In Carter, the court actually explicitly stated that Canada could avoid any of the problems Belgium is facing in the context of physician-assisted dying by adopting a strict regulatory regime that allows for less discretion. I noticed with some disappointment that the provincial–territorial advisory group now recommends a regime that is more flexible, less restrictive, and more open-ended than even the Belgian system. I invite you, therefore, to look in more detail at the documented cases and evidence about problems in the Belgian system, which I've documented in this memo, in order for you to fully understand the risk associated with a flexible and open-ended system. I have a more detailed chapter that I can share later with the committee as well.
I can only talk about the essence because I want to give more time for the proposal, but the essence is this: even if, in Belgium, physician-assisted dying requests are to be granted only when certain conditions are met, the vague and flexible criteria, coupled with the significant powers vested in physicians, have resulted in what I would call a quite open-ended access regime.
Individual physicians are the main gatekeepers, but their tools of competency assessment and informed consent assessment are questionable and difficult. There are documented cases of how it may not work in the Belgian system. More than 70% of the physician-assisted dying requests are now granted in Belgium, which is a significant increase over time.
In Belgium, physician-assisted dying has expanded beyond the original intentions of offering compassionate access and exceptional care. The numbers give you an indication. We have gone from 347 cases in 2004 to 2,021 cases in 2015, the latest number, but numbers tell us only so much. Obviously these could all be valuable cases, but they do suggest a normalization of the practice.
I want to emphasize, as I do in the memo, that it is actually more interesting to look at the areas in which physician-assisted suicide has expanded. I'm not saying that these are the majority of the cases, but these are cases that the committee should be aware of. It has expanded in areas that are more problematic and a bit more existential, such as suffering cases and also, increasingly, mental health. This expansion affects people who are experiencing life-changing disabilities; situations of loneliness, isolation, societal stigmatization, and rejection; difficulties with managing daily activities; and difficulties functioning independently. In those situations, good support measures and structures can prevent premature death, while all-too-easy access to physician-assisted dying can incite life-ending requests.
I won't discuss the many publicized cases in the memo that you have in front of you, which have been quite widely advertised, but I will say that these are not just anecdotal cases. They are actually real and lived physician-assisted dying experiences, which in some cases we have seen documented in detail. These are the publicly known cases.
In my main memo, I pay more attention to a less publicly discussed aspect: euthanasia in the context of mental health. I invite the committee to read this discussion in detail. When physician-assisted dying is defended in the context of mental health, it's often presented that PAD is only necessary and will only happen in exceptional cases of untreatable chronic depression, where physician-assisted dying is the only compassionate option, but reports in Belgium may surprise you. Also, ongoing research about practices in the Netherlands show that it now involves people suffering from personality disorders, post-traumatic stress, anxiety, eating disorders, schizophrenia, addiction, autism, and even profound grief. In most instances, according to ongoing research, it involved socially isolated, lonely people. In some cases, depressed people were euthanized without close family members even being alerted about the euthanasia request.
Reports have also raised questions about the safeguards in place. Again, you have documentation about that. I indicate why competency assessment is a notoriously problematic tool in very complex areas of mental health in particular, but certainly also in the context of disability, because, for example, it is influenced by the values of the physicians.
In Belgium, you have a small group of very committed physicians who are committed to physician-assisted dying and who by nature may be tempted to much more easily conclude that patients who are requesting access to physician-assisted dying are competent, and thus we see their lives being terminated.
There are also questions in many of these cases about how treatment resistance has been determined. Physicians may easily presume that people are treatment resistant, but this is a notoriously difficult thing to assess in the context of mental health, and it actually has been widely questioned.
I also discuss the limits of the reporting system with respect to the fact that there is still under-reporting, and also with respect to the fact that the reporting can actually give us the wrong sense of security. People are not looking sufficiently at exactly what is happening in individual cases, as is described in my memo. I won't expand on that here.
I will now turn it over to my colleague.