Evidence of meeting #12 for Physician-Assisted Dying in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was patient.

A video is available from Parliament.

On the agenda

MPs speaking

Also speaking

Carmela Hutchison  President, DisAbled Women's Network of Canada
Angus Gunn  Counsel, Alliance of People with Disabilities Who Are Supportive of Legal Assisted Dying Society
Margaret Somerville  Professor, McGill University, As an Individual
Margaret Birrell  President, Alliance of People with Disabilities Who Are Supportive of Legal Assisted Dying Society
Judith G. Seidman  Senator, Quebec (De la Durantaye), C
James S. Cowan  Senator, Nova Scotia, Lib.
Nancy Ruth  Senator, Ontario (Cluny), C
Serge Joyal  Senator, Quebec (Kennebec), Lib.
John Soles  President, Society of Rural Physicians of Canada
Hartley Stern  Executive Director and Chief Executive Officer, The Canadian Medical Protective Association
Michael Bach  Executive Vice-President, Canadian Association for Community Living
Gerald Chipeur  Lawyer, As an Individual

7:50 p.m.

NDP

Murray Rankin NDP Victoria, BC

It does. Absolutely.

Given your role with rural physicians, does that pose an obstacle in remote Canada? Do you see the use telemedicine where there's obviously a well-known lack of psychiatrists? How would that work?

7:50 p.m.

President, Society of Rural Physicians of Canada

Dr. John Soles

Absolutely.

Various witnesses have expressed approaches to this with legal frameworks, and so on, and all of those are challenging when we consider the circumstances in rural Canada. Seeing one psychiatrist in rural Canada is a challenge, never mind two. There was a proposal that most patients should have a psychiatric evaluation. There is very little chance of that being a practical solution in rural Canada, and I would argue there's very little chance of that being a practical solution in a great deal of this country.

7:55 p.m.

NDP

Murray Rankin NDP Victoria, BC

Thank you.

Mr. Bach, thank you for your excellent presentation.

I want to give you an opportunity to elaborate on the vulnerability assessment that you suggested ought to be made mandatory. You've got more information in your brief. Can you spend a bit more time on that? Would you train physicians on vulnerability assessments? Would you seek other professionals to assist? How would it work?

7:55 p.m.

Executive Vice-President, Canadian Association for Community Living

Michael Bach

We see it as a three-stage process.

The physicians who are assessing and doing the diagnosis of the person who is requesting would be required to identify whether there are factors that are motivating the request other than the condition itself. The equation is that the condition causes enduring suffering that's intolerable to the individual. We need to know whether other factors are motivating the wish to die. We know, especially from vulnerable people, that situations of economic insecurity, lack of support, domestic abuse associated with the time of onset of the disability, etc., are all factors that can motivate suicidal ideation.

We're in a period where health care providers are being called upon to implement standardized protocols for suicide risk assessment. They're going to have a patient come forward to them with a wish to die. Do they invoke the suicide risk assessment protocol or do they proceed with the request? Our view is that there needs to be clear guidelines for physicians at that point. When there's a concern that it may be a factor other than the medical condition motivating the request, there would be a requirement to go to what we call a stage 2 assessment. We expect that with most people, the physicians will review the request, it will be clear that it's related to the condition, and the request will proceed. Where there's a concern that there are other factors at play, as in some of the examples that I laid out today, there would be a requirement to engage additional health professionals to inquire into what those conditions are. Is it that a family is completely burned out and stressed out?

7:55 p.m.

Liberal

The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant

You can talk a bit more. You have half a minute.

7:55 p.m.

Executive Vice-President, Canadian Association for Community Living

Michael Bach

Okay.

The family is completely stressed out, and we need to address that situation, because that's what's motivating the request.

Then, at the third stage, if it is these other factors that predominate in motivating the wish, the person would not be eligible to proceed with the request at that point. Our recommendation is that a psychiatrist may be needed in that process to help determine whether there's a mental health issue at play.

7:55 p.m.

Liberal

The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant

Thank you.

Senator Nancy Ruth.

7:55 p.m.

Senator, Ontario (Cluny), C

Nancy Ruth

Dr. Soles, early in your testimony you said that physician-assisted death is palliative care. Could you elaborate on that for us, please?

7:55 p.m.

