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

[Dr. Guillaume Barbès-Morin]

That's an excellent question. It's one of the points we tried to clarify in our paper.

There are indeed some extremely invasive types of treatments in psychiatry. One example is implanting a vagus nerve stimulator. This is a device implanted in the brain. Some people might decide that it's too invasive for them. That should be clarified.

We have access to a fairly broad set of psychiatric treatments in Canada. I would say that in general, people hesitate because of a misunderstanding or misinformation. Take the example of electroshock, also known as sismotherapy. This treatment is extremely effective for major depression and is used regularly, but it carries significant social stigma. Often, people who are misinformed will refuse it. Personally, I offer this treatment to certain patients. When you take the time to sit down with them and adequately explain its usefulness, they usually understand it well.

Sometimes, an individual refuses treatments like those because they deem them unacceptable. Generally, however, it is possible to walk them through it, thoroughly illustrate the benefits these treatments can provide, and explain how tolerable they are compared to all the treatments available in physical medicine, which are often very invasive as well.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

That's all the time I have.

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Next we'll have Mr. Thériault for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

I'll start with Ms. Cohen.

Good morning, Ms. Cohen. Welcome to the committee.

I am somewhat perplexed. I understand that you left the Expert Panel on Medical Assistance in Dying and Mental Illness. However, I'm sure you read the final report.

On page 10, assessing the capacity to consent to care, it reads: “[W]hen the assessment is so difficult or uncertain that the clinicians involved cannot establish that a specific individual is capable of giving informed consent, the intervention is not provided to that individual.”

Further, on page 11, the report examines crises involving suicidality: “In any situation where suicidality is a concern, the clinician must adopt three complementary perspectives: consider a person's capacity to give informed consent or refusal of care, determine whether suicide prevention interventions—including involuntary ones—should be activated, and offer other types of interventions which may be helpful to the person.“

When reading this report, it's very clear that anyone with mental disorders or personality disorders, who is suicidal and in their 20s, for instance, would have to wait several decades before someday having access to medical assistance in dying, after having tried the entire range of possible therapies. Indeed, an assessment would be needed at that time to determine if they could have access.

What do you think of this part in the report? Are you for or against what it says?

[Ellen Cohen]

I'm not really understanding the question. The report talks about alternative supports and alternative therapies and young people. I think that's good, and I think people should be offered supports, but it's not always just mental health supports and services. Any access to those services doesn't come that quickly. There are waiting lists. There are a million reasons why people don't access services and supports.

I didn't really understand your question. I understand that there were a lot of suggestions about offering people supports and services. However—

[Luc Thériault, Bloc, Montcalm, QC]

Excuse me for interrupting, but I'd like to move on to another witness. It's not a problem if you didn't understand my question.

Dr. Barbès-Morin, some members of your association claim there's always a treatment to relieve suffering. Many oppose offering medical assistance in dying, since incurability is not necessarily a foregone conclusion in many cases.

In your opinion, does claiming that there's always a treatment to relieve suffering and asserting that there's no need for medical assistance in dying amount to medical paternalism, or a kind of therapeutic obstinacy in psychiatric practice? This was said in Quebec.

[The Joint Chair, Hon. Yonah Martin]

Answer very briefly, Dr. Barbès-Morin.

[Dr. Guillaume Barbès-Morin]

I would answer that the same concern exists in physical medicine. This might be the perception among doctors treating various neurological conditions and different disorders. I don't want to pass any judgment on their level of paternalism.

From my personal clinical experience, I can tell you about situations where people had appropriate and sustained access to an array of incredible treatments and, unfortunately, they continued to perceive their suffering as intolerable.

I think we should recognize their autonomy and their capacity to judge their situation. Of course, I am not talking about cases of suicidality. However, in general, people who are suffering are capable of assessing it and deciding what they want for their lives. We have to listen to them.

This is not unique to mental illness; it is the same in physical medicine.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Next I have Mr. MacGregor for five minutes.

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

Thank you, Madam Chair.

Thank you to our witnesses for helping guide this committee through a very serious subject matter. It's one that I know many Canadians are paying attention to.

Ms. Cohen, I'll start with you. I appreciate that you are nervous appearing before a parliamentary committee, but I can assure you that all members around this table do appreciate your being here. We want to make this as comfortable as possible for you.

When you were talking in your opening statement about how this process has been rushed, I can understand the fears that you have with the timeline. This joint committee did exist in the previous Parliament, but it had to be reconstituted in the 44th Parliament. We've really only been under way since April. We've been working with less than a year, until March of next year, when the law will be changed and mental disorder as a sole underlying condition will be allowed under our Criminal Code.

