Evidence of meeting #39 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 illness.
A video is available from Parliament.
8:35 p.m.
Liberal
The Joint Chair Liberal René Arseneault
Thank you, Dr. Gubitz.
For the interpreters, please, as much as we can, we should speak very slowly. I'm used to being told that.
Mr. MacGregor, the floor is yours for two minutes.
8:35 p.m.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you very much, Mr. Chair.
Dr. Green, I guess I will finish this round with you.
If it had not been for Bill C-39, which Parliament passed really quickly, we would, of course, be living in a country right now where mental disorders as a sole underlying medical condition would be eligible for MAID.
Looking at it from British Columbia's perspective, how did that additional year factor into the degree of preparation in our province? According to you, given how involved you are in this, when was the determination made that our province was ready, approximately? I'm just trying to walk backwards in the timeline here.
8:40 p.m.
President, MAID Practitioner, Advisor to BC Ministry of Health, As an Individual
British Columbia has always had some foresight in seeing things come down the pipe. For example, British Columbia developed a provincial working group that's been preparing for MD-SUMC since September 2022. It certainly took the extra time; it's been over a year now. That is a subcommittee of a different committee of the Ministry of Health, which took the expert panel recommendations and took the model practice standards into account and has now proposed new provincial safeguards with the creation of a case review committee for all MD-SUMC cases, for example.
Three of the regional health authorities are already ready to establish this case review committee. One of them is already running something very similar to that, and certainly all of them will be ready by March 2024. Both our regulatory authorities, the medical and nursing colleges, are making changes to the medical practice standards for the province based on the model practice standards and the working group's recommendations.
I think with all of that work having been done in the past year, the province feels ready to move forward. When did they say they were ready? I would say they're saying it now as they realize things are falling into place on time. Did we take advantage of the extra year? Absolutely, we did.
8:40 p.m.
Liberal
8:40 p.m.
Senator, Saskatchewan, CSG
I have a point of order.
I'm just not sure we should be requesting access to the professional training for a professional body. I don't know whether that's appropriate. I know they were going to go back to the board and ask about it, but I think that's kind of a questionable request. That's all.
8:40 p.m.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Madam Chair, let me just say that I guess for CAMAP, it's one big secret. Then again, this is an organization that had training programs in which they were discussing, among other things, sedating patients who were resisting the administration of MAID. That's what we're dealing with, with CAMAP.
8:40 p.m.
Senator, Saskatchewan, CSG
It was just a point that I wanted to put on the record. That's it. I don't think it requires debate.
8:40 p.m.
Liberal
The Joint Chair Liberal René Arseneault
Okay. Thank you.
I'd like to thank all the witnesses.
We will suspend momentarily to welcome the next panel of witnesses for the third hour.
8:45 p.m.
The Joint Chair Hon. Yonah Martin
I call the meeting back to order.
Colleagues, we will resume at this time.
I'd like to welcome our main witness, but there are two. We have a second person there in case additional backup is needed.
We welcome Dr. Jitender Sareen, a physician with the department of psychiatry at the University of Manitoba, by video conference. He is accompanied by Dr. Pierre Gagnon, director of the department of psychiatry and neuroscience at Université Laval. Welcome to you both.
Dr. Sareen, you will have five minutes for your opening remarks, and then we'll go right into the first round of questions. We have one witness presenting testimony to start.
Dr. Sareen, the floor is yours for five minutes.
8:45 p.m.
Dr. Jitender Sareen Physician, Department of Psychiatry, University of Manitoba
Thank you so much, Chair.
Thank you for the opportunity to speak to the Special Joint Committee on Medical Assistance in Dying.
I would like to acknowledge that the University of Manitoba campuses are located on the original lands of the Anishinabe, Cree, Oji-Cree, Dakota and Dene peoples, and on the homeland of the Métis nation. We respect the treaties that were made on these territories, acknowledge the harms and mistakes of the past and dedicate ourselves to moving forward in partnership with indigenous communities in a spirit of reconciliation and collaboration.
