Physician-Assisted Dying Committee on Feb. 1st, 2016

[Grace Pastine]

Our position is not that the Supreme Court of Canada has made any pronouncements on the availability of physician-assisted dying for mature minors. It has not. It has in previous situations reflected on and ruled on the ability of mature minors to make health care decisions.

This is a distinction between Carter setting a floor and Parliament being able to raise the ceiling. We agree with you that the Carter decision refers to competent adult persons. Certainly there wasn't evidence before the court about making physician-assisted dying available to mature minors. That said, we recommend to Parliament that Parliament affirm the principle that physician-assisted dying ought to be available to mature minors, because that's in keeping with laws across Canada that have established that individuals under the age of majority have the right to make health care decisions when they are competent to do so.

[Jay Cameron]

Thank you for the question.

My position is twofold. First of all, the idea of mature minors is, to a certain extent, oxymoronic. They require litigation guardians for all sorts of civil actions in our society, and we don't trust them to litigate on a number of issues. They're growing. They're learning about themselves. They are subject to sometimes unreasonable depression.

There is a reason the court mandated that physician-assisted death was for competent adult persons. There are two components of that. One is competence, and one is adulthood. It appears to me that there are very good reasons for that.

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

My next question is for Mr. Cameron and the BC Civil Liberties Association witnesses.

The court repeatedly refers to “those who seek assistance in dying”. It's in paragraphs 69, 98, and 106. As I read that, and as the court puts it, it would seem that what the court was saying was that the patient must seek assistance in dying, as opposed to a physician, for example, offering suicide. What are your thoughts?

[Jay Cameron]

If I understand your question correctly, you're referring to the difference between counselling a person to commit suicide and the patient asking for suicide.

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

That's correct. In other words, the patient is the one who would clearly have to go to the physician. It would not be the physician, for example, listing a menu of options that might be available to the person. Do you see the distinction?

[Jay Cameron]

Absolutely, there is a distinction. When people face hardship and extremely difficult circumstances, the suggestion that the best thing to do or that one of the options is to end their life can take roots of its own, I think.

Irrespective of the reasoning behind the recommendation, it can become coercive. These proceedings aren't happening in a vacuum. They're covered in the media. People are aware of what's happened in Carter, and people are aware that on some level there is a right, as stated by the court now, to seek physician-assisted death.

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

Thank you, Mr. Cameron.

I know that others want to get into that. I'm afraid you're not able to, but you can throw it in later, if you want.

We'll turn now to Mr. Rankin.

[Murray Rankin, NDP, Victoria, BC]

Thank you. I'll be sharing my time with Ms. Sansoucy.

I want to thank everyone for being here. We have a very limited amount of time, so I'm going to jump right in and ask the witnesses from the BC Civil Liberties Association about the issue of vulnerability.

You very powerfully presented the issue of access, and Mr. Paterson talked about vulnerability in two contexts that I want to explore with you.

The first was that no waiting period should be required. We've heard testimony about how, after a debilitating injury, it seems that a lot of people—the majority, we've been told—who contemplate suicide have deep depression, so the argument would be that a serious waiting period would help to protect the vulnerable in those difficult circumstances.

The second point you made was that there should be no requirement, you argue, for a second doctor's opinion, yet you have said that a nurse practitioner or a doctor might in certain circumstances provide this and confirm consent. Would it not be terribly onerous to provide that second opinion from another doctor via telemedicine?

I'd like your comments on both issues.

[Josh Paterson]

Thank you, Mr. Rankin.

In terms of a waiting period in the situation of someone who has suddenly been injured and who feels as though they don't want to go on any further, I would echo what Professor Downie had to say a few meetings ago, which was that informed consent law and the practices that doctors already use in determining whether someone has the capacity to make a decision and whether they are consenting in an informed way already deal with that. It's open for doctors to say, “You know what? I'm not sure you are quite grasping the situation you're in right now” and to use their own judgment, according to the authority that's regulating them, to work with a patient on those issues. We don't see it as being a problem. Conversely, we see putting a waiting period in place as having the potential to create a lot of harm.