You also made it very clear that you are not opposed to medical assistance in dying, but that you had very real concerns that there were no meaningful discussions on capacity, on vulnerabilities and on specific safeguards. Therefore, given that our committee is ultimately tailoring a report with recommendations to the federal government, do you have any comments specifically on...? Should we recommend that the March deadline be pushed back? What additional steps would you specifically like to see the federal government take in addressing the concerns that you have so clearly outlined in your testimony?

[Ellen Cohen]

First, I would like to see the government push the deadline back because it's unrealistic. I signed on in June and we didn't start our first meeting until the end of August, so it was rushed. I understand that your panel and this process is being rushed as well. I'm not sure what the hurry is.

I know that we made many recommendations. Dr. Wieman remarked on Dr. Goulet's experience in Manitoba as a MAID assessor. We talked about teams. She talked about having a great team. I think there needs to be some kind of thought into how people....

It's difficult for doctors, as I understand, as well. I clearly understood that as I was sitting at the panel. I understand the difficulties, but I think that if the government is going to move forward, they need to help support the medical community to develop the processes collectively. There needs to be a standard across the country so that things don't go off course.

Mental health legislation went off course. Every province does it differently. What I witnessed in Bill C-14 was that every province monitored differently and some of the provinces had “unknown” categories. Way too many people were dying from unknown—

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

Thank you for that.

I'm terribly sorry to interrupt.

[Ellen Cohen]

That's okay.

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

I think you gave some great points there, but I do have limited time and I want to get one question in to Dr. Wieman.

Dr. Wieman, thank you for joining our committee. I also hail from British Columbia. My riding of Cowichan—Malahat—Langford has a very large indigenous population. I very much understand the intergenerational trauma that exists among indigenous nations in my riding.

You have very clearly identified that broader engagement is necessary. Again, under the theme of us working with this March date that is rapidly approaching us, what, in your mind, does adequate consultation look like? What concrete steps should the federal government start with in this engagement process?

[The Joint Chair, Hon. Yonah Martin]

Be very brief, please.

[Dr. Cornelia Wieman]

Thank you for your question. I think a large part of what needs to be done in terms of engagement is listening to first nations, Métis and Inuit groups. I know that you've had some representation here at these committee hearings, but in my opinion, that probably is not sufficient.

I think a large part of it, as I referred to in my opening remarks, has to do with communications. Indigenous people in Canada deserve equal access to medical services. That includes having access to MAID assessment and provision. But as I mentioned, those misunderstandings and misperceptions need to be clarified for people. That, I think, would go a long way toward alleviating some of the concerns that come out of those misperceptions.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

I will turn this over to my co-chair so that we can go to our round of questions from the senators.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Senator Martin.

We will now start with senators' questions.

As Senator Kutcher is not here, his speaking time has been given to Senator Mégie. She has six minutes and I give her the floor.

[Marie-Françoise Mégie]

Thank you, Mr. Chair.

I thank all the witnesses who came today to enlighten us about their work.

My first question is from Senator Kutcher, and it is for Dr. Barbès‑Morin.

Does your association agree with the expert panel's conclusion?

[Dr. Guillaume Barbès-Morin]

Could you specify which expert panel conclusion you are referring to? I am sorry, I don't follow exactly what this is about.

[Marie-Françoise Mégie]

Senator Kutcher did not specify the exact conclusion. Could you speak generally about the conclusions and recommendations made by the expert panel and the direction of the report?

[Dr. Guillaume Barbès-Morin]

I am sorry, but I cannot answer that question on behalf of my association, as we have not discussed it specifically.

[Marie-Françoise Mégie]

In that case, I will focus on a specific point. According to the expert panel, there's no need for measures to safeguard people whose request for medical assistance in dying stems solely from a mental health problem. Does your association agree?

[Dr. Guillaume Barbès-Morin]

In our report, we did propose a process to follow, a way of setting up safeguards to make sure that the assessment is done appropriately. I imagine it would vary somewhat from province to province, as there are some differences. In our view, two psychiatrists must be involved in that assessment, for example. We've also defined minimum timeframes and guidelines to apply to proposed treatment.

I cannot tell you to what extent these protections or safeguards will ensure appropriate assessment. Regardless, we suggested a structured approach for assessment to make sure that things are done appropriately.

[Marie-Françoise Mégie]

You're a psychiatrist in Rouyn‑Noranda. In similar regions, do you think there's sufficient access to psychiatrists?