Consultations on Physician-Assisted Dying - Summary of Results and Key Findings

• Previous Page
• Table of Contents
• Next Page

Part I – Introduction

Chapter 1. The External Panel

When the three members of this Panel first convened on 20 July 2015, it was with a keen sense of the magnitude of the task ahead. Our mandate was clear: “engage Canadians and key stakeholders in consultation on issues that are fundamental to a federal legislative response to the Carter ruling.” In the five months that followed, we would travel from coast to coast in Canada, visit four international jurisdictions and tap the expertise of hundreds of thousands of Canadians who have thought long and hard about the issue of assisted dying. We would be challenged intellectually, emotionally and physically as we sought to encounter the broadest range of perspectives available to inform a truly open and inclusive consultation on a complex subject of immense importance.

Drawing from the strength and capacity of a small but highly skilled Secretariat, we set in place the ambitious agenda for engagement that is detailed in this chapter. With severe constraints of time, resources and our own individual capacities as volunteers, we are mindful of the constituencies we did not reach, and the questions that we could not fully explore. But as we report now on our encounters and discoveries, we are both humbled and grateful for all that we have heard and learned. It is in this spirit of appreciation for all who have contributed to and supported our process, that we now look back at the particulars of how we approached our task.

Thorough and substantive exchanges with academic experts, medical authorities, Supreme Court of Canada interveners in Carter and civil society organizations; reviews of legislation and relevant research; and online processes designed to gather the views of thousands of Canadians: these were the tools and methods of our work. As you will read in the following pages, each of these approaches yielded a wealth of insight and understanding, which, taken together, form the basis for the content of this report. A chronology of the External Panel’s key activities can be found in Annex H.

A. Mandate

The Panel was tasked with holding discussions with the interveners in Carter and “relevant medical authorities.” In addition, the mandate called for the Panel to put in place an online consultation “open to all Canadians and other stakeholders.” Originally, the Panel was mandated to deliver a report that would include options for a legislative response to the Carter decision. On 13 November 2015, shortly following the federal election, the ministers of Justice and Health adjusted the Panel’s mandate and removed the requirement to provide legislative options. Instead, the ministers requested a summary of the Panel’s consultation activities, including key findings.

The Panel’s consultation activities have focused on the following key issues, as identified by the government of Canada and outlined in the Panel’s terms of reference:

• The different forms of physician-assisted dying, namely assisted suicide and voluntary euthanasia
• Eligibility criteria and definition of key terms
• Risks to individuals and society associated with physician-assisted dying
• Safeguards to address risks and procedures for assessing requests for assistance in dying and the protection of physicians’ freedom of conscience.

This report summarizes the results and key findings of the Panel’s consultations. It is expected that this report will inform the government’s next stages of work, eventually leading to its response to the Supreme Court of Canada decision in Carter.

B. Consultations with Interveners and Medical Authorities

The Panel’s terms of reference required that it meet with the interveners in Carter, as well as relevant medical authorities. In total, through direct mandated consultations across Canada, the Panel met with 92 representatives from 46 organizations whose memberships represent several hundred thousand Canadians. The Panel consulted these groups during a series of in-depth, in-person meetings held between 20 October and 6 November 2015 in Ottawa, Montreal, Vancouver, Winnipeg and Toronto. A complete list of individuals and organizations consulted is provided in Annex C. Abstracts of consultation transcripts can be found in Annex E.

1. Consultations with the Carter Interveners

Twenty-six organizations intervened at the Supreme Court of Canada in Carter. The Panel extended invitations to each of these groups, with the exception of the Attorneys General of Ontario and Québec, whose opinions were to be gathered directly by the federal government through regular federal-provincial-territorial channels. Of the remaining 24 interveners, 19 accepted to participate in the Panel’s direct consultations, four declined the invitation, and one no longer existed. The few that declined the invitation noted scheduling issues and/or a lack of time to consult their members. Some also mentioned that their views were represented by other organizations already meeting with the Panel. All groups, including those that could not meet with the Panel, were offered the possibility of presenting their views and recommendations through a written submission. The participating organizations are listed in Figure 1, along with information on the date and locations of these meetings.

The interveners have significant expertise in the full range of issues related to physician-assisted dying as a result of their extensive involvement in the Carter litigation. The Panel is very grateful that these organizations invested time and resources to prepare comprehensive and thoughtful submissions responding to the questions raised in our mandate. The questions the Panel considered were different from those the Supreme Court addressed in its 6 February 2015 decision; rather than looking at whether or not physician-assisted death should be permitted in Canada, the Panel was tasked with looking at how a framework for physician-assisted dying could be implemented to provide access to eligible individuals while minimizing risks to potentially vulnerable groups. While their fundamental positions on physician-assisted dying generally had not changed, the interveners made their presentations with an understanding that the legal landscape had changed and that concerted efforts must now be made to find common ground that would respect the intent and spirit of the Supreme Court decision. While full consensus on issues related to physician-assisted dying might never be achieved, the Panel observed that there are areas of commonality where divergent opinions can overlap to strike a necessary balance between access and safeguards. The Panel is immensely appreciative of the efforts that all of these groups made to identify areas of commonality. Their contributions not only helped the Panel frame the current report, but will also be of great benefit to governments as they move to implement the Carter decision. Any progress made towards societal consensus will ultimately benefit all Canadians.

