I'm Dr. Cindy Forbes, president of the Canadian Medical Association. I'm also a family physician from Nova Scotia. I'm joined today by Dr. Jeff Blackmer, vice-president of medical professionalism at the CMA. Dr. Blackmer has led the CMA's work on assisted dying.
Today I'd like to begin by first reviewing a brief history of CMA's public and physician consultations on end-of-life care, followed by an overview of our report, “Principles-based Recommendations for a Canadian Approach to Assisted Dying”.
Before doing so, I would like to flag two critical issues for the committee's consideration. Both issues will be central to ensuring effective patient access.
First, how can we ensure that the legislative and regulatory framework achieves an appropriate balance between physicians' ability to follow their conscience and patients' ability to access physician-assisted dying? Second, how can we ensure that we emerge with a consistent, pan-Canadian framework?
We will speak to these issues as part of our remarks and will welcome your questions during this appearance. We want to highlight the potential role of federal legislation as an efficient and effective means of addressing these issues.
I'll start with a bit of history. As the national professional association representing Canada's physicians, the CMA has long recognized the importance of end-of-life care. We've played an important role over the past couple of years, in particular by leading the national discussion on end-of-life care, including assisted dying. Over the course of 2014, the CMA initiated the broadest consultation in Canada in recent years. We hosted town hall meetings across the country, as well as an online dialogue, to consult with the public as well as physicians on issues related to end-of-life care. This consultation has been instrumental in informing both our position and our focus on this issue.
During the Carter case, the CMA appeared before the Supreme Court as an intervenor, as a friend of the court, with the purpose of representing the physician perspective. In its ruling, the court made reference to the CMA's position. Following the Supreme Court's landmark decision last February, the CMA initiated the development of recommendations to guide the implementation of assisted dying. The development of these recommendations included extensive consultation and deliberation with CMA's committee on ethics, with Canadian physicians, and with key medical and health stakeholders.
In addition, over the course of the fall the CMA met with numerous provincial and territorial health ministers to discuss these recommendations. Our recommendations have now been finalized and were publicly released last week. The committee has been provided with our “Principles-based Recommendations for a Canadian Approach to Assisted Dying”. Guided by a set of ten foundational principles, the recommendations address the following four areas: patient eligibility for access to an assessment for assisted dying; procedural safeguards to ensure eligibility criteria are met; the roles and responsibilities of the attending and consulting physicians; and how to appropriately balance conscientious objection with a patient's request to access assisted dying.
This last issue, that of conscientious objection, is one we would like to discuss in more detail, as it is of particular concern.
I will now turn the microphone over to my colleague, Dr. Jeff Blackmer, to discuss this issue.
Thank you, Dr. Forbes, and thank you, committee members.
Ensuring effective patient access across Canada will depend in part on how this issue is addressed. I would like to point out that a key focus of the CMA's work has been to ensure that both physicians and the patients for whom we care are represented in the overarching regulatory and legislative response to the Carter decision. As it remains in society, assisted dying is a difficult and controversial issue for the medical profession. It must be recognized that this represents no less than a sea change for physicians in Canada. As the national organization representing physicians, I cannot underscore enough the significance and the importance of this change.
As we have mentioned, the CMA has extensively consulted physicians before and since the Carter decision. Our surveys and consultations indicate that approximately 30% of physicians indicate that they would provide assistance in dying. It's important to note that for the majority of physicians who will choose not to provide assistance in dying directly, providing a patient with a referral will not be an issue for them. They will not consider it to be a violation of their conscience or of their moral code.
For other physicians, however, making a referral for assisted dying would be categorically, morally unacceptable. For these physicians, it implies forced participation procedurally that may be connected to, or make them complicit in, what they deem to be a morally abhorrent act. In other words, being asked to make a referral for assisted dying respects the conscience of some physicians, but not of others.
Part of the obligation of government and stakeholders is to ensure effective patient access by putting in place sufficient resources and systems. The CMA's framework accounts for differences of conscience by recommending the creation of resources in order to facilitate that access. It is critical that we provide clarity for physicians and their patients and that we develop a consistent approach across all jurisdictions.
