Evidence of meeting #8 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 suffering.
A recording is available from Parliament.
Senator, Saskatchewan, CSG
Dr. Smith, thank you very much. I appreciate that.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Senator Wallin.
We'll now go to Senator Martin for three minutes.
The Joint Chair Hon. Yonah Martin
Thank you.
Thank you to all the witnesses who are bringing their expertise to the table.
Dr. Mishara, I note that you have worked as a clinician in suicide prevention and end-of-life care for 50 years. In your opinion does MAID for mental illness blur the line between suicide prevention and suicide assistance? Is it possible to establish this line under a MAID regime?
Prof. Brian Mishara
If it were possible to establish that, those very few rare cases in which a person is doomed to suffer interminably, there would be no debate. If you look at the expert panel report carefully and you try to find some indication of how you differentiate between someone who is suicidal and someone who is requesting MAID, all they say repeatedly is that it is not possible to provide fixed rules. They do not cite a single research study that shows that any human being is capable of differentiating between those two groups.
When Dr. Smith was asked how to determine whether someone is suicidal or they're requesting MAID, he did not give any diagnostic criteria that one could apply, but he said he is capable of doing this. The research is very clear. There is no evidence that you can predict the course of a mental illness, either treated or untreated, using any reliable criteria. The research that has different psychiatrists predicting shows that they don't usually agree. This worries me, because all of the seriously suicidal....
I'll repeat this. I'd love to provide the evidence that Senator Kutcher requested. When someone is seriously suicidal, they feel there is no hope. We are allowed to, against their will, send an ambulance to save someone's life who is in the process or on the verge of killing themselves. Most of them—the vast majority—are very thankful that we did that at that time. They do meet the criteria in the sense that they usually had a long history of mental illness, they had lots of treatments and they were feeling totally hopeless at that moment, but they made a mistake.
How many people were so grateful to be alive when against their will they were saved? I am just so worried that people will needlessly die because we do not have any criteria. Even though people believe they can make that decision, the scientific evidence isn't there, and I challenge you to just look at the expert panel report and try to find what the criteria would be, how someone talking to someone will make that determination.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much, Senator Martin.
That brings us to the end of our panel, but I want to thank our three witnesses today, Mr. Mishara, Dr. Derryck Smith and Monsieur David Roberge.
Thank you very much for your testimony.
Thank you for answering our questions on this very difficult but very important topic. We very much appreciate it.
With that, we will conclude panel number one. We'll suspend momentarily in preparation for the next panel.
Thank you.
Liberal
The Joint Chair Liberal Marc Garneau
I am going to call us to order and, hopefully, Dr. McKenzie will join us before we get to him.
I want to welcome the two witnesses who are with us at the moment.
From the Canadian Association for Suicide Prevention, we have Sean Krausert. We also have, as an individual, Dr. Valorie Masuda, and very shortly we hope to have Dr. Kwame McKenzie, also as an individual.
Thank you for joining us today. The way we run these things is that you will each have a chance to make a five-minute opening statement. We ask you to respect that five minutes. Please, during the actual panel, put yourself on mute when you're not speaking. If you want to draw our attention to something during the testimony, you can use the “raise hand” feature. Please address your comments through the joint chairs. I am accompanied today by Senator Yonah Martin, who will co-preside over some of this session.
Without further ado, we will start.
Mr. Krausert, if you are ready, please go ahead. You have five minutes.
Sean Krausert Executive Director, Canadian Association for Suicide Prevention
Thank you.
Good afternoon, honourable members of this special joint committee. I am Sean Krausert, the executive director of the Canadian Association for Suicide Prevention. Thank you for the opportunity to provide comments as you undertake this statutory review of provisions of the Criminal Code relating to medical assistance in dying and their application.
My organization acknowledges that Canadians who are deemed capable of making such decisions ought to be able to access MAID to exert control over a death process that is already happening. At the same time, efforts to prevent suicide, including healthy messaging across society, mean that we must work towards a future in which no Canadian uses death as a remedy for a difficult and painful life, especially when the challenges being faced by the individual are remediable.
