Medical Assistance in Dying Committee on Nov. 28th, 2023

[The Vice-Chair, Conservative, Shelby Kramp-Neuman]

Thank you, Dr. Gittens.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

We'll go into the first round of questions.

We will begin with Mr. Cooper for five minutes.

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

Thank you very much, Madam Joint Chair.

I am going to direct my questions to Dr. Gaind.

You mentioned that you thought CAMAP training on MAID and mental illness was not adequate to ensure readiness.

Can you elaborate on that?

[Dr. K. Sonu Gaind]

I'd be happy to, and I will reiterate that I think it's wholly inadequate. I'll be stronger in saying that.

I think we could have gotten a better use out of our $3.3 million that went for that. However, pejorative comments aside, it's something where, when I look at that, I am looking to see if this helps the assessors in any either evidenced or reasonable way to tease apart things like irremediability. As I said, it's not a question of whether a situation is irremediable; it's whether we can predict it to be. That's the whole point. We're making predictions in advance of giving someone death when they're not dying. There is nothing in there that helps us predict irremediability.

The other one is suicidality. This one, actually, I have to say literally shocked me. I am looking at it right now, but the module on suicidality consists of 10 pages of which five slides have content and a four and a half minute audio clip.

There is nothing in there about, for example, the 2:1 female-to-male ratio of psychiatric euthanasia in the places that get it. There is nothing in there about suicidal risk of marginalized populations. They simply make comments like this: "Managing suicidality is something most clinicians learned at some point in their training.... The general principles of managing suicidality apply in the MAiD context as well, whether the person is making a request under track one or two." I don't even know what that means. It doesn't provide guidance. But it does dangerously tell people that they think they can separate suicidality from a psychiatric MAID request, and no evidence supports that.

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

On the issue of irremediability and suicidality, Dr. Gupta, in the case of irremediability, says that psychiatrists are equipped to make judgments on a so-called case-by-case basis, exercising their clinical judgment.

With respect to suicidality, Dr. Gupta has asserted that there is no issue in terms of determining that of a rational request from one motivated by suicidal ideation, because supposedly, psychiatrists do this all the time.

I'd be interested in your comments in response.

[Dr. K. Sonu Gaind]

I've heard that echoed by many people, actually, and it is simply not true.

Our suicide assessments that we're trained to provide through residency are not about distinguishing suicidality from whether somebody wants to die through MAID. It's a completely different thing.

The CAMAP guidance focuses very heavily on whether it's impulsive or not, completely bypassing and missing the fact that many suicides are actually planned out, well thought out over a period of time. There is nothing in there that helps us tease those apart.

Furthermore, the evidence from the European countries shows overlapping characteristics between those who actually attempt suicide—most of whom do not try again and do not take their lives by suicide, and they benefit from suicide prevention—and the people who seek and get psychiatric euthanasia.

The obvious concern is: Are we converting transient suicidality, which may be fixed for a relatively long period of time, but still abates with suicide prevention, into a 100% lethality through MAID? That's why the 2:1 ratio of women to men who get psychiatric euthanasia should terrify any psychiatrist, because that 2:1 ratio is exactly the same as the 2:1 ratio of women to men who attempt suicide when mentally ill, as I said, most of whom do not die by suicide and do not try again.

We think that reflects gender-based marginalization. How can we be ignoring that, as a country, and just say that we're ready to march ahead in March 2024?

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

In her testimony, Dr. Gupta claimed that “some of the voices that are saying we are not ready have contributed nothing to becoming ready” and that “those voices have not been involved even when opportunities have clearly been presented to them.”

Do you agree that is a fair characterization?

[Dr. K. Sonu Gaind]

I don't agree it's a fair characterization. I am actually shocked that she said that. She should know better than most that many people have wanted to be involved and have not had the opportunity to be. That includes for many things that I can give further details on, but I know that the time for your question is limited, but I do not agree with that.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Next we have Ms. Koutrakis, for five minutes.

[Annie Koutrakis, Liberal, Vimy, QC]

Thank you, Madam Joint Chair.

Thank you to our witnesses for being here with us tonight.