The CMA is keenly aware of the risk if we don't—that a patchwork of differing and potentially conflicting approaches may easily emerge. That would not serve anyone well, doctors or patients. Today I can inform you confidently, and with gravity, that we are facing this risk. A number of provincial regulatory bodies have recently released draft or final guidelines on this issue. They differ either slightly or substantively on a number of important points. This is no longer a theoretical issue. We are indeed faced with a patchwork of approaches.
We look to Parliament for leadership to support the development of a pan-Canadian, national approach. The CMA's framework provides critical guidance for decision-makers in this respect. I must reiterate that in developing these recommendations, the CMA has given the issue our most careful and thoughtful deliberations, perhaps in the history of our organization, through the past two years. We've consulted at every step along the way with our membership, with the public, and with other health care stakeholders. Our recommendations are the result of this significant consultation in addition to our expert review of existing international frameworks.
I'm pleased to tell you that Canada's doctors stand ready to work with you to make sure that we are ready to respond in four months from now. As a country, we do not currently have a system in place to support us, but I'm pleased to tell you that the CMA's framework stands ready for your adoption.
Dr. Forbes and I would welcome any questions or comments you might have.
Good afternoon. My name is Anne Sutherland Boal, and I'm chief executive officer of the Canadian Nurses Association.
The CMA is a national professional association representing 135,000 registered nurses and nurse practitioners across the country in every province and territory. Today I'm joined by Josette Roussel, a senior nursing adviser in our organization.
At our core, our national association is an advocate for nurses, for Canadians, and for better health for all. Thank you for including CNA in the sixth meeting of the Special Joint Committee on Physician-Assisted Dying. It is our hope that the joint committee will consider the insight and specialized knowledge and expertise that nurses have to offer on the topic of physician-assisted death. We will also make remarks on the more general topic of end-of-life care.
Registered nurses and nurse practitioners are Canada's largest group of health providers. By the sheer size of the profession, which includes over 350,000 nurses, and the countless settings in which we work, we have the most consistent and direct interaction with Canadian patients and families seeking health care. Nurses are caring for people 24 hours a day, seven days a week, building trustworthy relationships with their patients, families, and caregivers. RNs and NPs are where Canadians are: at home, in the community, and in the hospital. In my following comments, when I use the term “nurses”, I am referring to RNs and nurse practitioners.
Canadian nurses have been closely monitoring the issue of physician-assisted death. In October 2015 we provided our views before the External Panel on Options for a Legislative Response to Carter v. Canada. We were also discussing and exploring implications for nursing practice long before the February 2015 Supreme Court of Canada decision and the Quebec Court of Appeal decision in December 2015. It is a topic of everyday discussion for Canadian nurses. Just yesterday, during a CNA webinar on end-of-life care, over 350 nurses focused on the ethical issues and nursing care related to physician-assisted death.
Canadians know that there is nothing easy, and Canadian nurses know that there is nothing easy, about watching someone you love experience pain and distress. We face these situations by advocating for patients and supporting one another as health care providers in honouring their wishes. Nurses have long supported patients and families during end-of-life care and planning and discussions. We are vocal advocates for improved access in palliative care across Canada. We believe that in addition to the work of your committee, efforts by policy-makers and providers must also continue the area of palliative care services and resources for all Canadians.
Nurses' practice in Canada is grounded in our code of ethics for registered nurses. My colleague Josette Roussel will now speak on the code and how relevant this issue is for nurses in Canada.
With that, I would like to introduce Josette.
I am a nurse, and I spent many years of my career taking care of end-of-life patients.
I will continue my presentation in English.
The Code of Ethics for Registered Nurses is a foundational document for nurses in Canada. To help me explain why it's important and how it helps nurses, I ask you to consider a scenario. An 85-year-old man is in the hospital after suffering a massive brain hemorrhage. He tells his daughter he's scared. He lies awake in his hospital bed throughout the night contemplating what will happen next. Is he going to die? When will he die? Will there be a lot of pain? These are big questions for anyone to face. As he lies there at 3 a.m. in the hospital bed, surrounded by strangers, one of the only people to turn to may well be the nurse.
