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

[Luc Thériault, Bloc, Montcalm, QC]

Yes, I understood that. It is quite a distinct situation. That is why mental disorders fall under a distinct category. It's much easier when a person has stage 4 cancer or a terminal illness. That's understandable.

It seems to me that, in its report, the expert panel laid out a certain number of conditions precisely because of that difficulty. For example, the mental disorder has to have chronicity. In the course of that chronic condition, the person may experience suicidal ideation. To my knowledge, suicidal ideation is reversible. Be that as it may, ultimately, there are a small number of patients who, after years of trying every possible treatment meant to improve their condition, continue to believe that their life has no meaning in their final moments. I'm not sure whether you heard his remarks earlier, but the president of the Collège des médecins du Québec spoke about cases where patients consistently saw no meaning in their lives.

Do you not think that the expert panel's report lays out parameters that, at the very least, offer hope of the possibility of providing MAID to individuals with mental disorders in a safe and sustainable way, versus discriminating against them simply because they fall under a category of patients who are difficult to care for from a medical standpoint?

[Dr. K. Sonu Gaind]

It's not about being medically difficult to care for. It's about being impossible to properly predict that they won't get better. That means that you would be providing death under false pretenses. That's my problem with this.

In terms of your question, I'll answer with two things about the people who don't get better.

The people who have those lengthy trials, and who have suffered that long, I will remind you that we have no legislative safeguards that actually require that. Dr. Gupta's expert panel explicitly said that they are not recommending any additional legislative safeguards.

That is remarkable, because anything else just becomes suggestions and reassurances. Even Dr. Li, the scientific lead for CAMAP has said this.

[Luc Thériault, Bloc, Montcalm, QC]

Sorry to cut you off.

Recommendation 10 of the report addresses something that other MAID practice guidelines don't cover. Recommendation 10 calls for the opinion of a second independent psychiatrist or another assessor with expertise in the patient's mental disorder before MAID can be administered.

Furthermore, recommendation 16 calls for a prospective oversight mechanism. What do you think of that recommendation? It's not something that any other practice guidelines in the country or even Quebec cover.

[The Joint Chair, Hon. Yonah Martin]

Be very brief.

[Dr. K. Sonu Gaind]

Regarding the things that you're quoting, first, I'll point out that it's not in the health practice standard. They actually removed the suggestion that there be a specialist involved, so that is no longer there. Dr. Gupta was one of the six people who also wrote that.

In the same expert panel report, they say, literally, that they are unable to provide guidance on the lengths, number, or types of treatments required before providing MAID for psychiatric illness.

That's not a guidance.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

[Luc Thériault, Bloc, Montcalm, QC]

Just because it's not in the report doesn't mean that we can't put it in place or recommend it. You would be supportive of reinstating recommendation 10, then.

[The Joint Chair, Hon. Yonah Martin]

Monsieur Thériault, the time has expired. We're over the time by several seconds.

Did you want a quick yes or no?

[Luc Thériault, Bloc, Montcalm, QC]

It would be helpful for the committee to hear the witness's answer. Given the interpretation delay, I would like an answer. The fact that it isn't part of the standards doesn't prevent the committee from proposing recommendation 10.

[The Joint Chair, Hon. Yonah Martin]

Okay, Monsieur Thériault.

Give a brief yes or no to the question.

[Dr. K. Sonu Gaind]

No, it would not provide the safeguard you're thinking it would.

[The Joint Chair, Hon. Yonah Martin]

All right. Thank you.

We have Mr. MacGregor next for five minutes.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you very much, Madam Joint Chair.

Dr. Gaind, I'd like to direct my questions to you.

Much has been made of the fact that someone who has an incurable mental disorder will have to show an extensive treatment history in order to access MAID for MD-SUMC. We have the federal government's expert panel, we have Health Canada's MAID practice standards group and CAMAP. The expert panel did say that no further legislative safeguards are required, and if you read the Criminal Code, there is a requirement that a person has to be “informed of the means that are available”.

What are your thoughts on that? You've previously voiced some discomfort with that. Why are these standards not enough compared to an actual legislative safeguard within the Criminal Code?

