Proceedings of the Subcommittee to
Update "Of Life and Death"
Issue 2 - Evidence
OTTAWA, Tuesday, February 15, 2000
The Subcommittee to Update "Of Life and Death" of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:00 a.m. to examine the developments since the tabling in June 1995 of the final report of the Special Senate Committee on Euthanasia and Assisted Suicide, entitled "Of Life and Death."
Senator Sharon Carstairs (Chairman) in the Chair.
[English]
The Chairman: Good morning, honourable senators, witnesses and those in the viewing audience. Today is the second day of hearings under our mandate to update the unanimous recommendations of the 1995 Special Senate Committee Report on Euthanasia and Assisted Suicide entitled "Of Life and Death."
I would remind honourable senators and witnesses that this committee is not reopening the debate on assisted suicide and euthanasia; rather, it is dealing strictly with the areas of the report where the original committee made unanimous recommendations. I would ask everyone to bear this in mind as we proceed through the hearings.
Today we have two witnesses. I welcome both of you. I would ask you to try to stay within the 15-minute time frame for your opening remarks; however, I do not have a stopwatch.
Before we hear our witnesses, Senator Roche has a comment.
Senator Roche: This comment will be brief and is not intended to be argumentative. It concerns the point I raised yesterday about the scope of the work of this committee with respect to the differentiation between the majority and minority points raised in the report.
I did not have the terms of reference before me yesterday to refresh my memory about the second point therein. While the first point is that the committee will study the unanimous recommendations of the committee of 1995, the second point is that it would look at all aspects, and I had that in my mind as to how the committee would differentiate.
My interpretation of the testimony of the witnesses yesterday -- though they had a right to express their views -- is that they were moving into areas that had previously divided the committee by looking at ways of enlarging the manner in which people can be assisted in the decisions they must take.
As I said, it is not my intention to argue that point here. You may wish to reserve comment on this and give me your advice at another time. That is perfectly fine with me.
I do not have it perfectly clear in my head as to the limitation of testimony. If witnesses are in a sense leading the members of the committee in their testimony, as I thought they were doing yesterday, then it seems to me that the committee, in looking at what it is going to discuss and hence recommend, would have difficulty seeing that fire wall. It would be difficult to detect a sharp distinction between what the minority was advocating with respect to assisted suicide and voluntary euthanasia and what the committee as a whole did recommend.
There is ambiguity in my mind. I wanted to register that with you and seek your guidance with respect to it. Is there any actual limitation on what the committee will examine, particularly in terms of point 2 of the terms of reference?
The Chairman: All I can say is that, according to the wording in the Journals of the Senate, point 2 refers to developments in Canada respecting the issues dealt with in the report. We can certainly look at some of the issues dealt with in the report, but I think that the overarching responsibility of this committee is the progress on the implementation of the unanimous recommendations made in the report. When we write our final report, that will certainly be the focus to which I ask the people at this table to begin the drafting process. I think that is where the focus should be.
Having said that, there are developments that have happened in Canada that will make addenda to the material, but we will make no judgment on those addenda. For example, if in fact there have been some legal cases that would add to the body of knowledge, we should make reference to those legal cases. However, I do not think we should make any judgment on those legal cases.
Senator Roche: I found your comments most helpful. I should also like to reregister my concern. Perhaps if there were some way in which we could discuss this question at an appropriate moment, I would find that helpful.
The Chairman: We will certainly discuss it when we are going to give instructions to those who will be drafting the original report.
We will begin now with Dr. Lapointe.
[Translation]
Dr. Bernard Lapointe, President of the Canadian Palliative Care Association and the Association québécoise des soins palliatifs: Madam Chair, the position of the Canadian Palliative Care Association was presented to you six years ago by Dr. Ina Cummings, who was the association's president at the time. Our position on euthanasia and assisted suicide has not changed since that time.
This morning, I will specifically focus my comments on your report's recommendations on the development of palliative care.
I would like to say, on behalf of the Canadian Association, that we appreciate your courage and leadership in dealing with the difficult and painful questions in your 1995 report. I am appreciative of the opportunity to meet with and report to you this morning on the evolution of palliative care.
As you noted in your report, there are many reasons why a person may request assisted suicide or euthanasia: unrelieved pain or other physical symptoms, depression and psychological suffering, isolation or untenable living conditions, perception and reality of being a burden to spouse, family, society, or despair and lack of self-esteem which are the result of catastrophic illness.
[English]
As you know, the palliative care approach, as we describe it in the Canadian Palliative Care Association -- you have the definition at page 4:
...is aimed at the relief of suffering and improving the quality of life for persons who are living with or dying from advanced illness or are bereaved. It affirms life and regards dying as a normal process. It neither hastens nor postpones death. It provides relief from pain and other distressing symptoms. It integrates the psychological and spiritual aspects of patient care. It offers a support system to help patients live as actively as possible until death. It offers a support system to help the family cope during the patient's illness and their own bereavement.
The association is a national voice of hospice palliative care in this country. We represent over 18,000 volunteers and health care professionals across Canada, and we have 11 provincial member associations, of which l'Association québécoise de soins palliatifs is a member.
[Translation]
The Association québécoise de soins palliatifs has approximately 650 members spread out throughout the province.
[English]
The Canadian Palliative Care Association seeks to ensure excellence in the provision of hospice palliative care so that the burdens of suffering, loneliness and grief are reduced. It seeks to accomplish its mission through collaboration and representation with other national organizations.
Increased awareness, knowledge, and skills related to hospice palliative care is afforded the public through our 1-800 number, which is available to every Canadian in the country who wishes to know more about care, services and where to turn for help in their own community for health care providers and volunteers.
As well, we seek to achieve our objectives through the development of national standards of practice for hospice palliative care in Canada -- and I will return to that topic later -- the support of research in hospice palliative care and advocacy for improved hospice palliative care policy, resource allocation and support for caregivers.
I speak to you this morning with a sense of urgency. Despite some progress in improving access and qualities of care in some regions, we are seriously concerned about the future of end-of-life care for Canadians.
As you know, Canadian society is undergoing profound demographic changes. The population is ageing. As well, there is significant rise in the mortality rate predicted during the next 15 years.
These demographic changes highlight the acute need for palliative care services, and will fuel, undoubtedly, the debate over euthanasia and assisted suicide in our society. We all know that the Canadian population is ageing. However, the health care system and health policy are not planning adequately for this crisis. For example, on page 12, there is table that shows the growth of the number of Canadians over 85 years old, which will increase significantly over the coming decades -- from 21,000 in 1921 to 140,000 in 1971. Statistics Canada estimated 400,000 people over 85 in 1998 and estimates that we will have over 1.6 million people over the age of 85 by the year 2041. As you all know, the most pressing needs for those over the age of 85 are social support and health care.