Our code of ethics for registered nurses and the resources that CNA provides are to prepare nurses for those 3 a.m. discussions. The code is there to help nurses practise in a competent, compassionate, responsible, and ethical manner. It provides guidance on the person's right to refuse or withdraw consent. It also emphasizes the importance of recognizing power differentials between the care providers and the person in care, and what to do when care conflicts with conscience. The code provides practical steps on how a conscientious objection comes about: before employment, anticipating and planning for a conflict, and when one is involved in nursing care that is creating a conflict.
While nurses have their code to guide their nursing practice, they also need legislation, regulation, policies, and procedures. These structures will in turn help us as providers to ensure that Canadians have access to the care they deserve.
As nurses, we know that physician-assisted death is intricate and complex and we acknowledge the potential conflict between professional values, personal values, and health practice. However, with the Supreme Court's decision made, the CNA's priority is to help nurses deliver the best ethical and competent care to all patients.
I wish to speak to the requirements that are the most important to the Canadian Nurses Association.
First are safeguards to support individual decision-making by patients. Safeguards are needed to ensure that physician-assisted death is dealt with carefully, competently, and ethically. We recommend mechanisms for an individual patient to have conversations with families, caregivers, and the interprofessional team; policies and procedures to ensure competency assessment throughout the journey; processes for patients to reconsider their decision; processes to ensure that vulnerable patients are protected; mechanisms for nurses to contribute to the decision-making and assessment of the supports required by patients; and guidelines for the documentation by the interprofessional team of the discussions held and the plans made.
Second is equitable and timely access to information about end-of-life options, including palliative care and physician-assisted death. Canadians need to have equal access to physician-assisted death regardless of their postal code and their physical setting, whether home or hospital. Culture and gender as well as the acknowledgement of inequalities and disparities are also considerations.
Canadians and health care providers need to have access to resources and information to inform them on all end-of-life options. As plans for processes for physician-assisted death are being developed, we support a parallel pan-Canadian approach to palliative care. We recommend information, resources, and navigation for nurses to use in every setting to respond to questions posed by individuals, families, and caregivers, as well as education for health care professionals to support individual patient palliative and end-of-life care options.
Third, we request support for patient choice through a person-centred approach. The desire for a dignified death with relief from suffering should be considered at the core of a patient's request. Dignity is a key element of any plan. Patient-centred care honours people's values and health care wishes by promoting autonomy, choice, and control as well as shared decision-making. We recommend policies and procedures that outline how the team will communicate with individuals, families, and caregivers. We also recommend that there be guidance to ensure open discussion and sensitive listening that recognize cultural sensitivity and appreciate personal autonomy and spirituality.
Fourth are quality and safety mechanisms. It is essential to establish a rigorous process for assessing patients and forming a decision. The process must be well defined, documented, and understood in a consistent manner across Canada. We recommend systematic mechanisms, including standardized data collection systems and standardized policies and procedures to ensure accurate national data collection. We also recommend public reporting and a harmonized framework led by regulatory bodies that standardizes education and evaluation related to the competencies required of health care professionals.
Good evening, everybody. It gives me great pleasure to come here. My intention is to be helpful and to really let you know the experience of a palliative care physician.
I am a palliative care physician. I see patients in their homes in Toronto, and I am here trying to represent the views of the Canadian Society of Palliative Care Physicians. I'm going to respect the fact that you've had a lot of information thrown at you and just focus on four priorities.
The number one priority is that, at the same time as we legislate hastened death, we need to increase palliative care. There are three reasons for that. Number one is that less than 3% of Canadians are likely to avail themselves of services to hasten their death, yet 100% of Canadians can benefit from palliative care. Number two is that we know that palliative care is underserviced, and we know that 65% of patients currently die in hospital, which is not what Canadians want. Number three is that this is more than a political issue; it's a personal issue. All of us sitting around this table have had loved ones die. Some of them have died not so badly, and some of them have died badly. If we really want to respect choice, there has to be an option and there has to be good palliative care.
One of the ways in which we think this need for palliative care could be met is through a national secretariat for palliative care. There are lots of organizations that have laid the groundwork for a national strategy in palliative care, such as the Canadian Cancer Society and the Canadian Medical Association. People have thought of lots of ways to navigate this area.
The whole reason for having this done nationally is that Canadians support fairness, and right now, there's a patchwork. What you get really depends on where you live.
