Health Committee on Feb. 14th, 2024

[Dr. K. Sonu Gaind]

It probably means different things, depending on the context, but it reflects a deep ambivalence. The person is not happy. “Happy” is too simplistic a word. The person is not feeling that they're able to live. It's not that they actually want to die. Usually what it reflects is that they want to live better. They want either their suffering to be dealt with or the social situation to be dealt with.

I see it as an abandonment. If we tell people in those periods of despair, “We're going to collude with the despair that your mental illness is bringing and the hopelessness and we're also going to say that you're never going to get better, and we're also going to say—in brackets—that we're not going to help with the social situations you're struggling with, but we'll provide you with an easy and quick death”, what does that say about us?

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

I appreciate your saying that. I said exactly that in my intervention yesterday, in my speech, on how far we have fallen as a society that we can perpetuate one's addiction, but we can't get them into recovery. We can allow somebody who is in despair to choose suicide rather than offer care and help when they need it.

Dr. Gagnon, you mentioned that we are failing Canadians. Perhaps I'm putting words in your mouth, but it's my opinion that we are failing Canadians when we do not even have a national suicide prevention strategy. Do you have a comment on that?

[Dr. Pierre Gagnon]

Yes, that's one of the problems. I think that's why Quebec decided, during the debates that were held a few years ago, to delay indefinitely or simply rule it out it because so much has to be done with regard to suicide prevention, as you mentioned.

Yes, the associations that work with patients with suicidal ideation are very concerned about the idea of opening up access to this kind of thing for these individuals before we have suicide prevention measures and adequate services in place. That's why Quebec was very wise in deciding not to discuss the matter for the moment. The issue may have to be addressed once again from a social standpoint, but we aren't there yet because we don't have the necessary suicide prevention services and measures, and certain issues remain unresolvable. We always come back to the irremediability of the patient's situation, for example, and to the difference between suicide and a legitimate request for euthanasia.

So that's where things stand.

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

We know the stats. Twelve Canadians per day die by suicide, and a further 200 attempt suicide. That's 73,000 Canadians who attempt suicide every year. Those are just the stats that we know.

How is MAID different from suicide in the context of those suffering from mental illness?

That's for Dr. Gaind and Dr. Gagnon, please.

[Dr. K. Sonu Gaind]

This is precisely part of the problem. We don't know how it is, or if it is. This is precisely part of the problem and, as I was saying, even some who are pushing for expansion have acknowledged that. The expert panel quite literally said, regarding chronic suicidality, “society is making an ethical choice to enable certain people to receive MAiD on a case-by-case basis regardless of whether MAiD and suicide are considered to be distinct or not.” This is a shocking statement to me. I don't remember our society making that choice ethically. The 10 people on that panel did.

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

Dr. Gagnon.

[Dr. Pierre Gagnon]

Indeed.

I work in a hospital and talk to the doctors in other disciplines who are used to medical assistance in dying. When I discuss this new development with them, they say it makes no sense and wonder how it's possible. They emphasize that the purpose of our profession is precisely to treat suicidal patients.

I talk to some of my very experienced psychiatrist colleagues who have seen some very serious cases, and they tell me that, with their patient cohort, they would never be able to distinguish a suicide from an authentic request.

A discussion took place within the Association des médecins psychiatres du Québec, in which one astute and highly experienced psychiatrist said he would never do it. He would ask a colleague to do it. He wasn't opposed to it in theory, but he said he didn't understand how he could do it in his career, despite the fact that he had extensive experience with very difficult and complex cases.

We're unfortunately unable to make that distinction at this time.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Gagnon.

Thank you, Mr. Doherty.

Next we have Mr. Powlowski, please, for five minutes.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Dr. Gaind, in his questioning, Mr. Thériault suggested that you and Dr. Gagnon were somehow outliers and that the majority of psychiatric organizations and psychiatrists agreed with allowing MAID for mental illness. Maybe you could comment on that.

What do we know about what psychiatrists think about MAID for mental illness?

[Dr. K. Sonu Gaind]

We actually know a lot now, and it is completely different from how it was represented initially in some of the earlier consultations. The reason I say that is, the CPA's position aside, we know that on the most recent national survey—it was conducted by the Ontario Psychiatric Association, but it was actually a national survey—by a 4:1 margin psychiatrists felt that MAID for mental illness should not be expanded this March. It parallels every other survey we know of for psychiatrists in Ontario, in Manitoba—wherever it's been done after the sunset clause came in—whereby a 2:1 up to a 3:1 margin of psychiatrists do not support expanding MAID for mental illness, even though they're not conscientious objectors.

Typically, 80% to 90% of them, similar to me, are not conscientious objectors overall. They recognize the exquisite vulnerability that these issues pose for our marginalized patients and the challenges that we're talking about here. That's why they oppose it.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Thank you.

Ms. Long talked about people with unremitting suffering. You've talked about the difficulty of determining irremediability, whether people really aren't going to get better. Also, as a practising physician, I saw someone I knew over Christmas when I was working at a walk-in clinic. As soon as he saw me, he said, “Hey, Dr. Powlowski. How are you?” I'd seen him repeatedly for either suicide attempts or suicidality over the years. In an emergency room, he would have been the exact kind of person Ms. Long would perhaps say had unremitting suffering. I was very gratified to see him, and he seemed quite happy. I asked him what had changed, and he told me a whole bunch of things.

