My Thoughts on Physician-Assisted Dying

This is modified from an earlier Facebook post on the same subject.

On Tuesday, February 2nd I testified before the Special Joint Committee on Physician-Assisted Dying as President of the Indigenous Physicians Association of Canada.

The Special Joint Committee on Physician-Assisted Dying is tasked with compliance regarding the ruling of the Supreme Court of Canada in Carter v. Canada, which struck down the prohibition against Physician-Assisted Dying unconstitutional. I was one of two Indigenous witnesses before the Committee. The hearings will continue until February 26th, followed by other consultation as parliamentarians prepare a new law to govern physician-assisted dying in Canada by mid-2016.

You can view mine and other testimony on CPAC or via the PDAM website:

http://www.cpac.ca/en/house-portal/ (click on February 2nd)

http://www.parl.gc.ca/Committees/en/PDAM/Meetings (click on February 2nd, Meeting 10)

My testimony begins at around 1:32 (half-way into the meeting).

The transcript of my testimony is below:

My name is Alika Lafontaine and I am an Oji-Cree Anesthesiologist practicing in Northern Alberta. I would like to acknowledge the Western Cree of Treaty 8 from where I’m videoconferencing, as well as the Algonquin people on whose territory these hearings are being held.

My thanks to the committee for the invitation to speak. 

I’d also like to thank the board members of the Indigenous Physicians Association of Canada, our past-presidents and IPAC membership for their input into this testimony. The Indigenous Health Advisory Committee of the Royal College of Physicians and Surgeons of Canada as well as the staff of the Royal College has also provided guidance, in particular Dr. Tom Dignan who has guided many Indigenous physicians -- like myself -- over the few past decades. Senator Ted Quewezance, the Chair of the Senate of the Federation of Saskatchewan Indian Nations and Mr. Mike Cachagee, the Executive Director of the National Residential School Survivors society have both been incredibly helpful. Senator Quewezance and Mr. Cachagee are also also residential school survivors. They both help me remember the responsibility of being Oji-Cree and that we should move forward with this work in a good way.

I am the President of the Indigenous Physicians Association of Canada, the only national voice of First Nations, Metis and Inuit physicians. For almost two decades, national Indigenous physician advocacy organizations have lobbied for improvements in Indigenous health. Our organization has current and past members who represent every Province and Territory in our great Canadian Federation. As one of the three Founding nations of Canada, Indigenous peoples have a critical perspective to add to all Canadian issues.

The Indigenous Physicians Association of Canada does not have an official position on medically-assisted dying. It has not been identified by our members or by the Indigenous patients that we serve as a high priority. They are focused on other pressing issues within Indigenous health. The comments I share are a reflection the ongoing discussion we have on this issue and how it fits more broadly into Indigenous health. Some of these perspectives are my own.

In reviewing these hearings, I feel obliged to identify the absence of the major National Indigenous Organizations. I believe that there has not been meaningful consultations with Indigenous peoples, although meaningful mainstream Canadian consultations have been carried out by many other organizations who have presented here.

You are all aware of the widening health disparities among Indigenous peoples and the rest of Canada. When considering the over-representation of Indigenous peoples in nearly every category that may qualify and pursue medically-assisted dying, it should be strongly considered that you may be ignoring the largest proportional demographic that is eligible to pursue this service. I hope the apparent absence of Indigenous consultation is remedied prior to any final decisions regarding Indigenous patients and medically-assisted dying.

As a physician, I recognize that medically-assisted dying must be provided in a thoughtful and patient-centered manner. I applaud the members of this committee for their commitment to explore an issue that can be divisive and emotionally exhausting. I also am thankful that so many organizations have taken time to provide meaningful advice to the committee and preface my comments as specifically pertain to Indigenous patients. Whether the issues I raise are dealt with, they will remain issues nonetheless.

My personal experience with Indigenous patients and their concerns regarding medical-assisted dying are very different from my experience with mainstream Canadian patients. One of these reasons is that medical assisted dying has existed in our communities for more than a century.

When residential schools exposed children to nutritional deprivation and medical experimentation...that was medically assisted dying.

When traditional medicines and cultural practices were made illegal, driving traditional healing underground...that was medically assisted dying.

When traditional medicine is appropriated, depleted and patented by private industry -- so called discoveries that have been known by Indigenous peoples for generations -- thereby removing access to our own ways of healing...that is medically assisted dying.

