Medical Assistance in Dying Committee on Sept. 23rd, 2022

[Dr. Guillaume Barbès-Morin]

That depends on the region we're talking about. Whether or not there are enough psychiatrists is a constant issue as people come and go. I'm sure it's the same throughout Canada.

I think that access to services and care is an extremely important issue which must not be resolved at the expense of medical assistance in dying. All of Canada's health systems should prioritize access to services and care. We must make sure that people with needs have access to services. That's true in every region. Speaking from what I know, I would say that in some sectors of Montréal, it is currently very difficult to get access.

Medical assistance in dying is for people who, in general, have had very serious and chronic disorders for quite some time. They've often had access to many quality services throughout their lives. This should not change. People with a serious mental illness must continue to have access to quality services throughout their lifetime, so that they can get the fastest and best relief possible.

Although related, this issue is different. It transcends medical assistance in dying, in my opinion, and remains fundamental.

[Marie-Françoise Mégie]

My next questions are for Dr. Wieman.

You mentioned medical assistance in dying being grounded in ceremony. As time grows short, could you speak briefly about some of those ceremonial aspects?

You also said that indigenous communities perceived medical assistance in dying as genocide. If someone were to express these thoughts in your office, as part of the doctor-patient relationship, how would you discuss it with them? Would you let them leave with this perception of genocide, or would you try to further inform them about medical assistance in dying?

[Dr. Cornelia Wieman]

Thank you for those questions. I will try to be brief.

For example, for first nations individuals who are accessing a medically assisted death, it is up to them to decide how they would like that to proceed. For some people, that may involve including part of their culture and ceremony into that process. As I spoke to in my opening remarks, I have heard some case studies of MAID being delivered to first nations individuals in British Columbia where the person did want aspects of ceremony included. In fact, the community was aware, since many of our communities in British Columbia are quite small, that this was happening on that particular day. It is one example I gave that gives some idea of what a medically assisted death could look like for a first nations person.

Additionally, to the second question, I have spent most of my career working with indigenous patients, as I mentioned, in a variety of settings. The first thing I try to do when I meet patients is hear where they're coming from. I think that's part of delivering culturally safe care. Of course, I would hear a concern such as a worry that someone would not be considered to be eligible for accessing a MAID assessment or provision. I would hear out their concerns, because their concerns are valid. They're coming from their point of view. Then I would obviously be able to spend some amount of time trying to provide the correct information or to correct misperceptions: Medical assistance in dying, particularly for those with mental disorders, is not a form of genocide.

There are people who are truly suffering and whose conditions, as Dr. Barbès-Morin mentioned.... Both of us, I think, have similar experiences. In my decades of working in psychiatry, there are very few individuals I can think of, probably fewer than 10, who I would think, based on my knowledge, would qualify for a medically assisted death under the MD-SUMC category.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Dr. Wieman.

We will continue with Senator Dalphond for three minutes.

[Pierre Dalphond, Senator, Quebec (De Lorimier), PSG]

Thank you, Mr. Chair.

I thank the witnesses for being here.

Since I only have three minutes, I will address my questions to Dr. Barbès‑Morin.

Reports from officials in the Netherlands and in Belgium show that medical assistance is dying is granted in at most 1% of cases of mental illness. They are therefore exceptional cases.

You spoke of your 16 years of experience [technical difficulties] are, however, worried...

[The Joint Chair, Liberal, Marc Garneau]

Senator Dalphond, we lost sound for a moment. Could you ask your question again please?

[Pierre Dalphond]

Reports from officials in the Netherlands and Belgium show that medical assistance is dying is granted in at most 1% of cases of mental disorders.

You estimated that three or four of the patients you've treated during your 16 years of practice could have been eligible for medical assistance in dying, based on current Criminal Code criteria.

However, others who testified before our committee said that they had concerns about it. In their view, medical assistance in dying would be too readily available to someone who is depressed or going through a difficult time, who has lost their job, who is unemployed, or who is experiencing economic hardship.

Do you think that federal standards are required to ensure consistency in this area and ensure that medical assistance in dying is only provided in the most serious cases? Or do you think that medical and professional practice is sufficiently structured to ensure such an outcome?

[Dr. Guillaume Barbès-Morin]

With respect to the federal-provincial challenge of managing uniform standards across the country, I am sorry, but I do not have the expertise to judge which standards are preferable and whether it is better to respect the provinces' views.

Originally, medical assistance in dying was implemented in Quebec. The rest of Canada then followed, but things evolved differently, which explains the disparities that exist today. I don't want to comment too much on that.

