Evidence of meeting #9 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 treatment.
A video is available from Parliament.
2 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
It being two o'clock, I'm going to call this meeting to order since we have quorum and the witnesses are ready.
Clerk, is there anybody in the room, either a witness or a member? I can't see the room.
2 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Very good. Thank you.
Good afternoon, and welcome to the ninth meeting of the Special Joint Committee on Medical Assistance in Dying.
I would like to begin by welcoming members of the committee, witnesses and those watching this meeting on the web.
My name is Marc Garneau, and I am the House of Commons' Joint Chair of this committee. I am joined by the Honourable Yonah Martin, the Senate's Joint Chair.
Today, we are continuing our examination of the statutory review of the provisions of the Criminal Code relating to medical assistance in dying and their application.
The Board of Internal Economy requires the committee to adhere to health protocols. I'm not going to name them, because by now you're very familiar with them and they're in effect until the end of Parliament in late June.
Before beginning, here are a few pieces of administrative information. I'd like to remind the members and witnesses to keep their microphones muted unless recognized by name by the joint chairs. I would remind you that all comments should be addressed through the joint chairs. When speaking, please speak slowly and clearly. Interpretation of this video conference will work like an in-person committee meeting. You have the choice at the bottom of your screen of floor, English or French.
With that, I would like to welcome our first panel of witnesses today. Here on the first panel to discuss whether to permit medical assistance in dying for mental illness in Canada, we have Mr. John Maher of the Ontario Association for ACT & FACT. We also have two individuals, Dr. Georgia Vrakas and Dr. Ellen Wiebe.
Thank you for joining us here today. We'll begin in the usual fashion. You will each have five minutes for an opening statement. I would ask you to respect that five minutes, so that we can allow as many questions as possible.
We'll start with Mr. Maher. You have five minutes.
2 p.m.
Dr. John Maher President, Ontario Association for ACT & FACT
Thank you very much, and thank you for the invitation.
The Canadian Mental Health Association, CAMH, the Canadian Association for Suicide Prevention and my own organization, the OAAF, which is the largest professional association of community-based tertiary mental health care in Canada, to name but a few, have all denounced Bill C‑7. Anyone who says there is an emerging consensus is grossly misinformed or worse.
The Quebec parliamentary commission listened to the facts. I am hoping that you will listen to the facts, because what is happening is tragic.
I am a psychiatrist, and I'm a medical ethicist. For 20 years I have worked only with adults who have the most severe and persistent forms of mental illness, in cockroach- and bedbug-infested rooming houses and on the streets, where our wealthy society forces them to live in poverty, our sons and daughters treated as social outcasts.
MAID activists say everyone must be able to access MAID regardless of crushing poverty, the shocking lack of treatment availability, protracted wait times of years or having brain diseases where it is impossible to predict irremediability. The rallying cry is autonomy at all costs, but the inescapable cost is people dying who would get better. What number of mistaken guesses is acceptable to you?
Death is not an acceptable substitute for good treatment, food, housing and compassion. You who voted for this law have not understood vulnerability and what it means for your doctor to offer you death over life. Do you seriously believe that you can prevent abuses by the 100,000 M.D.s and nurse practitioners in Canada who now have a licence to kill? Please read the news.
You know that Bill C-7 is not consistent with the Supreme Court's stated principle in Carter to preserve life. The ruling explicitly supported people getting help killing themselves only when they could no longer physically do it themselves. Please make a referral to the Supreme Court if you are so sure about how they will rule, because justice and the preservation of life demand it.
I am hearing shock and disbelief from psychiatrist colleagues. When the Ontario Medical Association in 2021 had a survey that asked Ontario psychiatrists clear questions after Bill C-7 became law, 91% objected to the law, 7% were uncertain and only 2% supported what this bill has done—only 2%.
Psychiatrists don't know and can't know who will get better and live decades of good life. Brain diseases are not liver diseases. If guesswork is good enough for you, it is not good enough for psychiatrists who understand the science and respect our duty to abide by a professional standard of care. You have been systematically misled by discriminatory ideology over clinical reality. Passing a law telling psychiatrists to make impossible predictions doesn't magically make it possible.
Some of my patients are now refusing effective treatment to make themselves eligible for MAID. They have been susceptible to the perverse lie that it is not suicide. Suicide is always clinically defined as taking the steps to arrange your own death. The Canadian Association for Suicide Prevention has stated that all MAID for mental illness is suicide. The frankly bizarre assertion that suicide is always an impulsive and unplanned act is not rooted in reality. Only 7% of people who attempt suicide in Canada actually die. I'm asking you, what will that percentage become? Likely number one in the world.