With regard to this testimony, I have no conscientious objection to MAID. I am an adult psychiatrist with clinical and research experience in suicide prevention for over 20 years, with over 400 peer-reviewed publications, 150 in suicide prevention.
In 2019, I testified on behalf of the Attorney General of Canada in the Truchon case. I co-chaired the federal 2016 expert panel on suicide prevention in the military with Dr. Rakesh Jetly.
Today, I am representing the department of psychiatry at the University of Manitoba and Shared Health in Manitoba. I am here with Dr. Pierre Gagnon, department chair of psychiatry at Université Laval, but we are also representing six other department chairs of psychiatry departments in multiple provinces in the country: Jack Haggarty from the Northern Ontario School of Medicine, Karin Neufeld from McMaster, Gustavo Turecki from McGill, Sarah Noble from Memorial University, Simon Hatcher from the University of Ottawa, and Leslie Flynn from Queen's University. Collectively, we have decades of experience in clinical practice, suicide research and responsibility for education and training of psychiatrists and medical learners.
We strongly recommend an extended pause on expanding MAID to include mental disorders as the sole underlying medical condition in Canada, because we're simply not ready. In our experience, people recover from long periods—“long” meaning decades—of suffering with depression, anxiety, schizophrenia and addictions with appropriate evidence-based treatments. We strongly believe that making MAID available for mental disorders will facilitate unnecessary deaths in Canada and negatively impact suicide prevention efforts. The clinical role is to instill hope, not to lead patients toward death.
We have carefully reviewed the 2023 Health Canada model standard for MAID. In September 2023, we wrote to the federal ministers expressing the following concerns. The standard does not require the involvement of a psychiatrist in the assessment process for all MAID assessments for mental disorders. There is no international or accepted definition of irremediability in mental disorders and addictions; you can look at past treatments, but the most important question is what is going to happen in the future. There is no accepted operational definition to differentiate suicidal ideation and medical assistance in dying requests among people who are not dying. There are inadequate safeguards to protect vulnerable groups that are disproportionately affected by mental disorders. Due to geographic barriers, patients in underserved areas will be more likely to obtain MAID instead of evidence-based care. International experience has clearly demonstrated that MAID is being used in common and treatable mental disorders and is not reserved for the very rare and refractory conditions. The Health Canada standard does not guide psychiatrists on how many treatment trials are required before recommending MAID, because there's no evidence on this particular issue.
The proponents of MAID believe that it is discriminatory to exclude people with mental disorders from accessing MAID, but we completely disagree with this. Equity does not mean each person gets the same treatment. Unlike physical conditions that drive MAID requests, we do not understand the biological basis of mental disorders and addictions, but we know that they can resolve over time. The real discrimination and lack of equity is not providing care for people with mental disorders and addictions.
Advocates of expanding MAID suggest that only a small fraction of psychiatrists need to be trained to prepare for MAID in 2024. Again, we disagree. Should MAID eligibility expand, all Canadian psychiatrists will need to grapple with how to deal with suicidal ideation in the context of mental illness. They will need to determine when to refer for MAID versus addressing suicidal ideation with medications, treatment and sometimes involuntary hospitalization.
Repeated Canadian surveys demonstrate that most psychiatrists are not in favour of MAID, and the Canadian Mental Health Association and the Canadian Association for Suicide Prevention are against the expansion of MAID to include mental disorders. Finally—
8:50 p.m.
Physician, Department of Psychiatry, University of Manitoba
Can I finish?
8:50 p.m.
Physician, Department of Psychiatry, University of Manitoba
Finally, we've reviewed the Carter and Truchon decisions, and we underscore that mental disorders were not tested in these cases. After careful debate in the Quebec assembly, they decided not to expand MAID to include mental disorders. We strongly believe Canada should follow their lead and not expand MAID to include mental disorders.