I think a framework is needed to set some fairly clear parameters, particularly in terms of assessment. We need to know what to assess, what we are assessing, what parameters to use and what values are assigned to those parameters, including initiation and duration of treatment.

To the best of my knowledge, this framework already exists in some form in the current legislation. As suggested, however, it needs to be adjusted somewhat to take into account certain characteristics related to mental health issues.

[Pierre Dalphond]

If I understand correctly, psychiatric medical practice is capable of setting these standards.

[Dr. Guillaume Barbès-Morin]

Indeed, psychiatric practice is capable of assessing the presence of a mental disorder and its severity, as well as establishing if this is an isolated moment of crisis or not. In general, we work with multidisciplinary teams.

That is already the case, and it should remain so for this type of situation. Assessing capability is already something that we are able to do in cases of grievous mental disorder. Psychiatric medical practice is therefore able of doing so.

[Pierre Dalphond]

Thank you.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Dr. Barbès‑Morin and Senator Dalphond.

We'll now go to Senator Wallin for three minutes.

[Pamela Wallin, Senator, Saskatchewan, CSG]

Thank you very much.

On my first question, I think I'll go to Dr. Wieman.

We've had, I would say, conflicting testimony over the months, perhaps even years, on this issue, with some parts of the indigenous community thinking that medical assistance in dying is an attempt at genocide.

You're presenting another case, on how we need the ability to incorporate traditional practices or rituals into the process for indigenous individuals. Can you give us some sense...? I know this is a hard one to do, but from the indigenous population in general, would you say there is cultural resistance or not? Could you quantify whether it's fifty-fifty, or sixty-forty?

[Dr. Cornelia Wieman]

Thank you for the question, Senator.

I'm not able to quantify.

What I believe, in a couple of short statements, is that first nations, Métis and Inuit people deserve equal access to any medical treatments and procedures that are available to any other Canadians in this country, including MAID, and for those suffering from mental disorders.

However, I think the issue, the conflict, comes from people's understanding of what that is and the pathway that someone must undertake to access a medically assisted death, for MAID in general and MD-SUMC specifically. I think people misunderstand, for example, the ease with which a medically assisted death might be obtained. That is clearly not the case. There are existing safeguards in the legislation.

I think that balance needs to somehow be found. That is why I was saying it's going to be found by having an engagement strategy and a communications strategy, probably nationally and provincially, so that people understand, because my concern—

[Pamela Wallin]

Do you mean something specific to the indigenous community?

[Dr. Cornelia Wieman]

That's correct. My worry is that there are people who are suffering in our communities and who have a right to access a medically assisted death but are not able to, because of the level of misunderstanding and misperception in some communities.

[Pamela Wallin]

Thank you.

So this is—

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Senator Wallin. I'm sorry. Time flies.

Senator Martin, you have three minutes.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Thank you to all the witnesses once more.

Ms. Cohen, I wanted to come back to your experience on the expert panel and the fact that you felt it was definitely rushed and the deliberations were restricted.

Your voice is missing from that report, since you stepped down, but what are some of the recommendations around monitoring and accountability that you would have liked to see in the report?

[Ellen Cohen]

As for monitoring, ultimately we need to make sure that people's experiences are being documented correctly. We need to understand and make sure that people who are choosing MAID because they have no other choice have their stories told, and that we don't skip over those kinds of stories. It's really important to ensure that.

Monitoring is a way for us to record and to manage the delivery of MAID. If we're not managing and we're not telling people's stories, we are not going to be able to understand why people are making the difficult choice of MAID over life, and what those reasons are.

[The Joint Chair, Hon. Yonah Martin]

Yes. What about the concerns that you have raised around the capacity to consent, particularly in the context of patients suffering from a mental disorder being hospitalized and treated against their will?

[Ellen Cohen]

Quite often, people who are put into hospital against their will are treated and come out, and I think it's wrong to be.... In my opinion, people are being treated unfairly. If somebody is ill and they go into hospital, they shouldn't have to be told that they have to stay there because of....

I'm not really being clear. I'm sorry. I'm a bit overwhelmed.

[The Joint Chair, Hon. Yonah Martin]

You have answered a lot of questions for us, so thank you very much.

I don't think I have enough time for a third question, but thank you.

[The Joint Chair, Liberal, Marc Garneau]

Thank you very much.

I'll now return the chair to Senator Martin.

[The Joint Chair, Hon. Yonah Martin]

This concludes our first panel. Again, we want to thank our witnesses for their testimony and for answering all of our questions. We wish that we had more time with each of you, but thank you very much.

We'll now suspend while we prepare for the second panel.

Thank you.