I have several concerns with respect to MAID for those who are not at the end of life and who are suffering solely from a mental disorder. Three of them are policy considerations, and one is very personal.
First is a life worth living. It is imperative that, as a society, we invest in finding ways to alleviate suffering and support people in connecting to a life worth living. Expansion of MAID to include those not at the end of life carries the inherent assumption that some lives are not worth living and cannot be made so.
Second is mental health care. Finding hope and reasons to live are quintessential aspects of clinical care in mental disorders. Having MAID as a treatment option is in fundamental conflict with this approach and is likely to have a negative impact on the effectiveness of some therapeutic interventions, which may lead both patient and provider to prematurely abandon care.
Third is psychiatric policy. Ending the life of someone with complex mental health problems is simpler and likely much less expensive than offering outstanding ongoing care. This creates a perverse incentive for the health system to encourage the use of MAID at the expense of providing adequate resources to patients, and that outcome is unacceptable.
Fourth is my personal story. I likely wouldn't be here today had the option of MAID been available to me in my darkest days. I experienced multiple deep depressions and extreme anxiety through my twenties and thirties. During my worst depression in my late thirties, the pain was unbearable. While I experienced suicidal ideation, I later realized that I actually didn't want to die but rather to end the pain. That ambivalence is common with those considering killing themselves.
While I once saw myself as a burden to my family, I now see that I am a benefit—and not only to them but to my community. I am now relatively depression- and anxiety-free thanks to medication and therapy that finally worked, as well as to finding out that I had severe sleep apnea that had been undiagnosed for decades. Now I have a rich life. I was recently elected as the mayor of my town, and my first grandchild will be born in a few weeks. To think that if, in my darkest and most painful time, I had been given the option of MAID, I might have given up on a future that was better than I could have asked for or even imagined.
CASP believes that we need to consider the broader context of suicide prevention and life promotion for all Canadians.
To this end, we recommend, first, that MAID should not be provided to patients suffering from a condition that does not have reasonable foreseeability of death, unless there is clear scientific evidence that the condition is irremediable. Irremediability must always be objective and never subjective. There is no evidence that concludes that mental illness falls into this category.
Second, increased funding should be available for health care to ensure that treatments are available to patients so that lack of access to treatment does not cause the condition to be deemed irremediable. A patient's refusal to receive treatment should also not equate to irremediability.
Third, extreme caution needs to be taken with MAID and a thought-out, fail-proof, measured system of safeguards needs to be in place so that those most vulnerable will be protected so that MAID does not become doctor-assisted suicide.
Fourth, tools should be made available to health care providers—especially MAID decision-makers—on how to move forward with providing support to the patient in order to avoid premature death.
In short, CASP strongly encourages removal of mental disorder as a condition eligible for medical assistance in dying. To do so will safeguard against the premature death of persons who are suffering from mental illness alone and thereby avoid inadvertently legitimizing suicide as an acceptable option for ending a difficult and painful life.
Thank you for your time.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Mr. Krausert.
We'll now go to Dr. Valorie Masuda.
Dr. Masuda, you have five minutes.
Dr. Valorie Masuda Doctor, As an Individual
Thank you, honourable members, for allowing me to present my views to the special joint committee on physician-assisted dying, considering access to MAID for chronic mental illness.
My name is Valorie Masuda. I've been in medical practice for over 30 years, specializing in emergency medicine for 20 years and in palliative care for over 10 years.
I am a MAID assessor and I've been supporting patients with their applications for MAID since May 2016. I work on Vancouver Island, which has the highest rates of MAID deaths in Canada. I'm also a physician certified in the provision of psychedelic-assisted therapy for terminally ill patients suffering from irremediable demoralization, depression and anxiety.
My work in MAID has shown me the scope of reasons why patients wish to end their lives prematurely. Some patients consider dying from increasing debility and dependency and decreasing cognition an option intolerable to them. Some avail themselves of MAID if they anticipate severe symptoms at end of life. Some patients with end-stage chronic disease may experience very extended periods of debility and suffering, and although their prognosis is unpredictable, they are still on a dying trajectory.
