Health Committee on Feb. 14th, 2024

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

With regard to irremediability, though, you continue to say that you need to get systems ready. Irremediability is something that you can't prove. You can't make a system to prove irremediability. It's an impossibility. That's a clinical judgment by a clinician in front of that patient. It doesn't matter what you change the system to. You're never going to get to the point of irremediability.

We've heard from multiple experts that they are the ones making that decision around irremediability, not a system.

[Mark Holland, Liberal, Ajax, ON]

What I'm saying is that—and this is why I posed the question; I think it's important for clarity—if you have somebody who is trapped in mental illness, who is saying that they want to end their life and have been saying that for five years, 10 years, 15 years or 20 years, who has attempted all therapy, everything at their disposal, at what point do you feel that this person has autonomy over that decision? If the answer is “never”, then that's an ideological position, and there's not a lot further to go.

However, if the point is that somebody at a certain point of suffering has an opportunity to have autonomy over their own life, then that's an important debate and one that is not rooted in ideology.

[The Chair, Liberal, Sean Casey]

Thank you, Minister.

We're going to move to Dr. Hanley, please, for six minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much.

Thanks to both of you, Ministers, for appearing, and thank you to your officials as well. I also appreciate the opening comments from both of you.

I want to just briefly continue on the train of irremediability and suicidality.

In your understanding, Minister, is determining suicidal ideation and distinguishing suicidality not already a part of MAID assessment, even as currently applied to someone with a physical condition and mental illness?

[Mark Holland, Liberal, Ajax, ON]

Yes, 100%. One of the things in our conversations with provinces and territories is that we want to make sure that the moment somebody expresses suicidal ideation, they have access to care and are channelled to a pathway of treatment. The circumstance, even for somebody who was attempting...who said that mental illness was the sole underlying cause and wanted to proceed with access to MAID.... Even if this regime was permitted, the person would need to demonstrate that they had tried everything and there would have to be two clinicians who would have to validate that the person had tried everything and that the person, in fact, had an irremediable condition.

[Brendan Hanley, Liberal, Yukon, YT]

I'm sorry for interrupting you, but I have so many questions.

In your understanding also—because you've had many conversations with practitioners—are there physical illnesses where irremediability requires judgment on the part of the physician?

[Mark Holland, Liberal, Ajax, ON]

Yes, in many instances there are physical conditions where you are told by a clinician that your condition is terminal and irremediable.

[Brendan Hanley, Liberal, Yukon, YT]

Then it's not necessarily a black and white decision or something in a textbook. It's a judgment that is required—

[Mark Holland, Liberal, Ajax, ON]

That's correct.

[Brendan Hanley, Liberal, Yukon, YT]

—as may well be required for mental illness.

Given that this is such a difficult issue, as we've all acknowledged, are you punting a difficult issue down the road?

[Mark Holland, Liberal, Ajax, ON]

No. If we were punting it, then we would have voted for MP Fast's bill, which set no date or would have set this off for an indeterminate length of time. What we've said.... I could run through it, but I want to be respectful of the time that you asked the question. I can run through specifically some of the things that I think need to happen.

We need time for our work with the provinces and territories to get to the position where there is system readiness, and that isn't present today.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

In the one-year extension that was applied a year ago, there were four criteria applied—a national reporting system, MAID practice standards to regulators in all provinces and territories, finalizing an accredited national MAID training program and considering the final report by the joint committee of the House and Senate. Of these four criteria, which have not yet been met, in your view?

[Mark Holland, Liberal, Ajax, ON]

I think excellent progress was made. There was the development of the MAID practice standards. There was the development and delivery of a national accredited MAID curriculum. There were 1,100 clinicians registered. I could go on, but I think one concern is that only 2% of psychiatrists have been trained at this moment in time. Of the 1,100 clinicians who received training, only 40 of them have completed that training. In talking with CAMH, there's discussion about wanting to have clinical guidelines. Those would take time to develop.

Lastly, perhaps I could very briefly mention the engagement with indigenous leadership. As I've gone and had these trilateral meetings, they're asking for more time—and specifically 2025. This is also true of the community of folks with lived experience in the disability community.

[Brendan Hanley, Liberal, Yukon, YT]

Thanks.

There's the letter from seven provinces and three territories. We all know about that letter. How influential was that letter in respect of the committee recommendations? How did each of those weigh into your decisions?

