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

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie (Senator, Nova Scotia (Annapolis Valley - Hants), C)]

We have a quorum and I'm calling the meeting to order.

Welcome to the 11th meeting of the Special Joint Committee on Physician-Assisted Dying.

I'm Kelvin Ogilvie, a senator from Nova Scotia and co-chair of this committee. I'm chairing it today along with my co-chair colleague, Rob Oliphant, the member of Parliament for Don Valley West.

In this session, which will go from 5 to 6 p.m., we have two groups presenting. First of all, we have His Eminence Cardinal Thomas Collins, Archbishop of Toronto, and with him Laurence Worthen, executive director of the Christian Medical and Dental Society of Canada and the Coalition for HealthCARE and Conscience.

We welcome you. I will remind you that together you have a total of 10 minutes for your presentation.

Appearing by video conference we have Vyda Ng, executive director of the Canadian Unitarian Council.

Ms. Ng, you have 10 minutes as well. Because it's technology, and we already know you've been shunted around Toronto a bit with something happening at the first site, we're going to invite you to present first.

Just before you start, I want to remind the witnesses and everybody that the committee members, when called, have five minutes in total for their question and the response, so the questioners should be efficient with language, and to the responders, if you could be direct in your answers, it would be much appreciated.

With that, I invite Ms. Ng to present.

[Vyda Ng, Executive Director, Canadian Unitarian Council]

Thank you for the opportunity to present before this joint committee.

As far back as the early 1970s, the Canadian Unitarian Council has advocated for the right of a terminally ill patient to make decisions about the time and manner of their death. We were involved as intervenor in the Taylor and Carter cases in 2012 and 2014. In this presentation I wish to emphasize the following.

First, around eligibility criteria and competency, we are of the belief that the competency requirement should apply at the time of the initial request for physician-assisted dying, and at the provision of the requested treatment. However, we do recognize that patients with an irremediable condition may deteriorate at any time. Therefore, we think that once informed consent has been fully attained, this should stand, and that decisions around the manner and time of death should be made on an individual basis, for example, where an individual suffers from dementia or lapses into a coma after providing the initial informed consent.

We also believe the consent to the termination of life must be made freely, without coercion or pressure, and after the patient has had a chance to consider all treatment options.

In terms of the grievous and irremediable condition, we believe there are a number of illnesses, disabilities, and conditions that cover this range of description, and we believe the condition that causes the suffering that is intolerable to the individual should be defined by the individual and not by any outside body. We believe very strongly that there should not be a predetermined list of illnesses, conditions, or symptoms, as the experience varies from person to person.

On the matter of equitable access, we believe that publicly funded institutions should be required to provide physician-assisted dying on their premises. Other health care professionals may provide assisted-dying medication, especially in situations where there is no physician available or willing, or in the more remote regions.

In areas that are remote, ways must be found to allow patients equitable access so that there are no delays and the same level of compassionate care may be provided.

In circumstances where the physician is unwilling to provide assisted dying, mechanisms must be in place for individuals to access this without undue stress.

We also believe physicians and health care practitioners should be able to make their own decisions based on their conscience. They should be able to refuse the provision of assisted dying if this is their personal belief. They should be able to make these decisions without fear of reprisals or consequences; the institutions for which they work should not be able to levy any kinds of consequences upon them.

When it is the case that a physician decides not to provide assisted dying, the patient must be given full access to other means. There should be no impediments to the individuals requesting assisted dying, and institutions should not prevent patients from accessing this care.

There needs to be a carefully thought-out system for transfer of care so that patients are not denied compassionate treatment and to make sure this is done without additional stress or trauma to the individual. Patients' needs need to come before doctors' wishes, and provincial, territorial, or municipal governments should not allow any roadblocks or barriers to exist for patients to access assisted dying.

Why does the Canadian Unitarian Council feel so strongly about this? As a religious institution, we realize different faiths have different beliefs, but we do not think the views of any one faith can be used to restrict the freedoms of other individuals. As a religious body, we have had a history of supporting choice in all manner of things, even when it hasn't been popular to do so, things such as choice in abortion, the rights of the lesbian-gay-bisexual community, or the call of women to be ordained. We've often taken the path that hasn't been popular, but we feel that this is the right thing to do.

It's very much in keeping with Canadian values to put the needs and wishes of Canadians ahead of the values of individual doctors and institutions, and to respect each person's dignity at the most traumatic period of their life.

