Health Committee on Feb. 14th, 2024

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Thanks, Chair. I appreciate the opportunity.

Dr. Gaind, I was on the special committee. You and I have met before.

In fact, I was on the special committee's most recent incarnation and the one before that. I was also on the justice committee that dealt with Bill C-7, so I have some knowledge of this. However, I don't profess to be anywhere close to any of you in terms of my ability to comprehend some of the challenges we're dealing with, which is where I'm going to go with my question.

We're here dealing with a piece of legislation on a fairly specific point. We're not here discussing the morality of medical assistance in dying. We're not here debating whether it is constitutional or is not. We're not here dealing with advance requests. We're dealing with whether or not this bill should proceed in its current form and why.

I'm not a doctor. There isn't a consensus on this. I've been on the committees, as I said. Look, we have three doctors on this committee, and I'm reasonably comfortable in saying that I don't think we have a consensus at this table, and that's excluding you, Dr. Gaind.

Here's my question. We have four witnesses here, two of whom, if I'm correct, have said that we should not delay. Two have said we should.

I want to start with you, Ms. Long. Here's my dilemma. We're tasked as legislators with deciding whether the system is ready or not. I've had the opportunity to hear from numerous witnesses, review numerous briefs and review all kinds of articles and information on all of this, and there's no consensus.

You're here saying there should be no delay because we need to safeguard people's rights—and I'll get to that in a minute too—but put yourself in my shoes. I've heard from all of these people and read all of this information and there's no consensus. It's not even close to being a consensus. I'm not a judge and I'm not on a jury. I don't get to decide who's right and who's wrong. What I have to do is decide whether the system is ready.

If you're in my shoes and you're faced with that situation—you have a whole bunch of people saying the system is not ready and they're highly trained professionals—am I not doing the responsible thing by saying we should delay it and discuss it further?

[Helen Long]

Thank you for the question.

I think if we go back and look at what the government outlined as what was required to demonstrate readiness, that has been done, and the testimony did say that. I think people need the ability to make their own choices once they've engaged in reflection and once they've had treatment. We talk about people not having to have treatment, people not needing to see a psychiatrist. The MAID assessors and providers that I know are people who are careful and thoughtful in their work. No one is looking to help people die by MAID instead of helping them to live.

I think there have been a lot of stories in the media that would lead people to believe that there have been cases of wrongdoing. There are no cases of wrongdoing. There have been no criminal charges laid in the past. These are careful assessments done on a case-by-case basis. Not being a psychiatrist, I can't speak to many of the points that have been raised. I think Dr. Gupta and others—

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Thank you, Ms. Long. I think I've given you adequate time to respond pursuant to the rules of this committee.

You're not answering my question. You're putting forward your opinion again.

Put yourself in my shoes. You have a large group of medical professionals—not like you, not like me—who are saying that the system is not ready. What would you do in my shoes? Am I not acting responsibly?

It's a fairly straightforward question, ma'am.

[Helen Long]

I think you're acting responsibly, considering everything you've heard, but we need to listen to those who are doing the work and those who testified.

I don't believe the testimony that I—

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

We are. That's precisely my point. There's a large number of them who disagree with what you're saying. They say that the system is not ready, so I'm doing precisely that.

My last point, while I have a few seconds, is this. In terms of safeguarding people's rights, does that not include people who might make a decision at a stage when it could be premature and who might potentially recover?

There are rights on both sides of the equation. It's not a one-sided issue. That's one of the challenges I have with this discussion. People pick one side or the other, but it's not black and white. When it comes to people protecting the rights of individuals, you have to look at both sides of the discussion. Is that not fair?

[The Chair, Liberal, Sean Casey]

Ms. Long, that's Mr. Maloney's last question. Please take 30 to 40 seconds to answer. I won't let him interrupt you again.

[Helen Long]

We need to listen to the clinicians who are doing the work and who believe they can assess these very specific and unique circumstances.

All individuals need to be considered on their own case-by-case assessment and their own merits. We need to listen to the testimonies. Yes, there were testimonies on both sides, but if you listen to the totality of the testimonies, there were certainly at least as many, if not more, people who testified that they were prepared to move ahead.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Long.

Mr. Thériault, you have the floor for two and a half minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Dr. Gagnon, the Canadian Association of MAiD Assessors and Providers, or CAMAP, and the expert panel on MAiD and mental illness say that individuals in suicidal crisis aren't eligible for medical assistance in dying.

