Medical Assistance in Dying Committee on May 26th, 2022

[Stan Kutcher]

Thank you for that.

We've also heard testimony that may have created confusion in our minds. I've written this down because it's complicated. The testimony suggested that people who have been accepted for MAID for a mental illness—including those who are comorbid, who have a mental illness and a physical illness at the same time, and who are currently acceptable—have not received substantial amounts of treatment and, therefore, MAID should never be provided to those individuals.

Can you help us through this conundrum? Maybe talk about what kinds of treatment processes, what duration of illness and what kinds of things a MAID assessor would have to look at, not just for mental illness but also for comorbid mental illness—a mental illness and a physical illness at the same time.

[Dr. Mona Gupta]

It's highly variable. It's going to depend on the condition and the treatment options available and so on. Generally speaking in psychiatry, for mental disorders, whether there's a comorbid physical condition or not is almost irrelevant really, but there are treatments that require a lot of time and patience and follow-up care and a lot of changes. Even with regard to the very first medication you prescribe someone, strictly speaking, according to the research, you wouldn't say there's been a treatment failure until three months have gone by—and that's the first one, not to mention the second, third, fourth and fifth ones that people try, and then all of the combinations that people try and then all of the neurostimulatory treatments that are accessible.

When we talk about standard treatment, we're really talking about years—years of trials of different things. That's the kind of treatment history that I think MAID assessors are looking for, whether it's a chronic mental disorder or a chronic physical disorder. Quite frankly, in Crohn's disease, epilepsy and rheumatoid arthritis, you're looking at exactly the same kinds of things: What kinds of care has the person had? What kind of follow-up? What subspecialty opinions have they had? Have they had novel treatments, etc.? It's a very similar kind of thinking.

[Stan Kutcher]

Thank you.

[The Joint Chair, Liberal, Marc Garneau]

Thank you.

Senator Dalphond [Technical difficulty—Editor].

[Dr. Mona Gupta]

Mr. Chair, I can't hear the senator.

[The Joint Chair, Liberal, Marc Garneau]

Senator Dalphond, we can't hear you.

Perhaps Senator Dalphond has had to step out for a minute.

[The Joint Clerk, Ms. Andrea Mugny]

I see that Senator Dalphond is in the Zoom meeting. However, his microphone does not seem to be working at this time.

Senator Dalphond, I suggest—

[Pierre Dalphond]

Can you hear me?

[The Joint Chair, Liberal, Marc Garneau]

Yes, we can hear you now.

[Pierre Dalphond]

I unplugged and plugged my headphones back in. It seems to be working.

[The Joint Chair, Liberal, Marc Garneau]

The floor is yours, Senator.

Senator Dalphond, we can't hear you once again.

[The Joint Chair, Hon. Yonah Martin]

He seems to be frozen, Mr. Chair.

[The Joint Chair, Liberal, Marc Garneau]

We'll just temporarily go to the next senator and come back to Senator Dalphond later.

Senator Wallin, if you're ready, you have three minutes.

[Pamela Wallin]

Thank you very much, Chair.

My questions or comments are for Ms. Gupta. I would just like to hear you express your views on these.

First, do you believe there is any real threat to a minority or a disabled community, a religious community or those with social constraints from the access to MAID legislation that exists?

My second question is this, and then you can judge your time. You have challenged all of us to do the hard work. I think that if we did not take up the complicated issues as legislators, we know that in this country we would not have medicare or railways or a constitution or energy or food. I know we need clarity for doctors and for citizens and patients. What is the most important thing that we must do as this committee?

[Dr. Mona Gupta]

Can I just clarify? Do you mean with respect to MAID for mental disorders?

[Pamela Wallin]

Yes, and I mean in the broader context, if you wish, please.

[Dr. Mona Gupta]

With respect to the question of threat, I don't know. I don't know what's going to happen. I can't promise you that there isn't going to be some impact on some of the other groups because that remains to be seen. That is not what we have learned from the countries that permit this practice, so to the extent that we can base ourselves on that, it seems like it's not very likely.

Actually, it's a credit to communities that have raised these worries. The disability community in particular, I think, has sensitized everyone in this debate to be mindful of the threats to well-being and to quality of life, and that MAID assessors and providers need to remember that, be sensitized to that and to take that into consideration.

Actually, they need to keep going in their efforts to sensitize us to their lived reality. I think that work has actually been invaluable. You will notice in the development of the CAMAP curriculum that this actually has led to the incorporation of people with lived experience, people with disabilities, etc., so that MAID assessors and providers are going to learn from their experiences. That would be my answer to that.

With respect to your second point, it's generous of you to ask for my opinion on that. The thing that has troubled me throughout the debate as I've been following it along is the strands of illogic or incoherence that we can allow MAID for mental disorders when the person has a comorbid physical condition, like somehow that erases their vulnerability or erases their history of suicidality. Now they have a physical condition, so it's okay and they can have access, but if that same person doesn't have the medical condition, they must never have access under any circumstances. There's an inherent illogic there that I have never understood. When somebody has a condition where it's really difficult to predict what's going to happen, they can have access as long as it's not a mental disorder. This illogic is concerning to me, and I would encourage you to find a solution to this illogic. I think there are different ways of doing that.

It worries me because it suggests that as a society we don't believe that people with mental disorders can really ever be capable of making their own decisions for themselves. I think we've really fought hard against that for a long time, so I am surprised.

I absolutely understand the arguments about lack of resources. To me, it's not a choice that we have MAID or we have better resources. We need to have better resources—period—but that's not a reason not to have MAID.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Dr. Gupta.

I see that Senator Dalphond is back.

You have the floor for three minutes, Senator Dalphond.

[Pierre Dalphond]

Thank you.

Dr. Gupta, you said that there are some uncertainties with some of the concepts and that's why your group has come up with a list of recommendations. You said these recommendations are based on the experience in Belgium and the Netherlands. Based on that, you also refer to the fact that very few cases are accepted. Most of them are turned down.

Is it right to reassure people who are listening here that your recommendations are aimed to lead to a denial of the request in cases of uncertainty and, therefore, are designed to protect and ,in cases of doubt, not to give access to MAID but rather to deny when there's a doubt?

[Dr. Mona Gupta]

Mr. Chair, you'll be very happy. My answer is very short.

Yes, that is exactly what we're trying to say. Like in all aspects of clinical practice, if you have doubt about the indication of what you're about to do, you do not go forward.

[Pierre Dalphond]

There's uncertainty with any words in the world, but you're trying to guide the practitioners to remove that uncertainty. If they still have uncertainty, they should say no.

[Dr. Mona Gupta]

Yes. We're not going to remove all uncertainty. Medicine is largely a probabilistic discipline, and we're always making decisions under conditions of uncertainty. There will always be some uncertainty.

The question is, how much is too much? The line shifts with respect to that with time, but when there's too much uncertainty and the practitioners cannot come to ground on whether this condition should be considered incurable along the lines of what we've laid out or the person does not have capacity, then they should not go forward.

[Pierre Dalphond]

The intent of the report is to err on the safe side, rather than otherwise.

[Dr. Mona Gupta]

Yes, absolutely.

[Pierre Dalphond]

Thank you.