The second question had to do with the second doctor and whether there was telemedicine and whether we could make this easy and maybe have an app or something that one could use. We think that regardless of the technology, regardless of whether you can put together a facility that would allow a second doctor from a big city to provide a second opinion for someone living in rural community, it's just inconsistent with other end-of-life practices to have it as a requirement. Sure, if the doctor feels that he or she would benefit from the judgment of another professional, then by all means we think it's open for a doctor to seek that out, as doctors already do for other end-of-life decisions. For us it's more about keeping this consistent with other end-of-life practices than it is about the technology.

[Murray Rankin, NDP, Victoria, BC]

I'm not sure how much time I have, Mr. Chair, but I would like to ask one quick question and then perhaps turn it over to Ms. Sansoucy.

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

You have two minutes.

[Murray Rankin, NDP, Victoria, BC]

This has to do with the issue Ms. Pastine referred to concerning advance declarations. The Carter criteria describe enduring suffering intolerable to the individual in the circumstances of his or her condition. I'm thinking of Alzheimer's disease and the issue of dementia that Wanda Morris of Dying With Dignity referred to. By definition, the person would not be suffering or would not have the kind of enduring suffering, perhaps, if they were unaware that they were in pain. They're not in pain if they have dementia at the end of life. They might provide an advance declaration for that.

I take your point about ceilings and floors, but I wonder if it's open to us, in faithfully applying the Carter criteria, to address dementia as you've described.

[Grace Pastine]

I think it would be open to you, and we would, in fact, recommend that if your interest is making advance directives in the area of physician-assisted dying available to patients, that you explicitly set that out in federal legislation, because that would modify the consent requirement, the consent parameters, that were set out by the Supreme Court of Canada in Carter. It's possible my colleague, Mr. Paterson, would like to—

[Murray Rankin, NDP, Victoria, BC]

I appreciate that, but I wonder if I could ask Madame Sansoucy.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you.

My question is also for Ms. Pastine.

In some U.S. states—such as Oregon, Washington, Vermont, California and Montana—assisted suicide is permitted, but voluntary euthanasia is not. However, the Netherlands, Belgium and Luxembourg permit both assisted suicide and voluntary euthanasia. Voluntary euthanasia is permitted in Quebec, under the Act Respecting End-of-Life Care.

Could you tell the committee what your interpretation of the Carter decision is on the matter. Does the decision prompt Canada to permit both voluntary euthanasia and assisted suicide?

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

Ms. Pastine, you have 15 seconds.

[Grace Pastine]

Thank you for your question. Absolutely the Supreme Court of Canada's decision mandates assisted suicide and euthanasia. Our position is that it's absolutely inconceivable that the court's decision could be interpreted in any other way.

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

Thank you.

Senator Seidman.

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

Thank you very much.

You've all talked about the right of conscientious objection for the physicians, and clearly the question that comes forward is what the best means is to assure equity and access to assisted death for patients who want it while reconciling that with the charter rights of physicians with regard to conscientious objection.

The CMA, in their 2015 report on this subject, called for the creation of a separate central information, counselling, and referral system, and I'm wondering what your reactions would be to that approach. I put that question to all three of you.

[Wanda Morris]

Our primary concern is that patients not be abandoned. If that recommendation effectively allows for care to be transferred and patients to receive treatment, then we support it.

We do have concerns, though, about an independent agency being able to carry out that function without access to confidential information about who is providing assisted deaths. Also, we're really concerned that this shouldn't be outsourced outside the medical system so that an independent group perhaps would have to fundraise to provide that critical service.

[Judith G. Seidman]

Mr. Paterson.

[Josh Paterson]

Thank you.

I'd echo everything that Ms. Morris just said.

I would simply add that whatever body is there would have to have the capacity to respond quickly. There can't be backlogs or situations of “We're not going to get to it this week.” This needs to be done fast. Whatever agency is there has to have a really robust responsibility to put the wheels in motion to ensure that patients can get the care they've asked for.

[Judith G. Seidman]

Mr. Cameron.

[Jay Cameron]

I think that such a response is effective. I think it's favourable. If it is properly implemented, I think it's the best solution.

[Judith G. Seidman]

Mr. Paterson and Ms. Pastine, in your presentations both of you said that physician-assisted dying basically should be treated like any other medical decision and should be governed by the established norms of informed consent and competency assessments.

In that case, I would like you to go through the steps, as you see them, that should be involved in making a request for physician-assisted dying and then for the physician to respond to that request. In very concrete, pragmatic terms, how do you see that happening?