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.
2:55 p.m.
Psychologist and Professor, Department of Psychoeducation, Université du Québec à Trois-Rivières, As an Individual
In my opinion, right now based on evidence, studies and research, there is no acceptable safeguard that will make MAID for mental illness safe.
2:55 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
That concludes our first panel.
On behalf of the committee, I would like to thank Dr. Maher, Dr. Georgia Vrakas and Dr. Ellen Wiebe.
Thank you for appearing before the committee today and answering our questions on an extremely complicated and emotionally charged issue. It is greatly appreciated.
We are now going to suspend momentarily to bring in the next panel.
Thank you everyone.
3 p.m.
The Joint Chair Hon. Yonah Martin
I have just a few comments for the benefit of our new witnesses.
Before speaking, please wait until I recognize you by name. As a reminder, all comments should be addressed through the joint chairs. When speaking, please speak slowly and clearly. Interpretation in this video conference will work as it does for in-person committee meetings. You have the choice at the bottom of your screen of floor, English or French. When you are not speaking, please keep your microphone on mute.
With that, I would like to welcome our witnesses for this panel, who are here to discuss whether to permit medical assistance in dying for mental illnesses or disorders in Canada. First, there's Dr. Alison Freeland, chair of the board of directors and co-chair of the MAID working group at the Canadian Psychiatric Association. As individuals, we have Mr. Mark Sinyor and Dr. Tyler Black. Thank you for joining us today for the second panel.
We'll begin with opening remarks by Mr. Sinyor, followed by Dr. Freeland and Dr. Black.
Mr. Sinyor, you have the floor for five minutes.
May 26th, 2022 / 3 p.m.
Dr. Mark Sinyor Professor, As an Individual
Thank you very much.
Good afternoon, committee members. It's an honour to be with you today. My name is Mark Sinyor. I'm an associate professor of psychiatry at the University of Toronto and a psychiatrist at Sunnybrook Health Sciences Centre who specializes in the treatment of adults with complex mood and anxiety disorders.
My research is focused on suicide prevention. I'm a former vice-president of the board of the Canadian Association for Suicide Prevention, lead author on the Canadian guidelines for responsible media reporting about suicide, a steering group member of the International COVID-19 Suicide Prevention Research Collaboration and I was recently asked to coordinate the International Association for Suicide Prevention's efforts to create a regional suicide prevention network across the 35 countries in the Americas.
I should note that I am not involved in MAID assessment or provision. I am also not a conscientious objector to MAID. To be transparent, my professional agendas, both in general and in these deliberations, are to do my best to help contribute to a Canadian society with fewer suicides and to protect psychiatry as an evidence-based science.
Given that I only have a few minutes, I will focus my remarks on what ought to be the overriding issue in your deliberations. As highlighted in the expert panel report, I and some of my colleagues have argued that, like any other medical procedure, physician-assisted death for sole mental illness should be permitted only if there is evidence that the benefits outweigh the harms. In their recently tabled report, the expert panel noted that they “considered this possibility but did not arrive at this conclusion.”
The imperative to do no harm has been a foundational principle of medicine for thousands of years and underpins the modern principles of evidence-based medicine, which call for us to undertake scientific evaluation of the benefits and harms of our treatments to determine whether delivering them is ethical. If, as a country, we're going to reject these ideas, first, we should be aware that we're doing so and, second, we ought to have a compelling reason.
In short, we are essentially missing all of the necessary scientific evidence to evaluate the safety of physician-assisted death for mental illness. If I had more time, I could list many examples, but let me focus on the fact that there is absolutely no research on the reliability of physician predictions of the irremediability of illness or suffering in psychiatric conditions. To my knowledge, there is not a single study.
Advocates for the practice are suggesting that we have safeguards, because the practice carries many inherent dangers. This is the entire reason for safeguards. We do not propose safeguards for practices that are already safe, but the degree to which any proposed safeguards actually fix that problem is entirely unquantified. No one has provided you with those numbers because there has been absolutely no research and they don't exist. As a result, if this goes forward, MAID assessors will have no idea how often they are wrong when they make a determination of eligibility in the context of physician-assisted death for sole mental illness. They could be making an error 2% of the time or 95% of the time. That information should be at the forefront of this discussion, yet it is absent altogether.
There are many other examples of evidence about serious harms that are simply missing, such as rigorous study of the impact on suicide and its prevention. Nothing in life or in medicine is certain. All of our treatments carry potential benefits and potential harms. In medicine, we deal in probabilities. Doctors help patients make decisions in cancer treatment, for example, by sharing that chemotherapy might result in survival 90% of the time or only 10% of the time. In neither case do we know the outcome for certain, but those numbers are crucial in helping patients make informed decisions. In physician-assisted death for sole mental illness, we have no numbers at all. Neither we nor our patients would have any idea how often our judgments of irremediability are simply wrong. This is completely different from MAID applied for end-of-life situations or for progressive and incurable neurological illnesses, where clinical prediction of irremediability is based in evidence.