In the few European countries that at least require that standard treatments be tried before euthanasia, there have been steady and significant rises in the overall suicide rates in the last two decades, while the rates went down in all the countries around them. Women in particular have much higher suicide rates. The false claim that the Supreme Court accepted without evidence that suicide rates do not go up with MAID is absolutely contradicted by the data. Suicide contagion should scare you. Do you support suicide prevention or not?
Telling my patients that you will make it easier for them to die has enraged me. They will doctor shop to find the few psychiatrists who fancy themselves defenders of autonomy at all costs, as already happens in the Benelux countries, and they will die because death was offered over full and purposeful membership in the human community. They will die because of the social suffering that this law enshrines. They will die because of lack of services. They will die because psychiatrists will now have legal permission to give up. They will die because, whether you can see it or not, you have told them they don't matter.
You have killed hope in Canada in the places it is needed most.
2:05 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much, Mr. Maher.
I will now go to Dr. Georgia Vrakas.
Dr. Vrakas, you have five minutes.
2:05 p.m.
Dr. Georgia Vrakas Psychologist and Professor, Department of Psychoeducation, Université du Québec à Trois-Rivières, As an Individual
Okay, I will make sure to try to respect that. I will be speaking in French.
Good afternoon.
My name is Georgia Vrakas. I am a psychologist and professor, and I live with a mental illness.
To start, I would like to thank you for inviting me to testify before the Special Joint Committee on Medical Assistance in Dying.
I want to take a stand against including mental illness as the only medical condition to access medical assistance in dying. This issue is vital to me as a professional in the mental health field and as a person living with mental illness since the age of 23.
For more than 20 years, I thought I had a major depressive disorder. I had several episodes, which resulted in a lot of suffering and time off work. I also had suicidal thoughts.
In March 2021, I had my most recent relapse. I was discouraged and disillusioned, as I had gone through all the treatments recommended to me. The problem was that I hadn't received the correct diagnosis.
I was finally diagnosed on May 3, 2021, one year ago. I have type II bipolar disorder, a severe and persistent mental disorder. The months leading up to my diagnosis were very difficult and painful. I seriously considered suicide. I had a plan and I started to carry it out. Ultimately, I went to the emergency room.
I also talked to a worker at the Suicide Prevention Centre. She helped me hold on to life. I didn't want to die, but I wanted to stop suffering. The reason we have these types of services is to help us find hope. A promising drug treatment gave me back my confidence. Even after 20 years and several relapses, I am still standing. Not only am I alive, I plan to stay that way.
This is my personal story, but it is also the story of many others in Canada. As you know, approximately 20% of the population in Canada will experience a mental illness in their lifetime, and 90% of people who die by suicide have a mental disorder. Mental illness and suicide are public health problems that require a public health response.
Including mental illness as the sole reason for the Canadian Medical Assistance in Dying Act is a political response to a public health problem. This law reduces a societal problem to the individual level: “I'm sick, I want to stop suffering.” Mental illness is still taboo, access to mental health services is very difficult, psychiatric research is underfunded, and funding for promotion and prevention programs continues to decline.
Our governments have chosen not to invest in what we need to improve our mental health upstream or what we need to recover when we are already ill. Now they want to include people like me with mental illnesses in medical assistance in dying. This will supposedly help us die better. But we don't even have access to the minimum services that would help us live better. I'm talking about living, not surviving.
In this context, giving people like me the green light to get medical assistance in dying is a clear signal of disengagement from mental illness. It sends the message that there is no hope and that we are disposable.
Yet we invest in suicide prevention. We know that it is not death that people are looking for, but the end of suffering. We say it over and over again, suicide is not a solution. So how can we reconcile medical assistance in dying with this, knowing that 90% of people who die by suicide have a mental illness? How do we differentiate between the desire to die by medical assistance and the desire to commit suicide?
We are told that we cannot exclude mental illness as the sole reason for MAID to avoid discriminating against people living with mental illness. Yet in life we face discrimination daily, whether it is access to housing, work, a decent income or disability insurance. In my view, the argument of discrimination in the face of death cannot be considered legitimate when there is discrimination in the face of life.
MAID on the grounds of mental illness alone, in the current context, is an easy and cheaper solution to a complex problem. The solution lies in increasing promotion and prevention programs, increasing mental health services, investing in psychiatric research, investing in mental health education programs, and fighting stigma.
The last 20 years have not been easy for me in terms of mental health. The last year has been very difficult, but I am still alive.
I know that the road to recovery will be fraught with challenges, but I am slowly learning to rebuild myself.
Recovery does not mean the elimination of all symptoms or a return to life before diagnosis. It is a process of rebuilding oneself that includes, but is not limited to, mental illness.
Many of us go down this bumpy road. Rather than stopping us halfway along our journey, give us a chance and help us move forward in our recovery process and live with dignity.
The Quebec government has obviously heard us by excluding mental illness from medical assistance in dying. Will you hear us?
Thank you.
2:10 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, professor Vrakas.
We will now go to Dr. Ellen Wiebe.
