cases in the Canadian case law that if the odds of survival are good with treatment, the court will override a minor's refusal. We know that Carter does not use the criteria of terminal illness, so how does one figure out the odds of survival for a child whose medical condition is a mental health issue or other form of disability?

This leads me to my fifth and final point, and then I'll turn it over to Dr. Davies.

Yes, we absolutely have processes that help us to discern a child's capacity and maturity for a particular decision, but the process for determining a minor's capacity does not answer the substantive question. It was more than just an acknowledgement of adults' capacity that actually drove the Carter result.

[Dr. Dawn Davies, Chair, Bioethics Committee, Canadian Paediatric Society]

Hi, I'm Dawn Davies. I'm a palliative care physician at the Stollery Children's Hospital in Alberta. I'm here today as a representative of the Canadian Paediatric Society, where I'm the current chair of the bioethics committee.

Thanks for giving the CPS an opportunity to address you. The legislation you are to consider is of particular importance to physicians who care for children and youth as the issues of eligibility and consent are complex. I'll highlight the relevant clinical dimensions of caring for seriously ill children, and how these intersect with the legislation about physician-assisted dying, which I will abbreviate to PAD for the sake of time.

The CPS recommends that the complex matter of assessing a minor's capacity be left to the minor's parents and immediate clinical team. Physicians are able to make this assessment as stated in Carter.

As has always been the case with mature minors, the greater the risk of serious harm or death, the more vigilant health care providers must be in their assessment of one's capacity to make the decision, and to ensure that it is free from duress from parents and other authority figures. It's also important to understand that these assessments are sometimes difficult to make, and that referral to the courts for life-and-death cases is not uncommon.

While the provincial and territorial panel suggests that capacity is more relevant than age, they did not consult with pediatric health care providers, parents, or minors. The CPS strongly recommends that comprehensive consultation must occur with the following groups prior to further legislation that would include children and adolescents: parents of children who are severely disabled or have terminal illness, and those parents who are bereaved after losing children with similar illnesses; relevant pediatric health care professionals; and representatives of major religious and child advocacy groups.

The Belgian law on euthanasia for adults came into force in 2002, and was extended to include children in 2014, but this has been widely criticized for lack of appropriate broad consultation prior to the inclusion of children.

There is also no Canadian pediatric data regarding either requests for a physician-assisted dying for minors, the opinion of Canadian pediatricians about PAD, nor their willingness to participate in assisting death of children specifically.

We must anticipate the source of requests for PAD, and parents of never-competent children deserve special mention. While we understand that proxy decision-makers will not be able to request PAD on behalf of any other person, requests from parents for euthanasia of their terminally ill children are neither new nor exceedingly rare. Decision-making for treatment of never-competent children is based on a best interest standard. It is possible that parents will challenge the courts on the basis that continued life, as experienced by their dying or profoundly disabled child, is not in their child's best interest.

Studies have shown that such requests are more likely if the child has uncontrolled pain. However, palliative care for Canadian children is greatly underserviced, with many community-based health professionals having little to no training in the provision of palliative care to this group. The CPS therefore recommends enhanced pediatric-specific palliative care funded and equipped to care for children and their families in the setting of their choosing, especially their homes. Given the rapid societal shifts since the Carter decision and the short timeline to enact legislation, the CPS strongly enshrines the physician's right to conscientiously object to providing PAD, especially in the case of children and youth.

Thank you.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you very much.

I will now turn to our guest in the room.

Mr. Hashmi, would you please present to us.

[Imam Sikander Hashmi, Spokesperson, Canadian Council of Imams]

Thank you very much, sir.

Good evening, everyone. My name is Sikander Hashmi. I serve as an imam at the Kanata Muslim Association in Ottawa. I'm also a member of the Council of Imams of Ottawa-Gatineau. This evening I'm here with you as a spokesperson for the Canadian Council of Imams.

In the Islamic faith tradition, neither euthanasia nor assisted suicide are supported or encouraged. However, since that matter has already been decided by the Supreme Court, our concerns regarding the legalization of physician-assisted dying centre around the preservation and the sanctity of life as well as the vulnerability of patients.

