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
Gary Anandasangaree Liberal Scarborough—Rouge Park, ON
Madam Joint Chair, if we've finished with the witness, I have a housekeeping matter that will take 30 seconds.
The Joint Chair Hon. Yonah Martin
Okay.
Thank you very much, Professor.
Yes, Mr. Anandasangaree.
Liberal
Gary Anandasangaree Liberal Scarborough—Rouge Park, ON
I would like to bring forward a motion, which says, “That the clerk of the committee be authorized to grant access to the committee's digital binder to the offices of the whips of each recognized party.”
It's a routine motion that's passed in a number of committees.
The Joint Chair Hon. Yonah Martin
Yes. I see heads nodding.
Is there any discussion?
(Motion agreed to)
We'll suspend for a few minutes to move to our second panel.
Thank you very much, Professor.
The Joint Chair Hon. Yonah Martin
For the sake of our new witness, Dr. Donna Stewart, before speaking, please wait until I recognize you by name. This is a reminder that all comments should be addressed through the joint chairs. When speaking, please speak slowly and clearly. This goes for all of us. Interpretation in this video conference will work as it does in an in-person committee meeting. You have the choice at the bottom of your screen of floor, English or French. When you are not speaking, please keep your microphone on mute.
With that, I'd like to welcome our witness for panel two, who is also here to discuss MAID when a mental disorder is the sole underlying medical condition.
As an individual, we have Dr. Donna Stewart, professor, University of Toronto, senior scientist, Toronto General Hospital Research Institute, Centre for Mental Health.
We will first hear from our witness, Dr. Stewart, for five minutes.
Dr. Stewart, go ahead.
Dr. Donna Stewart Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
Good evening, and thank you for asking me to present today.
I should mention that I practised as a family doctor in northern Ontario before qualifying as a psychiatrist nearly 50 years ago. In 2014, I became a member of the Order of Canada. I am also a member of the Canadian Psychiatric Association working group on MAID for mental illness, the Canadian Association of MAID Assessors and Providers, and the University of Toronto Centre for Bioethics. As mentioned, I'm a senior scientist at the Toronto General Hospital Research Institute where I conduct research, including research on MAID. I have assessed over 300 MAID applications. I presented to the Senate committee on MAID in February 2021. My opinions are informed by my affiliations and experience, but I speak to you today in my personal capacity.
As a member of the expert panel on MAID and mental illness, I endorse all 19 recommendations, but I'd like to highlight now a few specific ones based on my personal experience in practice. The recommendations I do not comment on are equally important, but my time today is limited.
Expert panel recommendation number 1 is about collaboration between authorities. It's essential that federal, provincial and territorial governments work to facilitate collaboration between physician and nurse regulatory bodies in the development of standards of practice for MAID. I understand that substantial government and regulator work on MAID for mental illness is currently under way and that two sections of the MAID CAMAP curriculum have been written, reviewed, and are currently being revised. I know that other professional organizations are offering MAID education in various formats. As pointed out, the looming March 2023 deadline is a very powerful motivator.
With respect to recommendations 2 and 3, establishing incurability and irreversibility, clearly, MAID assessors must consider the severity and duration of illness, treatment attempts, outcomes and other evidence-based treatments that may improve the patient's condition while weighing their likely benefits and the burden. This will involve conditions lasting for many years with many multiple attempted interventions. It's my strong opinion that this determination should be a shared one between a psychiatrist, in the case of a mental disorder, and the patient and not only the patient's decision. This is clearly specified in the Netherlands' standards of practice where physician-assisted death for mental conditions has been available for almost 20 years, and where in 2020 there were 95% of physician-assisted death requests for a psychiatric disorder rejected. In fact, completed cases with respect only to mental disorders comprised only 1.3% of all physician-assisted deaths in the Netherlands.
A clinical example I can give you is a patient who insisted that only treatments based on natural plant products could be used, and I accordingly felt he did not meet the MAID criteria.
With respect to recommendation 4 related to suffering, while enduring and intolerable suffering is subjective and determined by the patient, it is also important that the MAID assessor or provider agree from a realistic perspective. For example, I assessed a middle-aged woman with mild osteoarthritis who stated that her suffering was intolerable because she was raised in the tropics and was nearly always cold in Canada, which aggravated her suffering. Clearly, I did not feel this met the criteria.
Recommendations 6 and 7 are on means to relieve the suffering. Clearly, multiple safeguards should always be seriously considered, including medical, psychological and social supports. I recently assessed a cancer patient who was also very depressed. Antidepressant medication and referral to palliative care resulted in her withdrawing her MAID request.
With respect to recommendations 10, 11 and 12, relating to independent assessment with an expert, involvement with other health care professionals and significant others, in the cases of MAID-SUMC, this should be a psychiatrist, in my opinion, independent of the treatment team to avoid bias.
With respect to recommendation 16 on prospective oversight, again, this is vital, in my opinion, for many track two cases, many of whom have comorbid mental disorders that have been poorly treated. This process is not to make judgments of eligibility, but rather to ensure that the assessments are in compliance with legal and professional standards. This should not result in lengthy delays, but should be an added safeguard by improving quality, safety and timely practice feedback to support patients and practitioners.