2. Meeting with the Carter Claimants

Although its mandate did not require it, the Panel determined that its consultations would be greatly enriched by hearing the perspective of the original claimants in Carter. The claimants have had a direct and very personal involvement in this issue and brought a perspective that no other Canadians were able to provide. The Panel wishes to gratefully acknowledge the privilege of meeting with Ms. Lee Carter and Mr. Hollis Johnson, as well as representatives from the British Columbia Civil Liberties Association and its guests Elayne and Howard Shapray; the experiences and views that they shared were invaluable.

3. Consultations with Medical Authorities

Because the identification of “relevant medical authorities” was left to the Panel’s discretion, the Panel decided early on to adopt a broad and inclusive interpretation of this requirement to gather the widest possible range of perspectives. As a result, the Panel extended invitations to approximately 30 organizations and professional associations representing the fields of medicine, nursing, pharmacy, psychology, psychiatry, social work and pastoral care among others. While not all organizations were able to meet with the Panel due to scheduling challenges or an inability to consult their members in time, the majority accepted the invitation. The Panel is grateful that these organizations took the time to share their points of view, as their members may all be called upon to play significant roles when physician-assisted dying becomes accessible to eligible Canadians. The Panel would also like to take this opportunity to acknowledge the efforts of the Federation of Medical Regulatory Authorities of Canada, which helped facilitate and coordinate a meeting with the colleges of physicians and surgeons, or equivalent medical regulatory bodies, from all provinces and territories across Canada. Figure 2 includes the complete list of medical authorities that took part in the direct consultations.

C. Expert and Stakeholder Consultations

While direct consultations with interveners and medical authorities promised to be very instructive, there was an early recognition that these consultations might not cover the entire breadth of relevant issues the Panel needed to consider. Because the Panel’s terms of reference gave the Chair discretion to reach out to subject-matter experts to familiarize Panel Members with key documents and relevant issues, the Panel extended meeting invitations to individual experts and additional stakeholder organizations involved in areas where knowledge gaps had been identified.

As dictated by its terms of reference, and out of respect for longstanding government practice, the Panel suspended its formal consultations during the federal election period from 2 August to 19 October 2015. Direct consultations were rescheduled beginning on 20 October 2015. During this interval, the Panel took advantage of the opportunity to better prepare for its consultations by meeting a number of experts representing a wide range of disciplines including law, public health, philosophy, ethics, medicine, and women’s and Indigenous studies. Expert meetings took the form of informal exchanges between the Panel and the invited experts and allowed the Panel to get a better understanding of the legal framework and implications of physician-assisted dying, as well as many other related issues. These consultations proved to be very helpful for contextualizing the recommendations it heard during direct consultations. Experts consulted are listed in Figure 3 as well as in Annex D.

The purpose of the Panel’s stakeholder consultations was the same as that of its expert meetings: filling gaps in the knowledge required to gain a full understanding of the issues relevant to its mandate. Because these consultations involved organizations representing many members rather than individual experts they were treated the same way as the Panel’s direct consultations and did not take place during the election campaign. As was the case with the Panel’s expert consultations, these meetings were very helpful in providing the Panel with a better understanding of the context and issues at play when considering the implementation of physician-assisted dying in Canada. Figure 3 lists the stakeholder organizations and other experts consulted.

D. Consulting the Canadian Population

Conducting an online consultation was a specified component of the Panel’s mandate. It was clear that governments could not go forward with a decision of such social and legal importance on an issue as sensitive and emotional as physician-assisted dying without seeking input from those who will ultimately be the most affected: Canadian citizens.

While many if not most Canadians may have a clearly defined opinion on whether or not they support physician-assisted dying, views are not necessarily as clear when it comes to determining the manner in which the Supreme Court decision should be implemented. Some Canadians who suffer from serious illnesses believe strongly that a physician-assisted death will be the only way to end their life in dignity. The Supreme Court has recognized their right to receive assistance without exposing others to threat of criminal prosecution. At the same time, the Court also recognized that some people may be vulnerable to “being induced to commit suicide at a time of weakness” and that these people need to be protected in a manner that supports their dignity and choice.