President, Society of Rural Physicians of Canada

Dr. John Soles

Certainly. I think it's the other way around, though: palliative care is physician-assisted death. Palliative care is the assistance of someone through the last stages of life and involves symptom management, including pain management and so on. I think that whatever legislation is produced, the importance of providing palliative care needs to be emphasized.

7:55 p.m.

Senator, Ontario (Cluny), C

Nancy Ruth

At the end of your presentation you gave us a whole lot of questions to which I have no answers, so I'm coming back to you with them to ask for your best guess, or something like that.

You talked about the doctors who work together. They wouldn't necessarily be independent of each other. How do you get a second opinion or a psychiatric opinion?

You talked about patients who can't travel safely. You also asked what happens when everyone knows everyone, or what happens when there are radically differing medical views in the same community.

I don't know the answers to those questions. Can you give us a bit more help, beyond just stating them?

8 p.m.

President, Society of Rural Physicians of Canada

Dr. John Soles

Thank you for asking that. I'm not sure I have the answers for those either.

I think the role of telemedicine was mentioned. If we're looking at a patient who has requested a physician-assisted death and is in one of these communities in which there is only one physician group, it would be most appropriate that this patient be assessed by a second physician. If that can't be done in person, then it needs to be done in some other fashion; that would presumably be via video or telephone link, preferably video.

If you had a small community in which there was no physician willing to participate in this process, other than informing a patient about the process when a patient requested the information, that would create a great challenge. I really don't think it's appropriate for these decisions to be made without actually sitting in the room with the patient.

8 p.m.

Senator, Ontario (Cluny), C

Nancy Ruth

If the law were to allow a cocktail drug, such as is the case in Oregon, would you see that as being useful?

I don't know whether that's the word. I'm trying to figure out how nurse practitioners or other people in rural areas could deal with this, if there were a legitimate request, maybe assessed through telehealth, for physician-assisted death for someone who wants to stay in their home, whether in Grise Fiord in the high Arctic or anywhere else in Canada. A cocktail of drugs could be flown in by mail, as other drugs are sent by mail. Can you imagine that happening? What kinds of problems would there be?

8 p.m.

President, Society of Rural Physicians of Canada

Dr. John Soles

Certainly I can imagine it. As any physician who has provided palliative care does, I prescribe lethal doses of drugs to patients all the time without the expectation that they will take them.

Just to clarify that for the committee, if I have a patient who has terminal cancer, for instance, that patient will go home perhaps with a dose of medication that, if you or I had it, would be terminal. The striking thing to me is that I cannot recall, in my personal experience, any patient who has chosen to take their medication in that fashion.

I think the real challenge, if you're prescribing medications at a distance and sending them through the mail and they're being administered by the patient's family or a nurse, is to know what happens when things go wrong. I don't really want to make this comparison, but there have been cases in which death by lethal injection in the States has gone badly wrong, and those are cocktails delivered by physicians. I would hate to think of some nurse in Grise Fiord who has that kind of experience.

8 p.m.

Senator, Ontario (Cluny), C

Nancy Ruth

The provincial-territorial report recommended that all regional health authorities have an effectively funded care coordination system in place to ensure patient access to physician-assisted dying.

How would you see this coordination system being needed, particularly in rural communities, and what do you have now?

8 p.m.

President, Society of Rural Physicians of Canada

Dr. John Soles

I'm not sure what that process is in those provinces, so it's hard for me to comment specifically. I think there are a variety of networks in different provinces related to a variety of medical conditions, and some of them work well. Some of them do not. I think that over the next years, this kind of connectivity is going to improve, but what it will look like in different jurisdictions remains to be seen.

8 p.m.

Liberal

The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant

Thank you, Dr. Soles.

Senator Joyal.

8 p.m.

Senator, Quebec (Kennebec), Lib.

Serge Joyal

Thank you, Mr. Chair.

I would like to address my first question to Dr. Stern.

Dr. Stern, page 7 of your brief discusses rights of conscience. This issue has been discussed and raised by many witnesses. Yesterday we had the representatives of the churches, and they were wrestling with the issue of a physician or a care provider who would refuse on moral or religious grounds to be part of a physician-assisted death.