Dr. Wiebe, you have five minutes.
2:10 p.m.
Dr. Ellen Wiebe As an Individual
Thank you very much.
I want to tell you a bit about my experience. I have 30 years' experience as a full-service family doctor, during which I treated a lot of mental health, because we did not have good access to psychiatry. I have had a lot of experience with treating people with mental illness. I'm also a MAID provider and, for the last six and a half years, have assessed about 750 people for MAID, and I've provided about 430.
One of these was the one and only person who had MAID for mental illness as the sole underlying medical condition. That was E.F., who, as I'm sure all of you know, was approved by the superior court of Alberta to have MAID before I was allowed to provide it. I also have a lot of experience with our new group of patients, who we call “track two”. These are the patients whose natural death is not reasonably foreseeable and who we've been providing for since March of 2021. My own experience is about 40 assessments and 18 provisions.
In addition, I work with the Canadian Association of MAID Assessors and Providers and was the lead author for the clinical practice guidelines on assessing patients with dementia and with chronic complex conditions. I am also a MAID researcher and have published a number of articles on MAID in Canada.
One of those, for example, was on suicide versus MAID. We spoke with providers and the general public and people who we knew had a great deal of experience with suicide—namely, a very vulnerable population, the kind that Dr. Maher was talking about. They all were very clear that suicide and MAID were completely different. The differences they talked about—and again, this is a wide variety of people—were that MAID meant that people could be with their family and that having assistance wasn't illegal. They didn't have to be secretive. They could be open and with family. For example, E.F. arrived in Vancouver with 10 family members surrounding her to support her through her last minutes.
I want to tell you a bit more about track two patients, because my research team did a research project on the first six months of track two patients and the experience that MAID assessors and providers had. We got detailed information about 53 track two patient assessments. In 67.3% of these, the main challenge was the concurrent mental illness, and this is my personal experience as well. What I'm saying is that we have already had a lot of experience now at assessing and providing or not providing medical assistance in dying for people who have concurrent mental illness, not sole mental illness.
I want to tell you that when I assess somebody who has unbearable suffering from a grievous and irremediable condition that includes mental illness and I tell them that they are eligible under our law, you should see the smile that comes across their faces: They've been listened to and their suffering has been acknowledged in a way that often nobody else has really acknowledged, which is that their suffering is unbearable, it's unrelenting and they envision the rest of their lives with more of it.
How do I, as an assessor, say that it's irremediable?
They have had one treatment after another, after another, by different psychiatrists, different psych hospitals, and again, I'm extrapolating my patients who have both physical and mental illnesses, but that's my experience, of course, except for that one, who was E.F.
2:15 p.m.
Liberal
2:15 p.m.
As an Individual
I am done, except to say that I agree with the “Final Report of the Expert Panel on MAID and Mental Illness” that there should be no new law, that track two provisions are working and will work for mental illness as a sole underlying condition.
2:20 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much, Dr. Wiebe.
We'll now go to questions and I'll turn it over to my co-chair, Dr. Martin.
It's over to you, Dr. Martin
2:20 p.m.
The Joint Chair Hon. Yonah Martin (Senator, British Columbia, C))
Thank you, Mr. Garneau.
We'll begin with Michael Cooper and each of the members will have five minutes.
Mr. Cooper.
2:20 p.m.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you, Madam Joint Chair.
Dr. Maher, you stated in the case of mental illness it's impossible to determine irremediability. What can you add to the definition of “irremediable medical condition” in the Criminal Code? That includes serious and incurable illnesses in which the patient is in an irreversible state of decline.
Would you say, in light of that statutory requirement, that this could not be satisfied in any case involving mental illness from the standpoint of a MAID assessor?
2:20 p.m.
Dr. John Maher President, Ontario Association for ACT and FACT
Certainly, the Quebec legislation that was just tabled got it right when they said that you can't determine whether psychiatric disease is irremediable. You can't, and the paradox here is that I'm representing 80 psychiatrists in Ontario who do subspecialist work. We see only the sickest people who are people who have been treated for the longest time, suffering terribly, and we're part of a group of 200 subspecialists in Canada.
We do a different type of work. We see only the sickest, and the paradox here that a lot of people just don't seem to get, and it's incredibly frustrating for me, is that the longer someone has been sick, the easier it becomes to treat them because with psychiatric disorders we have, as treatment options, literally hundreds of medication combinations. There is no exhausting treatment possibilities like there is with a terminal cancer where this chemo no longer works. I literally have hundreds of combinations, and when people have tried things, it helps narrow down what will work over time.
It's the work of time. I'm going to use an analogy here. I worked in pediatric oncology for many years. When a child was diagnosed with leukemia and had to start a two-year chemotherapy protocol where they were vomiting and ill for that two years, come the one-year mark, we had kids who didn't want to keep going.
