Evidence of meeting #40 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 camh.
A video is available from Parliament.
Liberal
Darren Fisher Liberal Dartmouth—Cole Harbour, NS
What have you heard from medical practitioners who work at CAMH on whether they feel equipped to undertake assessments, provisions or consultations for MAID where mental illness is the sole underlying condition?
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
They are not experts, and that's what we've been hearing. We have several physicians and nurse practitioners who are open to being involved in the process of MAID assessments for eligibility, but we hear them very loudly that they need more guidance. They have no consensus standards to determine, if they see a patient in their office, whether this person has an irremediable illness or not. That's work that we've been involved in. We've been working on this within the CAMH environment internally. It's taking a long time to determine what type of assessment there needs to be, what types of questions there need to be, what types of information we need to collect and then, based on that information, how to determine that individual X has an illness that is irremediable versus remediable. Those decisions need to follow some standards based on consensus. The answer is that they clearly say that they are not ready.
Liberal
Darren Fisher Liberal Dartmouth—Cole Harbour, NS
What do you see? Maybe you can expand on the gaps and challenges that might hinder or limit the willingness of psychiatrists working at CAMH to undertake MAID assessments.
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
There is a lack of guidelines. How MAID has been approached is not the typical way that we, as clinicians, practice medicine. I'll give you an example. When psychiatrists prescribe an anti-psychotic, that's a medication, and there are different guidelines for how they prescribe it and when they prescribe it for someone with severe depression versus someone with schizophrenia or someone with dementia. There are guidelines that the profession follows to reduce variation and to ensure quality of care. Those discussions haven't happened with respect to MAID.
Liberal
Darren Fisher Liberal Dartmouth—Cole Harbour, NS
In less than 30 seconds then, Doctor, could you sum up what else needs to be accomplished to ensure readiness?
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
In addition to the development of those guidelines, there need to be efforts, as I mentioned in the statement, to build capacity, to also ensure that you're addressing how the social determinants of mental health are contributing to the suffering and the grievances versus the illness itself, and also how to separate a suicide intent and plan from a MAID request. This is also—
The Joint Chair Hon. Yonah Martin
Thank you very much, Dr. Rajji. The time has expired.
I see that Dr. Luyet's hand is up.
Dr. Luyet, I'm hoping that there will be questions for you as well. It's just that we had the questions from Mr. Fisher to the witness.
We'll move on to the next questioner.
Mr. Thériault, you have the floor for five minutes.
Bloc
Luc Thériault Bloc Montcalm, QC
Madam Chair, I would be grateful if you would keep in mind the interpretation delay as far as my time is concerned.
Dr. Rajji, you said there weren't any standards or guidelines, but I have here the Model Practice Standard for Medical Assistance in Dying. It's a 46-page document meant for regulatory bodies, physicians and so on. It was prepared by the MAID Practice Standards Task Group and covers patients under track 2.
Are you familiar with the document?
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
I believe you're referring to the actual expert panel document for the model of care. Am I right?
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
Yes, and I referred to it—
Bloc
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
No. The document itself states that these are not the guidelines.
Bloc
Luc Thériault Bloc Montcalm, QC
All right. Thank you. I just wanted to know whether you had read the document, and whether you felt it provided practice standards. I don't have a lot of time.
Dr. Luyet, you are a psychiatrist. What do you make of the views of your colleagues here today? What do you think of Dr. Rajji's position?
Dr. André Luyet Psychiatrist, Collège des médecins du Québec
I should start by recognizing how sensitive and complex the issue is. Taking the time to do things right is key. However, we should not shut out people whose MAID request is based solely on their mental disorder, because we don't have widely accepted standards and guidelines. We have to keep examining the issue and working together to set parameters and identify best practices and standards, so that a large segment of the population that has been overlooked—those experiencing tremendous suffering because of health disorders—can have access to a type of care that has been available in Canada for a few years already.
We have to keep working on it, but we can't just shut the door on them.
