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.
7:20 p.m.
Conservative
The Vice-Chair Conservative Shelby Kramp-Neuman
Yes, Senator Osler has about 45 seconds remaining.
Would you like to finish off? You were in the middle of—
7:20 p.m.
Flordeliz (Gigi) Osler
Dr. Rajii, have you finished your answer? Your connection froze in the middle of it.
7:20 p.m.
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
I'm not sure when I disconnected. I'll make sure.
We did share our feedback with the expert panel that there is a lack of clinical guidelines. We recommended that there would be pursuit of developing those guidelines beyond just the standard, so we did share that feedback, as CAMH, as an organization, to the expert panel when we were asked for our feedback.
7:20 p.m.
Flordeliz (Gigi) Osler
That's fine, Chair, thank you.
7:20 p.m.
Conservative
The Vice-Chair Conservative Shelby Kramp-Neuman
Senator Osler, we're willing to give you a little bit of grace here.
7:20 p.m.
Flordeliz (Gigi) Osler
Dr. Rajii, you've mentioned consensus-based decision-making, and I'm wondering if you could provide the committee with some examples from medicine, perhaps from psychiatry, where consensus-based decision-making is used to guide treatment decisions.
7:20 p.m.
Chair, Medical Advisory Committee, Centre for Addiction and Mental Health
An example of this would be when there is not enough high scientific evidence based on experimental evidence to guide treatment A versus treatment B or intervention A versus intervention B. Then the decision for the guideline will be based on the consensus of experts around that condition.
7:20 p.m.
Conservative
The Vice-Chair Conservative Shelby Kramp-Neuman
Thank you, Dr. Rajii.
Senator Martin, you have three minutes.
7:20 p.m.
The Joint Chair Hon. Yonah Martin
Thank you very much.
My question will be for Professor Kaiser. You talked about the Convention on the Rights of Persons with Disabilities, highlighting various articles. You've obviously placed great importance on the input and influence of representative organizations for people with disabilities.
Do you have any theory as to why those organizations feel so ignored?
7:20 p.m.
Professor, Schulich School of Law and Department of Psychiatry, Faculty of Medicine (Cross-Appointment), Dalhousie University, As an Individual
That is a tough question in many ways, but their answers are fairly simple. They say that this is a fundamentally ableist society and that those norms that devalue people with disabilities, especially persons with mental illness but also all people with disabilities, are ingrained in our medical systems and our legal system. That is really what we're seeing here, that persons with lived experience, who are the genuine experts about issues surrounding irremediability, psychosocial stressors and predictive issues, are not being heard. They have said universally, since the Rodriguez case, that they do not want this, and that's entirely contrary to the CRPD spirit, which is nothing about us without us.
The paradigm has been completely reversed by lawmaking judicially and in Parliament in terms of people with disabilities. It's just part of a systematic pervasive devaluation of their input into public policy, which is forbidden by the CRPD.
7:25 p.m.
The Joint Chair Hon. Yonah Martin
There's obviously considerable disagreement about the extent to which MAID for persons with mental illnesses either infringes or promotes charter rights.
What should we do in the face of this division of opinion?
7:25 p.m.
Professor, Schulich School of Law and Department of Psychiatry, Faculty of Medicine (Cross-Appointment), Dalhousie University, As an Individual
First of all, I deeply regret the fact that the Truchon case was never appealed in the court of appeal or in the Supreme Court of Canada. Failing that, the government should have had the courage to refer it to the Supreme Court of Canada, and I believe something more progressive would have emerged. I believe they would have denied this new extension.
If you look at it very simply under section 15 of the charter, this law does make a difference that's based upon disability, and it does cause suffering for persons with disabilities, whereas others who experience problems are not offered MAID. Second, it is a discriminatory distinction because it reinforces a grotesque stereotype that the lives of disabled people are not worth living, yet everyone else who experiences some form of obstacle to participation in society, which is not attributable to mental illness, is offered suicide prevention rather than suicide facilitation.
I think the answer would be obvious under our charter. This is a violation of section 15, the equality guarantee. I also think it's a violation of section 7, the principles of fundamental justice and the integrative principle of equality.
7:25 p.m.
Conservative
The Vice-Chair Conservative Shelby Kramp-Neuman
Thank you very much, Dr. Kaiser.
At this point, witnesses, thank you very much for joining us this evening. Your testimony has been appreciated.
Colleagues, we are now going to suspend briefly while we prepare for the second panel. Thank you.
7:30 p.m.
Conservative
The Vice-Chair Conservative Shelby Kramp-Neuman
Colleagues, the meeting has resumed.
I'd like to welcome our witnesses for the second panel, beginning with Dr. Sonu Gaind, chief of the department of psychiatry at Sunnybrook Health Sciences Centre, .
