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.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Maybe I'll leave it there, Madam Chair. Thank you very much.
The Joint Chair Hon. Yonah Martin
Thank you.
I'll turn this over now to our other joint chair, Monsieur Garneau.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much, Senator Martin.
Let us begin with the senators' round of questions.
Since Senator Dalphond is away today, I will give each of the first three senators four minutes of speaking time. We will begin with Senator Mégie.
Senator Mégie, you have the floor for four minutes.
Marie-Françoise Mégie Senator, Quebec (Rougemont), ISG
Thank you, Mr. Chair.
I would like to thank the witnesses for helping us towards a decision.
My question is for Dr. Smith.
Is there a specific diagnosis of mental illness that is stronger, indicating that it is an incurable illness?
Of course all the usual investigations would have to be done, bearing in mind all the relevant considerations.
Are some mental illnesses diagnosed as incurable?
Clinical Professor Emeritus, Department of Psychiatry, University of British Columbia, As an Individual
Thank you for that question.
There are certainly forms of mental illness that are incurable and terminal, and I'm referring here to the dementias. Alzheimer's and Lewy body dementia are all going to kill people eventually, so that's certainly one category of psychiatric illness for which there is no debate about that.
But it's not about whether the illness is incurable. Some people would have us believe that we should hold on for years and years waiting for some new treatment to come down the line. What that's doing is prolonging the suffering of a person who is actively seeking their death to relieve intolerable suffering.
I don't think “incurable” is necessarily what we want to look at. We want to look at whether there are treatments available that are acceptable to the person who has been through 10 years of treatment, that are going to improve their functioning. If the answer to that is no—in other words, there are no treatments or there may be some treatments but they're not acceptable to the patient—then my understanding of the law is that they are eligible for consideration for MAID.
Senator, Quebec (Rougemont), ISG
Thank you.
My next question is also for you.
In our society, mental illness is highly stigmatized. To what extent might that influence a clinician's decision when evaluating a person who has requested MAID?
Clinical Professor Emeritus, Department of Psychiatry, University of British Columbia, As an Individual
That's a very interesting question as well. I have to tell you that, when people ask me what I do for a living, I tell them I'm a medical doctor first and a psychiatrist second. The seat of all psychiatric illness is the human brain, which the last time I looked was part of the body and part of the human experience. Our personality, as we describe it, lies in the frontal lobes of our brain, so I'm very much opposed to this dichotomy between physical illness and mental illness. These are all disorders of the human body—and, in this case, mostly the human brain.
I don't have a problem sorting out whether people should or shouldn't. We have pretty clear criteria that are put down in the legislation. We have new criteria in Bill C-7. Assessment could involve a skilled clinician who knows what they're up to in psychiatry and a second assessor, and maybe even talking to the family doctor and to the patient's family. These assessments take literally hours and involve a wide variety of people—the patient, the doctor, a couple of assessors and the patient's family.
I can remember one assessment I did, in which I spent three hours talking to each of the children of a man who was seeking MAID. I want to make sure of what everybody's opinion is. In the end it's up to the individual person, but we want to listen to what other people have to say when approaching that decision.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much, Senator Mégie.
I will now give the floor to Senator Kutcher.
Senator Kutcher, you have four minutes.
Stan Kutcher Senator, Nova Scotia, ISG
Thank you very much, Mr. Chair.
Please give a very short answer to my first question, Dr. Mishara.
In your testimony you talked about MAID assessments. Have you ever conducted a MAID assessment?
Prof. Brian Mishara
I have not conducted a MAID assessment, but I've certainly assessed large numbers of people who wanted to have their lives ended.
Senator, Nova Scotia, ISG
Thank you very much. That's fine, Dr. Mishara. We're talking about MAID, sir.
Mr. Chair, could you ask Dr. Mishara to provide to this committee in writing, in a timely manner, the evidence for a couple of the assertions he made? He was talking about conducting MAID assessments, and he said that large numbers of mistakes are made in the MAID assessment. Could he give us the evidence for that?
The other thing he said is that “every single person who calls a crisis line meets the MAID criteria.” Could he provide us with the evidence for that as well?
Thank you.
Liberal
The Joint Chair Liberal Marc Garneau
Okay. Senator, I will follow up with the clerk and with Mr. Mishara after this meeting.
Senator, Nova Scotia, ISG
Thank you so much.
For Dr. Smith, the Royal College of Physicians and Surgeons of Canada has standards for psychiatric competencies, and in those competencies they expect a psychiatrist to be able to conduct capacity assessments, competency assessments and cognitive performance assessments, and to assess and manage suicidal behaviour.
Do you, as a MAID assessor and a psychiatrist, have the capacity and competencies to conduct these assessment properly and thoroughly?