Bloc
Luc Thériault Bloc Montcalm, QC
Does the CMQ feel that the level of readiness on the ground in Quebec is sufficient to move forward? Are the parameters you listed earlier enough to ensure the safe and secure delivery of MAID to individuals with mental disorders?
President, Collège des médecins du Québec
I will answer that.
The committee that came up with those parameters met over a number of months in 2021 and 2022. The medical community was also surveyed regarding the parameters, and we collected expert opinions. I think the five conditions I listed can be used to demonstrate that the person's illness or mental disorder is irreversible. Usually, that applies to situations that have existed for decades.
Yes, I do think the medical community is ready to move forward, in careful compliance with the conditions I listed, of course.
Bloc
Luc Thériault Bloc Montcalm, QC
We've heard from psychiatrists who have reservations about expanding MAID access to people with mental disorders precisely because it is difficult to establish the irremediable nature of such disorders.
When asked, however, they did tell us that they saw patients in their practice who never got better, after years, even decades, of treatment. Doesn't that prove that these disorders can be irremediable or incurable?
President, Collège des médecins du Québec
Yes, absolutely. As far as we're concerned, that shows the irreversible nature of the illness. It's really important to look carefully at the conditions we put forward. For instance, the patient must have had an extensive care trajectory, accessing all possible treatments and psychosocial supports. When all the conditions are met, the patient's illness can be deemed irreversible and MAID should be available to that person, in the CMQ's view.
The Joint Chair Hon. Yonah Martin
Thank you.
Lastly, we will have Mr. MacGregor for five minutes.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you very much, Madam Co-Chair.
I would also like to thank our witnesses for joining our committee and helping us.
Professor Kaiser, I would like to start with you, given that you hold a position that straddles both law and medicine.
I've been on this committee from the start. What I have been struggling with personally is, on one hand respecting the rights of individuals who have agency, capacity and the right to make decisions for their own body, and also with the larger concept of our duty to protect the most vulnerable.
You very clearly said that we are not ready. Can you offer any thoughts on the struggles that we as a committee have had on those two concepts?
Ultimately, do you think that one day we will ever approach a point where we have to respect people's agency or do you think the duty to protect the most vulnerable will always win out when it comes to mental disorders as a sole underlying medical condition?
Professor, Schulich School of Law and Department of Psychiatry, Faculty of Medicine (Cross-Appointment), Dalhousie University, As an Individual
The quick answer is that we have to disaggregate the concept of choice and autonomy for a person with a serious, long-term mental illness because of all of the psychosocial factors that infuse diagnosis and experience. If you think about persons with disabilities in general, their choices are driven by poverty, isolation, stigma, loneliness, feeling that they are a burden and so on, as well as potentially being coerced. There's also the suggestion, implicit or otherwise, which the UN is worried about, that they're better off dead than disabled.
When you ask about autonomy, you shouldn't be thinking about it in the same way you would if a person is unencumbered by all of those barriers to participation in society. I don't have a mental illness today, but if you stripped away all of the underpinnings that I enjoy that are protective, then I don't think I'd have the same level of autonomy. I don't think I could truly make the same kind of choice with respect to dying that others who have not been deprived of those fundamental rights could.
The commissioner on human rights in Canada said, “Medical assistance in dying cannot be a default to Canada's failure to fulfill its human rights obligations” because “systemic inequality results in inadequate access to services” and "In many instances people, with disabilities see ending their life as the only option”.
The commissioner on Canadian human rights said that.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you.
I'm sorry to interrupt you. My time is a little bit limited and I would like to go to Dr. Rajji.
You, sir, have very clearly told the committee that you don't believe Canada is going to be ready by March 2024. It's quite striking because Parliament had to quickly pass Bill C-39 to give us an additional year. Ultimately, this committee is going to be tasked with presenting a report to both Houses of Parliament with recommendations.
In terms of a recommendation, do you have a time frame in mind? Do you have knowledge of approximately how much time the medical community is going to need to arrive at those conditions you have given both in your opening statement and to other colleagues around this table?