Recommendation 19 relates to research. As a senior scientist, I believe that regular and targeted investigation-initiated research on questions relating to MAID should be funded. Research in the Netherlands has informed revisions to their physician-assisted death safeguards and have been very important.
In closing, I want to emphasize the fulsome discussion of all recommendations and their salient related issues was conducted during the many hours that the expert panel, its subgroups and individuals met. Various interconnected safeguard mechanisms were available to us and for your consideration. These include legislated safeguards, professional standards, guidelines and education, each of which plays a unique, interrelated and essential role.
Thank you so much. I look forward to your questions.
The Joint Chair Hon. Yonah Martin
Thank you, Dr. Stewart.
We will begin with five minutes, starting with Madam Vien.
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
Thank you very much, Madam Chair.
Dr. Stewart, welcome to the committee. Thank you for being here this evening and for providing us with your testimony.
Do you think the current safeguards are sufficient? Do you think we are protected against abuse?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
No system is foolproof, but I would say it's very important that the various provincial, territorial and regulatory bodies co-operate to make sure that these are firmly established in the standards of practice. If that doesn't happen, then I think legislative safeguards would be needed, but I recognize the cumbersomeness of that. I certainly hope that standards of practice and guidance and education can deal with many of these issues.
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
We put the question to the expert who appeared before you. 2023 will be here quickly, and all of it has to go into effect.
In your opinion, is 2023 too fast? Do we have enough time to see the costs coming and make sure that we choose the best possible path?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
You raise a very important question. My reply is that that deadline is a very important motivator. I think the speed at which these things are being determined has picked up. Most of us worked during the summer, but not everyone. Hopefully, between now and the next few months some of these things will be put in place.
As I mentioned, I know some of the curriculum is currently being circulated and revised. Certainly, there are meetings going on. I would hope that things could be put in place. I don't know for sure, but I certainly hope so and trust that will happen.
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
Dr. Stewart, you mentioned earlier that you had denied medical assistance in dying to some people who had requested it. I hope I understood you correctly.
Do you know what happened to those people? What happened next to those people who were denied medical assistance in dying? What happened to them?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
I think that's a very important issue. What I will say to people is this: “We have discussed your case very carefully. I have thought about this very carefully. I can see that you're trying to deal with this situation, which is incredibly difficult. I honestly don't feel at this time that we can proceed by approving MAID for you. That does not mean it will never be approved, but I think you need to spend more time around the following issues.” I would then detail the things I thought needed to be addressed.
I think it's very important that these people do not feel rejected, because many of them are very ill and suffering in various ways. But I think in a kind but firm way assessors need to be clear in their own conscience and their own mind that what they are approving is correct.
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
I would like to ask you one last question, Dr. Stewart.
As you know, Quebec is a very progressive province. I was part of the Quebec government when the first law was passed. The Quebec government decided not to put mental disorders as the only illness involved.
Has Quebec gone down the wrong path, in your opinion?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
I would agree with you that Quebec is usually very progressive and has led the way in many aspects of this. I think that you were overly cautious in this regard, and I know that many Quebec physicians feel the same as I do about this, that it was too cautious, but time will tell.
Conservative
Dominique Vien Conservative Bellechasse—Les Etchemins—Lévis, QC
Thank you very much, Dr. Stewart.
We could talk about this some more later if we have any time left. I will share my time with my colleague; he definitely has questions for you.
The Joint Chair Hon. Yonah Martin
Thank you.
We have our second panellist, as you can see.
Colleagues, if it's okay, I will invite Madam Doris Provencher, general director, to give her five-minute remarks, and then we will go to our second questioner, Dr. Fry.
Go ahead, Madam Provencher.
Doris Provencher General Director, Association des groupes d'intervention en défense de droits en santé mentale du Québec
Thank you, Madam Chair.
Good evening, everyone. I apologize for being late; I had some technical issues.
I would like to begin by greeting the joint co‑chairs, the Honourable Yonah Martin and the Honourable Marc Garneau, as well as all the members of the Special Joint Committee on Medical Assistance in Dying. Thank you for inviting the Association des groupes d'intervention en défense des droits en santé mentale du Québec, or AGIDD‑SMQ, to share its thoughts on the possibility of allowing medical assistance in dying owing to mental health problems.
At the outset, I would like to make it clear that the AGIDD‑SMQ never uses the terms “mental illness” and “mental disorders”. For us, these are people experiencing a mental health problem. So that is the term I will use.
Our association was founded in 1990, and its mission is to fight for the recognition and exercise of the rights of people living with or having experienced a mental health problem. In doing so, the association has acquired a unique expertise in the field. The AGIDD‑SMQ takes a critical look at mental health practices and is involved in their renewal. The collective voice of people living with a mental health problem is at the heart of our practices; I would even say it is part of our DNA.