In the context of physician-assisted death for sole mental illness, life or death decisions will be made based on hunches and guesswork that could be wildly inaccurate. The uncertainties and potential for mistakes in mental illness are enormous and, therefore, the ethical imperative to study harms in advance of legislation is accordingly immense.
What is so disconcerting here is that we could conduct the necessary studies. We demand evidence on benefits and harms before legalizing natural health products, new medicines and vaccines. Why skip that step in such a profound deliberation as the one you are engaged in now? I would argue that we owe it to our fellow Canadians with mental illness to have the necessary scientific information in hand before making such a consequential decision.
Thank you. I wish health and well-being to all during the pandemic.
3:05 p.m.
The Joint Chair Hon. Yonah Martin
Thank you very much, Mr. Sinyor.
Next we will have Dr. Freeland for five minutes.
3:05 p.m.
Dr. Alison Freeland Chair of the Board of Directors , Co-Chair of MAiD Working Group, Canadian Psychiatric Association
Thank you for the opportunity to be here today. My name is Alison Freeland. I am a psychiatrist, and I'm here in my capacity as chair of the board of directors of the Canadian Psychiatric Association and co-chair of the CPA's MAID working group.
Today I will focus my remarks on medical assistance in dying as it pertains to requests on the sole basis of a mental disorder to supplement the CPA's brief that was submitted to this committee a few weeks ago.
The CPA has not taken a position on whether MAID should be available where mental illness is the sole underlying medical condition. However, we do believe that any new legislation must protect the rights and choices of all vulnerable Canadians without unduly stigmatizing and discriminating against those with mental disorders where eligibility requirements are determined to be met.
In considering safeguards, the CPA discussion paper looked at the issue of capacity. A mental disorder does not in and of itself imply incapacity in any domain of decision-making, but when active, various forms of mental illness can impair decision-making and capacity. Psychiatrists have specialized training and expertise in the assessment, diagnosis and treatment of mental illnesses, including the assessment of decisional capacity as well as the durability, stability and coherence of a person's expressed will and preferences. Psychiatrists are well versed in taking into consideration any external constraints or internal psychopathology that may impact these issues.
Inequities of service provision and funding are an issue for all types of conditions. This is an area that is particularly problematic for people living with mental illness. Such inequities are further exacerbated for people who live in rural or remote areas. Whether the illness is physical or mental, or a combination of both, equitable and timely access to evidence-based, culturally appropriate clinical services is a first and essential safeguard to ensure that people do not request MAID due to lack of available treatments, supports or services.
In the context of mental disorders, there is no generally agreed definition of incurability. Within the field of psychiatry, there are some who do not accept that any mental disorder isn't curable and will argue that there is always another treatment to be attempted. Resolution of this issue requires a pragmatic approach that balances clinical expertise and assessment of incurability with the patient's perspective and experience of their illness.
Socio-economic determinants of health, which play a key role in each person's experience of suffering and adaptability to mental illness, are important to consider. If a patient refuses recommended treatment for their disorder without good reason, weighing both the potential benefits and burdens, they are unlikely to have met the eligibility criterion for incurable.
Vulnerability is not limited to those with mental illnesses. Many people with non-psychiatric illnesses are also vulnerable because of such psychosocial circumstances as isolation or poverty, cognitive distortions and demoralization due to failed treatment attempts or difficulty in adjusting to life with their illness. The trajectory of physical illness can be as unpredictable as that of mental illness. Loss of hope can occur, as can spontaneous remission. Predicting treatment outcomes is as much a challenge for psychiatry as it is for the rest of medicine.
Both acute and chronic suicidal ideation must be considered and evaluated to make a best determination as to whether the patient's wish to end their suffering represents a realistic appraisal of the situation, rather than a potentially treatable symptom of their mental illness. A request for MAID should be considered and sustained, and not be the result of a transient or impulsive wish. This is particularly important for persons with non-terminal conditions, such as a mental disorder where illness maybe more episodic in nature.
Therefore, separate from any MAID eligibility assessment, it is essential that at least one independent psychiatrist completes a comprehensive clinical assessment to validate whether the patient has received an accurate diagnosis and access to evidence-based mental health assessment, treatment and supports for an adequate period of time based on generally accepted standards of care.
Thank you very much. I'd be happy to try to answer your questions.
3:10 p.m.
The Joint Chair Hon. Yonah Martin
Thank you, Dr. Freeland.