I am a palliative physician, and therefore my duty is to ensure that I provide the patient with every available method to alleviate their suffering, even as I may support their application for MAID. The most difficult symptom to treat is demoralization or the terror that patients experience related to their diagnosis. In the past we had no treatment other than to sedate these people to alleviate this deep, deep suffering, but more recently, some have been choosing MAID to have this state, which is intolerable to them, relieved.
Over the past three years I have legally and successfully treated 20 patients suffering from irremediable demoralization, fear and depression under a section 56 exemption or the special access program. I treat these patients with psilocybin, which is a psychedelic medicine that is highly efficacious and safe. With one treatment I have witnessed a total alleviation of demoralization and fear. It is a treatment that I now offer to patients I see suffering from this kind of distress who may have otherwise accessed MAID.
I understand that some patients with chronic mental illness believe their suffering is intractable and that they should be able to terminate their suffering with medical assistance, but I do not support this. First of all, medical assistance in dying is a program designed to support dying people. Second, our Hippocratic oath is to cause no harm. Delivering a lethal injection to a patient who is not on a dying trajectory is causing harm.
Third, chronic mental illness is an extremely complex and multifactorial condition. It's often caused by early childhood trauma and abuse. It's compounded by unemployment, poverty, isolation and homelessness, and the demoralization and hopelessness are self-treated with substances. The lack of resources for these people perpetuates and compounds the suffering. The promise of pharmaceutical companies to cure depression and anxiety was a lie. Nine per cent of Canadians take antidepressants, and chronic antidepressant use has increased. A quarter of Canadians suffer from depression, and as a result we are seeing a crisis in substance use and an epidemic of drug-related deaths.
For some patients, despite pharmaceuticals, hospitalizations and dramatic interventions such as ECT, the demoralization, hopelessness and depression remain. Their mental suffering appears to be permanently imprinted in their brain, and in many cases substance use becomes a deeply established behaviour response. These patients are considered treatment-resistant because they have not responded to conventional therapy. I have had the opportunity to study the effects of psychedelic therapy in my palliative patients. With the proper supports and treatment context, the medicines reset the brain and give an enormous opportunity to change thoughts and behaviour patterns, but unfortunately they're restricted drugs and unavailable to patients outside of clinical trials.
In summary, Canadians suffering from depression have a constitutional right to have their suffering alleviated, but I do not believe that should be achieved through MAID. Canadians should not have medically assisted suicide because they lack access to basic mental health resources and basic living needs. Pharmaceuticals are not the answer to treating mental illness. Canadians need access to effective and publicly funded treatment programs using publicly funded therapists as well as access to psychedelic treatment.
Effectively treating mental illness gets people back to work, reduces poverty and homelessness, decreases hospital utilization, decreases crime and stimulates the economy. This is where I believe the answer to our mental health crisis lies.
If this special joint committee on MAID recommends proceeding with allowing access to MAID for chronic mental conditions, I would recommend that there be a robust, multidisciplinary review process involving physicians, psychiatrists, social workers and ethicists involved in a patient's MAID application, and that there be a transparent review of MAID cases shared between health authorities and provincial and federal oversight so that we ensure we are not treating social problems with euthanasia.
Thank you very much.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Dr. Masuda.
Mr. Clerk, was Dr. McKenzie able to join us?
The Joint Clerk of the Committee Mr. Leif-Erik Aune
Dr. McKenzie is still attempting to join. We have asked him for a contact phone number so we can call him to assist him. We're just waiting for his reply, but he's attempting to join.
Liberal
The Joint Chair Liberal Marc Garneau
Okay. Given that, I'm going to start the question period, because we do need to proceed at this point.
Unfortunately, with regard to Dr. McKenzie, we'll try to fit him in at a future meeting, because we need to start with the question period at this point.