Most Canadians would agree that life is sacred and that an effort should be made in most, if not all, circumstances to preserve it. The Quran highlights the importance of saving a life in verse 5:32, that whoever saves a life, it is as if they have saved humanity entirely. We understand that in some cases patients experiencing extreme levels of pain and suffering, and those expecting the same in the future, may desire an end to their life. We empathize with them. As we draw from our faith, we are instructed to pray for them to gain relief from their suffering and to try our best to make them comfortable by providing the best possible care.

Our concern is that the availability of the option to die with the assistance of another individual may, in some cases, be subject to the interests of others rather than the patient, leading to direct or indirect encouragement and promotion of physician-assisted dying. We believe there must be robust safeguards in place to ensure that this option is exercised only by those who voluntarily and independently choose physician-assisted dying after going through an informed decision-making process.

We propose that any such requests be considered and evaluated by an end-of-life team of four members: first, a physician, ideally one who is familiar with the medical history of the patient and is involved in treating the patient; second, a psychiatrist or a psychologist who is able to understand the mental state of the patient and the reasons for their decision; third, a social worker who can inform the patient of the care options available to them and discuss potential impacts of their choices on themselves and on their family members; and finally, a spiritual care provider, representing the faith tradition of the patient, who can offer spiritual counsel and advice if the patient desires their services.

This team shall ensure that all care options available to the patient have been clearly explained without bias; that the patient has made the decision voluntarily and without duress or encouragement from another party; that the patient understands the impact of their decision; and that the patient's immediate family members are informed, if possible, about this process, and counselling is offered to them unless explicitly requested otherwise by the patient.

Furthermore, we recommend that paragraph 241(a) of the Criminal Code of Canada be amended to ensure that encouragement to commit suicide, including physician-assisted death, remains a criminal offence. In our view, a patient should be able to seek the assistance of a physician to end their life only if they meet all of the following criteria: they're above the age of majority in their jurisdiction; they're capable for personal care; they're suffering from a grievous and irremediable medical condition; they're in an advanced state of irreversible decline and capability; and they experience regular and unbearable physical suffering that cannot be relieved in a manner the patient deems tolerable.

The patient should be required to sign a request form, or in the case of a disability, express their wish clearly in unambiguous terms through any other means. The process and procedures could be as follows:

The patient would inform the care provider of their request or their desire for care or for physician-assisted death. The end-of-life care team would visit the patient to assess eligibility and inform them about available choices. The team would contact family members, inform them about the request, and offer them support, unless requested otherwise by the patient. The team would make a follow-up visit to the patient. If the patient chooses physician-assisted dying, the team would have them sign appropriate forms. The request would be submitted to the health care provider. The health care provider would arrange for the time and location and for the physician who is willing to assist the patient in dying. Details of this would be shared with immediate family members, unless requested otherwise by the patient. Before the procedure, the end-of-life care team would once again confirm the decision with the patient if the patient is still able to communicate. If the response is in the affirmative, the physician would assist the patient in ending their life and the death would be reported to a central federal registry.

Physicians and faith-based care facilities should not be compelled, in our view, to perform this procedure if their conscience, faith, and personal values do not allow for the taking of life.

We would like to highlight the statement of the College of Family Physicians of Canada on issues related to end-of-life care, which says:

As a matter of social justice, all Canadians...should have access to palliative care that meets national standards. Palliative care must be available in all health care settings. In addition, a variety of settings must be available for end-of-life care.

We also echo their call for sufficient funding to ensure that all Canadians have access to palliative care that meets national standards and the needs of each community.

The teachings of our faith lead us to believe that every disease has a cure. We just have to work to find it. Therefore, we recommend placing a greater emphasis on medical research towards finding cures and better pain management methods, particularly through increased funding and reversal of cuts to programs such as the combined MD/Ph.D. program for which funding was withdrawn in June 2015.

In conclusion, we would like to reiterate that neither euthanasia nor assisted suicide are supported or encouraged in the Islamic faith tradition. We believe there is a need and an opportunity to improve quality of life for patients and to protect the vulnerable. We hope our suggestions are useful in developing legislation that is balanced and compassionate.

Thank you very much.