I don't see Dr. Black. Am I correct?
3:10 p.m.
Dr. Tyler Black Clinical Assistant Professor, University of British Columbia, As an Individual
I am here.
3:10 p.m.
The Joint Chair Hon. Yonah Martin
I see. Thank you very much.
Dr. Black, you have five minutes.
3:10 p.m.
Clinical Assistant Professor, University of British Columbia, As an Individual
Thank you for the opportunity to provide my perspective.
I'm a physician with 14 years of tertiary experience in emergency psychiatry involving suicidality, and I'm a researcher, teacher and expert in suicide and suicidology.
It's really important to note that what most people think of as suicide is far different from most experiences of MAID. I've submitted a brief regarding many of the myths comparing suicide to MAID, and I trust that it's been helpful to the committee. I'd like to draw special attention to three of the points that I made.
First, motivations in MAID and suicide are rarely the same. In suicide, it's very rare to have a combination of fatalistic motivation, which is a controlled response to a perceived stress, an agreed-upon lack of remedy and a rational calculation of the likelihood of change, whereas in MAID this is almost always the case. In the literature, psychiatrists generally agree with the patient's unbearable suffering and futility of treatment in psychiatric MAID cases in the countries where this has been studied.
Second, the wish to die is not indicative of a mental illness. While depression does include suicidality as one of its nine criteria, the presence of a serious mental health diagnosis is absent in 40% to 50% of all who die by suicide. Many who experience suicidal thinking do not have a diagnosable mental illness, and the vast majority do not die by suicide.
Third, capacity assessments are a core part of psychiatric training. This is probably the most achievable and least controversial aspect of these discussions and not an area of significant controversy in psychiatry.
To the larger complex question regarding psychiatric MAID, I'm comforted by an approach that helps me in my clinical life. You see, most of my patients are sent to me as a tertiary psychiatrist when other psychiatrists and doctors are seeking care and expertise for a complicated case. Where other physicians who deal with primary presentations follow guidelines or algorithms, I rarely have an algorithm to follow. In fact, the book of algorithms for my line of work would be minuscule.
Rarely do I ever have a perfect answer. For this, I both teach and practise science-based medicine and principle-guided medicine. For science-based medicine, we use the best evidence we have at the time. We apply plausibility in expertise and recognize the importance of updating our information as new, excellent information comes to light.
In this regard, there are decades of experience of MAID in some countries and some with psychiatric MAID, and it suggests that it's well practised, well accepted and represents only a small fraction of all MAID deaths, 1% to 2%. Given the number of people with suicidal thinking, there is simply no credible foundation for the fear that allowing MAID for psychiatric conditions would create a flood of deaths in Canada.
One study estimated suicidal thinking as an 8% lifetime risk for adults in the Netherlands, yet 65 or 0.0004% of adults in the Netherlands have died of MAID in any given year due to psychiatric reasons.
Adding the procedures that should be in place for MAID, the plausibility of a hasty, poorly thought out conclusion regarding MAID is drastically reduced. I've also submitted evidence regarding a review of studies of psychiatric MAID in various countries to the committee.
For principle-guided medicine, one uses a set of principles to dictate decision-making. There are many principles that I consider when it comes to psychiatric MAID. First, we must respect the autonomy of our patients, especially when we have determined that they have the capacity to make decisions for themselves.
Second, we must be cognizant of systemic racism, systemic ableism and lack of access to mental health care in Canada. It should never be that someone chooses MAID due to a system that inflicts racism or ableism on that person or limits their ability to access quality mental health care.
Third, we must not discriminate against people with mental illnesses nor discriminate against those with psychological suffering.
Fourth, not all conditions respond to treatment. No treatment in psychiatry has a 100% cure rate, and psychiatry has been loathsomely slow compared with other specialties to the medical notion that some people do not, for a variety of reasons known and unknown, respond positively to treatment. For some, treatment is a miserable experience with no benefits.
Fifth, psychiatry has a long legacy of paternalism, and decisions must be centred in a place where the expertise of physicians and those with lived experience overlap. Finally, only a physician's professional opinions, not their personal beliefs, should exert influence on a patient in their health care decision-making.
I can imagine a system in Canada that honours the best science and principles we have regarding this issue and, for that reason, I'm cautiously but generally supportive.
Thank you.
3:15 p.m.
The Joint Chair Hon. Yonah Martin
Thank you, Dr. Black.
Thank you to all of our witnesses for your testimony today. That will be very helpful to our committee.
We'll begin our first round with Mr. Cooper.
You have the floor for five minutes.
3:15 p.m.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you, Madam Chair.