Statistics Canada underlined that, in 1996, 46 per cent of all the elderly in institutions were over 85 years old. We all know the prevalence of degenerative diseases, particularly Alzheimer's in this age group. The prevalence is high and rising.
The other point that accompanies the ageing population, and certainly an aspect that is less known, is the increase in the number of total deaths that will occur during the next decade or so. We do not have statistics from StatsCanada, but we have statistics from the Ministry of Health in Quebec that show that, from the year 1996, where we have an estimated number of 54,078 deaths, we will encounter, in 2015, 69,700 deaths. These numbers might look somewhat different. However, as you can see, the population will grow.
On the next page, we see the numbers per 100,000, which is where we see that there will be a significant increase, that is, 21 per cent of the number of deaths between 1996 and 2015 in Quebec. Every community in Canada will face a similar increase in the number of deaths. We know what that means in terms of the burden on these communities, the families, and so on.
The number of deaths will increase. The proportion of deaths in our community will increase. There is not only that to consider. We also know that the causes of these deaths will change. Since 1980, according to StatsCan, the number of deaths linked to cardiovascular disease has decreased significantly. There were 34 per cent fewer such deaths in 1996 than in 1980. However, the proportion of deaths caused by cancer and other degenerative diseases will continue to increase over the next decades. Therefore, more and more Canadians will need and demand competent, compassionate palliative care and end-of-life care.
We know from public opinion polls we have conducted and focus group consultations that we have held throughout the country that Canadians want to be sure that their loved ones are receiving the best possible end-of-life care. However, as I speak to you this morning, only a minority of Canadians has access to palliative care services. The majority of those dying do so unnecessarily in pain, suffering and discomfort. The quality of dying for most Canadians is determined by their disease, their social network, and their financial means. With health care being increasingly devolved to the family, the stability of the family is threatened by the financial and emotional burdens heaped upon them.
I will turn now to the recommendations contained in your 1995 report. The first recommendation is to make palliative care programs a top priority in the restructuring of the health care system. To my knowledge, only four Canadian provinces have palliative care designated as a core service with its own budget line. Since the publication of your report, the number of palliative care beds has been cut across Canada as a result of health care reform. The survival of many programs is in jeopardy because of the difficulty of recruiting physicians and other trained staff.
Because palliative care services are not adequately funded compared with other health care services, hospice and palliative care services rely disproportionately more on charitable donations for their survival, such as paying for nursing care, volunteer coordinators, psychologists, and so on. We have yet to see a national palliative care strategy with demonstrated leadership from the federal government.
There is no effective inter- or intra-departmental strategy planning taking place within Health Canada on issues of end-of-life care and hospice palliative care. Very little provision, if any, of palliative care exists on First Nations reserves or in federal penitentiaries.
Canadian Palliative Care Association operational funding from Health Canada through the National Voluntary Health Organizations Program has been terminated this year. Compared with the $1 million received in operational funding by the Canadian AIDS Society each year, the Canadian Palliative Care Association was receiving $30,000 annually.
The second recommendation of your report dealt with the development and implementation of national guidelines and standards being continued. In 1995, with Health Canada's support through the National AIDS Strategy, a preliminary consensus was achieved on a first round of these standards. In 1998, with funding from the Canadian Breast Cancer Initiative, a national consensus was achieved on 70 per cent of standards.
In 2000, the CPCA has received $46,000 from Health Canada of an estimated $450,000 in costs to complete and disseminate national standards. Progress toward completion is very slow. Canada needs national standards to ensure that all Canadians have access to high-quality hospice palliative care services. Without national standards, the potential exists for substandard end-of-life services and undue suffering. I refer here to people who proclaim that they deliver palliative care services in the home. We have seen hospices in which patients have had to be carried on the back of a volunteer to the second floor. We have seen substandard nutritional status of those patients and so on.
Another of your recommendations dealt with the training of health care professionals in all aspects of palliative care being increased. I have to report to you that the creation of the new certificate in palliative medicine developed jointly by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada is a significant step in the right direction. However, as we speak this morning, only 7 of the 16 Canadian medical colleges have applied to offer this program.
Despite all we know about the growing need for end-of-life care and the explosion of clinical knowledge in the field, only a minority of medical, nursing, social work, psychology and other health care programs offer palliative care training. There is no accreditation process in Canada to ensure professional competence in palliative care for those who are practising in their field.
Another of your recommendations was that there be an integrated approach to the delivery of palliative care, whether in the home, in hospices or in institutions with the support of volunteers. You state that that must be coordinated to maximize effectiveness and that the provision of respite services is an essential component. With the exception of certain initiatives in Calgary, Edmonton, Ottawa, and certain parts of Montreal, this remains wishful thinking. Health care budget cuts have prevented support for the development of partnerships and collaboration models. For most Canadians, the choice of where they will be cared for does not exist. Whether they live in inner cities or in rural Canada, a large proportion of the elderly cannot count on family support when facing life-threatening illness. Respite care is rare and, as a result, caregiver burnout leads to rehospitalization.
Your last recommendation was that research into palliative care, especially pain control and symptom relief, be expanded and improved. We share with you the affirmation that the most promising approach to improving the quality of palliative end-of-life care for Canadians is the generation of new knowledge through research. The Canadian Palliative Care Association has invested a great deal of effort in promoting the need for palliative care research in developing -- for instance, a Canadian agenda for research in palliative care, conducting meetings throughout the country, and consultations with members of the public, caregivers and the teams of researchers in 1999.
We have as well held protracted and, unfortunately, unsuccessful negotiations with Health Canada to develop a Canadian palliative care initiative focusing on training and research.
An analysis conducted by an independent consultant firm of funding provided by three key research funding agencies over the past five years confirmed the relative lack of research support being received in the field of palliative care.
In fact, the two major agencies that provide ongoing programmatic research funding to Canadian investigators, the Medical Research Council and the National Cancer Institute of Canada, have supported just a few operating grants in palliative care research, amounting to a tiny fraction of their overall funding for health research in this country.
The lack of sustained funding from the two national funding bodies, MRC and NCIC, represents a major impediment to the generation of new knowledge that could improve care for dying patients and their families in Canada.
Since the publication of your report, Canada has lost a significant number of key researchers. If we look at the ten key researchers we had then, in 1995, we have lost four to other countries over the last three years. The total absence of end-of-life research and palliative care research from the new Canadian Institutes of Health Research structure, despite considerable advocacy by CPCA and its members, speaks of a bleak future.
