Medical Assistance in Dying Committee on Nov. 7th, 2023

[The Joint Chair, Hon. Yonah Martin]

Thank you, Dr. Gupta.

Next, we will have Dr. Grant for five minutes.

[Dr. Douglas Grant, Registrar and Chief Executive Officer, College of Physicians and Surgeons of Nova Scotia and Representative, Federation of Medical Regulatory Authorities of Canada]

Thank you. It's a privilege to speak to the committee.

I'm Dr. Douglas Grant. I'm a registrar of the college of physicians in Nova Scotia. I'm a family doc and a lawyer, and I represented the Federation of Medical Regulatory Authorities of Canada at the Health Canada working group.

My approach to the question is that all readiness must be built on regulatory readiness. My respectful submission is bluntly this: Regulators are ready for this. We don't need any more time. We're not coming for more time.

We will be ready for many reasons.

The first is that most of the hard work has been done. The model practice standard developed by the Health Canada working group is the best synthesis of the law with the input of all necessary stakeholder voices. I know I speak on behalf of my fellow registrars that we see these as very useful documents. The document can be adopted in whole, which Nova Scotia will do—and I can tell you that we will be adopting it in whole in other Atlantic provinces as well—or used as a template to build a professional standard upon. The supporting documents provide à la carte language that could be plugged into existing college standards.

At the end of the day, what will happen in March 2024 is that all medical regulators will have guidance and professional standards in place that are built from or informed by the model practice standard developed by the Health Canada working group. With exceptions for style and format, there will be substantial consistency between provinces.

The second reason why the regulators will be ready in March is that we have a solemn and legal duty to be ready.

There may be some slight variations in provincial legislation, but all medical regulatory colleges have a mandate to regulate the medical profession in the public interest. That mandate means we're in service to patients. In this case, we're in service to the specific patients who are suffering, who are being denied a form of care to which they are entitled in law, and who, as a class, have been suffering and denied this care since 2015.

Finally, our duty extends to physicians themselves who look to provide this care, who are entitled to a clear articulation of regulatory direction and expectations. I'm here to say that the regulators will meet their duties.

The fact that we're here implies that you have heard voices from non-regulators implying that the regulators are not ready. I would like to unpack those concerns.

First of all, they are not supported by history. At each step of MAID's evolution, there has been a chorus of voices asking whether the regulators were ready. After the one-year implementation period was coming to an end following Carter, there were calls of unreadiness. At the time, I was the president of the Federation of Medical Regulatory Authorities of Canada, and I made submissions to a joint committee like this—I don't think it was in this room—indicating that the regulators were ready. We were ready.

We were ready when the law evolved to include eligibility for patients whose natural death was not reasonably foreseeable. Then we were ready again when Audrey's amendment, which enabled a waiver of final consent to eligible patients at risk of a loss of capacity, came into law.

I guess I would like to say that this is par for the course. Medicine constantly evolves. MAID will evolve and the medical regulators will respond, because we have a duty to be nimble.

I hope that the concerns of unreadiness are not in response to silence on the websites of colleges like my own. That would be a mistake. Professional standards serve many purposes. They declare the regulatory expectations, direct the caregivers, and also serve a public purpose. They advise the public of what it is entitled to expect. Rooms like this indicate that the situation is fluid. The regulators in the college in Nova Scotia, which I run, will wait until the path forward is settled and political debate has stopped. The medical regulators have no desire to mislead or confuse the public.

I would encourage this committee to be disciplined in its efforts to distinguish opposition to MAID from accusations of unreadiness. In my experience, the choir of voices making accusations of unreadiness has been entirely composed of voices that are opposed to MAID. With the courts having made their final decision, opposing voices cannot advance arguments to stop MAID.

I would ask the committee to ask whether the accusations of unreadiness are a genuine argument or simply an attempt to buy time for the sake of time, when no time is needed—at least not from the regulatory perspective.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Lastly, we'll have Dr. Gamache for five minutes.

[Dr. Claire Gamache, Psychiatrist, Association des médecins psychiatres du Québec]

Good morning, everyone.

My name is Dr. Claire Gamache. I'm the president of the Association des médecins psychiatres du Québec.