In the wake of the decision in the Truchon and Gladu case, in September 2019, medical assistance in dying for mental health problems became a matter of consideration, and even more so when, in January 2020, the Quebec minister of health and social services announced that, as of March 12, 2020, medical assistance in dying would be accessible for mental health reasons. That announcement created a major shockwave. Of course, the pandemic put a sudden stop to any reflection or consultation on the subject. You know something about that because it was the same scenario at the federal level.
Not admitting defeat, in the fall of 2020, the AGIDD‑SMQ decided to launch a consultation with its member groups, which are mostly made up people living with a mental health problem. For the association, it was essential that those affected by this issue be the first to give their opinion.
To date, we have not been able to hold a meeting with our members to discuss this issue, which is so sensitive and full of uncertainties and questions for many of them. On the other hand, some member groups were able to consult their members. It is the fruit of their reflections that we have gathered in the brief “Entendre. Écouter. Prendre en compte la parole des personnes vivant un problème de santé mentale. Rien sur nous, sans nous.”—hear, listen, take into account the voice of people living with mental health problems; nothing about us, without us. We submitted this brief to the Quebec MPs who were members of the Select Committee on the Evolution of the Act respecting end-of-life care in August 2021, and we have submitted it to you, as well.
Three findings emerged from this consultation. First, there is a lack of understanding of what the practice of medical assistance in dying is. Second, people are seeking help to live with dignity and need hope. Finally, people with mental health problems need to be consulted—they want to be consulted—and involved in medical assistance in dying for mental health reasons.
Our association does not have an official position because, as I just said, we have not been able to meet to discuss it. On the other hand, for more than 30 years, the AGIDD‑SMQ has been at the forefront of denouncing abusive or discriminatory situations against people. Since the ruling in the Truchon and Gladu case, we have spoken out to denounce the double standard between the seriousness given to physical health problems and the ignorance of the suffering experienced by people with a mental health problem.
The stigma and paternalism surrounding mental health problems make it difficult to believe that a request for medical assistance in dying can be made “consciously” in these circumstances. When a psychiatric diagnosis is made, the person concerned loses all credibility. Moreover, a number of people have told us that they feared that if they requested medical assistance in dying they would be hospitalized against their will, as they would then be considered dangerous to themselves or to others.
Who is in a better position to judge the sustainability or unsustainability of suffering than the person living with persistent and intolerable suffering? Deciding to die with dignity is legitimate, and accepting it is a matter of respect for the person. We believe that every individual should have the right to make choices about his or her own life, especially when those choices closely affect human dignity.
Five minutes is a short time to talk about such a complex and important topic.
I will be happy to take the time to discuss this issue with you.
Thank you.
The Joint Chair Hon. Yonah Martin
Thank you, Ms. Provencher.
Next we will have Dr. Fry.
You have five minutes.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you very much, Co-Chairs.
Thank you for coming to present to us this afternoon.
I really want to focus on something that has been a recurring theme throughout this whole question on mental illness being a sole underlying condition. Inherent in this, from everything I've heard, are two very important things that I took away from the discussions of everyone else who has talked to us.
One of them is that this has to be done on an individual case-by-case basis. One cannot set blanket laws and blanket decisions for people. In fact, the whole Supreme Court decision on this issue said clearly that this had to be a case-by-case basis, because we all know—and I happen to be a physician—that when you deal with a patient with illness, even physical illnesses....
Let's just look at physical illnesses for a moment. Fifty people with the same physical illness are not going to respond to treatment in the same manner. We have to understand the nature of the individual when making these decisions.
The second piece that I took away from this is that there seems to be a huge level of discrimination against people who have mental illness as a sole underlying condition. The idea that people with mental illnesses do not have compos mentis, the ability to make decisions or to decide what is intolerable suffering for them and, working with a physician, would be able to come up with a decision that is reasonable for them....
We keep talking about blanket decisions and whether we should make a generic decision about this or that. I'd like to know your position on that situation. Should we make blanket decisions, legislative or otherwise, or should we deal with this on an individual case-by-case basis? Should we try not to discriminate between mental illness and physical illness?
I'd like Dr. Stewart to answer first, and then perhaps Ms. Provencher would be able to answer.
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
Dr. Fry, I completely agree with you. These do need to be looked at on a case-by-case decision. I think the A.B. decision in the Ontario Superior Court made it clear that, in fact, this was not a matter for the courts, that this was a matter for physicians to think about and make decisions about based on the entire situation the patient finds themselves in.
General Director, Association des groupes d'intervention en défense de droits en santé mentale du Québec
I also think that this has to be considered on a case‑by‑case basis because every situation is different.
All I would personally want, regarding discrimination, is for people with mental health problems to be treated the same as those with physical problems when requesting medical assistance in dying.
Also, since the criterion that natural death be reasonably foreseeable is no longer in the legislation, we certainly have to take a case‑by‑case approach. I am still concerned about discrimination and stigma because people with mental disorders are subjected to that a lot, even within the public health system. In short, we must indeed take a case‑by‑case approach, but we must also believe what these people tell us. I don't know how to include that in a piece of legislation, but I think it's important.
Liberal