Earlier you discussed suicide attempts and suicide prevention. These experts say that suicidality is a reversible state. So the question doesn't arise. There's no way a person in a suicidal state can be eligible for medical assistance and die.

Why are you confusing the issue? If an assessor sees a connection between a request and structural vulnerabilities, there's no way he or she should agree to a request for medical assistance in dying.

You say there are no safeguards, but there are. These people have established their own safeguards. They conduct assessments and tell their peers there's no way a patient can be eligible in that kind of situation. I imagine you agree with that.

[Dr. Pierre Gagnon]

It's true that suicidal crises may occur. That's obvious. However, earlier I cited the example of the patient who was chronically suicidal. His state has improved. He was suicidal for 20 years, but now is not. Suicidality can be acute, but it can also be chronic. There are subtle differences.

That's why we say it's extremely difficult to differentiate a suicidal patient from one who makes a genuine request for medical assistance in dying. We can't do it. There may be the obvious cases, but there are many cases between the two extremes. It's those cases that are becoming extremely difficult.

[Luc Thériault, Bloc, Montcalm, QC]

However, the extremely difficult cases must stay within the safeguards that the expert panel has put in place. Those safeguards are real. They exist. We could discuss them at another time because we can't do it in two minutes.

However, no one can say that there are no safeguards. Earlier I asked you what additional safeguards were necessary. You didn't answer me. I would have liked to hear an answer to that question today.

What specific safeguards should we add to improve this bill?

[Dr. Pierre Gagnon]

It's complicated. Some theoretical and practical issues are extremely complex and remain unresolved. How do you differentiate suicide from euthanasia? How do you determine the irremediability of a state? You have to examine those questions. This has been put off for some years now, and we still aren't able to resolve these issues.

That's why we say it will take a long time for us to come up with answers and solutions so we can say we need such and such safeguard.

[Luc Thériault, Bloc, Montcalm, QC]

In the meantime, patients suffer.

[The Chair, Liberal, Sean Casey]

Your time is up.

We will now go to Mr. MacGregor, please, for two and a half minutes.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you, Mr. Chair.

Dr. Gaind, I want to step back from this and approach it from a Charter of Rights and Freedoms angle.

I know that you and I are not constitutional experts, but you know what's invoked when we we look at section 7, which is the security of the person, the right to life and so on. Basically the layperson's interpretation is that everyone has the right to make decisions about what happens to their own body. Of course, section 15 provides that everyone has equality under the law. In section 1, some rights of the charter can be justifiably infringed upon by a free and democratic society.

My struggle through every aspect of my work on the special joint committee has always been trying to find a balance between an individual's rights to make decisions about their own body and the need for society to sometimes step in and protect our most vulnerable. That's been a real struggle for me—I won't lie.

I'm just wondering from your perspective and from other physicians' perspectives, when it comes to this particular issue of mental disorders as a sole underlying medical condition, how do you approach and find that balance?

[Dr. K. Sonu Gaind]

As you point out, I'm not a lawyer, so this is just my understanding of it and obviously not my expertise and stepping outside of that.

I do recall that, even in the original Carter decision and the section 7 argument, I thought part of that was the issue of foreshortened life, meaning that, if somebody is in a state where they can foresee that they will get to a point where they cannot act to end their own life and they choose to end their life earlier than that period of intolerable suffering, that's foreshortening their life. It was one of the rationales, in my understanding, that MAID needed to be an option.

That entire argument doesn't apply to mental illness because, while mental illness causes tremendous suffering and sometimes can affect capacity—although most of the time people remain fully legally competent—it very rarely takes away the person's agency to act to end their life or do other things. Right there you see some differences between some of the arguments that were made on that case in Carter. People sort of forget about that.

It is a significant issue because, as I alluded earlier, of the difference between doing something for someone or someone doing it themselves. When we talk about the right to my own choice, the way I think about that simplistically is that it's the right for me to do things for myself. When I expect something to be provided to me, that incorporates other things. If we're expecting the state to provide an easier, facilitated death, I think it's incumbent on us to think about how that plays out for everyone—not just on one person but everyone, including vulnerable populations.

We know that our laws can affect different people differently. As the poet Anatole France said, the law, in its majestic equality, forbids the rich as well as the poor to beg in the streets, to steal bread and to sleep under bridges.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Gaind.

The final round for the Conservatives will be Mr. Doherty, please, for five minutes.

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

Thank you, Mr. Chair.

Thank you to our guests for being here.

