Evidence of meeting #102 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was illness.
A video is available from Parliament.
Professor of Psychiatry, Faculty of Medicine, University of Toronto, As an Individual
In my opinion, it would actually be a more honest determination, because it would be openly showing that we're basing it on luck rather than on the false reassurance of a white lab coat.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
With respect to this legislation, the government is providing a three-year pause, but you cited, as did Dr. Gagnon, two fundamental clinical issues—irremediability and distinguishing between a rational request versus one motivated by suicidal ideation.
Are you aware of any evidence you can point to that would indicate a likelihood or, for that matter, any evidence that we would be on track to be ready for what would be a significant expansion of MAID in three short years?
Professor of Psychiatry, Faculty of Medicine, University of Toronto, As an Individual
No, I can't point to any, and none has come to light in the past three years either.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Dr. Gagnon, do you have any thoughts on the assertion that has been made by Dr. Gupta and others that this would, if implemented, be limited to a very small number of Canadians who have been suffering from mental illness for, in some cases, decades?
Psychiatrist, As an Individual
On the contrary, as I tried to explain in my opening remarks, the studies show that euthanasia requests are often associated with very common problems, such as depressive disorders, personality disorders, grief or socioeconomic problems. There's a genuine risk that a very large population would be eligible for it, especially in circumstances where safeguards and protective measures aren't sound. They are actually more sound in the Benelux countries, Belgium, the Netherlands and Luxembourg, which are expanding eligibility for euthanasia to include all kinds of psychiatric and even psychosocial conditions.
So we can expect the eligible population to be very large. It's disturbing.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Gagnon.
Thank you, Mr. Cooper.
Next is Ms. Sidhu.
Go ahead, please, for five minutes.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you, Mr. Chair.
Thank you to all the witnesses for being here. My question is for Dr. Long.
Are you aware of the available resources supported by the federal government, which are assessing this complex case, for example, the curriculum and practice standards? Have they been helpful?
Chief Executive Officer, Dying with Dignity Canada
Just for clarity, I'm not a doctor. I'm not a clinician. I am aware of those pieces and their development, but I cannot utilize them as I'm not a MAID assessor or provider.
Liberal
President, Association québécoise pour le droit de mourir dans la dignité
No, thank you.
Since I'm not a psychiatrist, I can't discuss clinical psychiatric issues. I'm simply relying on the data provided by the experts, particularly in their report and in a document published in 2019, if my memory serves me, on the situation regarding mental health and medical assistance in dying.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Are there any gaps or challenges that limit the willingness of health care professionals to undertake those complex cases?
You are talking about data. Have you seen those types of barriers?
President, Association québécoise pour le droit de mourir dans la dignité
As far as I know, relying once again on the data provided by the experts, I see that some data indicates that psychiatrists and physician providers of medical assistance in dying can assess the patients.
It's also very important to understand that some of the patients who request medical assistance in dying, or who are currently eligible for it as a result of physical diseases, also suffer from mental health issues. Their capacity to make decisions for themselves is therefore accurately assessed.
What's more, in my clinical practice, particularly in surgery, we also regularly work with patients who have mental health problems. You also have to assess those patients' suicidality and capacity to make decisions.
For example, if a 40-year-old patient suffering from abdominal pain tells his physician that he doesn't want surgery and would prefer to die, that patient will obviously undergo a psychiatric assessment, be treated and then be treated for the physical issue. The same is true for all physical diseases.
So physicians, generally speaking, are in the habit of assessing patients' capacity in their everyday clinical practice, where necessary, of course.
I'm absolutely convinced that very few patients with mental health issues would request medical assistance in dying for the simple reason that significant safeguards have been established in response to the expert panel's recommendations.
Medical assistance in dying may not be administered to individuals who simply appear one morning and request it. To be eligible, they must have been suffering for many decades, and attempts must have been made to administer all treatments.
Note, however, that no one is required to try all the treatments. The patient is free to reject them, as provided under the Canadian Charter of Rights and Freedoms.
Of course, if we're talking about a patient suffering solely from mental health issues who requests medical assistance in dying, they will have to have undergone a certain number of treatments. However, it's false to say that all possible treatments must be attempted because that would violate the Charter.
Liberal
Sonia Sidhu Liberal Brampton South, ON
My next question is for Ms. Long.
Should the government take three years to further prepare the system? What are your recommendations to the federal government on making sure systems in the provinces and territories across the country are ready?
Chief Executive Officer, Dying with Dignity Canada
We don't believe the government needs three additional years to prepare. In the event that it goes ahead with this delay, it's very important that there are clear parameters outlined that must be met. There must be a clear understanding of what the expectations are in terms of the provinces and territories, and a clear commitment not to further delay.
In this case, the federal government listed the things it thought needed to be established, namely, a nationally accredited curriculum, a set of practice standards and advice to the profession, as well as revised reporting under the Health Canada reporting system. Those metrics have all been met, so if there is a delay, there has to be a better way of establishing what the next set of metrics are going to be and then ensuring we get to them in a timely manner.
Liberal
The Chair Liberal Sean Casey
Thank you, Ms. Long.