When traditional medicine is treated with hostility by mainstream health professionals, despite being requested specifically by patients...that is medically assisted dying.

When child and family services apprehend Indigenous children at an alarmingly high -- if not the highest -- apprehension rate of all demographics, with medical decisions made by the Crown and inconsistent quality standards that contribute to children dying in care or missing...that is medically assisted dying.

When the trauma of residential schools is perpetuated intergenerationally and we do nothing to stem the tide of abuse, addiction and suicide that overwhelms our Indigenous communities through insufficient mental health intervention…except in crisis…that is medically assisted dying.

When Indigenous Peoples have programs designed without their input, then are chastised for poor engagement in mainstream health care...that is medically assisted dying.

When Health Canada provides 48 programs that do not provide comprehensive primary healthcare on-reserve and neglects to provide a seamless transition between Federal and Provincial health jurisdictions...that is medically assisted dying.

When the health system prescribes benzodiazepines, opioids, stimulants and other prescription substances without considering the high risk of addiction and overdose...that is medically assisted dying.

When health professionals request services for Indigenous patients and their requests are denied by bureaucrats at Health Canada who ignore clinical recommendations...that is medically assisted dying.

When nursing stations employ health professionals that lack the skill set to provide emergency and urgent care, or when nursing stations lack basic life-saving equipment and medication that does not meet the minimum standard of every other health facility...that is medically assisted dying.

When there is no monitoring, tracking or enforcement of standard of practice that every other Canadian can expect when receiving medical care...that is medically assisted dying. 

If an Indigenous person dies and no one tracks it, does anyone care?

What we are pleading for in Indigenous communities is not medically assisted dying. That already exists in more ways than can be counted. 

What we are pleading for is medically assisted life.

It is in this background that I make the following nine recommendations.

Recommendations:

1. Consult Indigenous Peoples regarding their opinions on medically-assisted dying and whether it is a priority. You can do this during the submission of each First Nations health strategy -- a requirement of funding for health programs on-reserve -- and through national consultations with off-reserve First Nations, Metis and Inuit. Continue to engage the national Indigenous organizations and weigh their opinion with the same weight as those who testify through this current process.

2. Implement the Truth and Reconciliation recommendations for health (18-24). Change the culture of medically-assisted dying towards Indigenous peoples by the health care system. Confront bias, discrimination and racism in Indigenous health.

3. Re-profile existing funding within Health Canada towards primary-care services, with a lower focus on Public Health programming. You do not build a health system around public health, you build it around primary-care services. Public health cannot exist in isolation and should not exist at the detriment of primary-care services.

4. Implement the recommendations of the Naylor Report on health care transformation, including creation of an Indigenous Health Quality Council so we can independently track Indigenous health outcomes and provide support to Indigenous communities. Health Quality Councils are central supports for Provincial health systems. The Naylor report goes into more detail about this.

5. Create a national Indigenous Health Strategy that seamlessly integrates medically-assisted dying. This deserves to be a stand-alone national priority in health, not as a sub-category below other health priorities. Dealing with this crisis should be at the same level as pharmacare, the opioid crisis and medically-assisted dying.

6. Pass an Indigenous patient bill of rights, that ensures seamless transitions in care between Federal and Provincial systems that puts patient need before policy and procedure within Health Canada. Design it to minimize jurisdictional ambiguity and emphasize jurisdictional responsibility.

7. Do not create a program for medically-assisted dying, unless you speak directly to the community who may access it. In a system where everyone is already dying, the effects of creating a literal program where patients intentionally die within the medical system will further disengage and disenfranchise Indigenous patients.

8. Provide access to a culturally safe educational organization, that will provide education on a patients right to live, a patients right to die and the legal mechanisms to that protects each. Empower patients with information.

9. Ensure that complaints from patients and patients families about bias, discrimination and racism of health care providers and/or administrators that pushes patients or patient families to choose medically-assisted death in a way that is not patient and family-centered is transparently addressed. The complaint process should outline the various ways that complaints can be pursued, including through health regions, regulatory bodies and civil actions.

I want to emphasize that I believe no individual in our healthcare system deliberately causes harm to Indigenous patients. Through historical trauma, mainstream attitudes and system design however, we do cause harm whether intentional or not.

Thank you for the opportunity to participate in these hearings. Medically-assisted dying is an important issue for Canadian and Indigenous patients. 

Migwitch.