We thank the House of Commons for the invitation and the opportunity to discuss these sensitive issues.

The Association des médecins psychiatres du Québec, or AMPQ, is one of the 35 associations affiliated with the FMSQ, the Fédération des médecins spécialistes du Québec, which represents 1,200 psychiatrists.

The association is a union that strives for optimal conditions of practice for its members, but since its inception, the association has been interested in the organization of care, access to mental health services, and the improvement of public literacy on mental disorders.

From the outset of the discussions on medical assistance in dying when mental disorders are the sole underlying medical condition, the AMPQ was involved and took part in the conversation.

We participated in the Standing Committee on Justice and Human Rights' consultations on Bill C‑7, the presentation of the position statement of the Collège des médecins du Québec in October 2020, the presentation to the Commission on end-of-life care of the AMPQ's discussion paper entitled “Access to medical assistance in dying for people with mental disorders”, at the national forum on the evolution of the Act respecting end-of-life care, and the consultations of the Special Commission on the Evolution of the Act respecting end-of-life care.

In 2020, the AMPQ's board of directors approved the position that people whose sole underlying medical condition is a mental disorder should not be systematically excluded from medical assistance in dying.

At the request of the Collège des médecins du Québec and the Commission sur les soins de fin de vie, the AMPQ published a discussion paper including a proposal on how medical assistance in dying could be organized within the province of Quebec. That brief was produced with the input of a patient partner and a member representing caregivers.

The AMPQ presented its work to its members at its annual meeting in 2021.

To educate its members, the AMPQ offers continuing professional development activities at its annual conferences and a day of update on medical assistance in dying for medical specialists in Quebec. That day will be held on November 17, 2023, with a session specifically on mental disorder as the sole underlying medical condition.

The AMPQ testified before the parliamentary committee responsible for studying Bill 11 in Quebec. During its testimony, the AMPQ advised the government not to include an exclusion clause for persons with mental disorders. A number of professional associations, including the Fédération des médecins spécialistes du Québec, the Fédération des médecins omnipraticiens du Québec and a number of regulatory bodies, including the Collège des médecins du Québec, the Ordre des psychologues du Québec, the Ordre des infirmières et infirmiers du Québec, and the Ordre des travailleurs sociaux et des thérapeutes conjugale et familiale du Québec, as well as the Commission des droits de la personne et des droits de la jeunesse du Québec, have expressed a similar opinion to that of the AMPQ.

In addition to its regular activities, the AMPQ sat on the national steering committee of the Canadian Association of MAiD Assessors and Providers and reviewed the program as a whole.

All of the AMPQ's interventions and participation in the conversation surrounding medical assistance in dying are intended to raise awareness of the reality of people with mental disorders, their loved ones and the caregivers who support them.

Our experience shows that mental disorders remain little-known and that their effects on life courses are poorly understood by the public.

When we talk about MAID when mental disorder is the sole underlying medical condition, we're talking about patients who we've been following for decades who have tried multiple therapies and treatments.

As you heard from Dr. Gupta, psychiatrists on the ground are already involved in assessing, in various forms, a complex clientele in the MAID processes. They participate in second assessments, collaborative assessments with GPs, and as in any new care, there will be graduated skills development through pairing, mentoring, and training.

The main objective of the AMPQ is to combat stigma by using its expertise and experience with the most vulnerable. However, to avoid perpetuating this stigma and discrimination, inclusion is the best option.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much, Dr. Gamache.

We will now go into our first round. For this panel, I think we're only going to get through one round for each of the MPs and the senators.

We'll begin with questions from Mr. Cooper.

You have five minutes.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Thank you very much, Madam Chair.

My questions are for Dr. Gupta.

Dr. Gupta, you said we're ready with respect to MAID and mental illness. I would submit that's tough to accept, given what we've heard in the previous hour about how there's no consensus among psychiatrists. Only 2% of psychiatrists have signed up for the curriculum program, and there aren't enough resources, but you say we're ready. Are we, really?

I would submit that the heart of the issue is the question of irremediability—whether someone can get better and whether that can be accurately predicted. As you will recall, on page 40 of the expert report issued by the panel you chaired, it states that:

There is limited knowledge about the long-term prognosis for many conditions, and it is difficult, if not impossible, for clinicians to make accurate predictions about the future for an individual patient. The evolution of an individual’s mental disorder cannot be predicted as it can for certain types of cancers.