Mr. Thériault, you now have the floor for two and a half minutes.
Bloc
Luc Thériault Bloc Montcalm, QC
Dr. Gagnon, would you please send us the studies on the cases you've mentioned, which were numerous and concerned disorders that would have been reversible and for which patients should not have received medical assistance in dying?
You also discussed the safeguards that exist and that could have been stricter. Would you please give us a list of those safeguards? I'd like to explore that with you, since earlier you discussed an "indefinite delay". I imagine you have an idea of the safeguards that would be necessary. What would they be?
Psychiatrist, As an Individual
The safeguards in those countries include a psychiatric assessment, which we don't have. The problem that I see when I talk about indefinite delaying, is this: how are we going to resolve the fact that it's impossible to distinguish suicidal ideation from what would be considered an authentic request for euthanasia? It's going to be tough to get there.
I can say this about irremediability. Since I've been a psychiatrist since 1992, very soon, I will have been practising psychiatry for 33 years. We've seen so many cases of individuals whose situations change completely, even decades later, as a result of a significant encounter, an event that occurred in their lives or a new treatment. They still have decades of good living ahead of them, and all the psychiatrists—
Bloc
Luc Thériault Bloc Montcalm, QC
What I'd like is to know what safeguards you recommend. Recommendation 10 of the expert panel's report is that a psychiatric assessment be done. What are the additional safeguards that don't appear in the experts' report and that should appear in an act?
Psychiatrist, As an Individual
I think that's why the legislators prepared this bill thinking it would not be simple, and I agree with them. I don't have the answer to that, but it won't be simple. We're talking about a delay of at least three years. I think that's wise because it will take a long time for us to identify those safeguards and properly substantiate them.
Bloc
Luc Thériault Bloc Montcalm, QC
All right. That being said, I wouldn't want us to rely on a wrong impression. There's the act, about which the expert panel said that the safeguards and the track two criteria were enough. However, it shouldn't be forgotten that regulations will be made under the act and that it's the regulations that may contain the statement regarding those safeguards and how to proceed. It isn't necessary for the safeguards to appear in the Criminal Code. Those practices must then be supervised by a college of physicians that will sanction the practice. So it seems to me we can get there.
Liberal
The Chair Liberal Sean Casey
Your speaking time is up, Mr. Thériault.
Dr. Gagnon, perhaps you'll have an opportunity to answer the question a little later, the next time Mr. Thériault has the floor.
We have Mr. MacGregor, please, for two and a half minutes.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you very much, Mr. Chair.
Dr. Gaind, every problem we've had with this particular issue of mental disorder as the sole underlying medical condition you can trace all the way back to that eleventh-hour Senate amendment to Bill C-7. I was here during the 43rd Parliament. I was here in the 42nd Parliament for the first debate on MAID. I remember when the charter statement was first issued for Bill C-7, which I think reasonably explained the government's original position for excluding mental disorders as qualifying for MAID. They recognized the inherent risks and complexities that would be present for individuals. They noted that the evidence suggests that screening for decision-making capacity is particularly difficult. They noted that mental illness is generally less predictable than physical illness. However, inexplicably they accepted a very consequential Senate amendment.
It seems that we've just been constantly kicking the can down the road. The first delay was for two years. Bill C-39 delayed it by a further year. Here we now are, with Bill C-62, looking at another three years.
I'm just wondering, first of all, what your reaction was at the time when the government did that 180° turn in their decision. Also, I think you sort of answered this, but I'd like you to expand on it a bit more. Can we actually ever be ready for this, or are we just setting ourselves up for failure in 2027?
Professor of Psychiatry, Faculty of Medicine, University of Toronto, As an Individual
On your last question, I'm not trying to be flippant, but I think the only honest answer is that we don't know if we would be ready in three years or not. This is why it's problematic to say that we will be ready in three years when we don't know.
The reason we don't know goes back to the first points you were making, which were reflecting the deeply flawed process that was behind this in the first place. We never asked those questions. We never actually asked those questions. From day one, with Senator Kutcher's sunset clause agenda, it was a predetermined course that we will offer this, without asking those questions that need to be answered first. To me, that's really putting the cart before the horse.
I'll also point out that on these key issues of irremediability and suicidality, I find it quite striking that it's not only the people who are expressing caution who cite those. Even the ones who have been at the forefront of saying that we should be doing this have acknowledged that.
Dr. Gupta has chaired a number of these expert panels. She also co-authored an AMPQ report in 2019 or so. I can't remember which year. In there, they literally acknowledge, the provincial association, that regarding irremediability it is possible that a person who has recourse to MAID, regardless of his condition, could have regained the desire to live at some point in the future. They acknowledge that, but then say that it should be an ethical question each and every time.
When you're getting a medical expert opinion, ethics are fine, but I think people are thinking they're getting a medical expert opinion and not the person's personal ethical judgment. On suicidality, they've acknowledged that as well on the expert panel.
Liberal
Conservative
Todd Doherty Conservative Cariboo—Prince George, BC
Dr. Gaind, I'm wondering if you're familiar with this saying: I don't want to live, but I don't want to die.
What does that mean?