Health Committee on Feb. 14th, 2024

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you.

Ms. Long.

[Helen Long]

I don't really have much to add. I think Dr. L'Espérance dealt with that quite well.

Certainly, in all the conversations we're having with MAID assessors and providers, with psychiatrists, with regulatory health authorities, with members of the provincial health teams, there is readiness. I think if there is a province that for whatever reason does not feel they can proceed, they don't have to do so. I think those that are ready should be able to proceed as soon as they are ready, and that would be March 17 for some.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Ms. Long, I will go to you first.

I want to pick up on what Mr. MacGregor was talking about when he was citing the letter that has been signed by most provinces and all territories explicitly making the point that the health care system in their respective jurisdictions—and they are responsible at the end of the day—is not ready and requesting that the federal government, or this Parliament, give an extension.

Does that not indicate to us—and again, as Mr. Maloney was saying, put yourself in our position in terms of options available to us—to extend at least for three years so that the provinces and territories are ready to provide that particular health care provision for people who may need it?

[Helen Long]

Again, I think those who administer MAID are ready. The individuals I speak to who work within the health care system indicate, for the most part, that they are ready. I don't know what it is that the ministers would be looking for in order to continue to prepare. I think it would be very helpful to understand what they feel is missing in the system.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Long.

That concludes three complete rounds of questions. We're at five minutes before nine. We're expecting the ministers at nine, so we're going to suspend now as we switch over to the other panel.

Please allow me, on behalf of the committee, to say to all of you that this has been an absolutely fascinating panel. We very much appreciate your expertise and how quickly you responded to the invitation from the committee. We gave you as much time as we had in terms of lead time, which is a lot less than we usually have, but you responded. You've been very patient and professional throughout the evening with your answers, and we are absolutely grateful to you for that.

With that, we're going to suspend and await the arrival of the two ministers.

Thank you very much to our witnesses. You're welcome to stay, but you're free to leave.

We're suspended.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

Before we begin, I would like to welcome the Honourable Mark Holland, Minister of Health, and the Honourable Arif Virani, Minister of Justice.

We also welcome the officials accompanying them tonight. From the Department of Health, we have Jocelyne Voisin, assistant deputy minister, strategic policy branch; and Katarina Pintar, director, health care programs and policy directorate. From the Department of Justice, we have Robert Brookfield, director general and senior general counsel, criminal law policy section; and Jeanette Ettel, senior counsel, human rights law section.

Before I invite you to bring your opening remarks, I will just say that I know this is your first time before this committee, Minister Virani. We've adopted in this committee a convention that, I would say, has worked fairly well for us, so I just want to make you aware of it. It's quite simply that you will be afforded as much time to answer the question as the person who poses it takes to ask it. It is the prerogative of the questioner to allow you to go on for longer, but if they ask a four-second question and you speak for 10 seconds, they'll probably interrupt you and I won't stop them.

With that, we're going to begin with opening statements, beginning with Minister Holland. I know it has been a long night for both of you after a couple of hours in the Senate. We appreciate your being here.

You have the floor, Minister Holland. Please go ahead.

[Mark Holland, Liberal, Minister of Health]

Thank you very much, Mr. Chairman. It's good to be back in front of the health committee.

We did just have a very productive session, the last couple of hours, with the Senate, getting an opportunity to talk about what is a very delicate and sensitive issue, one that requires a lot of calm, patient deliberation.

I appreciate the members of this committee for their input and work. I certainly appreciate the work of the joint committee as we attempt to navigate this very difficult issue.

I think I'll start by making a very clear and important distinction between mental health and mental illness. Mental health, not only in Canada but across the world, is in a state of crisis. Coming out of the pandemic and dealing with the rise of very devastating wars, global economic uncertainty and the existential crisis of climate change, these are difficult times to be a human being.

However, the challenges we're facing in mental health are completely separate and apart from the issues that we're talking about in Bill C-62 with respect to mental illness. That distinction is an important one, because a conflation is both dangerous and, I would represent, irresponsible.