This initiative needs to be carried out at a national or federal level in order to set standards, monitor standards, and collect data—which we don't have—and to advise on such things as how to shift care from acute-care hospitals, which currently have 95% of the budget, to the community, which currently has 5%. We need some guidance, and we need to think about it nationally. How do we provide public education to try to dispel some of the fear around death and dying?
The second priority is reducing the risk of premature death. As palliative care physicians, we've all seen patients ask for assistance in hastening death, and then change their mind and say something like, “I'm so glad I couldn't do this.” This is not to imply that everybody will do that, but we need to have safeguards in place, and one of them is a waiting time that is proportionate to the amount of time that this person may lose in their living.
For example, when a woman who's dying of breast cancer, with potentially four weeks of life left, makes this request, we should be able to respond much more quickly than in the case of a 21-year-old gentleman who's just had a spinal cord injury and cannot imagine his life in a wheelchair. We know that people can accommodate a new normal, and a rigid waiting time will not do that.
We also need to make sure that the people who are exploring this request are skilled. If this young man spoke to a physician who didn't know about options, this physician might conclude that the situation was hopeless and that of course he would need hastened death. We know, as palliative care physicians, that most requests are expressions of despair, some of which we can help with. With great humility, I know that we cannot help everybody.
We also need to make sure we have access to addiction counsellors, psychiatrists, and spiritual care professionals to make sure that this patient has truly been supported. In the brief, I have made some comments on graduated implementation, and I'd be happy to answer questions about that.
The third priority is having a national oversight organization so that we have a pan-Canadian way of ensuring that everybody has access to this service. This could be bigger than that, because right now we do not have a problem, as Dr. Blackmer pointed out, with finding willing providers, but we have a big problem with connecting patients to these providers, and it should not be on the shoulders of Canadian doctors to self-organize.
This national oversight could not only be collecting data, looking at trends, and setting Canadian standards; it could also be a repository of willing providers, information, and referral services. Not every health care provider who is asked for assistance is going to have the resources to give this good information.
In addition to supporting institutions and regions that don't have a lot of resources, this separate oversight would really make the distinction that physician-hastened death is not synonymous with palliative care. We're concerned about this point because we've had to work very hard to make palliative care a safe option for people. If, in their minds, assisting in dying—which is what I do every day as a palliative care physician—is the same as hastened death, then we are going to prevent access to palliative care for some patients.
Finally, as a priority, we need to create a sustainable system. We need to offer protections in the Criminal Code for all of our health care practitioners—everybody, not just physicians. We also need to consider legislating for protection of conscience, because you cannot build a sustainable system on moral distress. I think Dr. Blackmer talked to you about this point. We need to make sure that institutions that opt out do so in a way that doesn't overly burden other institutions. As Anne pointed out, those providers who actually provide this service need to be supported with psychological support and spiritual support to make sure they're not overburdened.
Part of the sustainable system, I would put to you again, is making sure that this is seen as distinct from palliative care. I hope I've offered some ways that might happen.
Thank you, co-chairs, honourable members of Parliament, and senators, for the opportunity to present before this committee.
My name is Carlo Berardi. I'm a practising pharmacist in Sudbury, but I'm here today in my capacity as chair of the board of directors for the Canadian Pharmacists Association.
CPhA is the national voice for pharmacy in Canada, focused on advancing the health and well-being of Canadians through excellence in pharmacist care. Through our 10 provincial associations, we represent more than 20,000 pharmacists and pharmacy students across Canada.
I'm joined today by my colleague, Phil Emberley, who is also a practising pharmacist and the director of professional affairs with CPhA. We recognize that you all have an incredibly difficult task at hand, one that must balance the views and perspectives of various stakeholders, the public, and, most importantly, the patients. We are here today to speak to you about the role of pharmacists in physician-assisted dying and, conversely, the impact that physician-assisted dying could have on pharmacists.
Since the Supreme Court ruling almost a year ago, much of the public debate has focused on the role of physicians in assisted dying, and understandably so. However, physicians don't work alone. Rather, they are part of a larger system that relies on nurses, pharmacists, social workers, and other health care providers, each with their own scope of expertise and responsibility. While the Carter decision focused primarily on the role of doctors in providing end-of-life care, we have had the opportunity to reflect on the important role of pharmacists in both end-of-life care and assisted dying.