That report was issued in May 2022. Has anything changed since May 2022 with respect to that conclusion?

[Dr. Mona Gupta]

If your question is whether there is something different about mental disorders compared to other conditions for which someone can currently access assisted dying, then, no, that hasn't changed since May 2022. That was exactly the point the panel was making: Yes, there are these difficulties, but these difficulties exist in track two as well. If track two can go forward and people can be afforded appropriate protections under track two, the same can occur for mental disorders.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

It's not just a challenge; it's a Criminal Code prerequisite in order to qualify for MAID. What you have said—and you confirmed it tonight—is that it is difficult, if not impossible, to predict. We heard testimony from experts when this committee last convened, including from Dr. Mark Sinyor, who said that the error rate for predicting irremediability could be anywhere from 2% to 95%. In other words, we're flying blind.

In the face of that, how can you say we're ready?

[Dr. Mona Gupta]

Well, I can say we're ready because we are doing these kinds of eligibility assessments for all kinds of complex patients, including patients who have comorbid mental disorders, in which the mental disorder may play a significant role in motivating the request. There are many medical conditions for which prognostication is “difficult, if not impossible”, to borrow the same language of the expert panel report, and yet we reason clinically about these cases in full respect of the Criminal Code requirements. As you know, no physician has been prosecuted and not a single successful college complaint has been made. Physicians and nurse practitioners are using these criteria to reason about cases when people have had, as my colleague Dr. Gamache said, very long histories of treatment—

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

With respect, Dr. Gupta, I've given you some time to answer, and I think you've made my point—that we're not ready, not in the face of that.

Would you agree that suicidality is often a symptom of mental illness?

[Dr. Mona Gupta]

I would say it is one of the criteria of a small number of specific conditions.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Page 7 of Health Canada's “Advice to the Profession: Medical Assistance in Dying”, which you helped write, states, “MAID eligibility assessments must not be undertaken in circumstances of acute suicidality.” What about in cases of chronic suicidality? Why is that missing from your advice to the profession?

[Dr. Mona Gupta]

It is precisely because some people with mental disorders—a very small number, I think—are going to be able to make a capable, informed decision to access MAID despite the fact that they may have also struggled with suicidal thinking over the course of their lives. This is already the case, because people who may have struggled with suicidal thinking over the course of their lives make MAID requests now.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

How much time do I have?

[The Joint Chair, Hon. Yonah Martin]

You have 15 seconds.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Okay.

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Ms. Koutrakis, go ahead.

[Annie Koutrakis, Liberal, Vimy, QC]

Thank you, Madam Chair.

Thank you to our witnesses for being here with us this evening.

I'm going to start my questions with Dr. Grant.

I wonder if you can confirm for us, please, whether you are speaking tonight on behalf of the Federation of Medical Regulatory Authorities of Canada or the College of Physicians and Surgeons of Nova Scotia, or if you're here as an individual.

[Dr. Douglas Grant]

I was invited here as the Federation of Medical Regulatory Authorities of Canada representative on the Health Canada working group.

[Annie Koutrakis, Liberal, Vimy, QC]

That's great.

Would you be able to please explain how the MAID practice standards task group's guidance on MAID eligibility assessments differs from what has been practised up to this point? My understanding is that you were a co-chair of that group.

[Dr. Douglas Grant]

Actually, the invitation said I was a co-chair and I wasn't, so I don't want to.... I was just a member of the group.

[Annie Koutrakis, Liberal, Vimy, QC]

Thank you for clarifying that.

[Dr. Douglas Grant]

Your question is how the model standard put forward by the working group differ from what's in practice right now.

[Annie Koutrakis, Liberal, Vimy, QC]

Yes.

[Dr. Douglas Grant]

It contemplates the inclusion of people whose sole underlying medical condition is a mental disorder. It also unpacks—and I think Dr. Gupta was getting into that—some of the more difficult cases. It gives guidance on some of the more difficult cases in what are track two cases, where one's natural death is not reasonably foreseeable.