We also think that in order to safeguard good processes, reviews should take place after each instance of physician-assisted death. These are necessary, but we do not think that having a review before the medication is in the best interests of the patient in case doing so leads to delays.

That is the end of our presentation.

Thank you.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you very much.

Now, Your Eminence, I will turn to you and your colleague. Please make your presentation.

[His Eminence Thomas Cardinal Collins, Archbishop, Archdiocese of Toronto, Coalition for HealthCARE and Conscience]

Good evening, and thank you for allowing us this opportunity to provide input on such a profoundly important subject.

I appear today on behalf of the Coalition for HealthCARE and Conscience. Joining me is Larry Worthen, the executive director of the Christian Medical and Dental Society of Canada.

We are like-minded organizations committed to protecting conscience rights for health practitioners and facilities. In addition to the Catholic Archdiocese of Toronto and the Christian Medical and Dental Society of Canada, our members also include the Catholic Organization for Life and Family, the Canadian Federation of Catholic Physicians' Societies, the Canadian Catholic Bioethics Institute, and Canadian Physicians for Life.

I will address two issues: conscience protection for health care workers, and palliative care and support services for the vulnerable.

For centuries faith-based organizations and communities have cared for the most vulnerable in our country, and they do so to this day. We know what it is to journey with those who are facing great suffering in mind and body, and we are committed to serving them with a compassionate love that is rooted in faith and is expressed through the best medical care available.

We were brought together by a common mission: to respect the sanctity of human life, which is a gift of God; to protect the vulnerable; and to promote the ability of individuals and institutions to provide health care without being forced to compromise their moral convictions. It is because of this mission that we cannot support or condone assisted suicide or euthanasia.

Death is the natural conclusion of the journey of life in this world. As the author of the Book of Ecclesiastes wisely observed long ago, the dust returns to the earth as it once was and the life breath returns to the God who gave it. Death comes to us all, so patients are fully justified in refusing burdensome and disproportionate treatment that only prolongs the inevitable process of dying, but there is an absolute difference between dying and being killed. It is our moral conviction that it is never justified for a physician to help take a patient's life under any circumstances.

We urge you to consider carefully the drastic, negative effects that physician-assisted suicide will have in our country. Killing a person will no longer be seen as a crime but instead will be treated as a form of health care. According to the Supreme Court, adults at any age—not just those who are near death—may request assisted suicide.

Following the lead of some European countries, whose experience with assisted suicide and euthanasia we disregard at our peril, the provincial-territorial expert advisory group has already gone beyond the restriction of assisted suicide to adults and has proposed that children be included.

The right to be put to death will, in practice, become in some cases the duty to be put to death as subtle pressure is brought to bear on the vulnerable.

Those called to the noble vocation of healing will, instead, be engaged in killing, with a grievous effect upon both the integrity of the medical profession committed to doing no harm, and the trust of patients and those from whom they seek healing. Even those doctors who support this legalization in principle may be uneasy when they experience its far-reaching implications.

The strong message from the Supreme Court is unmistakable: some lives are just not worth living. We passionately disagree.

In light of all this, it is clear that reasonable people, with or without religious faith, can have a well-founded moral conviction in their conscience that prevents them from becoming engaged in any way in the provision of assisted suicide and euthanasia. They deserve to be respected. It is essential that the government ensure that effective conscience protection be given to health care providers, both institutions and individuals. They should not be forced to perform actions that go against their conscience or to refer the action to others, since that is the moral equivalent of participating in the act itself. It's simply not right or just to say, “You do not have to do what is against your conscience, but you have to be sure it happens”.

Our worth as a society will be measured by the support we give to the vulnerable. People facing illness may choose to end their lives for reasons of isolation, discouragement, loneliness, or poverty, even though they may have many years yet to live. What does it say about us as a society when the ill and the vulnerable in our midst feel like burdens? Often a plea for suicide is a cry for help. Society should respond with care and a compassionate response to these vulnerable people, and not with death.

Proper palliative care to date is not available to the majority of Canadians. It is a moral imperative for all levels of government in our country to focus attention and resources on providing that care, which offers effective medical control of pain, and even more importantly, loving accompaniment of those who are approaching the inevitable end of life on earth.

Larry Worthen will now provide more detail about some specific recommendations.

[Laurence Worthen, Executive Director, Christian Medical and Dental Society of Canada, Coalition for HealthCARE and Conscience]

Thank you, Cardinal Collins.

Ladies and gentlemen of the committee, His Eminence has provided you with some insight into our concerns about how legalizing physician-assisted suicide or euthanasia will impact vulnerable patients.