You have heard from various witnesses on the scope of the Carter decision and the extent to which other health care professionals should be involved in assisted dying. It is our opinion that regardless of how assisted dying is regulated in Canada, pharmacists will have a role to play.
Pharmacists are consistently rated as being among the most trusted professionals in Canada. Their accessibility and visibility within their communities also mean that pharmacists are often the first point of contact for patients who are looking for timely, evidence-based, and informed health information.
As a practising pharmacist, I know first-hand how the public relies on pharmacists for information on a wide variety of health issues, so it's quite likely that pharmacists will be asked to provide information on assisted dying to help in making an informed choice.
Over the past several months, CPhA has been consulting extensively with our members and with experts in the field in order to develop a policy position and framework to help inform governments as they themselves grapple with the issue. This consultation has included a national survey of pharmacists and pharmacy stakeholders, to which we received nearly 1,000 responses. The number of responses we received speaks to the high degree of interest within our profession.
We have also reviewed existing literature and looked at experiences in other jurisdictions that have legalized assisted dying to help inform our policy, and we will provide this information to the committee.
While we have not yet finalized our policy recommendation or a proposed framework for the role of pharmacists in assisted dying, we would like to highlight some of the areas that have consistently been raised.
As primary health providers, we are not surprised that assisted dying elicits various perspectives from within the profession, similar to what you have heard from our physician and nurse colleagues. We consistently heard that pharmacists care first and foremost about the health and well-being of their patients and about ensuring that their patients have access to the best possible care through their end-of-life journey. This means having access to high-quality palliative care, effective pain management, and assisted dying.
However, our consultations have also revealed some more practical considerations for pharmacists that we would like to bring forward today. While many of the concerns mirrored those of other health providers, including what you heard a short while ago from our colleagues at CMA and CNA, there are also issues that are unique and of particular relevance to pharmacists.
Regardless of the legislative framework that is put in place or of how the practice is regulated either federally or provincially, one of our primary concerns is ensuring the appropriateness and accessibility of drug therapies. There is no single drug that exists for the purpose of ending someone's life, so, as in the case of any other medication, we believe that the federal government must ensure that the prescribers and the pharmacists have access to the necessary drugs in order to provide the best possible care, including drugs for assisted dying.
In addition, we also recognize that existing jurisdictions that have legalized assisted dying have taken different approaches, each with different implications for how the actual practice is administered. While we have not finalized our policy and proposed framework on the role of pharmacists in assisted dying, we want to provide some context as to how some of the models could have an impact both on patient care and on the role and the responsibilities of pharmacists.
If we take Quebec as an example, assisted dying there is limited to medical aid in dying, which requires the physician to directly administer the lethal injection. The exact dosage and mix of drugs is set within the provincial framework, and while it's prepared by a hospital pharmacy, it is then administered by the physician in a hospital setting.
However, in parts of Europe and in the state of Oregon we've seen a broader approach that also allows for the oral ingestion of drugs in various settings, including in a home or community setting. In such cases, while physicians continue to play an important role as the prescribers, the role of pharmacists would expand significantly.
Beyond these issues that we feel are particularly relevant to pharmacists, we have also heard feedback from the profession that is consistent with that of other health providers. Pharmacists overwhelmingly support the inclusion of a protection-of-conscience provision in legislation. Like other professions, pharmacists feel strongly that they should not be obligated to participate in assisted dying if it is against their moral or religious convictions. In its ruling, the Supreme Court clearly stated that nothing in the declaration would compel physicians to provide or participate in assisted dying, and we believe that such protection must be extended to pharmacists as well.
While we also believe that patients have the right to receive unbiased information about assisted dying and how to access end-of-life care, like other health care professionals, pharmacists are divided on the obligation to refer someone to another pharmacist who is willing to fill a prescription for the purpose of assisted dying. Our priority remains ensuring patient access, so we encourage the government to examine options that could help facilitate referral while also protecting pharmacists' right to conscientious objection. Further to this, for those pharmacists who wish to participate, we strongly urge legislative frameworks that would limit the liability of health care professionals.
Regardless of the legislative framework, we want to ensure that pharmacists who are members of the interdisciplinary patient care team and also dispensers of lethal doses of medications are fully equipped to provide the necessary care to their patients. This means ensuring that there is effective collaboration between prescribing physicians and pharmacists and ensuring that pharmacists have access to appropriate information, support, and resources should they choose to participate in assisted dying.