Dr. Sinyor, in your testimony you said that what is lacking is literally all necessary scientific evidence to establish that MAID can be carried out safely in the case of sole mental illness. You focused in specifically on the lack of study around predicting irremediability. You did go on to say that you could cite other examples of evidence that is missing, so I'd invite you to take this time to do so.
3:15 p.m.
Professor, As an Individual
Thank you very much.
I think there are a few key things. The first is that the legislation doesn't only talk about incurable illness, but also incurable and intolerable suffering. The idea of incurable and intolerable suffering doesn't actually have a scientific definition. There was an article in the Canadian Medical Association Journal just a month ago in which there were calls for a scientific definition for that, which would really be a precursor of being able to study it. It's important to alert the committee that the concept we're trying to treat doesn't even have a scientific definition. That's part of the reason there have been no studies of it.
I think there's a whole host of other things that we need to look into beyond.... There's not only the irremediability of psychiatric disorders but also the irremediability of psychiatric suffering. While I agree with the other witnesses that there are psychiatric illnesses for which we know we can't cure the underlying illness, that's actually somewhat different from the idea of whether we can provide a treatment that may be able to alleviate the suffering that corresponds to that illness. To my knowledge, that has never been the focus of a single psychiatric study or any kind of study.
The large rest of studies that would be necessary are those related to suicide and suicide prevention. We just heard correctly, for example, that there's this question about whether MAID is suicide or not. Some people say it's exactly the same thing. Some people say it's totally different. The reality is probably that it's something in between. Obviously, in the case of mental illness, we have to be concerned that there may be substantial overlap. Trying to quantify the degree to which that overlap exists and the degree to which messaging....
I'll just say that my research mainly focuses these days on public messaging. We find that when you message across society that when you're having difficulty and struggling with mental illness, you can go seek treatment and get help, we see fewer suicides across the population. When you see media reporting about the idea that people will take their own lives when they're in difficulty in life, we see an increase in suicides. The degree to which that media reporting and this sort of cultural change that we have may have an influence is something worth studying, as is the impact on the physician-patient relationship and how people view psychiatry.
I would say the last thing that probably would be worth studying is an economic analysis of whether there are perverse disincentives. Of course, if this goes forward you would want any money that's saved through MAID to then be funnelled back into the mental health system. There is the possibility, of course, that there's a perverse disincentive to invest because if you don't invest, the more people have what appears to be irremediable illness and they die through MAID. Then our health care system just gets worse, which I think we can all agree would be a complete disaster.
All of that research would be helpful to know before going forward.
3:20 p.m.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you very much.
I presume that, absent being able to establish irremediability, talking about safeguards is really putting the cart before the horse. If you can't establish irremediability, you really can't go forward—certainly from the standpoint of the legislation, but even putting aside the statutory requirement, from a safety standpoint.
3:20 p.m.
Professor, As an Individual
I think that's correct. If you think about it logically, if someone asks if this plane can fly.... We have a dangerous plane. We know that it crashes. Can we get it safely from point A to point B? You could get a group of people to say that we should put a whole bunch of safeguards into place, but without actually testing those safeguards, I wouldn't want to get on the plane.
3:20 p.m.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
That's right.
Could you perhaps just explain what full disclosure for informed consent for MAID in the case of sole mental illness would look like?
3:20 p.m.
Professor, As an Individual
I think here's the difficulty. One could construct a study where you take all of those people who might be eligible for MAID for mental illness and provide them with really excellent care, provide them with whatever they might need—psychotherapy, adequate pharmacotherapy, a nutritional program, exercise, access to neurostimulation, other psychosocial interventions that might help—and you could look and see what proportion of those patients actually change from appearing irremediable to remediable. I think many of us are concerned that it's probably a very large proportion of them.
The concern there is that psychiatrists don't know that because we don't have the research. There's no evidence for it, so you could have a patient and a psychiatrist sit together and earnestly decide there's nothing that can be done, that this case is irremediable, and both have that entirely wrong, and then have that person end their life. As a practitioner or clinician or psychiatrist, the idea that we might go forward with that without informing patients that this is a possibility is a problem. At the moment—
3:20 p.m.
The Joint Chair Hon. Yonah Martin
Thank you very much.
Next we'll have Mr. Maloney.
You have five minutes.
3:20 p.m.
Liberal
James Maloney Liberal Etobicoke—Lakeshore, ON
Thanks, Madam Joint Chair.
Thanks to all three witnesses. Your presentations were excellent and levelly presented, based on some previous panels we've had, most recently an hour ago.
Dr. Sinyor, I'd like to start with you if you don't mind. At one point you said you're trying to protect psychiatry as evidence-based science, which I respect and I thank you for. Have you ever rendered an expert opinion in a legal matter before?