By video conference, we have Dr. Eleanor Gittens, from the Canadian Psychological Association; and Dr. Sam Mikail, psychologist.
Thank you all for joining us.
We're going to begin. You will each have five minutes, and we'll begin with Dr. Gaind.
The floor is yours, Dr. Gaind.
7:30 p.m.
Dr. K. Sonu Gaind Chief, Department of Psychiatry, Sunnybrook Health Sciences Centre, As an Individual
Thank you very much.
My name is Sonu Gaind. I'm a full professor, psychiatrist and governor at the University of Toronto, the chief of psychiatry at Sunnybrook, and a past president of the Canadian and Ontario Psychiatric Associations.
My expertise is in psycho-oncology. I work with cancer patients and their families. I am not a conscientious objector. I was the physician chair of my prior hospital's MAID team. My roles inform my expertise, but I'm presenting as an individual, not for any group.
Thank you for the chance to speak. My testimony is not easy to say, nor easy to hear, but it's necessary to be said. Those seeking expansion claim that not providing MAID for sole mental illness is discrimination, echoing claims by Senator Kutcher.
The opposite is true for three reasons. MAID is for irremediable medical conditions. These are ones we can predict won't improve. Worldwide evidence shows we cannot predict irremediability in cases of mental illness, meaning that the primary safeguard underpinning MAID is already being bypassed, with evidence showing such predictions are wrong over half the time.
Scientific evidence shows we cannot distinguish suicidality caused by mental illness from motivations leading to psychiatric MAID requests, with overlapping characteristics suggesting there may be no distinction to make.
Finally, those with mental illness have higher rates of psychosocial suffering. This all means that MAID assessors will be wrong over half the time when predicting irremediability, will wrongly believe they are filtering out suicidality and will instead provide death to marginalized, suicidal Canadians who could have improved. That is the ultimate discrimination.
Those setting policy have reassured us that we're ready to provide MAID for mental illness. I've reviewed our legislation, the Health Canada practice standard and the CAMAP training for MAID for mental illness. As someone who supports MAID in general, I assure you that we are not ready.
Regarding irremediability, Dr. Gupta acknowledged in her 2020 AMPQ report that “It is possible that a person who has recourse to MAID...could have regained the desire to live”, saying this should be an ethical decision each time. Her 2022 expert panel refused to recommend any additional legislative safeguards, despite Canada lacking legislative requirements for due care and no reasonable alternatives before MAID, unlike other countries.
Professor Downie claimed that irremediability is a legal term rather than a clinical concept. Try those mental gymnastics on your constituents. Convince them it was okay that their loved ones with mental illness got MAID, not because of a clinical assessment based in medicine or science, but because of the ethics of the particular assessor.
Regarding suicidality, Senator Kutcher and Dr. Green claim suicidal people won't get psychiatric euthanasia, and Dr. Gupta claims assessors can identify and separate suicidality in MAID requests because they have been doing it—
7:30 p.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Madam Chair, could you ask the witness to slow down? He'll have a chance to say everything he wants to say, but he's going too quickly for the interpreter. They have to be able to understand what he's saying.
7:35 p.m.
Chief, Department of Psychiatry, Sunnybrook Health Sciences Centre, As an Individual
I hope I'm not losing time.
7:35 p.m.
The Joint Chair Hon. Yonah Martin
We've paused the time.
You can continue. Slow down your speech.
Thank you.
7:35 p.m.
Chief, Department of Psychiatry, Sunnybrook Health Sciences Centre, As an Individual
I can't slow down. I won't be able to finish my comments.
7:35 p.m.
Chief, Department of Psychiatry, Sunnybrook Health Sciences Centre, As an Individual
I'm sorry, but I have prepared material I'd like to finish.
7:35 p.m.
The Joint Chair Hon. Yonah Martin
Okay. We're at two minutes and 54 seconds. I stopped as soon as there was an intervention.
Thank you.
7:35 p.m.
Chief, Department of Psychiatry, Sunnybrook Health Sciences Centre, As an Individual
Thank you.
Saying something false repeatedly doesn't make it true, and evidence shows they can't make the distinctions they claim. The CAMAP curriculum dangerously doesn't teach assessors how to distinguish suicidality from psychiatric MAID requests, but convinces them that they can, leading to remarkable statements like Dr. Gubitz asking “whether the patient is suicidal or actually has a reason to wish to die, which is not the same thing.”
This highlights a key problem with psychiatric MAID assessments; namely, it's the hubris of the assessor thinking they can determine irremediability and distinguish suicidality from psychiatric MAID requests, when evidence shows they can do neither.