What this law is offering people is an opportunity to stop because the healing is hard and long, but recovery is always possible. I've surveyed my colleagues on this. We've talked about this. We have yet to find a case where treatment and recovery were not possible. The challenge is that 70% of all people with mental illness in Canada stop taking their medication or they don't want to continue treatment because of suffering. What you are saying is to give up before the remedy is provided, give up before the healing is possible, and it's done under this guise that we have to relieve their immediate and horrible suffering—poor them.
If you did that with dying children, where would you be? Right now you're offering to do it with dying adults and these are neurodegenerative diseases. The longer you wait, the harder it becomes to treat, but it doesn't mean they are not treatable.
Let me give you numbers. My teams in Ontario treat the 7,000 sickest. We have 6,000 on our wait-list waiting up to five years. I would like to know, have any of you had a serious illness where you've had to wait five years for treatment? This is stigmatization entrenched in our system.
2:20 p.m.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you, Dr. Maher. What you're saying essentially is that the expert panel got it backwards in saying that, in terms of assessing irremediability, somehow this could be determined on the basis of treatments that had been provided over the patient's medical history.
2:20 p.m.
President, Ontario Association for ACT and FACT
Right. In every other case, we're looking at future treatments that don't work. What the panel said was that we look at past treatments that didn't work, but that's helpful and critical information for guiding next steps.
Let me quote a line from the panel that I thought was remarkably apropos your question.
This is from the Gupta report: “There is limited knowledge about the long-term prognosis for many conditions, and it is difficult, if not impossible, for clinicians to make accurate predictions about the future for an individual patient.” They said it in their report—they said it right in their report—and then they add that it's an ethical decision. Unlike every other case of MAID in in Canada, where you're trying to gauge the clinical reality of whether treatment will work, they say it's an “ethical choice”. It's in there as well.
This is astonishing to me. This report is astonishing in terms of its abrogation of responsibility for us, as psychiatrists and clinicians, to treat the sickest and most vulnerable. I literally defy anyone...and Dr. Kutcher, I'm going to single you out.
You said that all psychiatrists in Canada who object to MAID for mental illness are selfish and paternalistic. I'm not sure what purpose that comment served, but I defy literally any psychiatrist to say that this particular patient has an irremediable illness, because you can't. I have patients who get better after five years, after 10 years and after 15 years. You cannot do it. It's guesswork. If you're okay with guesswork, if you're okay with playing the odds, or if your position is let's respect autonomy at all costs—if someone wants to die, they can die—call it what it is. It's facilitated suicide.
2:25 p.m.
The Joint Chair Hon. Yonah Martin
Thank you, Dr. Maher.
As a reminder to our witnesses, please address the chair in your response. Thank you.
We now have Dr. Fry.
You have five minutes, Dr. Fry.
2:25 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you very much.
I had a bit of a glitch with all my technical stuff, and I wasn't able to hear fully the ACT group. However, I was listening to Dr. Maher answer this particular question.
You make the point, Dr. Maher, that what the expert panel said was that they were looking at what treatment has been done, but not what is possible in the future. You then equate that to [Technical difficulty—Editor], if we look at it from the patient's perspective, that what for the patient is intolerable and irremediable and what they refuse to continue to put up with, is not important. It is always about what the physician treating them desires.
I don't believe that this is what this is about. I think we heard from Dr. Wiebe about the chronicity of people who have had it and don't want to try anymore. We see that in physical decisions as well, with physical ailments, where people say, “I don't want the chemotherapy anymore. I don't want to to do this anymore.”
I'd like to ask what makes it different for a patient who has a mental problem. That is a real problem. We shouldn't put it into a category that says, because a patient has a mental problem, they do not have the ability to decide for themselves in many instances.
Can you answer me whether it is about what the doctor should be doing, or is it about what the patient requires?
2:25 p.m.
President, Ontario Association for ACT and FACT
Thank you for the question.
I never said that it's about what the doctor wants. I'm answering the legal question.
The legal criterion is irremediability, so let's start with that. If you have a law that says doctors are asked to offer an opinion on irremediability, we can't.
2:25 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Dr. Maher, I only have five minutes to get questions and answers, so I just need you to answer some simple questions.
From what I heard, and I may have misunderstood—
2:25 p.m.
President, Ontario Association for ACT and FACT
I think you did misunderstand me.
2:25 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
—you're saying that it's what is possible in the future. However, if the patient says they have gone through enough and don't want to go through any more, you think that is helping somebody to commit suicide. Obviously the patient has no say in the matter, from what I heard you say.
Do you think the patient has a say?
2:25 p.m.
President, Ontario Association for ACT and FACT
My daily work involves trying to sustain hope in people who are suffering terribly.
2:25 p.m.
Liberal
2:25 p.m.
President, Ontario Association for ACT and FACT
I am answering your question.