The current lack of capacity in the form of independent investigators in the field of end-of-life and palliative care research is a significant barrier to progress. Only an immediate and concerted research strategy aimed at capacity building will allow the emerging field of palliative care research to survive over the next decade in this country.
In conclusion, the hospice and palliative care community of this country is very appreciative of the clear recognition in the 1995 Senate report of the value of the palliative care approach for all Canadians facing life-threatening illness and their families. In this presentation, we have highlighted the relative lack of action on your 1995 recommendations. We urge you to show strong leadership so that all Canadians will benefit from competent and compassionate end-of-life care and that no Canadian will consider euthanasia and assisted suicide as their only way of exercising control over a life filled with pain, emotional suffering, social isolation, and the feeling of being a burden to their family and society.
The Chairman: I was not surprised by your remarks, although they were even stronger than I thought they might be. I appreciate your forthrightness.
I now call on Dr. MacLachlan.
Dr. Richard MacLachlan, Head, Faculty of Medicine, Dalhousie University, College of Family Physicians of Canada: Madam chair, I greatly appreciate the opportunity to appear before the Senate for the second time in six years for this important continuing discussion. At both appearances, I have been representing the College of Family Physicians of Canada. I have included some information about the college in the brief, which I hope was circulated to you this morning. It is available in both official languages. I will not repeat that information here, but suffice it to say our college is a voluntary organization that represents over 15,000 family doctors in Canada. We as a group provide the primary medical care to the majority of Canadians.
I would like to highlight the activities of the college's committee on ethics in the intervening five years since we appeared here in November 1994. Following the release of your report "Of Life and Death" in June 1995, we continued the discussion of the issues we raised in our brief to you the previous November and your report and recommendations. We felt it was important to encourage national discussion of these issues and, following an extensive consultation, published a discussion paper in the Canadian Family Physician, our journal of the college, which is circulated to an excess of 30,000 Canadian general practitioners, family doctors. The article was publish in February 1997, and we titled it "Lobbying the lawmakers: the College and Assisted Death." You should have a copy of that article in the package that was delivered to you this morning. In that article, we tried to outline the background behind our presentation to you in 1994 and our feeling that we needed urgent public and professional debate on this topic concurrent with governmental action. We welcomed advice from readership on this topic.
During the subsequent two years, calendar years 1997 and 1998, we continued active discussion of the issue, including analysis of the rather overwhelming input we received from the readers of our 1997 article. Based on that input and our thinking at the time, we drafted a statement on euthanasia and assisted suicide, which we circulated to two other committees of our college, the committee on health care of the elderly and the committee on palliative care, as well as other key individuals in the health care profession nationally. We put those three committees together in November 1998 for a real thrashing out of the statement and made major changes to it. The following month, December 1998, we took our statement on euthanasia and assisted suicide to the board of directors of the College of Family Physicians of Canada and it was adopted unanimously by them.
The college's committee on ethics subsequently circulated the statement on euthanasia and assisted suicide to all 16 medical schools in Canada, the licensing authorities, and other key individuals. Nevertheless, we felt the need to ensure wider dissemination of the statement, and we have worked to develop an explanatory article, which was actually -- perhaps this is more good fortune than good timing -- published last Friday and circulated to 32,000 Canadian family physicians today. It is the lead editorial in the February issue of the Canadian Family Physician. You should have a copy of that also in your brief. I think it will trigger significant discussion of the issues.
I wish to point out that the pre-print copy you have has one typographical error. It says that it was adopted in December 1999 when in fact it was December 1998, as I mentioned. That has been corrected for the journal, but you got a slightly premature copy.
What we have tried to do in this editorial, and indeed in our statement, is to demarcate what is good, ethically acceptable clinical practice and what activities at the present time are illegal in Canada. We have tried where possible to restate what we felt were clear statements of facts in your document "Of Life and Death." For example, the statement that "a decision to withhold or withdraw certain treatments might result in an earlier death of a patient, but this consequence is ethically acceptable and legally permissible if carefully and thoughtfully made," I believe is entirely congruent with your report.
We focused on the importance of ascertaining patients' wishes, including their possible wish to forgo life-sustaining treatment, ideally well in advance of any crisis. We noted the need to involve other family members in decision making, particularly when the patient was no longer capable of expressing his or her wishes. We focused on the intent of care, noting as you did in "Of Life and Death," that "providing treatment aimed at alleviating suffering that may shorten life is legal."
We tried to be explicit that "all care aimed at alleviating symptoms due to advanced, terminal disease is ethically acceptable and legally permissible if administered to relieve the patient's suffering, if it is commensurate with that suffering, and if it is not a deliberate infliction of death."
We noted that concerns that treatments aimed at alleviating suffering might occasionally hasten a patient's death were overstated, particularly as it relates to increasing doses of opioids or narcotics. We noted the reality is that the suffering of many dying patients is caused by, or related to, being undertreated.
We urged readers, whether professionals or lay, to continue discussions on these important topics, and we welcomed feedback to the statement. The feedback since it was released 14 months ago has been overwhelmingly positive.
As I look back at the discussions in 1994 and 1995, I would contend that the Special Senate Committee on Euthanasia and Assisted Suicide seemed to be challenging organized medicine, our professional associations and medical schools to take leadership on these issues. I would contend that "we have gone as far as we can go" -- to quote Rogers and Hammerstein -- without legislative reform and other governmental action, as recommended in your 1995 report.
There is much unfinished business relating to the recommendations included in "Of Life and Death." You have requested input and advice. We were certainly encouraged that the recommendations that we made to the Senate in 1994 were largely incorporated in your 1995 report. Unfortunately, my feelings are similar to those of Dr. Lapointe, that there has been little perceptible activity in the intervening five years. Your chair, Senator Carstairs, in her motion establishing the subcommittee, indicated that your mandate should be to examine the progress on the implementation of the unanimous recommendations in your report, so what I will do is try to respond section by section to your 1995 report.
Your first chapter with recommendations was chapter 3 on palliative care. I would agree with Dr. Lapointe that there has been little discernible government action on the five recommendations. I would acknowledge that there has been some discussion of increased attention to home care. As Dr. Lapointe noted, the Royal College of Physicians and Surgeons and my college, the College of Family Physicians of Canada, have agreed upon a common one year of extra training acceptable to both colleges following certification by either college. Whether you come out of a royal college program in neurology or cancer care or respiration or come out of my program in family medicine, you will do one common year and be certified with special competence in palliative care. Our colleges have come together and created the framework for programs to submit proposals. Those are underway right now with the possibility that these programs will commence this coming summer. However, to put on residency programs requires governmental support. It is only the minority of medical schools that have been able to get that support to launch these residency programs.