When we talk about mental health, there are the historic investments we're making in mental health across this country, co-operating with governments of every stripe. I had an opportunity just yesterday to be in the Northwest Territories and announced our bilateral agreement on both aging with dignity and working together. Just the day before that, I was in British Columbia announcing our aging with dignity agreement there. Of course, I've already announced the working together agreements with B.C., Alberta, Nova Scotia, P.E.I. and many more to come, with specific and detailed plans of how we're going to take on the challenges we're facing in mental health.

When we're talking about mental illness, we have to recognize that there are some people who are trapped in an irremediable situation, where their state of illness is not able to be remedied through medical intervention, so we have to ask the question, as a society and indeed as Parliament, of at what point we allow a person, of their own recognizance, if they have an irremediable condition, to be able to make the choice to access MAID.

If somebody has suffered for 10 years, 20 years, 30 years or 40 years, where they've tried absolutely everything, where they've gone to medical practitioner after clinician after expert and have never been given the opportunity to escape that mental health illness—not a momentary mental health crisis—what do we do as a society? That's what we've been trying to navigate.

The decision we have in front of us now is to ask for more time to prepare the system. I've had opportunities to talk with health ministers. We had a very constructive conversation in Charlottetown when I was together with all the health ministers, Mr. Chairman, in your home province, discussing how we navigate that and how we get the system ready.

Frankly, we need more time.

We need more time for indigenous engagement. We need more time to work with the provinces and territories to make sure they have appropriate safeguards. Talking with CAMH, we want to make sure that, if there's a possibility that clinical guidelines are required to create uniformity across the country, we have an opportunity to explore that. We need more time to work with the disability community and with the community of folks with lived experience, so a three-year pause is appropriate so that we can deal with mental illness, which is separate and apart.

I would welcome the conversation on mental health, but hopefully tonight people will not be conflating those two because they are two separate conversations.

We do need time and I'm appreciative of the opportunity to be before committee tonight to have that conversation and to take the questions of the committee.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Minister Holland.

Minister Virani, welcome to the health committee. You have the floor for the next five minutes.

[Arif Virani, Liberal, Minister of Justice]

Thank you very much, Mr. Chair. I'm pleased to be here to speak to Bill C-62, which proposes to delay for three years, until March 17, 2027, the expansion of the eligibility of MAID to persons whose sole underlying medical condition is mental illness. As members will be aware, this bill also requires that a joint parliamentary study be undertaken on the topic, by a mixed committee of Senators and MPs, approximately one year before the new date of expansion.

I will start by expressing my sympathy for anyone experiencing intolerable suffering. I acknowledge that mental illness can cause the same level of suffering as physical illnesses, and that having a mental disorder does not mean that an individual does not have decision-making capacity. Everyone deserves dignity and respect.

As this health committee is aware, the Supreme Court of Canada's decision in the Carter case led to the legalization of medical assistance in dying in Canada. In that decision, the Supreme Court declared the Criminal Code's absolute prohibition at the time on physician-assisted death to be unconstitutional, noting that it should be available to competent adults who clearly consent to the termination of life and who have a grievous and irremediable medical condition. That led to Canada's first MAID law in 2016. Many members were here with me in 2016 when we enacted that law, which restricted eligibility for MAID to persons whose natural death was “reasonably foreseeable”.

A few years later, in the Truchon decision, a trial court in Quebec ruled that the reasonably foreseeable natural death requirement was unconstitutional.

The federal government didn't appeal the decision. Instead it made the general political decision to introduce Bill C-7 to expand eligibility for medical assistance in dying to persons whose death wasn't reasonably foreseeable. When it was introduced, the bill permanently excluded from eligibility for MAID persons whose only underlying health issue was a mental illness.

During consideration of the bill, the Senate introduced an amendment to make that exclusion temporary. The House of Commons supported the amendment, and the bill, as adopted, would automatically have nullified the mental health exclusion two years later.

I want to be clear about something, which is that the government's decision to go forward with those expansions at the time was a matter of social policy. I appreciate, though, that there are those who believe that the charter required us to act in this regard on mental illness, and I want to address this point directly.

