The MPs and senators on Parliament’s Special Joint Committee on Physician-Assisted Dying have been assigned the unenviable task of quickly cobbling together recommendations for new federal legislation on medical aid in dying. The committee has begun holding hearings, interviewing a breadth of key stakeholders.
From his perch in Lethbridge, Alta., Dr. David Amies, a member of DWDC's Physicians Advisory Council, has been keeping a keen eye on the proceedings in Ottawa and has written up a helpful summary of what he saw of this week’s hearing. Here’s are his observations.
The new Liberal government has assembled a committee of senators and members of Parliament to help it formulate its response to the Carter decision. The committee has begun its hearings and I sat in on two of them via video link earlier this week.
I must say how impressed I was with the tone of the meetings, the seriousness with which the topic was addressed and the civility of both the committee members and the witnesses. There was no doctrinaire grandstanding on either side.
The External Panel, set up by the previous government, has recently released its report. The Canadian Medical Association, the Canadian Nurses Association, the Canadian Pharmaceutical Association and the body representing the 5,000 or so psychiatrists in the country have all prepared position statements. The Provincial-Territorial Expert Advisory Gourp, organized by the province of Ontario, has also released its findings. The committee has begun to interview representatives of these important bodies and put questions to them on their findings.
Presentations from dueling panels
Prof Benoît Pelletier, representing the External Panel, was questioned at length about the panel's report. This report, more than 400 pages long, revealed that online survey involving 15,000 persons had been conducted, which revealed strong support for, among other measures, a national oversight body for physician-assisted dying, a desire for a national strategy on palliative and end-of-life care and improved palliative care education for all healthcare providers. It also concerned itself very greatly with semantics. Who is an adult? Who is competent for the purposes of making a request for physician-assisted death? What does a “grievous and irremediable medical condition" mean? What is meant by “enduring suffering that is intolerable to the individual”? How is the voluntary nature of the request to be guaranteed?
The representatives of the Provincial-Territorial group spoke very eloquently and were well-informed. Their work indicated that there was a strong body of support for the notion of PAD among Canadians. They acknowledged that there were some rough edges to be smoothed out in terms of definition. They had a more elastic definition of adulthood than the other witnesses. They suggested that a seriously ill patient’s desire to bring his or her life to an end should depend much more on their competence, and in particular their grasp of the implications of their decisions, than their age. In other words, they are suggesting that in some circumstances, requests for death from mature minors ought be considered.
Doctors', nurses' and pharmacists' groups have their say
The representatives from the Canadian Medical Association (CMA) appeared to be very concerned about the rights of doctors to refuse involving themselves in physician assisted dying (PAD). They went so far as to say that physicians who did not wish to take part for conscientious or religious reasons should not be obliged to refer a patient, making a request, to another willing practitioner. I did not hear them make it clear what should happen in such cases, for clearly they cannot be recommending that doctors can abandon their patients because of their own misgivings.
The CMA pointed out that there are over 85,000 registered medical practitioners across Canada and that although only 30 per cent have indicated their willingness to perform PAD, that still leaves 25,000+, who are willing. To some degree the CMA also shared the semantic concerns of the External Panel and felt that there should be some attempt to define the terms used in the Carter decision.
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Representatives from the Canadian Nursing Association noted that the Carter decision spoke only about the role of physicians in PAD. They pointed out that in many parts of Canada, physicians are not available and that medical services are provided by nurse practitioners or registered nurses. They maintained that such folk are able and qualified to provide PAD having consulted physicians via ‘tele-link'. The narrowness of language employed in the Carter decision was neatly illustrated when it was translated into French. The latter version spoke of medical personnel rather than only physicians. The Nurses Association pointed out that almost all of medicine is today carried out in a team setting and they saw no reason why PAD should be any different.
Representatives from Canadian pharmacists pointed out that their members are often part of medical teams. They had some concerns about pharmacists with conscientious objection to PAD should not be obliged to fill prescriptions aimed at supplying the agents that will bring about a patient's death. They also dealt with a very practical point. They said that the drugs used in PAD should be freely available across the country. For example, in some overseas jurisdictions barbiturates are used in the process. Such drugs have now become obsolete in Canada and are not widely available. There are several practical concerns about ensuring that there would be adequate supplies of this class of medication.
The representative from the Canadian Psychiatrist Association spoke at length about competence and how this could be affected by certain psychiatric illnesses. He was at pains to point out that a patient with a mental affliction might well remain competent. Some, however, would be rendered incompetent by their illness. He held that it would be the job of a consultant psychiatrist to tease these matters apart. It was reassuring to hear him say that many patients with mental illness are managed by primary care physicians and that those who made an application for PAD would not necessarily require a formal specialist psychiatric consultation.
Growing acceptance of assisted death as a valid end-of-life option
All endorsed the view that PAD should necessarily be part of end-of-life options and that health professionals must raise their game with communicating such options to patients. Likewise, it was generally felt that palliative care availability is not sufficient for this country. Medical representatives assured the committee that undergraduate training in the discipline is improving but fall far short of what is adequate. Everyone wanted a robust reporting system for PAD to enable facilitate oversight, research and teaching. The need for further education around the practical aspects of PAD will be required. It is not certain who could or would provide this!
What has been written above is a summary of my impressions of four hours of dense questioning and answering. I take full responsibility for any omissions or wrong conclusions that I may have drawn from what I heard. All of the witnesses and the parliamentarians appeared preoccupied with ‘what if’ situations. The federal politicians made it very clear that they had jurisdiction over changes to the criminal code but that health, by and large, fell to the provinces. Everyone hoped that the final process would not produce a patchwork of regulations across the country. They also appeared to be aware that any new law will be subject to challenges and amendment.
I came away impressed by the hard work and dedication shown by all concerned. I felt confident that a workable mechanism will be in place by June 6.
You can stream the hearings live, or watch recordings of completed sessions, on the committee's website.