With respect to the development and implementation of national guidelines and standards for palliative care, as you recommended in 1995, our palliative care committee of the college is currently developing clinical guidelines for care at the end of life. We were not aware of any significant expansion and improvement of what you recommended -- that is, research into palliative care, especially pain control and symptom relief -- beyond the Health Canada support for the Canadian Palliative Care Association to establish a working group to look at what the research agenda should be, as Dr. Lapointe described earlier.
We need to recall that this is five years later, and we are looking at support to develop an agenda. I think we have lost a crucial five-year period for this research activity. As I said to the Senate in 1994, and you quote in your report, "only with a comprehensive palliative care program available throughout the country should there be consideration of assisted suicide or euthanasia". My feelings have not changed.
Chapter 4 concerns pain control and sedation practices. We are aware of little, if any, progress on the recommendations in this section. Indeed, the case of Regina v. Dr. Nancy Morrison in Nova Scotia -- and, this was based at my hospital, where all criminal charges are now dismissed -- has put a chill on appropriate analgesic management of dying patients. Your report stated, on page 31, that "the committee recognizes that providing treatment aimed at alleviating suffering that may shorten life is legal." Your first recommendation in chapter 4 was that "the Criminal Code be amended to clarify the practice of providing treatment for the purpose of alleviating suffering that may shorten life."
The failure to indicate what specific amendment was needed to support your first statement and the absence of legislative initiative may have, perhaps inadvertently, only added to the confusion and, potentially, the under treatment of our patients.
Chapter 5 concerns withholding and withdrawal of life-sustaining treatment. We are aware of little, if any, progress on the five recommendations in this section. As I mentioned earlier, our college has amended our professional guidelines to be consistent with your report, but we have gone as far as we can go. We cannot proceed with further amendment of our professional guidelines without the legislative changes and other government actions contained in your 1995 report.
Chapter 7 relates to assisted suicide. We are not aware of any activity on the two recommendations for change in this section.
Chapter 8 covers euthanasia. This is often challenged with the current interpretation of euthanasia, but we must remind ourselves that the Greek interpretation means "good death". We would all advocate good death, but in the context of your report "euthanasia" has a different interpretation. We are not aware of any progression on the two unanimous recommendations in this section requiring specific action by government.
In summary, I would echo Dr. Lapointe's comments that we are grateful the Senate has chosen to reactivate discussion on this important topic after five years of virtual inactivity. Public discussion continues, including a lot of attention this last week on the front pages of national papers. The college has attempted to foster public and professional discussion on these crucial and complex issues. Our statement on euthanasia and assisted suicide has been welcomed by many as an important step forward. We ask you to review it carefully as you proceed to build on the work done by the Senate in 1994-95.
The lack of parliamentary action on your 1995 report is clearly causing unjustifiable, continuing confusion, pain and suffering for patients, their families and care givers.
The Chairman: A number of senators have already indicated that they want to be on the questioning list.
[Translation]
Senator Pépin: Dr. Lapointe, there is much talk about reduced services due to hospital budget reductions. It seems that health care reform is focussing more on home care. If we are to make new accommodations regarding health care services, don't you think that home care will receive more attention? Should we focus specifically on home care?
It would be cheaper for hospitals but more expensive for patients. The more seriously ill patients will have to be hospitalized, of course, but there is an increasing trend towards sending people home. So should we not pay more attention to home care services?
Dr. Lapointe: For most of us, home is the best place to be. It is where we live with our family, it is the place where our relations take place and it lies within our community. That is where life unfolds and, of course, everything revolves around home.
However, we have to destroy the myth that every terminally-ill patient wants to be at home. Last year, polls showed that most Canadians would rather be looked after at home if they were terminally ill.
However, when we broke down the poll by age group, we realized that the desire to stay home falls off as people reach age 65 and beyond. Fewer people aged 75 and over want to stay home, whereas after the age of 85, the opposite happens: people would rather not be looked after at home anymore for several reasons.
One of these reasons is the absence of a natural caregiver, such as a member of the family who is able to look after the loved one, such as the spouse or a child. Just think of the elderly who live in remote villages in Gaspésie whose children have moved to the city, or people who are isolated downtown and who cannot see members of their family.
Also, when you have a terminally-ill person at home, they may die there. Home care is a good idea when the conditions are right. But there have to be alternatives.
In Canada, some specialized institutions within the communities create a home for the seriously ill and hospital services are offered for those who request it. We know that most of the costs of home care are paid by the family.
The presence of health care personnel is limited by the budgets that shrink away according to the time of the year. For example, before March, at the end of the fiscal year, the availability of nursing staff is very limited. This means that the spouse or family member who is caring for someone in the home must take time off work and risk losing income.
This year, the Canadian Palliative Care Association decided to concentrate its efforts on calling the federal government's attention to the importance of protecting families against the often disastrous consequences of agreeing to care for a family member in the home. We know that this can lead to a loss of jobs, of income, et cetera.
Senator Pépin: These people can never take a day off.
Dr. Lapointe: No. People of course prefer to remain at home, but when we talk about home care, we imagine an end-of-life health care administration system that will be sufficient and able to cope with the demand seven days a week and 24 hours a day. If there is a crisis at 2:00 a.m., you want to be able to reach something other than voicemail. Within our communities, we need residences for institutions that will recreate a family setting at a lower cost, institutions that will be able to handle crises requiring acute care or even hospitalization. We must think of the Canadians who suffer from degenerative illnesses, such as Alzheimer's disease, who end up in homes where they have no access to palliative care expertise.
Senator Pépin: According to your statistics, there is an increase of 21 per cent for people who are dying. It upsets me to see that AIDS agencies were given a million dollars in grants while your association only received $30,000. Further on, we see that there was an increase in 1998. Can you explain that to me?
Dr. Lapointe: The comparison was not meant as a complaint because the Canadian AIDS Association received those amounts but it weighs the grants that were given for the operation's budgets. We are comparing $30,000 to a million for operating budgets and not for budgets related to specific projects. Of course, we benefitted, as I indicated, from other sources of funding that allowed us to produce training materials for visiting homemakers and for those who supply palliative care on the street for intravenous drug users. We published documents, courses and curriculum vitae for a number of professionals thanks to this support. Unfortunately, all of the funding is exhausted in completing these projects, and in the meantime, we must survive. Even if the Canadian Palliative Care Association is the only organization that promotes palliative and end-of-life care in Canada, it is having a difficult time at present.