Provided they can consent, people with disabilities such as rheumatoid arthritis and paraplegia, or those with mental health difficulties could qualify for assisted death according to the criteria set down by the courts. Often people who have these challenges are struggling in a world with many barriers. The danger is that they will choose assisted death because of the failure of our society to provide the necessary support.

Through increased access to palliative care, disability, chronic disease, and mental health services, Canada can significantly reduce the number of people who see death as the only viable option to end their isolation, their feeling of being a burden, and their sense of worthlessness.

Our concern for our patients extends to our concern for conscience protection. Recently the College of Physicians and Surgeons of Ontario passed a policy requiring referral for assisted death. A referral is the recommendation or a handing over of care to another doctor on the advice of the referring physician. The requirement to refer forces our members to act against their moral conviction that assisted suicide or euthanasia will, in fact, harm their patients. If they refuse to refer, they'll risk disciplinary action by the Ontario college.

When a proposed practice calls into question such a foundational value of the common good of society and the foundational value of the very meaning of our profession, a health care worker has the right to object. Health care workers do not lose their right to moral integrity just because they choose a particular profession.

In the landmark Carter case, the Supreme Court of Canada said that no physician could be forced to participate in assisted death. It also said this was a matter that engaged the charter freedoms of conscience and religion. It is not in the public interest to discriminate against a category of people based upon their moral convictions and religious beliefs. This does not create a more tolerant, inclusive, or pluralistic society, and it is ironic that this is being done all in the name of choice.

Fortunately, six other colleges have not required referral. We have enumerated several possible options for the federal government to ensure these charter rights are respected all across the country. We have a legal opinion, which we will make available to the committee, that lists five ways the federal government could protect conscience rights.

If the federal government does not act, then we risk a patchwork quilt of regulatory practices and a serious injustice being done to some very conscientious, committed, and capable doctors.

Despite our concerns, members of our coalition will not obstruct the patient's decision should this legislation be put in place. The federal government could establish a mechanism allowing patients direct access to a third party information and referral service that would provide them with an assessment once they have discussed assisted death with their own doctor and clearly decided they wish to seek it.

Our members do not wish to abandon their patients in their most challenging moments of vulnerability and illness. When we get a request for assisted death, should this legislation go ahead, we'll probe to determine the underlying reason for the request to see if there are alternatives for management. We'll provide complete information about all available medical options, including assisted death. However, our members must step away from the process, allowing the patient to seek the assessment directly once they have a firm commitment to take that path.

Like our coalition, the Canadian Medical Association has stated that doctors should not be required to do referrals for assisted suicide or euthanasia. It's important to remind the committee that no other foreign jurisdiction requires physician compliance in assisted death through a referral.

In closing, we highlight four areas of serious concern, the need for the following: improved patient services, including palliative, mental health care, and support for people with disabilities; protection of the vulnerable; provisions that physicians, nurses, and other health care professionals not be required to refer for or perform assisted death or be discriminated against because of their moral convictions; and finally, protection for health care facilities, such as hospitals, nursing homes, and hospices, that are unable to provide assisted death on their premises because of their organizational values.

Thank you for your time and consideration.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you very much.

I'll now turn to our colleagues, and Madam Shanahan.

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

Thank you very much, Mr. Chair.

My question is addressed to Monseigneur Collins and Mr. Worthen.

I just want it on the record that I am a practising Catholic, although I say “practising” because I'm not very good yet. You can be assured that I have reflected and prayed on this matter greatly, both before and now during this time that I am a member of Parliament, and I have had to make my peace with my own personal beliefs. I know what I believe and I know that if I'm ever faced with the choice, I'd like to think that I will be able to make the choice that my faith requires of me. But that being said, I'm here as a parliamentarian and I cannot impose my beliefs on others and I am very conscious of the fact that we have to make recommendations for legislation that is going to address the beliefs and values of all Canadians.

I am relieved to hear that you acknowledge the Carter decision, as indeed we must. How do you reconcile, then, your approach given that so many Canadians, and Catholic Canadians, look to faith-based care for that end-of-life care? How do you reconcile the process of delivering end-of-life care to Canadians in the event that they ask for physician-assisted dying?

[Cardinal Thomas Collins]

Larry will give some of the details.

