Physician-Assisted Dying Committee on Feb. 4th, 2016

[Rachael Thomas, Conservative, Lethbridge, AB]

I have another question for you, very quickly.

Based on what you've outlined here, could you perhaps help us understand, based on the rights that we're seeking to give other individuals in the nation of Canada, what rights are we robbing you of as an individual?

[Carmela Hutchison]

That's what I'm trying to get at.

Exclusion criteria, people need to be able.... This is a time when we have Google. This is a time when we have the ability to communicate electronically with health professionals, to collaborate and be able to come together to figure out solutions to problems. Instead, we complain that there's too much information and people don't bother to look it up.

I was at a point—and I want to talk about this, because this comes to the point where I talk about complications. The lab couldn't find a vein. They couldn't draw samples, so they refused to come up. What happens when somebody's requesting euthanasia? They couldn't come up. Nobody could insert a trach, because anatomically it wasn't a long enough space. I was intubated and I was awake for two weeks until there was enough air space so I could be intubated. There are many things like this. I couldn't get brain injury rehab early in my illness because I have a mental illness. There are many exclusions that happen. Those exclusion criteria have to be stopped. There are unrealistic recommendations all through this: that oh, the family doctor, you're going to have this conversation, and he's going to hold your hand all the way through, blah, blah, blah. No. I've had my family doctor since 1989. I've probably had 10 or 15 doctors, because you have an intensivist, and you have a hospitalist, and now there are rehab doctors. There have been different doctors all the way through this. So the vision—

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

Thank you, Ms. Hutchinson.

[Carmela Hutchison]

I'm trying to go quickly, but I've been cut off all the way through this. I would like to finish one question at least.

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

We have time limits because we have several questions and several witnesses.

I'm sorry. Thank you very much.

We'll move to Senator Nancy Ruth.

[Nancy Ruth, Senator, Ontario (Cluny), C]

To the Alliance of People with Disabilities, my understanding is that you want us to do the floor in Carter; you want the government to make a robust commitment to the ceiling stuff, and you want us to have a white paper. I don't know why. We've had a provincial-territorial report. We've had the external panel. We've had many, many witnesses on a whole variety of issues and ideologies: religious, legal, medical, whatever. Over 15,000 people responded to the questionnaire in the external panel.

What do you think this discussion is going to bring and add that we should not move in the direction of the ceiling now?

[Angus Gunn]

I accept all the observations made by the honourable member. We don't have draft legislation. The reality is that the translation of all that data—and I acknowledge it's a mountain—the translation of that mountain into operational legislation is the most critical phase of the process, and it has yet to happen. That's no criticism of anyone. I think these processes inevitably take time. The reality is that when this is reduced to a draft piece of legislation it will be appropriate and desirable, in my submission, for it to be given an opportunity for public scrutiny and comment. That's simply not possible except in a minimalist way in the timelines within which this committee is now having to work.

[Nancy Ruth]

That surely is the function of Parliament when a bill comes forward, both within the Commons and the Senate, to have public scrutiny of the bill.

Have you read the three bills that were proposed in the last Parliament, both within the Commons and in the Senate? If so, do you have any comment on them?

[Angus Gunn]

I'm sorry, but I'm not in a position to respond to that, and I think Ms. Birrell is not either.

[Nancy Ruth]

All right.

Do you have recommendations about specific procedural safeguards that we should build into the physician-patient relationship for physician-assisted death?

[Margaret Birrell]

You could look at the suggestion that someone who is going forward must have the opinion of two physicians. They have to have met with the person. If we have it in place that they have to have an in-depth discussion with two physicians, that would be the most basic safeguard. It also would allow the individual requesting it to change their mind. It also re-ensures that there be no pressure from others.

If you look at the Ontario Superior Court of Justice's position that came out six days ago, they are suggesting that some of the safeguards would be that family and friends be brought into the dialogue. Where is the individual who wants physician-assisted dying in this picture when you're pushing those kinds of structural barriers? I have never seen so much invasion, detailed invasion, on the rights of the individual as I saw in that paper that came from the Superior Court.

The safeguards should be very, very basic. They should be set up. No physician should be pushed into doing it. That system can easily be put in place. There should be no exclusion from health centres or hospitals or other facilities where the physicians want to administer the drugs. Those things can be put in place, and they are safeguards. There should be no pressure on the individual—

[Nancy Ruth]

I have a point of clarification.

[Margaret Birrell]

—but the system should be there.

[Nancy Ruth]

Nobody wants—at least, I don't want—to force anybody into doing any of this, whether they're the patient or the doctor, but after you talked about having two physicians—and I assume there'd be a consent form—that people should have the right to change their minds. Did you have a waiting period in your head when you said that? When people first consent to asking for this, did you want a delay of a few days, or whatever, before they reaffirmed their desire? What were you thinking of?

[Margaret Birrell]

What I was thinking of was that in the case of advance care directives, the person could change their mind, and that would be fine, but if you've gone as far as getting two physicians who are not pressured but are willing to assist and you have the consultation, the timeline is probably going to be very, very short.