Have you had the same experience with people who had been written off as never getting better, who actually did get better?

Maybe afterwards I can ask the same thing of Dr. Gagnon.

[Dr. K. Sonu Gaind]

Yes, I have. That's precisely part of the challenge here. This is why it's not an issue, as Ms. Long presents it, of autonomy. It's not an issue of capacity of the patient. It's the capacity of the assessor to honestly judge when the person won't get better—and they can't make that assessment, which is the problem.

Just yesterday, I was on a panel at the U of T faculty of law with the former head of the Ontario Bar Association, Mr. Orlando Da Silva. If you get a chance to see that streamed, I highly recommend watching his portion of it. He very poignantly describes his own experience of repeated, severe depression when he was suicidal, and also, by the way, functioning, doing cases, trial law, and completely competent. He knows he would have been able to get it, and he would have wanted it. He is very concerned about what this would do to people who would be in situations like he was.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Dr. Gagnon, can I ask you the same question?

[Dr. Pierre Gagnon]

Yes, I saw some of these patients, and my colleagues always talk about these patients who improve. Often, they don't understand why. Often, it's a relationship, a life event or a change in therapeutics.

I have an example. As a psychiatrist, I also follow cancer patients when they're depressed. I had a patient like that who had a severe borderline personality disorder and depression. She had been suicidal for decades and was always in the emergency room, like some patients you saw, maybe. Then suddenly she had metastatic cancer and she stopped being suicidal. She told me, “Before I had cancer, I always wanted to die when I couldn't, and now I could die and I want to live.” She had five years of very productive and fertile happiness. You see that all the time with our colleagues. It's very tough to predict.

What I also wanted to add is that we always forget that now there are new treatments. I'm the chairman of the department of psychiatry at Laval University, and my job is to recruit young physicians with new techniques and new procedures. They train all over the world and come back to our centre in Quebec City. They go into different kinds of psychotherapy, such as neuromodulation and transcranial magnetic stimulation. There are new treatments that are very promising, such as ketamine treatment or psilocybin. You have all these new treatments that could be game-changers. We sometimes forget to talk about these new treatments that could really give hope and change the course of the illness.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Gagnon.

Next is Mr. Majumdar, please, for five minutes.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

Dr. Gaind, you mentioned earlier that when people try to commit suicide those who are unsuccessful often don't try again. They they often seek and receive treatment.

Do you think this policy would mean that people struggling with mental illness who have the possibility of recovery and overcoming this illness will end up dying and never having the chance to recover?

[Dr. K. Sonu Gaind]

That's precisely what I and most of my colleagues fear. You've hit the nail on the head. That is exactly what will happen, and the problem is that we will not know which of those people would have recovered. They will all go in the bucket of MAID assessors saying that this would have never gotten better. We will assume that they never would have recovered, and more than half of them would have.

I've actually heard from patients who have said that they are fearful for the future and are potentially not wanting to seek help when they get depressed again. Why? Because they're concerned that somebody is going to say to them, “Do you want MAID instead?”

We talk about the model practice standard. Remarkably, in that, it says that, for any adult who could be eligible—unless you already know, somehow, that MAID would not be in their value system or their goals of care—you need to advise them MAID could be an option. That actually means any adult with a disability, because MAID could be an option for any adult with a disability.

I don't know of any other country that has basically said something so permissive. Most say that the physician cannot be the one to bring it up, because that can be seen as suggesting it from the white lab coat.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

You called it the ministry of what in your opening comments...?

[Dr. K. Sonu Gaind]

What I personally believe we should have is a ministry of living with dignity.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

Shouldn't we be prioritizing hope and more accessible mental health resources over hurt—as my colleague MP Todd Doherty proposed with his 988 hotline—and shouldn't what this government be putting first be that main goal, which is exactly as you have named your proposed ministry?

In your professional experience, what has the data shown you? Do your patients get better with proper treatment and recovery?

[Dr. K. Sonu Gaind]

Yes, the vast majority do. What we know is that, as Dr. Gagnon was speaking of, there are also many treatments that our patients can't access, even for basic care. We know that less than one in three adults is able to get the basic mental health care they need, and that for things like neuromodulation and other things that can help, it's far fewer.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

We have about 90 seconds left, Dr. Gaind.

In the stories I've heard from Canadians suffering from mental illness, hope seems really far away in a world of darkness, and there's a lot of darkness in this world today. However, when given proper support networks, treatment and medication, etc., these people cherish the chance at a better life.

Do you think the government should be offering a second chance at a better life rather than a path with no return?

[Dr. K. Sonu Gaind]

I think we should be working on helping people live better and to address their real suffering. We can't forget that they're suffering, and it's not just from illness symptoms. It is also from other things. In fact, suicide prevention doesn't focus only on illness. It focuses on living with dignity.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

I appreciate the evidence-based advice you've provided this committee. You've published over 21 papers on this. It's a far superior background than being some sort of suicide lobbyist.

Thank you for being here.

[The Chair, Liberal, Sean Casey]

You have another minute if you want it. Okay.

Thank you.

Mr. Maloney, please, you have five minutes.