[English]
Senator Pépin: My next question I will ask of you both. You say, on page 27, that only 7 of 16 Canadian medical colleges have applied to offer this palliative care program. Do you know the reason for that?
Dr. MacLachlan: Perhaps I can use my own medical school as an example. We intend to offer the program starting in the summer of the year 2001 as a one-year program. We have not yet been successful in getting government support for the residents' salaries. In order for a resident to complete that program, he or she would require a salary for that year. It would cost about $42,000 a year, plus a few other costs of training. We have not yet secured the funding. That is why we did not think we could offer the program for the summer of 2000.
Many other schools are in the same position. We want to offer the program. There is no question that we have the resources and the expertise to do so. We just do not have the support for the residency positions at this point this time. It seems pointless to offer it until we have secured that support.
Does that relate to your situation or to your knowledge of other programs, Dr. Lapointe?
Dr. Lapointe: In a few universities, the expertise is simply not available to participate in the residency program of palliative care. We monitor what is going on in the delivery of curriculum. We are particularly concerned with the absence, in the majority of our medical schools, of an undergraduate curriculum in end-of-life care or palliative care beyond communication issues and ethical issues. That means, in a good number of our medical schools, there is no clear curriculum on pain and symptom relief. There is no clear curriculum on end-of-life care, per se. That is worrisome.
Senator Pépin: You refer in the brief to the total absence of end-of-life palliative care research from the new Canadian Institute of Health Research.
[Translation]
If I understand correctly, at this time, no research is being done in the area of palliative care?
Dr. Lapointe: If I look at the documentation provided by Canadian institutes, it mentions cancer research, but nowhere is palliative or end-of-life care mentioned. We vigorously seek out and meet with many people who are in a position to influence the development of end-of-life and palliative care institutes in order to have these places concentrated and not spread about here and there according to the institutes' wishes. Of course, when you have to choose between curing people of a disease or making those who are going to die of it more comfortable, traditionally, the decision has always gone one way.
We are quite worried about the lack of willingness to create an institute for end-of-life or aging care where concerns for palliative or end-of-life care could be clearly addressed.
[English]
Dr. MacLachlan: The research of the Canadian Institute for Health Research often tends to be disease-specific, focusing on diseases such as AIDS or cancer. We all will die but not all of us will die of aids or cancer. Many of us will die from heart disease or in the emergency department. Many will die in critical-care units. Many will die of lung disease, not necessarily cancer-related. If we tend to focus on disease, rather than on the process of dying, then palliative care does not get adequate recognition. That is a real problem with the mandate of CIHR.
[Translation]
Senator Beaudoin: Dr. Lapointe, you say that everyone is in favour of palliative care and that we should have national standards. I agree with that because the medical profession is the same everywhere.
But as someone who is in charge of a Canadian, federal, movement, et cetera, and who is well aware of the situation in Quebec, do you foresee certain jurisdictional problems in this area? Health can sometimes be a provincial responsibility and sometimes it is federal.
For palliative care, I think that the provinces have a fairly large role to play and we should take that into account in our report. We are all in favour of palliative care and we would all like the federal government to intervene, but do you think there might be a jurisdiction problem?
Dr. Lapointe: It is obvious that health care and services are a provincial jurisdiction. That is why this morning I took the time to point out the absence of palliative care, and therefore a lack of leadership, in areas of federal jurisdiction, that is, among other things, in the administration of health care and services on the First Nations reserves, as well as in federal penitentiaries. The federal government has to play a preeminent leadership role and it should begin in its own backyard, as they say in Quebec: on the one hand, it must demonstrate an interest in offering health care and services in Canada penitentiaries for inmates who are living with cancer or AIDS and, on the other hand, on the First Nations reserves, for Aboriginal people and their families who are facing a terminal illness and who require end-of-life care that is specific to their culture.
Senator Beaudoin: And the armed forces?
Dr. Lapointe: Thank you for reminding me; in military hospitals as well. Then, there are health promotion roles that are the responsibility of the federal health department. For example, Health Canada is responsible for the training of professionals, through its support for the development of national standards.
Do you remember, some years ago, when geriatrics was becoming an emerging practice in Canada? A number of doctors said that they practised geriatrics because they cared for a number of elderly people. It is not because you are caring for the dying that you are offering palliative care and it does not mean that you have the necessary knowledge or expertise to care for these people. Anyone can say that they do, but as long as there are not standards for best practices, then we have a problem.
The federal health department also has a role to play in post-secondary education and research. Grants would obviously allow for the emergence of a critical mass of researchers and professors in medical and nursing schools as well as in other professional institutions of learning.
Therefore I would say that yes, there are jurisdictions, and each of our provincial associations is lobbying. I can tell you, for example, that the Quebec Association will be submitting an important and imposing report in the coming weeks during a provincial tour where we have checked on the availability of services as they exist in each region, indicating the status for each of these regions. The association will be submitting a strategic plan to the minister that is aimed at correcting the deficiencies that we have noted throughout the province of Quebec. Each of our provincial associations will be undertaking this lobby, however, within the federal government, there are a number of areas for which the federal health department is responsible.
Senator Beaudoin: I wholeheartedly agree with you when you say that both levels of government are responsible for a number of areas depending on the sector.
[English]
My second question is addressed to Dr. MacLachlan. Part of our mandate is centred on withdrawing, withholding and the Criminal Code, because the Criminal Code is a federal statute. Since our 1995 report, has anything of significance happened at the judicial level in either of those areas? The law is always evolving. We regularly amend the Criminal Code of Canada. Our Criminal Code is good, but nothing is perfect, therefore, we must amend it from time to time. There are also cases before the courts. Our judicial system is very strong and, in my opinion, accurate.
Over the last five years I did not notice many cases that touched on those two issues, but I know there must have been some. You told us that the charges were dismissed in the Morrison case. That happened in your own province. In other provinces we had jurisprudence of the court of first instance, in the Court of Appeal and, in the Supreme Court of Canada with the Rodriguez case. What developments have there been in those two particular areas in the last five years, that is, withdrawal and withholding of treatment?
Dr. MacLachlan: The difference from 1994 to the year 2000 is that there is a clear understanding among health providers that it is ethically supported and legal to either withdraw life-sustaining treatment or withhold the treatment. There are guidelines for that and, as I mentioned, the best approach is to discuss it with the patient, ideally when they are able to give directions as to what they would wish. Failing that, you have discussions with the family members. However, it is very clear, from both the courts and professional standards of practice, that we are not obligated to offer futile treatment. That is very clear.