Information about a patient's diagnosis and the purpose of the prescription, as well as confirmation of the patient's consent and confirmation that the patient has met all of the eligibility criteria, are key to ensuring appropriate dispensing and will enhance patient care at all points of contact in the system. We believe that this could help mitigate liability for all health providers involved.
We recognize that there is very little precedent to guide the government in addressing this important issue. This is a new area for pharmacists. Nevertheless, the pharmacist profession has the expertise in drug therapy, counselling patients on medications, and drug distribution to play an integral role in ensuring quality end-of-life care.
In conclusion, as this is a new and evolving practice, we believe that it will be critical to monitor and review the implementation of both federal and provincial legislation for years to come. We suggest that this be done through a national advisory panel of interdisciplinary health professionals that would include pharmacists.
In the coming weeks, we will be finalizing our policy and our proposed framework and we would be happy to share these with the committee.
We thank you for your time and we welcome any questions you might have.
Thank you, Mr. Chair. I'll start for us.
On behalf of the Canadian Psychiatric Association, we'd like to thank the co-chairs and committee members for this opportunity to present to you on this important issue.
My name is Karandeep Sonu Gaind, and I'm president of the CPA. The CPA is the national voice for Canada's 4,700 psychiatrists and more than 900 psychiatric residents. Founded in 1951, the association is dedicated to promoting an environment that fosters excellence in clinical care, education, and research.
My remarks today will focus on specific issues related to mental illness that must be considered in any physician-assisted death framework. The CPA is actively engaged in developing a full position with a range of specific recommendations. My comments today are meant to raise key points for the committee to consider in its deliberations, but should not be construed as CPA's final position on this issue. That definitive position is still being developed.
I'll start with key issues that need to be taken into consideration when discussing terms like “irremediable”, “intolerable and enduring suffering”, and “capacity” in the context of mental illness.
The evaluation of what is intolerable and enduring suffering due to illness symptoms is affected by the severity of those symptoms and impairment and by the individual's perception of their experience. The subjective assessment of “intolerable” and the predictive assessment of “enduring” can both be affected by mental illness in particular ways.
Mental illnesses can affect cognition and impair insight and judgment. Symptoms of cognitive distortions common with clinical depression include negative expectations of the future; loss of hope; loss of expectation for improvement, even when there may be realistic hope for positive improvement; loss of cognitive flexibility; loss of future-oriented thought; and selective ruminations focused on the negative and minimizing or ignoring the positive. There are commonly distortions of a person's own sense of identity and role in the world, including feelings of excessive guilt and worthlessness or feeling like a burden to others.
When clinically depressed, people also have lower emotional resilience and are less capable of dealing with normal life stressors. They can experience even moderate levels of stress as being intolerable or overwhelming. While we are not at the point of being able to apply this clinically, increasingly research findings are suggesting that there are areas of the brain with altered functioning during times of severe depression that correlate with some of these cognitive changes.
In terms of what is “irremediable”, careful consideration needs to be given about what this means in the context of mental illness. Irremediable, of course, cannot simply mean incurable. Many conditions in psychiatry and medicine are considered chronic and not curable, but things may be done to remediate or improve the situation. Multiple treatment options exist typically for even the most severe instances of mental illness, whereby symptoms and suffering may be treated and reduced, even if not cured.
It is equally important and essential to remember that the person is more than the illness. Psychosocial factors play an enormous role in a person's illness experience, particularly so in many mental illnesses. For example, if you take an overly narrow view of assessing “irremediable” only in the context of potential symptom improvement through biomedical treatments in severe depression, you potentially ignore remediating or improving the person's experience by addressing such key factors as social isolation or poverty.
I'll make some comments on “capacity” now.
In medicine we consider four broad components when assessing capacity: the ability to make a choice, the ability to understand relevant information, the ability to appreciate the situation and the consequences of decisions, and the ability to manipulate information rationally. Even when persons with mental illness can express a choice and understand and recall information, their appreciation of the situation and of present and future expectations, as well as their ability to manipulate information rationally, can be affected by the cognitive distortions previously discussed.