[Dr. K. Sonu Gaind]

There are a few things. One is, keep in mind that I know of no other thing we do in medicine that requires a carve-out from the Criminal Code to avoid prosecution for homicide. What we're talking about is helping people die when they're not dying—that's the bottom line of what we're talking about.

In terms of the potentially required safeguards, to answer your question, when they're not in legislation, the consequences are, let's put it this way, that there's a lot of leeway given to assessors. This is not just coming from me; this is coming from people working in the field. Dr. Li, who was the lead for the CAMAP guidelines, has specifically said that the current law permits too much latitude based on practitioners' personal values. Currently, it is a legal fiction that determinations of the eligibility of MAID are based on objective clinical judgment. In fact, I regularly witness practitioners' values influencing the interpretation of the current MAID eligibility criteria and safeguards.

If you recall when Dr. Gupta testified here—I found this quite remarkable—she seemed to use as a measure of things going all right, and thus that we shouldn't worry, the fact that no assessor has been prosecuted. That's not the sort of threshold I go by. If people aren't aware of this, CAMAP guidelines—this is not in the mental illness piece, but in a prior thing from 2022, which they called “The Interpretation and Role of 'Reasonably Foreseeable'”—quite literally go through a process of providing guidance for assessors to convert track two MAID requests to track one and for proceeding with track-two MAID, thereby bypassing all track-two safeguards, including the 90-day period, even if assessors don't agree the patient should be on track one.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you for that, Dr. Gaind.

In my opinion, there have been conflicting reports on the figures regarding the number of psychiatrists in Canada who are comfortable with this going forward versus those who are not. I think you have previously referenced the Ontario Medical Association and psychiatrists in Manitoba. Do you have anything to report to the committee on the numbers you are aware of?

Furthermore, how could this committee get its hands on actual surveys of psychiatrists from organizations like the Ontario Medical Association, from Manitoba, so we can have definitive numbers?

Should we be sending for those documents to have them tabled as a part of this report?

[Dr. K. Sonu Gaind]

I can't speak for Manitoba, but for Ontario, I'm happy to forward those to the committee afterwards so that you can see exactly the questions that were asked and how they were answered. The results of those are consistent with the vast majority of surveys that have been done of psychiatrists. They show that—

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Do you recall the numbers?

[Dr. K. Sonu Gaind]

Yes, it's about....

Firstly, most psychiatrists are not conscientious objectors. Like me, they support MAID—I'm not a conscientious objector—with 80% to 85% supporting it, but by a 2:1 ratio, they do not support MAID for sole mental illness. These are not the people who are the most stigmatizing and discriminatory; they've devoted their lives to working with people with mental illness.

I'd be happy to forward you those numbers afterwards.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Finally, I'd just like a quick comment from you.

Much has been said...that we don't need to have consensus on this, but what does it say to you when such a high number seem to be opposed, with those kind of ratios?

[The Joint Chair, Hon. Yonah Martin]

Please be very brief.

[Dr. K. Sonu Gaind]

What it says to me is that not only has this not been driven by consensus, but that a small minority with ideological viewpoints who are true believers have driven the expansion.

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

Thank you.

At this point, we'll transition to questions from the senators.

Senator Osler, you have three minutes.

[Flordeliz (Gigi) Osler]

Thank you, Madam Chair.

For something different, I have a question for Dr. Gittens and Dr. Mikail.

In August 2022, the Canadian Psychological Association responded to the “Final Report of the Expert Panel on MAiD and Mental Illness” with a series of recommendations. The recommendations included a statement that psychologists must be included.

Outside of government-operated mental health services, are psychologists covered under any provincial or territorial health insurance plan?

[Dr. Eleanor Gittens]

Psychologists are not currently covered under a health insurance plan.

In fact, I think it's important to note that in this discussion, when we're talking about MAID where mental disorder is the soul underlying medical condition, we're really asking to examine mental illness in the same way we look at physical illness. As a country, we have not yet established parity. Care and treatment of mental illness are not covered by medicare, nor is it readily accessible.

[Flordeliz (Gigi) Osler]

Thank you.

In this context, where many patients currently do pay for psychology services out of pocket, how would the involvement of psychologists assist in this country's state of preparedness and readiness?