There have been a couple of legal speed bumps. There was one situation in Winnipeg where the courts ordered reinstatement of the need to undertake cardiopulmonary resuscitation, but that was subsequently dropped after extensive discussion with the family. I believe that was more a communication issue. That was one case that caused us some concern that, indeed, the courts were going to override statements by health-care providers that cardiopulmonary resuscitation in that case would be futile.
The Chairman: To interject, I believe you are talking about the Sawatsky case.
Dr. MacLachlan: Yes.
The Chairman: In fact, Dr. MacLachlan, it was not withdrawn. The patient died. His wife was still pursuing that legal action against the hospital at the time of his death.
Dr. MacLachlan: Thank you for that clarification.
That did give us a bit of a jolt because we had been working on the understanding that we were clear, we were in keeping with your report on withholding and withdrawal of treatment, that that was an accepted professional standard where care was futile and ideally where this followed the wishes of the patient or the family.
With respect to the withdrawal, withholding of therapy, I do not think there is much controversy in the country. I believe that is accepted as a standard where you can demonstrate futility and, ideally, that you have the assent of the patient or the family.
Senator Beaudoin: We were unanimous on those two points and I believe we were also unanimous on the guidelines. The guidelines, in my opinion, are very important. They may perhaps vary from year to year, to a certain extent, because this is the way we legislate in our country. We try to improve legislation. In my opinion, that is the role of the Senate.
Are you aware of any case that has improved the situation in that particular area?
Dr. MacLachlan: I am not aware of any case that has improved the situation. The Sawatsky case has caused us to be cautious.
The implementation of the first recommendations from your 1995 report would be very helpful for some clarity on this issue. We could then support the third recommendation to develop professional guidelines to match the amended Criminal Code.
Senator Corbin: Dr. MacLachlan, in your paper you spoke about ethics and morality. What distinction do you make between the two?
Dr. MacLachlan: There is a subtle distinction. We have our own set of moral values that drive individual behaviour. Morals are more individual and drive behaviour. Ethics is more a pooling of those moral values, trying to come up with a societal norm. Both can be dynamic. However, ethics is more a global reflection of society's moral thinking at the time.
Senator Corbin: I was a member of the earlier committee and heard, among others, a witness from Montreal who spoke about ethics. That particular witness said that, in this day and age, you do not tell young medical students how to ethically conduct themselves. Those may not be the exact words. The meaning of that statement was that you set out in a broad way what medical ethics is all about, but then individual medical practitioners interpret ethics in a clinical environment in whatever way they wish.
My question is: If there is such a thing as a medical ethical code, how strictly is it adhered to by individuals? Is there room for wide interpretation? Does a person's sense of morality come into play in these situations, or is it strictly cold, clinical ethics?
You referred a number of times in your paper to your guidelines, which I do not assimilate to be the same as morality or ethics. What are the barriers? What are the common fringes between the various notions? Ultimately, how does a doctor in a clinical situation resolve these conundrums?
Dr. MacLachlan: Our reference point for ethics, as far as the practice of medicine, is probably best reflected in the code of ethics that comes from the Canadian Medical Association that has been in place for over 100 years but is revised frequently. Its last revision was four years ago.
If you asked me where is my reference point today for decision making, it would be a brochure that I have on the wall in my office and in all my examining rooms which is the CMA code of ethics. It is helpful to know what that body has stated. My college and the Royal College of Physicians and Surgeons have endorsed the code.
That is perhaps the best reference point from which we might determine ethical professional behaviour in this case. Unfortunately, these tend to be general statements, such as: That I am not to denigrate the reputation of my colleagues, but I am to report unprofessional activity to the appropriate authorities. However, would that apply in the case of a physician who I felt was not prescribing medications appropriately? Very general types of statements tend to come from the code of ethics.
We then take those and develop guidelines for clinical practice and for professional activity in specific areas. That is what we are trying to do with the statement on euthanasia and assisted suicide. We wanted to reflect the current code of ethics of the Canadian Medical Association and apply it to the areas of assisted suicide and euthanasia. We had hoped to demarcate what was ethical practice, what was good clinical practice, and what are practices that are clearly illegal at this point in time in Canada.
There is a significant amount of information available, particularly from the report. My worry is that, if you were to ask any of the 55,000 doctors in Canada today for the best reference point for statements about the intent of treatment and alleviating suffering and what if it advances death, not many would have "Of Life and Death" in their bookcases. That is regrettable; it is a very well written document.
We wanted to take reference points that we felt were clear and develop them into guidelines for physicians to use from February 2000 as a reference point in patient care. Our goal was to take the code of ethics as well as reference documents such as yours, and develop a practical aid for physicians to use in making clinical decisions.
One of the things we raised with you in November 1994, was that we operate in a patient-doctor dyad. We tend to have individual decisions to be made in clinical care based on an individual patient, that patient's own moral framework, environment, their wishes, and their family's wishes. That is the locus of our operation is a one-on-one dyad with a patient and their family in their environment and context.
The law may not be particularly helpful in a one-on-one dyad. We do not want to urge health care providers to break the law, but the law must apply to the country. We must operate on a one-on-one dyad with you and your family. That is why we need guidelines that are perhaps more explicit, but we cannot advocate activities that are clearly illegal. That is why we have been trying to say to physicians: "Beyond this point is illegal. Do not go there."
I am not sure if I answered your question, Senator Corbin.
Senator Corbin: The presentations this morning were substantial in terms of ethics, morality, philosophy and what life and death are all about. I am not in a position right now to admit that I have absorbed all of the statements. I certainly wish to reflect upon them. I may write to the witnesses to ask them to clarify some of their statements.
I rapidly read the editorial. What I get from it is that things are evolving constantly. Medicine must re-adjust itself to standards, ethics and so on. You are doing that and that is positive. You are trying to help your membership and the general public.
Parliament, unfortunately, in my opinion, has refused to address this matter front on. This committee must tell the governments, Parliament, and assemblies, that these bodies are not assuming their responsibility. One of the most frustrating things following the presentation of our report was that very few people moved the way they ought to have moved.
Dr. MacLachlan: To pursue your comment in the context of what I referred to earlier, there is no question that at my hospital, following the arrest of Dr. Nancy Morrison, our approach to pain control was very different. I am not sure we are back to where we were, much less at the current standard.
It was a shock to everyone that a physician who seemed to be wanting to care for a patient and alleviate suffering -- I will not get into the specifics of the case, but it seems to most of us who know something of the case that the intent was to alleviate suffering -- would be charged with murder. I think the repercussions of that case, although the charges have been dropped, have not yet been forgotten. I would urge you to proceed with a very important task to give us the clarity we need.
