Medical Assistance in Dying Committee on May 26th, 2022

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Excuse me, Mr. Joint Chair, but Senator Wallin didn't have her turn. I don't know if we want to return to her or not, sir.

[Pamela Wallin]

No, it's fine. I'm having a lot of technical problems so please go ahead.

[The Joint Chair, Liberal, Marc Garneau]

Senator Wallin, I'm happy to have you. I looked across all of the screens and I didn't see you so I assumed you were gone.

Would you like your three minutes?

[Pamela Wallin]

No. Go ahead, please.

[The Joint Chair, Liberal, Marc Garneau]

Okay, we'll catch you on the next one.

MP Ellis, you have the microphone for three minutes.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you, Mr. Joint Chair.

Thank you, Dr. Gupta, for being here.

I have a couple of things. Just to paraphrase, I heard you say that patients need to be assured of appropriate treatment and social supports. Certainly we know that we're at a time in Canada when there's a realistic inability to access.... We've heard that from multiple witnesses and certainly I've been a family physician for 26 years, so I've heard that over and over.

How would you characterize in your mind the access to treatment and appropriate social supports for mental disorders in Canada at the current time?

[Dr. Mona Gupta]

Just to make sure that I understand your question, are you asking me if I think people with mental disorders have appropriate access?

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

To treatment and social supports...that's correct.

[Dr. Mona Gupta]

I'm going to again preface my question by saying my area of expertise is not administration and service provision in mental health. I'm going a bit from my clinical experience and my work on this report and on this topic.

I think it's highly variable. I think there are groups that do not have quick and appropriate access. I see that every day in my practice. Particularly in first-line care, people are waiting a long time for pretty simple things. I see people who have great access to mid-level care, but when they need something subspecialty, it's difficult to get—and the opposite. It depends on where you live in the country, unfortunately.

You see people who actually are quite severely affected and they actually have—that's a good thing, right, the system actually works sometimes—appropriate services that are at a level of intensity that is needed for the care of those folks. I do think it's highly variable. Obviously, like all health care services, it's worse, I think, and access is poorer the farther away you are from urban centres. In urban centres you have lots of providers, but there's a discontinuity there that maybe is less obvious than in rural areas. That's something I experienced when I did locums up north, where there was less provision but it was actually more coherent.

I think there's a lot of variability.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Dr. Gupta, you did talk about the indigenous communities having a variety of ideas around MAID, etc., and that they should be taken individually. Does that also mean then, going along with this line of reasoning, that rural communities that have different access perhaps should have different inputs on how MAID is performed or safeguarded in their communities as well?

[Dr. Mona Gupta]

Yes, I have to assume that in each province, each province with its different geography, east, west, north, south, right, and some are very long, and some are this way, and with different regional characteristics, that there needs to be thought, as there is for all health care services, I would say, about the best way to deploy a service or a practice.

I'm hesitating about the idea that all rural communities will have the same vision about how it should be done. I'm thinking that at the level of provincial planning, working with different rural areas is going to be necessary in order to ensure that service provision is what they want it to be.

For example, I can imagine in some areas, growing on what we were doing during the pandemic, the idea of doing video consultations will be quite welcome. In other rural areas where actually getting there in person might not be so difficult, people might say they actually want to have what I did up north—have locums where people come in and they can see them in person.

I think it's going to be, again, quite variable depending on the region.

[The Joint Chair, Liberal, Marc Garneau]

Thank you.

We'll go to Dr. Fry now.

Dr. Fry, you have three minutes.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Chair.

There are two questions I wanted to ask Dr. Gupta. Thank you for coming and taking this yeoman's duty today to spend all of this time answering our questions.

There are two things. During the course of hearing our witnesses, we have heard something that kept recurring. People said you shouldn't look at establishing incurability based on looking backward at what people's treatments were, what their access was, etc. You should be looking forward at what is the next big cure or what the next thing is, and giving them that kind of hope before you offer MAID. It's saying, “No, let's keep going and look forward to what we have to offer.” That's the first question that I'd like to hear a comment on.

The second one is about a point you made in the report. Basically, a lot of people can't.... Witnesses in the hearings tended to take suicide and mental health and conflate them. You clearly said in your report that people do not have suicidal ideation purely because they have a mental health problem. In fact, the majority of people with mental health problems don't express suicidal ideation.

The second piece is that a lot of people with suicidal ideation do not have a mental health problem. Should we conflate those two? Should we see them as separate issues? You are making the point that they are separate issues.

[Dr. Mona Gupta]

Thank you very much for those questions.

