Medical Assistance in Dying Committee on Nov. 21st, 2023

[Julie Campbell]

I think there's a wish for a simple checklist that doesn't exist, because people are complicated.

Let's take an individual and follow what Dr. Gubitz just outlined for you. We're talking to their psychiatrist and psychologist, reviewing their conditions, and asking what treatments they've tried, what treatments worked, what treatments didn't work and what the results of those were. It's the answers to all those questions that start to build a picture around irremediability.

It's not as simple as, “Do they have this condition? Is it irremediable?” It is an in-depth, thorough review of that patient and all the people involved in their history and what that looks like.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Well, it's not a wish. Rather, we're trying to ascertain the quality of training. We're talking about people's lives. Whether it's in the tens or hundreds, we're talking about individual lives.

Perhaps for assurance, would you be able to provide the committee access to this module? I know, as a former educator, that seeing it in print would definitely give us some assurance. Is that something you can provide to the committee, Ms. Campbell?

[Julie Campbell]

I don't know the answer.

[The Joint Chair, Hon. Yonah Martin]

Can CAMAP provide the module being used, in order to assure us? It's just for us. We are not experts. At the same time, seeing it in writing will give us that sort of assurance. I believe the training is being undertaken, and I know everyone is learning the practice, but it is important for us to see that module.

Is that something you could provide?

[Julie Campbell]

It's a question I could certainly ask the board, but it's not a decision I would like to make independently at the moment, unless Dr. Gubitz or Dr. Green has more information.

[The Joint Chair, Hon. Yonah Martin]

Okay. Thank you.

Dr. Gubitz, just quickly, you mentioned in your remarks that there's an addictions specialist who was recently hired. Is that correct?

[Dr. Gordon Gubitz]

We had an addictions specialist as part of our provincial advisory group developing the documentation, yes.

[The Joint Chair, Hon. Yonah Martin]

Does that mean you're also anticipating that, potentially, people with addictions would be eligible?

[Dr. Gordon Gubitz]

It's entirely possible, yes. As long as they meet all the criteria, it's possible.

[The Joint Chair, Liberal, René Arseneault]

Thank you, Mr. Gubitz and Ms. Martin.

Now we will go to MPs for questions.

Mrs. Kramp‑Neuman, you may go ahead for three minutes.

[Shelby Kramp-Neuman, Conservative, Hastings—Lennox and Addington, ON]

I have some concerns.

Have there been actual, real-life conversations with individuals with lived experience with mental illness? Have they been adequately consulted with respect to the potential implementation of enticed suicide to escape a very painful death?

Ms. Green, would you like to answer that?

[Dr. Stefanie Green]

It's Dr. Green.

Yes, I can tell you that we have been fortunate enough to involve people with lived experience on several of the content committees for the development of the MAID curriculum project—in particular, for module seven on MAID and mental illness. This is not only about MD-SUMC but also about when mental illness is a comorbidity. There was a person with lived experience on the committee developing the content, so there has certainly been an effort to do that, from the CAMAP curriculum point of view.

Does that answer your question?

[Shelby Kramp-Neuman, Conservative, Hastings—Lennox and Addington, ON]

I can move on from there.

To my knowledge, and from what we've gathered earlier, there is no real, solid data about socio-economic factors driving requests for MAID for individuals with mental illness. If we're providing marginalized, lonely, homeless and potentially suicidal people a premature death based on unscientific medical assessments, I'm concerned about where we are at as a country. Is Canada ready for this?

[Dr. Stefanie Green]

There's no evidence that people with those characteristics are actually requesting and receiving MAID in a higher proportion in Canada. We actually have evidence to the contrary.

The increased data that's being collected right now by Health Canada, since January 2023, will be reported in 2024, and it will give us a more fulsome picture of the people who are requesting and receiving MAID. I think that would be helpful.

As with other jurisdictions around the world, we absolutely do not see those drivers for MAID and we don't expect them to be in Canada. We know very clearly, from the very clear eligibility criteria, that socio-economic vulnerabilities on their own do not allow someone to become eligible for MAID.

Obviously, as Ms. Campbell mentioned, people are quite complicated and it's hard sometimes to discern which factors are involved. It's not to say that people with those factors do not come forward and ask for MAID, but there's a difference between that and a screaming headline that says someone with a vulnerability is trying to access MAID. There's a difference between being assessed for MAID and being found eligible for MAID. It's important that this committee keep that in mind.