I would say first of all that we do not agree, obviously, with assisted suicide and euthanasia. We think this is a direction that leads all kinds of people into tremendous suffering and is not good for our whole community. It is really a thing that causes great ultimate suffering for all of the most vulnerable, including those who are considering suicide and things of that nature. We know, though, that obviously, as you say, people are proceeding along this path in response to the Supreme Court judgment, but individuals.... And I would not presume to say that I'm going to, by my words, stop that from proceeding. This is the parliamentary process that's in place. It is not for me to engage in it. But I would simply say that there are many, many Canadians, especially those most deeply intimately involved in caring for people, who are profoundly troubled by our country moving in this direction, and that in whatever procedures you are in the course of setting up for those who have that profound conviction I think their conscience needs to be protected. I'm glad the Unitarian Church also agrees with that. I think it's not only individuals, but also institutions.

There are ways of providing protection for conscience and dealing with this issue. I think Larry has mentioned that, and might want to give more detail on it.

[Laurence Worthen]

Yes, the proposal which we will leave behind was one that we discussed at length with the Canadian Medical Association, and which they have approved. It basically shows the physicians articulating their conscience issue around assisted suicide and euthanasia with the patient, having the dialogue and discussion with the patient, giving the patient information about all viable options, but then simply stepping back from the process and allowing the patient to have direct access to an assessment for assisted death. Our hope would be that either the federal government or the provincial governments would create an information referral service so that after patients have had the discussion with their own doctor, they are able to access that directly. We've checked that out with moral theologians, both on the evangelical and Roman Catholic side, and they find it morally acceptable. This seems to us to be a way for our physicians to continue to care for the patient, not affect the physician-patient relationship, and also allow the patient to make their decisions without there being any obstruction from the physician.

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

So would you be open to this duty to inform, then, if not an active referral, but to inform another body that the patient has requested physician-assisted suicide?

[Laurence Worthen]

We differ slightly from the recommendations of the provincial-territorial expert advisory group. They suggested that it would be the physician's responsibility to inform the third party. Our feeling is that it would be unacceptable for us to have to take that responsibility and that the actual patient could be the one to contact. In the situation where the patient is unable to contact, which would normally happen in an institution, then we could look to a patient transfer that would be the opportunity, then, for another physician in the facility to be able to respond to the patient's concerns.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you.

Mr. Warawa.

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

Thank you to the witnesses for being here. It's very interesting.

I researched the Unitarian Council and I didn't see any hospitals that had been established by the Unitarian Church, but I did find many that are faith-based Catholic hospitals.

I appreciate the question from MP Shanahan and her sharing that we should not impose our beliefs on other Canadians. However, there's this balance of faith and doing what's right in our own hearts too. Also there's been comment around this table that a doctor's conscience should be protected, and maybe not to do it themselves, but to refer.

I've heard from most physicians.... Actually, I think it was 70% of physicians who do not want to have to be required to refer, so 30%, which is 24,000 physicians, are willing to practise this. Focusing on the 70%, I think that most Canadians believe they should not be forced to perform assisted suicide or euthanasia and they should not be forced to refer.

There's been a question, I think from one of our senators, that institutions, bricks, do not have a conscience. If you could comment, do institutions have a value system that would say yes or no? Should they have the right to say no as an institution?

Is there a possibility of having a harmonizing system? You could have institutions, hospitals, like a Catholic hospital, that are not bound because they're providing health care. They could be known as a hospital that provides health and natural death, and there could be some hospitals that provide that other choice. Could you comment on that?

[Cardinal Thomas Collins]

I think it's very true to say that institutions are not bricks and mortar. You don't look around and say this is.... Institutions are made of people. Institutions are like the Sisters of St. Joseph, the Grey Nuns, all of the various groups who have brought loving health care to this place. They're not things; they're communities of people. They have values, and that's why people come to them. That's why they seek them out.

They know when they go, for example, to a hospital—and I can think of St. Michael's Hospital, St. Joseph's Hospital, Providence centre which has a wonderful palliative care place.... They know they can trust when they come to the sisters or to the church. It's true, as well, for Jewish and Protestant institutions, similar institutions, of which there are many. In my own diocese, there are very many. They can trust that we have certain values that we hold to. Those values are important for our whole society. Political parties have values; other institutions have values. They're not objective things. They're not material things. That's a great value for our whole community.

These institutions are funded by the government because they do immensely good work. They provide a variety, diversity, choice, I might say, to people, and that's very, very important.

I would say that institutions provide the spirit. I think of the one next to where I live, the Urban Angels, St. Michael's. It's a sign of hope for people. If you undermine the institution for what it is, our society will be very much harmed. Our whole community would be a lot harsher, colder, crueller, without the witness given by communities of faith who are on the ground, on the street, day by day, caring for the most needy. I don't think they should be undermined or attacked.