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

Thank you very much.

Senator Joyal.

[Serge Joyal, Senator, Quebec (Kennebec), Lib.]

Mr. Chair, I apologize to the two previous witnesses, but I had to stay in the Senate for debates, so I missed the presentations. Of course, I listen carefully to each and every answer given to the questions by my colleagues. Unfortunately, Professor Somerville, I was not here when you were testifying, but I read before this meeting the op-ed that you published in The Globe and Mail on October 27, 2015, and I just heard the last sentence of your presentation. If I can quote the last line of that op-ed, I think it parallels your conclusion. You were promoting, of course, to protect, and I quote you:

...all of us as vulnerable people by upholding 'respect for life' (a preferable term to 'sanctity of life') in society as a whole.

I understand that you still maintain that fundamental position.

[Dr. Margaret Somerville]

Yes.

[Serge Joyal]

Okay, so then I feel safer to question you. I thank you for writing, because it's very challenging to read what you write.

When I try to wrestle with the concept of “respect for life”, is it not as much a code term, as with different religions filled with different beliefs or different sets of understanding? There are some religions which believe, for instance, that the death penalty for killing a policeman who is exercising their function is acceptable, and the same for a soldier. There are others who have the position, in terms of abortion, that it's okay for a short period but not after another period. Then there are other religions that would accept the concept of what is in PAD and so forth.

A respect for life is, in other words, a concept that could be filled by different content. In fact, it could have a religious substance. It could also have no religious substance. There are people who advocate respect for life even though they don't believe in any god. I would say it's difficult to follow you on that word because it is a word that opens a lot of avenues in front of us. I prefer, in a way, to follow the Supreme Court proposal, in a decision that it made almost at the same time as you published your article in mid-October, in le Mouvement laïque québécois in Quebec. I'm sure you know the decision. I want to quote just three lines of that Supreme Court decision, which illustrates my quandary about the concept of respect for life: “A neutral public space free from coercion, pressure and judgment on the part of public authorities in matters of spirituality is intended to protect every person's freedom and dignity...”.

It seems to me that's where we are wrestling with this concept of physician-assisted death. The state doesn't compel anyone to impose that. A doctor is free not to practise it; a person who feels it is not in sync with his or her belief is not compelled to have it, and so forth. Protecting the vulnerable; we all accept that. How can we reconcile your respect for life—

[Dr. Margaret Somerville]

I'll try to answer your question.

[Serge Joyal]

I know it's a thesis.

[Dr. Margaret Somerville]

If you look historically at the situations in which life could be taken, and I'm talking here about civilized societies and societies we would equate ourselves with in Canada, they were all situations where it was thought necessary to take life to save human life. Indeed, it's actually the trial judge in Carter who gives the example of self-defence: the reason you may kill without legal punishment in self-defence is that it's necessary to save innocent human life. It's the same with just war. It was the same originally with abortion; it was to save the mother's life. It's the same with capital punishment, because it was believed that if somebody had killed once, they would kill again.

Respect for life is not just a religious concept. We've used religion in the past—and this is what I said in my remarks—to uphold it, but it's not fundamentally just a religious concept.

The book that's best on this is by Jürgen Habermas, the German philosopher, who points out that it is a foundational value in every society in which you would want to live. The question becomes, does our legalization of physicians, putting it bluntly, killing their patients—because that's what they're doing—derogate from upholding the value of respect for life in society in general to such a serious degree that we shouldn't do it, even though we can understand why the person might want that and even though they're exercising their autonomy?

First of all, because I believe there are other completely set ways to deal with the suffering of the person, I've promoted that a health care professional leaving someone in serious pain is a breach of human rights. That's now recognized, for example by the WHO, by the World Medical Association, by the Canadian Pain Society, etc.

It's not that I want to leave people to suffer, but I just think that when you have the institution of medicine, which for 2,500 years has said that they will never kill, and which upholds the value of respect for life in society in general, and you've had a law, and the law of all societies like Canada says that you must not kill—that's what our Criminal Code says—and which upholds the value of respect for life, should we be derogating from that with this?

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

We have to close there. I suspect you two could go on Tout le monde en parle and have a wonderful discussion.

That ends this section of the first part of tonight's meeting.

We will suspend now, and we will resume in this room at 7 p.m. with another panel of witnesses.

Thank you to our witnesses for joining us.

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

I am calling the meeting back to order, after having been suspended for the last hour.

We continue with our 12th meeting of the Special Joint Committee on Physician-Assisted Dying.

We welcome witnesses who are joining us this evening. Thank you for taking the time and also for bringing your expertise to our committee's deliberations.

We have Dr. John Soles, president of the Society of Rural Physicians of Canada coming to us from Clearwater, British Columbia.

I think we're going to begin with Dr. Soles, because you never know; we could lose technical connectivity. If we start with you, that gives us a chance to get you back if we need to.

From there, we will go through the list of other witnesses, with Dr. Hartley Stern, Michael Bach, and Gerald Chipeur.

You're each given 10 minutes to speak tonight. We will begin with Dr. Soles.