[The Joint Chair, Liberal, René Arseneault]

Thank you, Dr. Green.

Thank you, Mrs. Kramp‑Neuman.

We have Mr. Scarpaleggia for three minutes.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

Thank you very much.

I have a couple of quick questions.

I forget who said it, but I think maybe it was Dr. Green who said that to be eligible for MAID in cases of mental illness, a person would basically not have been allowed to refuse treatment in the past. Is that correct? Did somebody say that? Did I understand correctly?

[Dr. Stefanie Green]

What I said was that if somebody had been offered treatments and refused them and gave no particular rationale as to why, they couldn't just come forward and say, “Well, I refused those treatments and therefore I'm still eligible.” That is certainly not the case, and they would not be found eligible.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

They'd have to have a reason. I'm sure there are many. For example, a person may have tried many treatments but then balked at one particular treatment. For whatever reason, they didn't want to have electroshock therapy. Maybe that might not be considered a sufficient reason, but they wouldn't be disqualified because they refused one of many treatments. The evaluation is a little more subtle than that, I would imagine.

[Dr. Stefanie Green]

The evaluation is much more subtle than that, and we would look to see if maybe they'd tried a similar medication and found the side effects unacceptable to them. Every case is different. It's case by case.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

What I heard was that when it comes to irremediability, it's very complex. You have to look at the whole situation, and there's no test for irremediability.

I would like your opinion on an abstract from an article published by Cambridge University Press called “Irremediability in psychiatric euthanasia: examining the objective standard”. I'll read you the abstract and maybe you can comment on it.

Irremediability is a key requirement for euthanasia and assisted suicide for psychiatric disorders (psychiatric EAS). Countries like the Netherlands and Belgium ask clinicians to assess irremediability in light of the patient's diagnosis and prognosis and “according to current medical understanding”. Clarifying the relevance of a default objective standard for irremediability when applied to psychiatric EAS is crucial for solid policymaking. Yet so far, a thorough examination of this standard is lacking.

This was published only a year ago. I would elicit a comment, one way or the other, on this particular article.

Dr. Green, go ahead.

[The Joint Chair, Liberal, René Arseneault]

Your mike is on mute, Dr. Green.

[Dr. Stefanie Green]

I'm very sorry.

This question has come up repeatedly. I think what I would do is encourage the members of this committee to review the model practice standards for MAID, where these notions of what “irremediable” means are fleshed out. I can't find it in front of me right now, but there is a paragraph that explains what goes into something being incurable or something being irremediable or something being irreversible. By no means are they the be-all and end-all, but they give a sense of what is involved in this.

I do have the paragraph in front of me if you have time to hear it.

[The Joint Chair, Liberal, René Arseneault]

You have two minutes, Mr. Thériault. Go ahead.

[Luc Thériault, Bloc, Montcalm, QC]

In a nutshell, what the three of you said is that only a small number of people would be eligible given the parameters you had developed. The person must have tried everything and cannot have refused treatment that would without question improve their condition, even though a person is still allowed to refuse treatment.

If, indeed, a small number of people will have access to MAID, in light of all the parameters you're putting in place, can it be argued that making MAID available to people with mental disorders could have a preventive effect?

Dr. Gubitz can answer that, since I haven't asked him a question yet.

[Dr. Gordon Gubitz]

I think we know that for MAID in general, the involvement of a MAID assessment will often improve the health care of the person. For example, if they have not accessed palliative care services, and they do, they find some benefit so that they don't have to have a medically assisted death and can die comfortably under the care of palliative care. That's an example generally speaking.

I think that if we are being truthful about how we assess people with mental health disorders, we sometimes need to push the standard a bit, go into the depths and ask, “What have you tried? What have you not tried? Oh, I found this. It's something you might be interested in thinking about, and it's something we could trial to see if it makes sense for you.” That's the reason we have to have people who have expertise in the subject area.

As Dr. Downie mentioned, it doesn't necessarily need to be a psychiatrist, because many primary care physicians who have been looking after certain populations of patients are experts in their treatment. It's really about knowing the condition, knowing the patient and getting a sense of “Have I really done my due diligence in caring for this person?”