Senator Roche: This question is in the form of a comment to Dr. MacLachlan, not excluding Dr. Dr. Lapointe if he wishes to join in this. Like Senator Pépin, I was neither a senator nor a member when the committee compiled this report. Since I did not participate in it, I feel freer than perhaps my colleagues do to say it is an excellent report.
Dr. MacLachlan: It is.
Senator Beaudoin: We agree with you.
Senator Roche: I thought you might. I am always looking for agreement.
Although it has taken a little while, I think I have finally figured out what this committee is all about. I am sitting here asking myself why the recommendations on palliative care, pain control and advanced directives and so on have not been taken seriously by the government. The testimony of both our witnesses this morning is a devastating comment on the inaction by the government.
That leads me to conclude that, while palliative care as a centrepiece of this discussion this morning is a growing social need in our country, it is not on the political agenda, and I must ask myself why. Dr. MacLachlan, in your last comment to Senator Corbin, you touched on what is on my mind, and that is the confusion in the public mind and the government's sensitivity to shying away from yet one more controversial question in our society. I think that it is the public's inability or hesitation in differentiating between bona fide palliative care and all that it takes into account, which includes the voluntary termination of life-sustaining medical equipment, assisted suicide and involuntary euthanasia.
I am not presenting this as any definitive analysis, but I wonder if the government, in receiving this report, noted that the committee itself was divided on the questions of assisted suicide and involuntary euthanasia. I wonder if that division drew the attention of those government persons, whether in the justice department or finance -- I hope we will hear from them in due course -- and sapped their attention, thus reducing the attention they paid to the unanimous conclusions of the report. If I may put it in crude terms, the committee was divided because some wanted a "gutsier" reaction by the government than the very important steps that needed to be taken. Both our distinguished witnesses this morning have said society is suffering as a result of the almost indiscernible government action toward what the committee felt was necessary to enhance the life condition of those in a terminal illness.
I suppose Senator Carstairs and her colleagues were right in saying that this time we should get a report that deals with what was unanimous in 1995. They advocated a report going forward to the government that presses the government to take action on what we are all agreed on, and which has been highlighted here this morning, and that is palliative care. Perhaps this time the government will listen.
Dr. MacLachlan, you said in referring to the fallout from the Morrison case that it made the persons in your profession "gun-shy", if I may use that term, about steps that they could take. It probably made them gun-shy in approaching the government. In other words, everyone is going soft on hitting the government hard on palliative care and home care and everything that goes with that because they are afraid of being misinterpreted as advocates for involuntary euthanasia or assisted suicide.
Assisted suicide advocates and involuntary euthanasia advocates get so much publicity in the country. This has resulted in a public interpretation of the issue that has brought us to this table this morning on the topic of assisted suicide rather than palliative care.
The palliative care advocates are being tarred by the assisted suicide advocates. I put that to you, but not as a definitive analysis for I have not been here long enough. Please give me your opinion of my thinking.
Dr. MacLachlan: You have given it a lot of thought. There was very helpful comment in the report early on in the definition section that attempted to clarify the difference among euthanasia, assisted suicide, and withholding of treatment. Euthanasia was described as being the causation of death; assisted suicide being assisting with the death; and withholding/withdrawal of therapy being watching death unfold, if I can paraphrase the definition section.
You are correct in thinking that we are, perhaps, confusing good palliative care practices with assisted suicide. That is why I wanted to highlight what seemed to me to be one of the more crucial actions that you recommended in 1995. The Criminal Code should be revised to match your very clear statement in the document that providing treatment aimed at alleviating suffering that may shorten life is legal. You made a very clear statement and went on to reflect in chapter 4 that perhaps the Criminal Code needed to be amended to be explicit on that. You alluded to the fact that we do need urgent action on that, so that palliative care does not get tarred with the brush of assisted suicide and euthanasia. We would all agree with what you are advocating in your statement.
Good palliative care is appropriate treatment for alleviating suffering. It may hasten death. In many cases, that has been overstated. Appropriate treatment with narcotics and opioids may not hasten death and may actually prolong life because a person is under less stress because they have less pain.
You are very apt in saying that we, perhaps, have done palliative care a disservice by not being clear about what we are advocating in your statement that treatment aimed at alleviating suffering which may shorten life is legal. A very clear statement on that and, perhaps, changes in the Criminal Code might have meant that we would not have had to agonize over the Morrison case.
Dr. Lapointe: I, too, wish to comment on the non-intended effect, that is, providing a patient with adequate and appropriate medication to relieve his pain or other symptoms could hasten his death. In most cases, it will prolong the life of the patient. It is a vastly exaggerated risk. I believe it is a myth. In fact, the risks attached to the use of morphine or other strong narcotics, and other drugs of that nature, in the proper hands and administered with the expertise we have gained over the last 30 years of the existence of the palliative care field is extremely rare. I use the word "extremely" knowing that it is the case that it will hasten death, that it will provoke the double effect. In fact, the fear that exists among physicians in using those drugs to relieve that pain and the fear that they might be accused of hastening death, as well as the fear among family members concerning those drugs, prevents the proper relief of pain and causes the suffering of many, many patients in this country. There is a role here for the Senate to dispel that myth. Too much emphasis on the double effect has itself a double effect which has a negative impact on the patient.
The Chairman: I have a number of practical questions that I want to put to both of you. When we did our original study, the figure we heard over and over again was that 5 per cent of dying patients had access to genuine palliative care. For the most part, they tended to be cancer patients because of the pain associated with death by cancer in many instances. Is that number still valid, or has it increased or decreased?
Dr. Lapointe: I will admit that we do not have the data to answer your question. I referred earlier to a one-year study of the situation in Quebec. What we encountered is that everyone admits to performing palliative care. Thus, when you ask a health centre if it has a palliative care program, the answer is "yes". However, when you ask whether they have specific people working in the program, the number of affirmative responses decreases. When you ask if they have a program to detect people in the family who are at high risk of pathological bereavement reaction, then a small proportion of those who answered "yes" in the first place were able to say "yes".
I cannot really say if the 5 per cent number appropriate. All I know is that it is a minority of Canadians. If you are looking at cancer patients, patients with Alzheimer's and other degenerative diseases, you will see an absence of palliative care and end-of-life care with trained professionals in the majority of nursing homes in this country. We do not have in our hands at the moment the statistics that you ask about, Madam Chair.
The Chairman: You talked about the financial and emotional burdens borne by families who look after a person dying within the home. You made particular reference to the very elderly who I suspect partly because they have no one on whom to be a burden but who, because of their own wish not to be a burden, actually choose the option of dying in a hospital. Do you have any data on the health consequences to a person looking after a dying person?