I'll start with the second one first. I think that's absolutely right. There's obviously an overlap between mental disorder and suicidality. It can be a symptom of a certain number of psychiatric diagnoses. It is associated with completed suicide, but it is also the case that there are people who are suicidal who do not have a psychiatric diagnosis, so they need to be understood as two separate things.

As I mentioned earlier, there was suicidality in track one. I remember a case in which a man attempted to kill himself because of the severity of his chronic pain. He did not complete suicide and he came back and asked for MAID. I think that case raised very similar questions. Are we basically helping him kill himself? This was not a man with any kind of psychiatric history.

You're absolutely right that they should not be conflated, and suicidality should be treated as its own phenomenon independent of mental disorder. It may be the case that the person has a mental disorder, but we should be just as concerned about suicide in the person who does not have a psychiatric diagnosis as we are in the case of the person who does.

With respect to incurability, I'm going to come back to the technical clinical point that I made earlier, which is that with certain diagnoses, because of what we know about the trajectory of those conditions, the moment the person receives the diagnosis, we have a pretty good idea of how things are going to evolve and we have a greater degree of certainty. With others, particularly what we call chronic medical conditions, at the time the person is diagnosed it's very difficult to know what's going to happen, so they have to try a bunch of things and see what impact that has on their condition.

When we translate that to the MAID situation, if somebody has a chronic condition, the only way we can say something about the severity of their illness is to look back and say, “What has this person done?” It is the case that some people try lots and lots of things and don't get a significant degree of relief or an improvement in their quality of life? Happily, many do.

[The Joint Chair, Liberal, Marc Garneau]

Thank you very much.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you.

[The Joint Chair, Liberal, Marc Garneau]

We will move on to Mr. Thériault now.

Mr. Thériault, you have the floor for two minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Mr. Chair.

In reading the report, in which each of the recommendations includes precautions, I got the impression that very few people whose only medical problem is a mental disorder would have access to medical assistance in dying.

The Quebec commission that discussed eligibility and non-eligibility for MAID did not reach this conclusion and the bill tabled yesterday excludes this situation entirely.

Given the lack of social consensus or social acceptability related to mental illness, Dr. Gupta, don't you think the March 17, 2023 date is premature?

[Dr. Mona Gupta]

I'd like to say two things about that.

First, it's true that very few people are going to have access to it if we follow our recommendations. At the same time, these are similar recommendations to those of countries where this practice is allowed and where very few people have access to medical assistance in dying. If they have little access to it, it is precisely because there are many treatment options.

We should ensure that people have access to care and services. A minority of people will find themselves at the end of a long and dark journey caused by mental illness, but this could happen if "incurable" were defined that way.

Secondly, with regard to exclusion and the notion of social consensus or acceptability, I hesitate. Sometimes, what is socially acceptable is not the right thing to do. Not long ago, homosexuality was not socially acceptable, whereas driving while intoxicated was socially acceptable.

[Luc Thériault, Bloc, Montcalm, QC]

Wait a minute—

[Dr. Mona Gupta]

I think we can challenge the consensus.

[Luc Thériault, Bloc, Montcalm, QC]

Wait a second, Dr. Gupta.

There is a commission—

[The Joint Chair, Liberal, Marc Garneau]

Mr. Thériault, your time is up.

You will have the opportunity to ask other questions during the next round.

Mr. MacGregor, you have two minutes.

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

Thank you.

Dr. Gupta, the conclusion of your report stated, “This report is the beginning of a process, not the end.” You very clearly outlined that the expert panel played a very specific role. It was defined clearly by your terms of reference. As we, as a parliamentary committee, take the baton, so to speak, and carry on with this study, we're grappling with a major role because we're ultimately going to make recommendations to the government as well. We, as legislators, may ultimately play a role in debating a future bill on this.

I don't have much time, so my question to you would be this: Do you have any advice for us on the things that we should be keeping in mind as we continue this study based on the experiences that you had, being so deep in these issues before us?

[Dr. Mona Gupta]

Thanks a lot for the question.

I'm going to take advantage of the question to also answer Senator Mégie's question from earlier about last advice.

I think that I would be really critical about exceptionalizing mental disorders and treating mental disorder as a sole underlying medical condition as some entirely distinct reality from people with comorbid mental and physical disorders or people with other kinds of physical disorders. That would be my advice. The clinical reality does not support that idea.

It's worth noting that, in the small number of countries where this practice is permitted, there are no legislated safeguards that are specific to people with mental disorders as a sole underlying medical condition. The reflection I think has pretty much landed where we've landed in terms of the greater commonality versus difference, particularly when it comes to eligibility.

As for Senator Mégie's question—