MAID is a complex and deeply sensitive topic, and there are important charter-protected interests that arise in this area. On the one hand there is the autonomy and dignity of individuals in making end-of-life decisions. On the other hand, there is the protection of those who are vulnerable and who might be at risk in a permissive regime. In its decision in Carter, the Supreme Court recognized the complexity of legislating in this area and suggested that Parliament's choices on how to balance these competing interests would be given a high degree of deference.

MAID is particularly complex in the context of mental illness. As noted in the various MAID-related charter statements, these inherent complexities are the basis for the mental illness exclusion. Some of the complexities include that the course a mental illness may take is more difficult to predict than that of a physical illness and that many people with a poor prognosis will improve, at least in terms of their suffering, which may alter or impact their wish to die. Moreover, distinguishing routine suicidality and a valid request for MAID becomes particularly challenging when suicidality may be a symptom of the mental illness that led the person to request MAID in the first place.

The MAID mental illness exclusion is not based on harmful assumptions nor stereotypes about mental illness. We recognize, as Minister Holland just said, that the suffering mental illness can cause is on par with the suffering that physical illness can cause. This exclusion is not a denial of this fact. We also accept, as I said at the outset and as I repeat here again, that the decision-making capacity of those who are mentally ill is well established.

As we have said, we do believe the exclusion should be lifted when the health care system is ready to manage the inherent risks and complexities of assessing requests for MAID that are based on mental illness alone. Our provincial and territorial partners agree that more time is needed. Medical experts agree that more time is needed. The lack of consensus on this issue proves that more time is needed.

This bill reflects the caution required to ensure the safety of Canadians and to get this right. As the interests at stake are significant and the consequences, Mr. Chair, are permanent, we must get this right.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Minister.

We will now begin with rounds of questions, starting with the Conservatives for six minutes.

Dr. Ellis, go ahead.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much, Chair.

Thank you to both ministers for being here.

Minister Holland, in your mind, will having MAID for solely mental illness be a foregone conclusion at some point? Is that the destination we're going to get to?

[Mark Holland, Liberal, Ajax, ON]

It's my belief that folks who have an irreversible, irremediable mental illness for which they've sought all kinds of treatment and have been unable to get any relief, in many cases for decades, eventually, when the system is ready, should have access to MAID.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you for that.

How do you propose to get systems ready given the two outstanding issues of suicidality and irremediability?

[Mark Holland, Liberal, Ajax, ON]

Suicidality is an issue that's completely separate and apart. If somebody who is having suicidal thoughts goes in and sees a clinical professional and seeks assistance, that's somebody who is able to be helped.

Somebody who has a mental illness is somebody who, despite going and getting help for, potentially, decades, is unable to lift themselves out of that circumstance and is in an irremediable state, a state of decline, so there's an important distinction to be made.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thanks for that, Minister.

You talked about suicidality being an incidental thing, but, realistically, it's part of the diagnosis of many mental illnesses. Do you not think that is true?

[Mark Holland, Liberal, Ajax, ON]

As somebody who has suffered greatly and who has spoken publicly about my own mental health challenges, I do not believe that suicidality is at all incidental. What I'm trying to do is to make a distinction between the folks we're talking about in Bill C-62 and folks who are having a mental health crisis.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Minister, that was not the question I asked you.

What I asked you specifically was whether suicidal ideation was an important part of a diagnosis of many mental illnesses. That's correct—is it not?

[Mark Holland, Liberal, Ajax, ON]

This is—

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

It's a simple question.

[Mark Holland, Liberal, Ajax, ON]

Yes. If you are mentally ill, then that could absolutely be present.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much.

How do you then expect, Minister, to get systems ready when suicidal ideation is a part of the illness that you're talking about? That doesn't make any sense.

[Mark Holland, Liberal, Ajax, ON]

What we're talking about is not somebody who has a mental health crisis and who has suicidal ideation in a moment. We're talking about somebody who, potentially, for decades...and this is why we need to take time, so that we can make sure we are talking about the same cases.

I'm sure, if I would pose it to you—

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Respectfully, Minister, when you read the diagnosis—

[Mark Holland, Liberal, Ajax, ON]

Let me just pose it to you so we're talking about the same thing.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

No, I'm sorry. I'm asking the questions, not you. Thank you.