[Dr. John Soles, President, Society of Rural Physicians of Canada]

Thank you for asking the SRPC to make a presentation to the committee.

The SRPC is a national voice for Canadian rural physicians. Our mission is to provide leadership for rural physicians and to promote sustainable conditions and equitable health care for rural communities.

I did send you a copy of the major points that I made in the fall to the external panel, and I won't repeat them in detail. Your request is for recommendations on a framework for the federal response on physician-assisted dying that respects the Constitution, the Charter of Rights and Freedoms, and the priorities of Canadians. I'm sure you're going to hear from many physician groups, and I suspect that most of them will have similar thoughts about this, as I have.

What I would like to do is give you a little background about rural Canada and a little framework of the major points that you wanted opinions on, and if we have time for further discussion about specific rural issues, then that would be what I would like to discuss more of.

As you know, Canada is 90% rural by geography, with slightly less than 20% of the population being rural. Roughly 10% of Canadian doctors work in rural areas. Canada's rural population is poorer; it's less healthy, and it has a significantly higher proportion of indigenous peoples, particularly in the north. Rural Canadians have less access to health care and may have to travel very significant distances, particularly in the north, to get such care. Canada's rural physicians are older, and they are much more likely to be international medical graduates—I'm an exception in that instance. The health care in very small rural communities may be provided by nurses and other health care workers rather than physicians. Access to specialists is limited, and most rural physicians work as generalists and include palliative care within their skill set.

That's where I'd like to start.

In designing legislation, it should be noted that good palliative care is truly physician-assisted dying. What we're really considering here is physician-assisted dying at an earlier moment in the trajectory of a life. As in all processes that are irreversible, it is vital that mistakes in assessment not be made. Patients who choose this option must be competent to make the decision, must have reasonable time to reconsider their decision, and must not have treatment options that will have a high likelihood of reversing their suffering.

Physicians are not uncommonly asked to assess competence; however, they may not have particular training or skill in this area. Legislation related to physician-assisted dying must be accompanied by clear definitions of competency, and must require patients to be assessed by two unrelated, unassociated physicians.

Although children are considered competent to make many medical decisions based on their understanding, I believe that initially they should be excluded from this process. If we do not allow adults to make decisions regarding physician-assisted dying for other adults who are incapable of consent—and I don't think we should—then we cannot allow adults to make those decisions for children.

In most other jurisdictions “adult” is defined as 18 and over, and I think Canada should use this definition as a starting point.

What is a grievous and irremediable medical condition? This is defined mostly by patients. There must be no treatment acceptable to the patient that will effectively relieve suffering and no major psychiatric condition that is treatable. If the condition that is causing enduring suffering that is intolerable to the individual is a psychiatric one, then assessment by two psychiatrists should be required prior to considering physician-assisted dying. If there is concern that there is a psychiatric condition affecting the request for physician-assisted dying, I think it would be reasonable to request a psychiatric opinion.

It's important in the evaluation of a patient who has requested physician-assisted dying that interviews be done in such a fashion that no one else can influence the patient. It's important to protect vulnerable patients from pressure from others, and it's important to ask patients about who else may have influenced their request.

The process is a challenging one, and I'm glad I'm not designing the legislation. There must be a formal process to make these requests. Patients will often talk to physicians about wanting to die, but if it came to actually requesting it, they probably would not do that. There must be some form of formal document that they sign.

There has to be an evaluation regarding competence and the presence or absence of psychiatric disease. There must be an assessment regarding other treatment options, and a discussion of what those might be and whether they are acceptable to the patient. There must be a second assessment, as I mentioned, by another physician within a reasonable period of time, and there must be an appropriate waiting time for reconsideration by the patient. All interactions and discussions must be well documented.

Finally, I will turn to the question of who does what. I believe that whatever the personal beliefs of a physician may be, they must be willing to discuss all legal options with their patients and make appropriate referrals if they themselves are unable to take part in that service. I think the way abortion works in Canada has some similarities. Physicians should not be obligated to be involved with a service that they have moral difficulties with, but they should be able to have such a discussion with their patients and to refer when necessary.

One of the questions that has arisen in discussions about this is death certificates and how they're filled out. I think death certificates should have physician-assisted dying as the immediate cause of death with the diagnosis that led to this as an underlying cause.

There are concerns in rural areas. The challenge in rural areas is often, as in the community where I live, that there is a group of physicians who work together, and how is it possible to arrange a second opinion about someone's suitability for this, or competence? I think it's inappropriate to do that within a group of physicians who work together. How is it possible to arrange and expedite a psychiatric consultation, if that's required, if all physicians in a group are conscientious objectors to this process? How do patients obtain a service, which is considered legal in a small community, where the physicians are not able morally to provide that service? This is a little different from the abortion discussion in that these patients are much less likely to be able to travel safely.

Where and how in a rural community where everyone knows everyone is it possible to carry out this process? What would the effect be on other members of the community? What would the effect be on the staff of a rural hospital? What would the effect be if there were radically different viewpoints within a small group of physicians?

Those are the important points of what I would like to say.