Thank you.
8:50 p.m.
The Joint Chair Hon. Yonah Martin
Thank you very much.
We'll begin with Mrs. Shelby Kramp-Neuman.
8:50 p.m.
Conservative
Shelby Kramp-Neuman Conservative Hastings—Lennox and Addington, ON
Thank you.
Thank you, Dr. Sareen, for your testimony this evening.
We've heard assurances that there will be a very small number of patients who qualify for MAID for mental illness. Is that true?
8:50 p.m.
Physician, Department of Psychiatry, University of Manitoba
It's not true at all. We have a lot of people in the community who deal with treatment-resistant depression or treatment-resistant schizophrenia, and the Health Canada standard does not require treatment. It says that you have to have some treatment, but it doesn't require treatment. This is really a major issue, and there's lots of evidence from other countries as well that there will be more requests and completions, because our laws don't prevent people from accessing MAID without going through a number of different treatments.
8:50 p.m.
Conservative
Shelby Kramp-Neuman Conservative Hastings—Lennox and Addington, ON
Thank you.
We've also heard assurances that people will get MAID for mental illness only if they've had years of unsuccessful treatments, and yet I'm not aware of any actual safeguards that would require that. If MAID is expanded to include mental illness conditions in March 2024, is it true that only people with extensive treatment histories will qualify for MAID, or would Canadians be able to get assisted suicide for mental illness if they have not yet had access to or tried standard treatments?
8:50 p.m.
Physician, Department of Psychiatry, University of Manitoba
That is exactly our concern with the standard. It does not state that the person has to go through treatment. It's encouraged, but it's not necessary.
Again, the idea of someone who has thought reasonably about suicide and MAID is more concerning, as far as risk of suicide goes, than somebody who is in crisis. Some of the testimony before was around whether somebody had planned it very carefully. That's not suicide; that's MAID. As a suicide researcher and a clinician, I'm much more concerned about the person who's thought about suicide for a long time and has planned it than about someone who's in crisis. Both are at risk.
8:55 p.m.
Conservative
Shelby Kramp-Neuman Conservative Hastings—Lennox and Addington, ON
Thank you for that.
We've also heard reassurances that psychiatrists are trained and know how to separate suicidal ideation due to mental illness from psychiatric MAID requests, and that suicidal people will not get MAID. Do you feel that's true?
8:55 p.m.
Physician, Department of Psychiatry, University of Manitoba
Again, it's false, because there is no clear operational definition differentiating between when someone is asking for MAID and when someone is asking for suicide when they're not dying. Internationally, this is the differentiation. If somebody is dying, then it can be considered MAID. When they're not dying, it is considered suicide. It's very difficult, and there's no operational definition on it.
8:55 p.m.
Conservative
Shelby Kramp-Neuman Conservative Hastings—Lennox and Addington, ON
Thank you.
Last year, the Association of Chairs of Psychiatry in Canada wrote to the government calling on it to delay MAID for mental illness, citing a pure lack of readiness. Among the issues cited was a lack of certainty around determining irremediability in the case of mental illness, and a lack of understanding with respect to distinguishing a request for MAID from suicidality.
My first question is, are we any better off now than we were a year ago when it comes to reliably determining irremediability?
8:55 p.m.
Physician, Department of Psychiatry, University of Manitoba
No, we're not. We haven't changed from a year ago.
8:55 p.m.
Conservative
Shelby Kramp-Neuman Conservative Hastings—Lennox and Addington, ON
It's sadly so. Are there any adequate guidelines that you're aware of on how to distinguish a request for MAID from one for suicide? Has that changed from one year to the next?
8:55 p.m.
Physician, Department of Psychiatry, University of Manitoba
No. We have carefully reviewed the standard. Again, to emphasize, we as psychiatrists providing education and training think there is no differentiation, at this point, between MAID and suicide requests.