Evidence of meeting #17 for Medical Assistance in Dying in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was disorder.
A recording is available from Parliament.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
I will try to get a succinct answer. You are all very succinct.
A lot of people have been concerned that people with suicidal ideation may decide they want MAID. I have heard answers from physicians and psychiatrists who say that's a decision the physician and the psychiatrist who understand their case can make, a decision between whether a person only has suicidal ideation or whether that person is indeed suffering intolerably and has tried all methods they wish to try. I want to use the words "wish to try".
Go ahead, Dr. Stewart.
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
Every day psychiatrists make decisions about suicidal patients. You see them in the emergency department, in the community and in the hospital. This is part of a psychiatrist's role, to sort out suicidality from a well-considered request for MAID after somebody has suffered for many years, tried many treatments, has carefully thought this out and feels that this is best for them, and they meet the criteria.
General Director, Association des groupes d'intervention en défense de droits en santé mentale du Québec
Of course, there is the issue of suicidal ideation, but my understanding of medical assistance in dying is that, just because I make a request, it doesn't mean I'm going to get the response I want. There are a lot of steps involved. As the Association des médecins psychiatres du Québec said, the decision should be made based on the person's history. I think a person who has suicidal thoughts and really wants to end it is going to take action anyway. You have to listen to them and check that with them.
The Joint Chair Hon. Yonah Martin
Thank you.
Next we have Monsieur Thériault for five minutes.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you, Madam Chair.
My first question will be for Dr. Stewart.
Dr. Stewart, in your testimony before the standing Senate committee on Bill C‑7, you talked about safeguards, which I think are reflected in the recommendations of the expert report. In that sense, don't you find that the report and the recommendations are also, through the guidelines that they command, additional safeguards that don't need to be written into law, but would frame practices and practitioners?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
I think I mentioned in my report that there are various mechanisms available to consider. We would hope that practice standards, guidance and education would be enough, but you know, there are people who feel that there need to be specific additions to the legislation. I do not personally feel that, but I think it's a valid consideration that you need to make.
Bloc
Luc Thériault Bloc Montcalm, QC
I am concerned about the feasibility of this. You said that the deadline, set for March 2023, was a great motivator. Your words are very elegant, noble and motivating, but at the same time, there are practical problems. For example, are there enough assessors? What about the resistance of the psychiatric medical profession? Will we be able to find assessors and providers across the country?
I would also like to hear from you on prospective oversight. Is the notion of an independent assessor realistic? What about prospective oversight? There are some things that are involved on a practical level. Tell me about how you think this prospective oversight may play out.
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
I think, as Professor Chandler said earlier, there will probably be a small group of people who talk with each other, experts who talk with each other about some of these issues. I think that, certainly, there is some anxiety about doing this, particularly until we know what the standards are going to be.
I think that the prospective oversight should not take a long time to put in place. For example, in Ontario, we have the Ontario capacity and review committee that meets within seven days to consider the treatment of mentally ill people. A similar mechanism could be put in place for people who meet MAID criteria. As others have said, I think that's going to be a tiny number of people. Based on the Dutch experience, 95% of these people get rejected and would never come before such a committee. They comprise about 1% of all physician-assisted deaths. We're not talking about large numbers of people who reach this level. I think they deserve a sober second thought through prospective oversight.
Bloc
Luc Thériault Bloc Montcalm, QC
Who would make up such an oversight committee? Should all cases be subject to this prospective oversight?
Wouldn't we end up in a situation where, as was once the case with therapeutic abortion committees, these committees would not be equally accessible from coast to coast to coast, which would be a barrier to medical assistance in dying?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
I'm old enough that I will remember those abortion committees, having served on a few of them. I would hope that we don't replicate that.
As an early step to make sure that these things are proceeding smoothly and that people are not getting physician-assisted deaths who should not be getting them, I think some oversight at the beginning is very reassuring, both to patients and to practitioners. I know that the Canadian Psychiatric Association strongly endorsed this and felt that they would really welcome such oversight.