I want to emphasize that none of this is to suggest that simply the presence of any mental illness alone impairs people's judgment and cognition, but in the PAD discussion, by definition, we are talking about the most severe situations, and in severe cases of mental illness, the risk of such cognitive distortion is, of course, higher. We think with our brains, not with our hearts or limbs.
All these issues speak directly to the court's concern about ensuring the person is not induced to take his or her life at a time of weakness. Apart from the actual suffering caused by symptoms, if cognitive distortions are present, these distortions risk undermining the person's decision-making process. In the court's consideration of factors of coercion or duress, it would be as if the mental illness is undermining the person's autonomy to make a decision free from the influence of cognitive distortions. It's this recursive effect of symptoms on the evaluative process, where the very symptoms of mental illness may interfere with people's evaluation of their mental illness and its present and future impact, that poses the challenge.
Finally, one other point bears consideration. In the context of the court's finding of loss of liberty if a person chooses to end his or her life prematurely because the person fears eventually becoming unable to take their life in the face of progressive physical incapacity and suffering, mental illnesses on their own very rarely, if ever, lead to such progressive and severe physical incapacity.
With that as a general background, and again emphasizing that the full CPA position is still being developed, there are a few guiding principles we can offer at this time.
First, when a psychiatric illness is present, in order to ensure that nuanced issues that could affect decision-making are properly assessed and to allow for time for potential remediation of symptoms and/or psychosocial factors, multiple assessors with suitable skill sets should do sequential assessments over a period of time. Our final position will reflect more specifics, and there may be varied mechanisms depending on jurisdictional needs and resources, but spreading the assessment over multiple suitable assessors who are aware of the potential impact of mental illnesses on cognition, capacity, etc., and also having sequential assessments are necessary safeguards.
Second, the concept of irremediable and intolerable and enduring suffering should not be exclusively focused on the biomedical condition but must be considered in the full context of the person's condition, including the potential impact of possible psychosocial interventions on suffering and symptoms.
Next, psychiatrists may choose not to be involved in the PAD process, consistent with what you have heard from other professional organizations. In such situations, patients requesting PAD should have access to information regarding available PAD resources and the referral processes, including psychiatric resources as required.
Finally, it is important to recognize that the term “treatment-resistant depression” or “treatment-resistant mental illness” in general does not define an illness that is irremediable. “Treatment-resistant” in this context is typically used to help guide the course of further treatment options using an evidence-based approach. This should be explicitly articulated in any PAD framework to avoid risking conflation of the terms “treatment-resistant” and “irremediable”.
I'd like to end by thanking the committee once again for your thoughtful consideration of these issues, and I'm happy to answer any questions that you may have.
Thank you to our witnesses for being here tonight.
I was particularly encouraged to hear you, as professionals, openly declare your concerns about some of the subjective nature of the language that is being used—“irremediable”, “intolerable”, “enduring”. I think this underscores for us as committee members the severe nature of this topic that we're dealing with and how important it is for us to deal with it seriously and to move with extreme caution.
Over the last number of years, I've devoted a fair bit of my time to dealing with mental health issues and suicide prevention. I know that since 1991, there have been no fewer than 15 initiatives in Parliament to authorize physician-assisted suicide. All of these have been defeated. Parliament, in fact, in the last couple of years, has strongly supported some suicide prevention initiatives. Currently the Public Health Agency of Canada is undertaking the job of creating a federal framework for suicide prevention, which is a result of the passage of Bill . In fact, today the Bell Let's Talk initiative is all over Twitter. I don't know how many thousands or millions of tweets have gone out.
Society is concerned about continuing their concerted efforts on suicide prevention. For me, then, it's something of a paradox that we have these initiatives to prevent suicide going on in our country and our health agency, yet here we are, looking at ways to give greater access to suicide.
It's quite clear that physician-assisted suicide is an irreversible act. We know from some of the mental health studies that have been done that people go up and down and that people's minds change over time. We also know that depression is by and large a treatable condition, and you pointed out in your testimony, Dr. Gaind, that there are varying degrees of success.
One of my concerns is that in terms of giving access to people who may be suffering with mental health issues or depression, what additional safeguards should this committee be looking at to make sure we are protecting some of our most vulnerable at the most vulnerable times in their lives?