Clinical Professor Emeritus, Department of Psychiatry, University of British Columbia, As an Individual
Yes. I don't want to be overly enthused or state things that are not true for me, but I think all psychiatrists in Canada have a vigorous training and licensing system. I think any psychiatrist who wants to is competent to do all of those things. We have to assess competency on a case-by-case basis on a regular basis. We have to look at capacity. We have to take into account the views of the family of the patient and the family doctor who has referred the patient. These are all things that happen routinely.
When it comes to MAID, you're not looking at a unique set of skills. You're looking at using the same skills psychiatrists have to answer a particular question, and that is, “Does the person who is seeking assistance in dying, who is sitting of front of you, meet the criteria established under law?” That's the basis of a MAID assessment. It may take three hours to do that, but that is really what we're up to. We're doing a clinical assessment and interpreting the clinical findings against the requirements in the law for assisted dying.
Senator, Nova Scotia, ISG
If you, as an assessor, are not certain about whether the person is suicidal or if you're not certain about whether the person has the capacity to provide free and informed consent, what's your standard procedure? How do you go ahead?
Clinical Professor Emeritus, Department of Psychiatry, University of British Columbia, As an Individual
As with all patients about whom I'm not certain, I'd get a second opinion. There's nothing that says you have to have only two assessors. I don't do a lot of assessments. The assessments I get involved with involve cases in which there are two assessors and they can't decide on an issue when it involves a psychiatric illness. We're at liberty to call up our colleagues and bring in other assessors. We want to make sure we get this right.
This is an irrevocable decision. This is not a decision that anyone—the people who assess, the patient, their family or the providers—takes lightly. We must make sure we get it right. I think using the skills of the psychiatrist and the backup of our colleagues in the community, we have ample resources to get this right in assessing an individual patient.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much, Senator Kutcher.
We'll now go to Senator Wallin.
Senator Wallin, you have four minutes.
Pamela Wallin Senator, Saskatchewan, CSG
Thank you very much.
I'm sorry, but we're having problems with the video here. Can you hear me?
Senator, Saskatchewan, CSG
Thank you.
I'd like to go back to Dr. Smith as well, and just follow up on something that Dr. Kutcher raised.
When it's stated that everyone who calls a suicide prevention hotline is eligible for MAID, I would gather you don't agree with that.
Clinical Professor Emeritus, Department of Psychiatry, University of British Columbia, As an Individual
Thank you for that question.
Not only do I disagree with it, I think it's preposterous. People who call suicide hotlines may be in a situational adjustment—they've broken up with a loved one in their family or they've been fired from their job. These are not the kinds of patients who we're thinking about at all for MAID.
We're talking about patients who have been suffering from mental illness, psychiatric illness, diagnosable illness, who have been treated for multiple years by multiple treatments and have seen many psychiatrists and therapists. Those are the sorts of people likely to be eligible for MAID.
The vast majority of people who call suicide hotlines are nowhere close to being considered for MAID. That's really a red herring.
Senator, Saskatchewan, CSG
Okay. I would also like to follow up with you on your comments about Alzheimer's and dementia, which are an extreme form of mental illness. Again, it comes back to the issue here, which is, if that is the case and if mental illness can in fact be the sole reason to access MAID, we come back to the issue of advance requests here, because how else could that happen for somebody who was going down that particular road? How do you look at that dilemma?
Clinical Professor Emeritus, Department of Psychiatry, University of British Columbia, As an Individual
Thank you.
This is one of my passions in life. I think we're all facing, unfortunately, a wave of dementia that's going to affect most of the people in this room and on this conference call.
With respect to the other issue, competent minors and psychiatric patients, there are small numbers of patients. The tsunami is dementia. The problem currently is that if you wait too long to apply for MAID, you're going to become incompetent. If you become incompetent, then you are sentenced to five years of sitting around in a home in adult diapers, not knowing who you are, not knowing who your family is, not enjoying life in the least bit, for five or six years. The risk of waiting too long is to have to live through dementia. I've seen it. It's not pretty.
The other risk is that you could make the decision too early. I had a friend, the wife of a physician, who had MAID a year and a half ago. She did not want to go down the road to dementia. She had MAID, in my view, much too early even though she qualified. She missed seeing two of her grandchildren because she did not want to take the risk of dementia.
Yes, I'm all in favour of advance requests for people with dementia.
Senator, Saskatchewan, CSG
However, do you see these as part of the mental illness category in a sense?
Clinical Professor Emeritus, Department of Psychiatry, University of British Columbia, As an Individual
Yes, they're part of the functioning of the brain. This is why I think, again, we have this dichotomy between dementia and, say, depression. We understand exactly what dementia is about. We're not quite sure what depression is, but we do know they're both disorders of the brain.
I would much prefer that we were discussing brain disorders and not psychiatric illness or mental illness.