Dr. Gagnon and Dr. Gaind, you said some things that are resonating with me. Last night, in my intervention on Bill C-62, I shared for the first time something that I had not shared previously. While I have spent every minute of being elected for the last eight and a half years fighting for mental health supports for our frontline personnel, whether it's those who are struggling with PTSD or OSI, and I've been fighting tooth and nail for the country to adopt a national, three-digit suicide hotline, there was a time in my life when I struggled. The thoughts of death consumed my whole being. I attempted suicide twice. I'm living proof today that life is worth fighting for.

When I speak about fighting for those who don't have a voice and about my concerns about what Ms. Long is saying, I don't believe there are enough safeguards we can put in place to ensure that somebody who, like I was, is in a dark spot and finds a permanent solution for a temporary problem....

I appreciate your comments and all of your testimonies. I can respect all of the testimonies. My worry is that there will be many people, if we expand this to those who are struggling with mental illness, who say that they want to die, but they don't want to be dead. It's such a final act.

I also have a loved one who has recently chosen MAID. While we hear about the safeguards that are in place—a cooling off period and what have you—I also know that if that loved one of ours wanted it right away, they could get that.

My worry is for those who are struggling with mental illness and want to die because of whatever situation they're in. If only we can provide hope for the helpless and care instead of despair, I think we can really make a difference.

I thank you for your testimony.

[Dr. K. Sonu Gaind]

I'll just say thank you for sharing that. It cannot be easy and it takes deep courage too.

I also think it conveys a profound message of hope, so thank you for sharing that.

[The Chair, Liberal, Sean Casey]

Mr. Cooper, you have a minute and a half.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Thank you, Mr. Chair.

Dr. Gaind, one thing that Dr. Gupta and others have repeatedly said on the issue of suicidality is that this is something that psychiatrists and medical professionals deal with all the time, so there's nothing to be concerned with in cases of persons suffering from a sole underlying mental health disorder requesting MAID.

Could you comment on that?

[Dr. K. Sonu Gaind]

With respect to Dr. Gupta and others, including Senator Kutcher, they will tell a room full of psychiatrists who don't share this view that this is one of their core competencies.

We are trained to assess and address suicidality. Professor Gagnon was not confused when he said that we can't separate that suicidality from MAID requests for mental illness because we don't know how to do that. Those are different things. Anyone who's providing that kind of reassurance.... Frankly, I would say they are selling a bit of snake oil.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Gaind.

A final round of questions will come from Mr. Naqvi for the next five minutes.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you very much, Chair.

This is obviously a very sensitive, emotional and, for many, personal issue that we're discussing here today.

I don't profess to have the depth of knowledge on this particular issue, especially as it relates to MAID that applies to people with mental disorders, that many members of this committee do, given the extensive amount of work that has been done. My engagement on issues on MAID goes back to 2016 and 2017 when the Carter decision was being implemented. I served as the attorney general for the Province of Ontario and worked along with the minister of health at that time to apply the federal law in the provincial space.

What I do know from that work is that there needed to be a fair amount of work that had to be done in terms of the health care system being ready to apply MAID in a manner that, from a legal perspective, protected people's rights, but from a health care perspective, ensured there was appropriate training, curriculum and safeguards in place so there was no abuse of any kind.

That's where I'm coming from. For me, BillC-62 is about whether or not the system is ready to apply the laws being passed by Parliament. It is the view of the government, based on what we have heard from experts, based on what we have heard from the requests we have received from the provinces and territories, that the system is not ready and we need more time, hence, the extension for three years.

I will go to Dr. L'Espérance first and then to Ms. Long.

In your view, is the system ready to administer MAID for people with mental disorders as early as March 17 of this year, or is it appropriate and prudent to have an extension of time before we are sure that the health care system across the country, and not just in certain parts of the provinces but across the country, is sufficiently ready to administer MAID to people with mental disorders?

I will start with Dr. L'Espérance first.

[Dr. Georges L'Espérance]

Thank you for your question.

I'll answer it simply by saying that it isn't the system that administers medical assistance in dying; it's the clinicians.

All the clinicians who belong to the Canadian Association of MAiD Assessors and Providers, or CAMAP, have worked very hard in the past two years to establish safeguards. To do that, in the past year, they've followed the recommendations of the experts' report, among other things. We agree this isn't a simple issue. However, three years have now elapsed, and I don't think we'll be any further ahead if we delay another three years.

The issue is based on a clinical decision element, with all the necessary safeguards, as recommended in the expert's report. However, I repeat that this isn't a simple issue. In my view, delaying for another three years will result in absolutely no change in the situation. We will only be indefinitely postponing the decision, as we mentioned earlier.