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.
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
I think I addressed that in my presentation. I think all of it, but the ones I specifically mentioned are especially important.
NDP
The Joint Chair Hon. Yonah Martin
Thank you very much.
That concludes the round of questions from the MPs.
I'll turn this over to the joint chair for the senators' questions.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Senator Martin.
We will now move on to questions from senators. Each person has three minutes. Let us begin with Senator Mégie.
Senator, Quebec (Rougemont), ISG
Thank you, Mr. Chair.
Thank you to the witnesses for being here.
My first question is for you, Dr. Stewart.
If I may, I would like to talk again about the establishment of practice standards for MAID. How can we ensure that health care professionals who conduct assessments and provide MAID services are properly trained?
I also have a sub-question, since I have just three minutes. What are the greatest challenges that these assessors and providers of MAID services would face if persons with mental health disorders become eligible?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
First of all, I think there are educational curricula currently being developed by CAMAP. Certainly, the Canadian Psychiatric Association has been very involved in its working group around trying to develop some standards for practice. I think that all of these things need to proceed. I think the various regulatory colleges for both physicians and nurse practitioners need to weigh in on this. I think the work is well under way and needs to keep moving along in a rapid pace to meet the deadlines.
You asked about the main concerns. The main concern is the uncertainty that currently exists about what the standards are going to be. The sooner this can be firmed up, the more reassured the practitioners will be.
I conducted some research with 131 Canadian MAID assessors and providers from across Canada, now published in the Journal of Palliative Care. It was very clear that one of their main concerns, their main stressors, was wanting to know what the standards were going to be so they felt as though they were operating within the safety of clear standards, rather than having to make decisions that weren't clearly defined at the present time.
I would urge you to include the expert panel recommendations very clearly and to endorse some of the CAMAP educational materials and the college regulatory requirements as they appear.
Senator, Quebec (Rougemont), ISG
Thank you for your reply.
Do I still have a few seconds?
Senator, Quebec (Rougemont), ISG
Very well.
My next question is for you again, Dr. Stewart. In all your research and discussions of practice standards, was there any mention of support services for the professionals practising MAID? From colleagues, I have heard that some of them were suffering. They provide the service but feel unhappy and suffer afterwards. Have you heard of any such cases? Have you heard that resources are provided to support them?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
These currently exist. CAMAP, the Canadian Association of MAID Assessors and Providers, provides a forum for providers, and it's a very active forum where people talk about their difficulties and their feelings. People share suggestions. It's very powerful.
I should point out that in our research we found that although there were stressors to this practice, there were many more personal rewards. People felt this was very important work, very compassionate work, and many felt that it was some of the most important professional work they do.
It's a combination of both stressors and protective factors, and there are a lot of protective factors, but the CAMAP forum offers a big support.
Liberal
Senator, Nova Scotia, ISG
Thank you very much, Mr. Chair.
Thank you to the witnesses for being here.
My first question is for Ms. Provencher.
Do you think that denying access to a MAID assessment for a competent person with a mental health condition who meets all other criteria for that assessment could be a form of stigma against people who have a mental health condition?
General Director, Association des groupes d'intervention en défense de droits en santé mentale du Québec
If you put it that way, I have to say yes. If the person meets all the criteria, why does the process stall at that stage?
If I may, I would like to make a few comments on training.
I would urge you to include people who have mental health problems. To my mind, it is essential for the professionals being trained to hear what they have to say.
Getting back to your question, I would say the following. It is indeed discrimination. On what basis is the person refused? Is it solely on the basis that the person has a mental health disorder? If that is the case, it is stigmatization if not discrimination.
Senator, Nova Scotia, ISG
Thank you very much for that. I certainly agree with your comments about training and the role of people with lived experience.
Dr. Stewart, I'm going to share a quote with you from The Globe and Mail of something an individual has said, and I'd like you to respond to the statement.
[A]ny attempt at identifying who [would] have access to MAiD will make large numbers of mistakes, and people who would have experienced improvements in their symptoms and no longer wish to die will die by MAiD.