My own personal experience tells me that my mother probably would have lived many years longer, despite her deteriorating heart condition, if she had not been for 10 years the principal care worker for her husband, a stroke victim, a brittle diabetic and suffering from a number of other ailments.
Do you have any data on that?
Dr. Lapointe: There is some research data that I could provide which shows, for instance, that the bereaved, or the recently bereaved, are at higher risk of health problems. In fact, a good number of the recently bereaved will consult a physician for a health problem that is directly related to the bereavement or the recent loss.
Presently, we have underway research projects looking at the quality of life of family members and caregivers in Montreal and in other centres across the country. In time, we will be able to report the results to you. Those are very important questions as we are devolving more and more of the responsibility of the care to people who find themselves very ill equipped, most of the time, to take care of a loved one.
A study done in Canada showed that the successful death at home was connected to one's financial means. That is to say you could grant the wish of your loved one to die at home, if you had the money to contract for private services.
Dr. MacLachlan: It is always worrisome to add an anecdote, but in this case it may be relevant. In talking with a doctor who provides a consulting service out of the Royal Victoria Hospital he related to me circumstances involving a home visit he made last week to a 54-year-old man who is caring for a 93-year-old mother at home. She has end-stage Alzheimer's disease and has not been able to communicate for 10 years. She was maintained at home with the help of live-in help paid for by himself and receiving 24-hour-a-day care. It took about three hours per meal to feed her the pureed food which she eats. Her care was impeccable. However, the son said that he could not go on providing this care. He said, "I have spent 10 years doing this. This is not my mother. This is a mere memory of what my mother was. Please help me. Is there anything we can do at home?" He was told by the doctor that there was no way the doctor could help him, and he explained why. The son said, "I can understand that, but I think then we are going to have to admit her to a nursing home or hospital." He went on to say, "And I bet she will be dead within two weeks." The sad thing is that due to cutbacks and other things, he is probably right.
Your point is very apt in terms of bringing forward the burden on family givers. I do not want to cloud things with one anecdote, but you have raised a number of important points. There is an indirect burden on caregivers who provide unofficially supported palliative care at home.
The Chairman: Dr. Lapointe, you said that it is an enormous cost financially -- forgetting for the moment the emotional cost -- to look after a seriously ill patient in the home environment. Currently, the tax system does not address that issue. It is addressed better in Quebec than in other provinces but, in my experience, essentially the issue is not addressed As well, we have made no provision which deals with those who give up their jobs -- primarily women -- to look after a terminally ill family member.
Is that your understanding of the situation?
Dr. Lapointe: You are totally correct in saying, first, that the burden of care is mainly shouldered by the women of this country who find themselves caring for their parents and often for the parents of their spouse, and who are left wondering who will care for them.
Second, there are really no provisions at present, either fiscally at the federal level or through security-of-income legislation, that protect family members in this country. This is something we need to do. We need to change rapidly if we are to, at the very least, not create a disincentive for home care. If it is possible, home, as I mentioned, is the place where people would live, so let us not create negative incentives to home care. Let us change the system and change all those laws and regulations in order to provide better security and certainly not plunge a family into debt or into being at risk of losing their home or so on, which is the case at present.
If I remember correctly, the Canada Health Act was enacted to prevent the fact that disease would financially destabilize a family and compromise its hope for a good life. What we are facing at the present is that the one member of the family living with a life-threatening illness is provoking that very thing we hoped to avoid with the creation and the enactment of the Canada Health Act. We need to move quickly to correct this.
The Chairman: Finally, there was an aspect of your presentation that confused me. Perhaps you could clarify it. At one point, you implied that in one of our recommendations -- and I was not sure whether it was with respect to withholding or withdrawing or pain treatment -- we may have made the situation worse rather than better by our recommendation. Would you elaborate on that?
Dr. MacLachlan: I was referring to the first recommendation in chapter 4 under pain control and sedation practices where the committee recommended that the Criminal Code be amended to clarify the practice of providing treatment for the purpose of alleviating suffering that may shorten life. The difficulty I have is that, although there is some supporting text in the section, it does not specify what amendments you felt would be necessary in order to clearly support the statements you made on page 31, with which I think all our bodies agree, where you say that you recognize that providing treatment aimed at alleviating suffering that may shorten life is legal. It is a clear, crisp, direct statement. Then when I read your first recommendation, I wondered, if it is that clear and legal, what particular amendments require to be made to the Criminal Code? You need to know, of course, that I am coming from the land of Morrison, so I may be more twitchy than others, but it was not clear from your report what specific sections needed to be amended to make it absolutely explicit that your earlier statement was accurate. That is where the confusion lies. It was not that I was questioning in any way what you were saying, but if you found inadequacies in the Criminal Code, it would have been very helpful if you had identified what they were and addressed them. I hope that clarifies my remark.
The Chairman: I understand where you are coming from.
Senator Beaudoin: I would like to make one point on that. If pain is being experienced, it should be alleviated. I have no problem with that. Of course, the person may die earlier than expected, but the purpose of the treatment is to alleviate the pain. The purpose of the committee recommendation was that the situation should be made clear in the Criminal Code. We were informed that some doctors and nurses and some people generally do not know exactly where the law stands on this. In a democratic society, we need laws that are as clear as possible. This might have been the reason we worded our recommendations as we did.
Of course, although a committee of the Senate may prepare a report, the decision to make changes is up to the government. The government will do what it wants to do, at the time it wants to do it. The Criminal Code is amended often, and it can be done again. However, the purpose of legislation is to improve the wellbeing of society and that might be achieved by amending the Criminal Code.
It is good if doctors, nurses and all those involved in the health system do not know exactly what their rights are and what the law is. It is part of our duty here in the Senate and the House of Commons -- the Parliament of Canada -- to legislate as clearly as we can.
Dr. MacLachlan: Yes. I think you are correct there. In your first recommendation, where you stated that the Criminal Code should be amended to clarify the practice of providing treatment for the purpose of alleviating suffering that may shorten life, perhaps if you had added a couple of words at the end to ensure that it would be clear that this practice is legal, it would have been better. A few words at the end of that recommendation might have alleviated my anxiety.
Senator Beaudoin: We may improve that. The sky is the limit.
The Chairman: I thank you both for being with us this morning.
I was pleased to hear that Senator Roche now seemed to understand exactly what it is we are trying to do this time around, which gave me some hope for the whole study. We want to focus on what it is that there was no disagreement upon, so that we can bring the government, quite frankly, to account for their lack of action; and to not obfuscate the issues in any way, because there were some recommendations about which we were not unanimous.
Honourable senators, our meeting is adjourned.
The committee adjourned.