[Mark Holland, Liberal, Ajax, ON]

I'll be frank. When I became health minister and I had initial conversations, because of the points that you've just raised and the enormous progress made in a year, I really felt that the system might be ready. In Charlottetown, what I heard every health minister say was that they weren't ready. They needed more time. That caused me to have a pause at that moment in time. It led me to a lot of other conversations where I'm reflecting on some of the things that happened here. I would say that the joint committee in its testimony and work was also very important in coming to that determination.

It was certainly a part of the equation, the position of the provinces and territories.

[Brendan Hanley, Liberal, Yukon, YT]

Let's say that letter came from maybe one province or from two provinces and one territory. How would that have changed? In other words, if some provinces are stating that they in fact are ready, how can we justify holding back when they say they're ready to go and they have all the systems in place?

[Mark Holland, Liberal, Ajax, ON]

Maybe I'll paint the picture in an inverted fashion and say that it was no province and no territory. All 13 said they were not ready. I had very thoughtful conversations with many different health ministers who completely agreed on the equivalency between mental and physical suffering. However, they were requesting more time to get their systems ready. That was an earnest expression, I believe, on their part.

[Arif Virani, Liberal, Parkdale—High Park, ON]

Perhaps I can point out to Dr. Hanley that, in Quebec, they actually legislated the fact that, for mental illness alone, this should not be provided. They took a more active step than the letter.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Hanley.

Mr. Thériault, you have the floor for six minutes.

[Luc Thériault, Bloc, Montcalm, QC]

The structure of the bill reiterates the recommendation that the members of the special joint committee voted on, except as regards the matter of the three-year delay. Everyone but the Conservative Party members felt people weren't ready. We thought that, a year later, it would be wiser to work on that timeframe.

I think we were lax in that regard. How was it that, at the moment when the committee tabled its report and a decision had to be made a few weeks before the deadline, the provinces submitted a letter to us that we hadn't heard about in the previous year? You allowed the panel to submit a recommendation to us that became a bill, and you talked about the constitutional right of the people who were suffering, but what did you do about Sandra Demontigny? What did you do about the main recommendation that this committee accepted by majority vote one year ago, and who said we had to focus on advance requests? How is it that we don't have a bill that contains that component when you had a year to prepare it? The final component on the mental disorders issue could have appeared at the end. Why are you abandoning people like Sandra Demontigny when there's a consensus across the country?

[Mark Holland, Liberal, Ajax, ON]

That's a good question, and I do appreciate it.

People definitely suffer a great deal. I detest that, and it really disturbs me.

At the same time, we clearly have to ensure that the system in general is prepared for a change regarding medical assistance in dying. If the system isn't prepared, the consequences will be very serious.

We've made a lot of progress in the past year. It's remarkable, as I explained to Mr. Hanley, but it isn't enough.

The advance requests issue is extremely complex. For example, if a person is in poor shape, and one member of that person's family believes it's time to administer medical assistance in dying, while another family member thinks it isn't, it's the physicians who will have to make a decision. The individual won't be capable of making a decision. So there's a lot of complexity, and we're going to speak with the others—

[Luc Thériault, Bloc, Montcalm, QC]

No, I'm going to stop you there. Stop that; this is disinformation. Stop it.

Read the Quebec statute. You aren't being rigorous. I'm going to calm down, but your answer makes no sense.

This isn't about one member of the family or another. Under the Quebec statute, the assessment is conducted by a third party. A third party will be appointed, and that third party won't have the authority to tell the attending team to administer medical assistance in dying. The third party will be the guarantor of the person's wishes based on criteria that will have been established, and that third person will tell the attending team that he or she thinks the person meets those criteria and will request that assessment.

What are you talking about? We made that recommendation to you one year ago, and you're giving me a truly crazy answer this evening. I'm going to calm down, but I understand why we don't have a bill by now if that's how you understand advance requests in Quebec. The National Assembly of Quebec is unanimous on this point, and the approval rate across the country is 85%. People are waiting for this because people are suffering.

What are you waiting for? Are you at least going to commit, this evening, to helping us come up with a bill before the end of this parliament?

Get informed.

[Mark Holland, Liberal, Ajax, ON]

I understand the reasons why people want access to a system that permits advance requests. It's logical. However, my point is that this is completely different from the present situation and from what the bill proposes.

Today people can say in advance what they want to happen in a given future situation. However, if, at that time, they're incapable of expressing what they want, someone else will have to do it. That's a major change because someone else will have to make a choice instead of that person.

I'm entirely prepared to discuss this. We're going to speak with all the provinces and territories—

[Luc Thériault, Bloc, Montcalm, QC]

No, but, listen—