My questions will be directed to Dr. Gittens and Dr. Mikail. We have heard this question time and time again, and other witnesses have answered it, so I will ask the same one to see how your view differs, if in fact it does.

Do you think that the health system is ready for an expansion of MAID eligibility on March 17, 2024, for individuals whose sole underlying medical condition is a mental disorder?

[Dr. Sam Mikail, Psychologist, Canadian Psychological Association]

I think the issue of readiness involves looking at several components.

The first is legislation. Is it in place? Yes, it is.

Second, are regulations in place? I would argue that regulations are incomplete because they have not been looked at by the broader mental health community. They have been looked at, as was indicated earlier, by the Federation of Medical Regulatory Authorities. That's a narrow group, I think, that's involved in mental health care, so there's more work to be done there.

A third element in terms of determining readiness is having some indication of what the demand will be, and we have no idea of that. Obviously, we need to measure demand against available resources in terms of individuals who are prepared to do these assessments, and we don't know that ratio.

I think we have a lot of gaps in terms of making that determination.

[Annie Koutrakis, Liberal, Vimy, QC]

What in your view then needs to be accomplished to ensure readiness of the health system for MAID and mental illness? Could you give this committee one recommendation to take back? What are the points that you think, as an organization or as an individual, would ensure readiness?

[Dr. Sam Mikail]

I think one of the points Dr. Gittens made in her opening remarks is that it's really critical to look at a thorough and expansive way of assessing someone's request for MAID, whether it's someone with a mental disorder or another track two request.

To do that simply based on an interview, I think, is short-sighted and inadequate. Interviews and conversations with patients are prone to bias, and we need more objective indices of assessing someone's mental state and putting the request within the context of that mental state.

There's a very extensive body of research that goes back to the 1950s and has continued since that makes it very clear that actuarial prediction is far superior to clinical prediction. At the very least, I think that's one of the things that's necessary for us to move to a state of readiness. Look at how these assessments are done and whether that actually meets the standard.

[Annie Koutrakis, Liberal, Vimy, QC]

Do you feel, Dr. Mikail, that the resources that are in place right now are adequate enough to help people to assess...? Do our health care providers have the resources, the adequate training, the adequate tools they would need to assess whether someone should qualify for MAID or not when faced with a mental disorder?

[Dr. Sam Mikail]

My view would be no. I don't think we're quite there yet. Again, if we are to take the issue of assessment seriously, expand it beyond simply having a conversation or a clinical interview with the individual, record reviews and so on and so forth, and then include more objective measures, I don't think that training is there, at least not as it currently stands.

[The Joint Chair, Hon. Yonah Martin]

You have about 40 seconds.

[Annie Koutrakis, Liberal, Vimy, QC]

Thank you.

Do you think we will get there as a country given what we're seeing so far? Do you think we're ever going to get to the place where we will reach consensus?

[Dr. Sam Mikail]

No. I don't think there will ever be consensus. I think there will always be people in a segment of the health care community as well as society who don't feel this is something that should occur, and a segment, obviously, that supports it.

I think one of the issues around mental disorders is that we're saying, “mental disorders as the sole underlying medical condition”. Not all mental disorders are medical conditions, and I think we have cornered ourselves by using that terminology.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Next, we'll move to Mr. Thériault, for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

Dr. Gaind, how many years have you been a psychiatrist?

[Dr. K. Sonu Gaind]

If I have to answer that, publicly, it's maybe 25 years, something like that. It's 20 to 25 years.

[Luc Thériault, Bloc, Montcalm, QC]

In all your years of practice, have you ever seen a patient whose condition was irremediable?

[Dr. K. Sonu Gaind]

I've met patients in the course of my practice who have not gotten better, but I've met more who I never thought would get better and did.

[Luc Thériault, Bloc, Montcalm, QC]

I should hope so. Psychiatric treatment has to do more than just provide palliative care to suffering patients indefinitely, does it not?

[Dr. K. Sonu Gaind]

Absolutely. It's about trying to help somebody re-engage meaning and purpose of life. We are able to do that.

The point I was making in my preceding comments is that I could not have predicted which of those people would or would not get better. The vast majority did get better, and if I had thought they would have—