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

Thank you, Cardinal Collins.

I'm wondering about the safeguards to ensure the conscience. You said you had some ideas on physicians who do not want to participate within a federal regime. I had heard that one of the suggestions was that it could be a criminal offence to force someone—a physician or an institution—to be involved with this.

Is this one of the suggestions that you were considering?

[Laurence Worthen]

Yes.

Our legal brief has five different options in all. Just as in some of the provincial college documents, doctors who choose to do euthanasia are protected against discrimination on the part of faith-based institutions, so also we would ask that doctors who do not want to do euthanasia be also protected. That could be by way of criminal statute that would make it unlawful for someone to be coerced into participating in this.

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

[Inaudible—Editor] institution.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you.

Mr. Rankin.

[Murray Rankin, NDP, Victoria, BC]

Thank you, Chair.

Thank you to all of our witnesses. I particularly appreciate, Cardinal Collins, your strong assertion of the need for our committee to address palliative care. I really appreciate your putting that on the table.

I want to explore a little bit of what Mr. Warawa was just saying in his question, presumably to Mr. Worthen. I'm going to read to you from the the “Interim Guidance” of the College of Physicians and Surgeons of Ontario. They talk about how physicians must provide an “effective referral...to a non-objecting, available, and accessible physician or agency...in a timely manner”. In my province of British Columbia, the similar body says that physicians must ensure “an effective transfer of care for their patients”. This is in the context of conscience protection for health care providers.

Now, you have stated that this obligation to refer patients would violate the conscience rights of certain physicians and that instead there should be a mechanism to provide patients with third party information, assessment, and services. I'm a little concerned, though, because other witnesses have told us that simply providing a person who wishes to exercise their constitutional right can't be limited by a Yellow Pages reference, an 800 number, or a website.

I'm trying to get my head around what you're suggesting and, in particular, how that would affect “effective” right of access for Canadians in remote communities if one were to accede to your recommendation.

[Laurence Worthen]

Thank you for the question. It's a very good one.

I think there needs to be more.... Our proposal is not to simply send someone to the Yellow Pages, far from it. Our doctors are committed to the life and well-being of their patients, so they would want to maintain the physician-patient relationship. They would want to discuss this important decision with their patients. They would want to spend time determining what the reason for the request is. They would also want to ensure that the patient was able to get the assessment if they so desired it. They would not want to stand in the way of that.

We should not be talking in this country about simply having an operator at the end of the phone who is going to give someone a number. In my view, we should be responding compassionately to these people, because many of these people will need services, support, and help. This service that is anticipated by the Canadian Medical Association, and similarly, I think, in the provincial-territorial expert advisory group recommendations, would be for support services to be made available and for this person to get an appropriate assessment in a thorough way. We're not talking about sending someone to the Yellow Pages; this is in a thorough way.

I think something like this is really important in a more remote community, because even in a remote community you might have one doctor or two doctors. Both might be people who are not prepared to participate in assisted death. This means that it would be important for that individual to be able to get access to this service, and I think the responsibility is on government to ensure that service is available and provided.

[Murray Rankin, NDP, Victoria, BC]

In the time that's available—it's so short—I want to go to the institutional side. We've talked about the conscience of the health care provider. I'd like to turn again to the institutional argument and to quite boldly put forward the point that if an institution of which the cardinal has spoken receives public funding, shouldn't they be required to provide all Canadians with the constitutional rights they now have?

I understand about the professional, and you've put some good arguments forward, but I'm still at a loss to understand why a body that receives public funding shouldn't be required to be providing constitutional rights that all Canadians now enjoy.

[Laurence Worthen]

To answer that quickly, I would say that it's misreading the Carter decision to say that it requires individual physicians or facilities to provide the service. What it says is that Canadians have the right to this, but it doesn't say that they have a right to it from every individual institution or individual doctor.

[Murray Rankin, NDP, Victoria, BC]

But what if there's only one such institution in a remote northern Ontario community, for example?

[Laurence Worthen]

This happens all the time in medical care. There are certain procedures that are only provided in certain places. It's up to government. The departments of health cannot shirk their responsibilities here.

If this is something that the Supreme Court has mandated, then the departments of health have to find ways to provide these services. If that means they have to send a physician out to that individual or bring that physician in.... That commonly happens.

[Murray Rankin, NDP, Victoria, BC]

If there's a hospital in a particular community, they shouldn't be providing that service even though it's—