You ask who should be on such a committee. Off the top of my head, I think we should clearly have one or more psychiatrists. We should have one or two good legal experts. We probably should have one or two bioethicists. Perhaps we should have a patient representative.
I think that we need to think very carefully about who best would serve on such a committee. It should be small and nimble and it should be able to meet quickly.
Bloc
Luc Thériault Bloc Montcalm, QC
That's getting to be a lot of people. This is increasing the concern I had earlier about feasibility. I'm concerned that all these people will have to be brought together to review decisions made by professionals. It is worthwhile to continue to explore what is meant by this prospective oversight. Usually, in ethics, we look at issues that are retrospective in nature.
Bloc
Luc Thériault Bloc Montcalm, QC
So why do we need a committee that will end up being the one to decide if the practitioner, the assessor—
Bloc
Luc Thériault Bloc Montcalm, QC
—the psychiatrist really did their job properly?
Could there be a contrary decision?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
With respect, I have named four categories.
The Joint Chair Hon. Yonah Martin
I'm sorry, but we're well over the time. Thank you very much.
We'll go to Mr. MacGregor for five minutes.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you so much, Madam Co-Chair.
I want to thank both of our witnesses for helping guide our committee through this study.
Ms. Provencher, I'd like to start with you.
You were talking about the advocacy work that your organization does. Our previous witness was talking about the Charter of Rights and Freedoms and how it applies, such as section 7, which says that everyone has the right to life, liberty and security of the person, and also section 15, which says that everyone has the right to be equal under the law.
You know more than anyone around this committee table that a high degree of stigma exists in our society when we are talking about people who suffer from mental health conditions, as you like to say. Your organization is not taking a position one way or another. Maybe you can put your answer in the context of those charter rights, the case-by-case basis and how important it is to try to combat that stigma and to understand that people who are living with mental health conditions do have that agency and that capacity.
Is there anything more that you want to add to this conversation so that not only this committee understands the issue, but also the wider Canadian public that is listening to this?
General Director, Association des groupes d'intervention en défense de droits en santé mentale du Québec
Thank you.
I don't know if I would go that far. As you said, the Quebec Charter of Human Rights and Freedoms and the Canadian Charter of Rights and Freedoms include the sections you mentioned and the issue of discrimination. It is the decision in Truchon and Gladu that would really provide the main support for these two sections of the charter.
As you know, just because I have a mental health disorder, that does not mean that I lose my ability to consent. I am able to consent until there is proof to the contrary. As a society, we will therefore have to consider persons with a mental health disorder as being able to make decisions, even serious decisions, such as making a MAID request. It will take a lot of work to get there though.
The Association des groupes d’intervention en défense des droits en santé mentale du Québec, AGIDD-SMQ, maintains that the best approach would be for people with mental health disorders to speak out publicly. For my part, I have worked with people with mental health disorders for 30 years, and I can guarantee that they are like you and me. They are people dealing with emotions and problems. Who doesn't have problems? Our view of people with mental health disorders is fundamentally discriminatory because we consider them unable to make decisions.
How can we change that view of people with mental health disorders?
We have been working on it for 30 years. Including these people in legislation such as this, putting them on the same footing as all Canadians who have rights, would in my opinion already be a step in the right direction.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you. I really appreciate that.
Dr. Stewart, in the limited time I have, I'd like to ask you, on the same theme, if you have an answer on the stigma part on a similar question.
The other thing, too, is that this issue of capacity keeps on coming up because every province has something. In my home province we have the Mental Health Act. It does allow for people to be involuntarily held if a physician feels there is a medical reason for doing so.
These are the kinds of thorny issues we're trying to assess when it comes to that issue of capacity and consent. If you can add anything more to the answer, I'd appreciate it.
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
I agree with Madam Provencher. In general, mental patients have equal capacity, but a few don't. Of those who don't, they're the ones who end up as involuntary patients.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Yes.
Finally, you know the work that has been done by the expert panel. Do you have any final recommendations you would like us as parliamentarians to put in our report to the federal government? What other areas does the government need to address?