Remarkably, the CAMAP suicide module neglects mentioning known risks to marginalized populations. European data shows a gender gap of twice as many women as men getting psychiatric euthanasia, and of unresolved social suffering. Dr. Gupta stunningly dismissed this, saying this gender gap doesn't concern her since nobody really knows what it means. Signals of a gender gap are already emerging in Canada on track two.
An echo chamber has driven expansion with reassurances but no safeguards—it's reassurance theatre.
In recent weeks, I've worked with over 200 colleagues on debunking a slew of disinformation shaping our policies. You can see today's piece at impactethics.ca. Check the new Society of Canadian Psychiatry site, socpsych.org, for other links.
CPA chair Dr. Freeland reluctantly acknowledged she couldn't say all the readiness is there. The lead for CAMAP's curriculum, Dr. Li, wrote she has grave concerns about our preparedness. Dr. Gupta testified that one to two patients in her practice would qualify. I can't speak to the severity of illness she sees, but Scott Kim, a researcher at NIH, estimated we'd have well over 2,000 patients yearly getting psychiatric euthanasia.
This expansion is not so much a slippery slope as a runaway train, like the Lac-Mégantic disaster. The government has plenty of signs we should not be proceeding. You can choose to go ahead, but you can't pretend you weren't warned.
We are not ready. You'll have to decide whether you stick with an arbitrary deadline or you responsibly stop this train.
Thank you.
7:35 p.m.
Conservative
The Vice-Chair Conservative Shelby Kramp-Neuman
Thank you, Dr. Gaind.
Dr. Gittens, you have five minutes.
November 28th, 2023 / 7:35 p.m.
Dr. Eleanor Gittens Member, Canadian Psychological Association
Thank you, Madam Chair and members of the special committee, for your invitation to the Canadian Psychological Association to appear before you this evening.
My name is Dr. Eleanor Gittens, and I am the sitting president of the CPA. I'm a professor and program coordinator in the addictions treatment and prevention program at Georgian College. I'm joined by Dr. Sam Mikail, who is a CPA past president and an adjunct clinical faculty member at the University of Waterloo.
The CPA is the national association for the practice, science and education of psychology. There are approximately 19,000 registered psychologists in Canada.
The CPA recognizes the significant work of the special joint committee on such a sensitive and delicate matter as medical assistance in dying. In considering the pending application of MAID where mental disorder is the sole underlying medical condition, the CPA made a series of recommendations in response to the report of the expert panel on MAID and mental disorders, released in May 2022. This was in advance of the special joint committee's June 2022 interim report. These recommendations have been shared with the ministers of Mental Health and Addictions, Health and Justice, as well as the committee.
The CPA also created the Task Force on End-of-Life and produced two reports. The first was in 2018. It discussed various issues related to MAID, such as decisional capacity, advance directives and the role of psychologists. The other was in 2020. It outlined practice guidelines for psychologists involved in end-of-life decisions.
In the interest of time, we will not cover all the recommendations in our reports, but we would like to highlight the following.
First, the expert panel's report currently recommends that an independent assessor should be involved with MAID where a mental disorder is the sole underlying medical condition. It names psychiatrists as the experts. We fully agree these cases will require an assessment independent of the treating team or provider. However, we strongly recommend that psychologists be named as additional expert assessors in these cases. Psychologists are the country's largest group of regulated mental health care providers able to assess, diagnose and treat mental disorders. We can offer expertise relevant to MAID decisions while expanding the qualified assessor pool. Psychologists' expertise in the administration and interpretation of objective measurements has established validity, reliability and embedded indices aimed at identifying inconsistent responding, feigned responding, symptom exaggeration and suicidal ideation or intent. This is vital to the assessment of individuals requesting MAID where a mental disorder is the sole underlying medical condition.
Second, in the development of the newly established curriculum for MAID assessors, the CPA has not been given an opportunity to review or provide input. Given psychologists' expertise in the development, administration and interpretation of psychometric measures for the purpose of complex assessments, we see this as a significant oversight. When it comes to a decision regarding end of life, and when that decision may be impacted by even the slightest possibility of compromised decision-making due to impaired cognitive functioning, the highest standard of care must be taken in conducting objective assessments, in order to guide the final determination of eligibility. Psychologists, as specialists in the assessment and diagnosis of cognitive functioning, are uniquely positioned to ensure this standard of care.
Given this training, and because they also have extensive training in research methods, psychologists should be equally involved in MAID research questions on end-of-life care when a mental disorder is the sole underlying medical condition. Here we refer to recommendation 19, which states, “The federal government should fund both targeted and investigator-initiated periodic research on questions relating to the practice of MAiD”.
Third, we would also like to address the expert panel's recommendation 2: “MAiD assessors should establish incurability with reference to treatment attempts made up to that point, outcomes of those treatments, and severity and duration of illness, disease or disability.”
This recommendation—