Implementing the Carter decision also requires us to consider the perspective of health professionals, some of whom may be confronted with patient decisions that go against their personal, clinical or moral convictions. While the Court has indicated that doctors should not be compelled to assist in ending the life of a patient, does this extend to other professionals involved in the care of a patient, or to hospitals or other medical facilities? If their own doctors are unwilling, how will people access physician-assisted death and receive care that does not make them feel they are being abandoned? These are only a few of the complexities we face as a country preparing to provide access to physician-assisted death for those who qualify. Identifying and understanding these complexities promised to be a challenging task.

1. Online Questionnaire: the Issue Book

Because of the complexity of issues associated with physician-assisted dying, and because the focus of the consultation was on designing a physician-assisted dying framework and not simply asking respondents their views in support or against a particular approach, the online consultation could not be limited to a list of questions. The situation called for an educational component to help respondents develop a better understanding of the vocabulary and the scope of topics and circumstances in which assisted dying must be considered before they shared their views. For this reason, the Panel’s online consultation went beyond traditional surveys and questionnaires that are typically used in public opinion polls. The name of this online consultation tool, the Issue Book, reflects this process of learning and active engagement in the discussion. Additional resources were also available directly on the Panel’s website for those who wished to delve more deeply before sharing their views.

The development of the Issue Book was contracted out to one of Canada’s leading strategic communications firms. The contractor handled the design, coding, hosting and operation of the Issue Book and the Panel's website. The Panel allocated a significant portion of its time during its first few weeks of activity to ensure the quality, neutrality and usefulness of the Issue Book and all online material. The intent of the online consultation was not to verify the general opinions about physician-assisted dying that had been collected through regular opinion polls, but to test the borders and limits of a theoretical physician-assisted dying framework. To develop a better understanding of Canadians’ views and to assess the finer points of agreement and disagreement, the Panel included questions on issues for which there is no known consensus and where debate can be expected to emerge over time e.g. views on access to physician-assisted dying for mature minors and requests made via advance directives.

Between its launch on 20 August 2015, and its closure on 22 November 2015, a total of 14,949 individuals provided their views through the Issue Book. This includes 12,883 voluntary respondents as well as a group of 2,066 individuals who form a representative sample of the Canadian population. This control group is regularly engaged by the contracted firm and was thus formed prior to, and independently of, any other activities associated with this consultation.

The Panel is grateful to all the individuals who gave their time to share their opinions; their responses have been taken seriously and key observations from the Issue Book have been included in this report. Issue Book results are available in a report provided in Annex A. An independent review of the Issue Book is also appended as Annex B.

The Panel and others closely involved with this project can confirm that personal opinions on physician-assisted dying are not immutable, and positions evolve as understanding deepens and a variety of perspectives are explored. The Panel hopes that those who took the time to complete the Issue Book found the experience to be helpful and thought provoking, and provided them with the opportunity to clarify and express their views. Evaluations completed by respondents of the Issue Book tend to indicate that the main objectives have been achieved:

• 90% of Representative Sample respondents and 74% of Open Public respondents agreed that "The information was clearly presented" (respectively, only 2% and 9% of these groups disagreed);
• 87% of Representative Sample respondents and 65% of Open Public respondents agreed that "The information was well balanced between different views on the issue." (3% and 16% respectively disagreed); and
• 83% of Representative Sample respondents and 61% of Open Public respondents agreed that "This online consultation helped you learn about the key issues and concerns." (3% and 17% disagreed).

2. Online Submissions

Canadians were also given the opportunity to share their views by providing a written submission to the Panel. In this way, individual Canadians and organizations were able to provide more detailed explanations of their thoughts and recommendations regarding forms of assisted dying, eligibility criteria, risks and safeguards. In total, the Panel received 321 such submissions. A summary of all submissions received is provided in Annex F, and the abstracts of these submissions are attached in Annex G. While the online submission tool was primarily intended for those who could not meet with the Panel or who could not offer a complete expression of their views through the Issue Book, some of the groups and individuals participating in the direct consultations also opted to provide written submissions.

The time and effort that individual Canadians and groups spent in preparing quality submissions to share their views, expertise and experiences did not go unnoticed by the Panel. We are deeply grateful for the contributions that the Canadian public has made to this report.

E. Learning from other Jurisdictions

There is no roadmap, no simple formula, for the task of creating a legislative framework for physician-assisted death. While the Panel was confident that its direct and expert consultations would be instructive and invaluable, it was clear that few Canadian professionals had the same level of insight as those working in a system where the practice of assisted dying has been a reality for some time.

Although a growing number of nations have or are currently contemplating legislation permitting assisted dying, the total number of permissive jurisdictions remains relatively small. Further, assisted dying is a fairly recent policy development in several of these jurisdictions. Because of this, those with direct experience in implementing, delivering and supervising the practice have valuable expertise to pass along to other jurisdictions. The Panel seized the opportunity during the suspension of its direct consultations in September/October to undertake fact-finding missions in several of these jurisdictions. In total, the Panel travelled to four countries, held 34 meetings and met with 46 experts. Abstracts of the transcripts of these meetings are provided in Annex E.