I'll read your recommendation to us, which is in the last paragraph on page 7:

With a view to ensuring patient access to care, an appropriate approach to consider is the one adopted under Quebec's An Act Respecting End of Life Care. In Quebec, a physician who refuses a request for medical aid in dying for reasons of conscience, must notify the designated authority

—I underline “the designated authority”—

who will then take the necessary steps to find another physician willing to consider the request.

Could you explain to us who the designated authority is and how it works in practice? The act has been implemented in Quebec, so I understand you might have the information we're seeking in relation to protecting the rights of conscience.

8:05 p.m.

Executive Director and Chief Executive Officer, The Canadian Medical Protective Association

Dr. Hartley Stern

It's been three years since I left Quebec, and there are some specifics of the implementation of this that I am not current with.

When we read Quebec's act, we felt that it offered a very elegant solution to a very complex problem for physicians, and that is that for those who truly have an inability on the basis of conscience to consider referring directly to another physician who would be willing to provide this, Quebec provides for an opportunity to refer the patient to the authority. Now, I am not certain whether this refers, under the reforms that have occurred recently in Quebec in terms of the way they have reorganized the system, to the hospital in one instance, or whether it's to a regional health authority, many of which no longer exist, or which authority they're referring to, but it is something that Quebec has contemplated as an elegant solution to try to assist physicians who have significant....

We think this a solution that could be adopted in other jurisdictions.

8:05 p.m.

Senator, Quebec (Kennebec), Lib.

Serge Joyal

The way I read that section of the Quebec act, section 31, in the case of a doctor practising in a hospital, it is referred to the executive director of the institution, so the institution is not neutral in that case. We had a witness last night who pleaded to us that institutions are also protected by the rights of conscience. In the case of Quebec, it's clearly in the act that the institution is not neutral; the institution has an obligation to provide the service.

In the case that there is a local authority that is not in an institution, they have to refer to the local community service centre, what we call the CLSC in Quebec. In other words, the public institutions have a responsibility to make sure that the request will be acted upon and taken care of.

Do you consider that this is safe protection in relation to the right of a physician to object to being part of physician-assisted dying?

8:05 p.m.

Executive Director and Chief Executive Officer, The Canadian Medical Protective Association

Dr. Hartley Stern

We, like everyone else who has appeared before you, have wrestled with this most complex issue of conscience. I know very well that in the Carter decision the Supreme Court specifically said that it is improper or unacceptable to compel a physician to participate in assisted dying.

Following that inability, the issue becomes “What then?” How do we move the patient to ensure the patient has appropriate access to someone willing to do it? Again, when I left Quebec as the CEO of a hospital, we were preparing. This was before the legislation was enacted. We were preparing for a mechanism, through the director of public health, to ensure that we would be able to provide a physician in that instance.

Each province has a different governance mechanism. I can't speak to every provincial governance and I can't speak to every provincial management system, but I agree with your position that the CEO of the hospital and the board of the hospital have an obligation to participate under the law of the land.

Again, I go back to the point that we think this is the best solution, a solution similar to what Quebec is providing for their patients in need.

8:10 p.m.

Liberal

The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant

Thank you, Dr. Stern.

Ms. Dabrusin.

February 4th, 2016 / 8:10 p.m.

Liberal

Julie Dabrusin Liberal Toronto—Danforth, ON

I would like to thank all of the witnesses for speaking with us today and sharing their information.

I want to thank you, Mr. Chipeur, for bringing us your expertise, your having been the intervenor in the Carter decision on behalf of the Christian Legal Fellowship.

I wanted to ask you a question because you mentioned the practice advisory that the Ontario Superior Court of Justice has issued. I just wanted to confirm that you understand that this is not legislation by the Ontario legislature.

8:10 p.m.

Lawyer, As an Individual

Gerald Chipeur

Yes, absolutely. It is something that the Chief Justice brought in, in light of the January 15 decision of the Supreme Court of Canada, and my suggestion is that it is a wonderful way for you go to. I am suggesting that you adopt the model that's currently followed.

8:10 p.m.

Liberal

Julie Dabrusin Liberal Toronto—Danforth, ON

But it isn't a legislative decision by the Ontario legislature to adopt court review for Ontario.

8:10 p.m.

Lawyer, As an Individual

Gerald Chipeur

You could adopt that model. You have that jurisdiction.