I will now turn it over to my co-chair, Senator Yonah Martin.
The Joint Chair Hon. Yonah Martin
Thank you, Mr. Garneau.
We'll begin with five-minute questions from MPs.
We'll start with Mr. Cooper for five minutes.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you, Madam Joint Chair.
Mr. Krausert, you said in your testimony that there's no evidence that mental health falls into the category of irremediability. Could you elaborate on that?
Executive Director, Canadian Association for Suicide Prevention
I'm advised by those at CAMH in Toronto that they have no evidence and by other prominent researchers in the area—Dr. Mishara and Dr. Sinyor. There's just no evidence. The studies would have to be done.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you for that.
This is for Dr. Masuda, as a MAID assessor. The expert panel report, in the case of mental illness, acknowledges that it would be “difficult to predict for a given individual” in terms of whether they can get better, but that it would be sufficient to take into account past interventions and treatments and determine irremediability on that basis. Could you comment on that in the case of mental illness?
Doctor, As an Individual
I'm not a psychiatrist, but in my emergency department lifetime, I have had a lot of experience in seeing chronic illness come back and forth. Patients get into a point of great darkness, and this is where we see patients who attempt suicide. Often these patients have had many interventions in the past, and we know that some of them do recover. We know that some patients with substance abuse do recover.
When we talk about it being irremediable, how do we predict which patients are going to recover from intervention or not? I think that saying a patient has had three courses of anti-depressants does not give predictability as to whether or not this is recoverable.
With more and more science behind the use of medications that have been restricted and are not accessible by psychiatrists or therapists, we are starting to see that there is a potential for recovery for these patients. When we look at what irremediable means in mental illness, I think it's very difficult to predict and to say that this person has tried a lot of things, but their depression they cannot recover from.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you for that.
Dr. Smith said in his testimony that you have to look at the patient as a whole. He seemed to focus almost singularly upon suffering, but the last time I checked the Criminal Code and looked at the definition of what constitutes an “irremediable” condition, “intolerable” suffering is one of the three criteria, but it is not the only criteria. The upper two are an “incurable illness” and there being an “irreversible” state of decline.
As I understand what you're saying, it's not possible to determine if there is an incurable illness and that the patient is in an irreversible state of decline, because there's always the possibility to get better. Therefore, it's not possible to establish irremediability. Am I correct?
Doctor, As an Individual
I would say that is correct. The inevitable decline is also a question for people with mental illness, because what we're saying is that they have this mental illness and we expect that they will never get better and that they'll continue to get worse. I'm not sure that's been established either.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you.
Mr. Krausert, as someone who had suffered from mental illness and did get better and has gone on to live a very successful, or seemingly successful, and happy life, can you speak from your personal experience and your work with those who are suffering from mental illness and who are contemplating suicide about the impact that opening the parameters of MAID can have, more broadly, on the culture of suicide prevention in Canada?
Executive Director, Canadian Association for Suicide Prevention
It opens the door. Just to be clear, I'm talking about conditions that do not involve a reasonable foreseeability of death.
In the previous session, Dr. Smith spent a lot of time talking about dementia, and I don't understand why we would be going through this mental disorder route. When there's a reasonable foreseeability of death such as there is with dementia, you would go through that route.
I actually don't believe dementia would be excluded if we took out mental disorder.
From personal experience, though, I can say that the darkness that Dr. Masuda talked about is overwhelming. It's painful. It's isolating. It lies to you. It is not the state of mind in which somebody should be making a decision to get married or buy a house or do things in life, let alone end life.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
I really want to ask a couple of questions to Dr. Masuda.
Dr. Masuda, are you a psychiatrist?
Liberal
Hedy Fry Liberal Vancouver Centre, BC
You really have no basis for discussing whether psychiatric disease is irremediable, non-irremediable, curable, not curable, etc., or whether a diagnosis can be made on any of those things. We heard from a psychiatrist in the last panel who told us that it is indeed possible to do those things.
Have you used psilocybin on all your patients who request MAID?