1. European Countries

From 30 August to 9 September 2015, the Panel travelled to three European countries where assisted dying is practiced. During the tour, the Panel traveled to the Netherlands, where it met with 13 experts over 7 meetings, Belgium, where it met with 10 experts over 9 meetings, and Switzerland, where the Panel met with a further 8 experts over 7 meetings. The selection of countries allowed the Panel to learn about different systems and approaches. While the Netherlands and Belgium both regulate assisted dying through legislation, for example, Switzerland does not regulate the practice through federal laws, but allows assisting suicide for non-selfish motives. These countries have also adopted different eligibility and procedural rules, and different reporting and monitoring mechanisms. Individuals and organizations consulted during the European fact-finding mission included members of parliament, government officials in health and justice, academic experts, advocacy groups, and, in the case of Switzerland, private organizations that facilitate assisted suicide. These individuals and organizations are listed in Figure 4. The Panel is grateful to the Canadian Ambassadors and Embassy staff in each European country visited for taking the time to meet with the Panel, for providing strong contextual briefings, and above all for helping with the coordination and planning of the fact-finding missions at such short notice. Without their assistance, these study missions would never have been possible.

2. Oregon and other U.S. Jurisdictions

An increasing number of American states are contemplating legislation on assisted dying. As of the time of writing, Oregon, Washington, Vermont and California had enacted legislation, and Montana permits assisted dying according to the terms of a decision of its supreme court. The eligibility criteria and processes for assisted dying in these states are significantly different from European models. For this reason, to better understand these differences and to see how an existing assisted-dying framework operates in North America, the Panel undertook a fact-finding mission in Oregon from 1 to 3 October 2015. Because assisted dying has been in place in Oregon since 1997 making its assisted dying regime one of the oldest in the world experts there had a great deal of insight to offer the Panel. Because of time constraints and the similarity between state models, the Panel travelled only to Oregon, although it did consult with experts from national American disability organizations. Over the course of its Oregon and U.S. study mission, the Panel held 11 meetings with 15 experts, including physicians, members of the task force that produced guidelines for Oregon’s Death with Dignity Act, as well as members of groups representing persons with disabilities and organizations that support access to physician-assisted dying. These individuals and organizations are also included in Figure 4.

F. Provincial and Territorial Jurisdictions

In Carter, the Supreme Court held that the federal government and provincial legislatures could, if they so choose, enact legislation on physician-assisted dying. Given that both levels of government may choose to respond to Carter, it is reasonable for parallel processes to be established to inform the creation of mechanisms appropriate for each level. At the time the Panel was appointed, the existence, format and mandate of the Provincial-Territorial Expert Advisory Group were not known. However, consistent with the Panel's mandate to “be mindful of federal and provincial/territorial jurisdictions in health and criminal law,” the Panel took advantage of its consultations in Toronto to meet with the co-chairs and several members of the Provincial-Territorial Expert Advisory Group. The meeting proved to be an informative, collegial discussion about activities and informal impressions. It became clear that the work of both bodies would be complementary and that governments and Canadians will benefit from these dual deliberations, providing rich and thoughtful sources of information about issues of great importance.

G. Reporting

With the culmination of this multi-dimensional process of information gathering and dialogue, the Panel is left with a deep sense of humility and a reminder of the weight of the task with which we have been entrusted. The written briefs and verbal submissions that we received were prepared with integrity and care, expressing respect for the Court’s decision and for the mandate with which our Panel was charged. The experts and stakeholder groups with whom we met both within and outside our borders were thoughtful, principled and generous with their time, their research and their expertise. Similarly, Issue Book participants volunteered precious time and attention in an impressive display of civic engagement.

During each of our consultation processes, people have spoken with passion and candour, and although their views may differ widely, each and every one spoke with courage of conviction about the respect and support we owe to those who suffer. There can be no doubt that this is an issue that matters profoundly to Canadians. To honour the contributions of so many individual citizens and organizations in this final report is no small task.

In the pages that follow, the Panel presents a distillation of all that we have heard and learned on the subject of assisted dying over the past five months. The opinions and reflections gathered through the Issue Book, the written submissions, and the direct consultations have made it clear that physician-assisted death is an issue of utmost importance to Canadians. It is in this spirit, and out of respect for all those who invested time and resources in preparing and sharing their views, that this report may include items that, constitutionally, fall outside of the federal responsibilities in health. Ultimately, the Panel concludes that it is important that the federal government, along with provincial and territorial governments, and all Canadians be made aware of the full array of expertise, insights and views that have been shared through this exercise.

• Previous Page
• Table of Contents
• Next Page