What do you think of that statement?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
Well, I think that statement echoes one that was also written, perhaps by the same person or groups of people who said that we're trying to fill our graveyards with mentally ill people through MAID. Those kinds of statements are extremely unhelpful and hyperbolic. That kind of misinformation fuels the public anxiety and to some extent the professional anxiety about this. I think we need to be very clear and very factual in these kinds of things, and I wish that people would stop writing and printing this kind of misinformation and fearmongering.
Liberal
Senator, Quebec (De Lorimier), PSG
Thank you, Mr. Chair.
Thank you also to the witnesses.
My question is for Ms. Provencher.
I read with great interest the brief you tabled in Quebec's National Assembly, in which you present your group's position. I have the recommendations in front of me. One of your conclusions was that people with a mental disorder should not be excluded from accessing MAID, as that amounts to stigmatization and discrimination.
In your brief, you recommend establishing standards, training and social measures, as well as clearly defining the parameters. On page 40 of your report, you talk about criteria and parameters.
After reviewing the report of the Special Joint Committee on Medical Assistance in Dying, would you say that the proposed parameters are sufficient?
General Director, Association des groupes d'intervention en défense de droits en santé mentale du Québec
As to the parameters mentioned here, it is the people themselves who set those parameters for us. I have to say that some of the parameters are very interesting, but [inaudible] what role do the people play? That is the question that always comes to mind.
The people do want parameters. Dr. Stewart said that and we see that in the papers: people with mental disorders think that we want to kill them, assassinate them. So the government has a big job to do informing people.
As to the remaining recommendations, they are roughly in line with want we want, with some nuances, of course.
Senator, Quebec (De Lorimier), PSG
Your association was concerned about MAID coming into effect, since the guiding principles are being taught and given to all psychiatrists and to those providing MAID services.
General Director, Association des groupes d'intervention en défense de droits en santé mentale du Québec
We are not concerned about MAID coming into effect. As we said, the issue is not whether we support or oppose MAID. Our basic question is whether people with a mental health disorder can make a request, like any citizen in Canada. That is our most basic concern.
There was a question earlier about Quebec, about the last committee on the end-of-life care act and how it had been addressed. We were very disappointed with the conclusions of that committee, because it closes the door to any discussion of giving people with a mental health disorder access to MAID. That is what Quebec is doing now, and it is unfortunate. Yes, there is work to be done, the parameters have to be established, training is needed, but let us please keep the discussion open. They are human beings.
In any case, even if those people are excluded from the act, someone at some point will take legal action, will claim discrimination, and will win. You will be in the same situation.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Ms. Provencher.
We'll now proceed to Senator Martin for the last questions.
The Joint Chair Hon. Yonah Martin
Thank you, Mr. Joint Chair.
My questions are for Dr. Stewart. I'll ask them all together and you can answer.
We've heard a lot of people say at this committee that MAID is not suicide, and it is clearly important to differentiate MAID from suicide. This is really at the heart of this issue. In the spring, psychiatrists told this committee that MAID for sole mental disorder blurs the line between suicide prevention and suicide assistance.
Given the uncertainty around determining irremediability in the case of sole mental illness, how can this line be defined? How do we distinguish between intolerable suffering and suicidality?
What additional safeguards do you think are necessary to ensure that the MAID regime does not provide assisted suicide?
Professor, University of Toronto, Senior Scientist, Toronto General Research Institute, Centre for Mental Health, As an Individual
Thank you, Senator.
It is true that there are a few psychiatrists who express exactly those views. They are certainly not the majority. The working group of the Canadian Psychiatric Association did not express that.
Psychiatrists make this determination every day of their practice around suicidality, as I said earlier, in communities, emergency departments and hospitals. It's an essential part of being a psychiatrist to assess suicidal risk.
I submit that a request for MAID that is carefully considered and meets the safeguards is not the same as suicide.
The Joint Chair Hon. Yonah Martin
The fact that MAID for sole mental disorder requires very specific safeguards, did you want to add anything else regarding specific safeguards that you would recommend?
