Medical Assistance in Dying Committee on May 26th, 2022

[The Joint Chair, Hon. Yonah Martin]

Welcome back, colleagues.

We now have a very special panel for one and a half hours. We have the chair of the expert panel on MAID and mental illness, Dr. Mona Gupta. I'm not sure if there are others accompanying her, but I see her online.

This panel will be one and a half hours in length. Therefore, the format will be slightly different from our usual format. Following Dr. Gupta's opening statement of five minutes.... Actually, I misspoke. We will be going back to our original round of questions. We have never been able to get to round two, as you know. We'll be doing round one with MPs and senators, and then the second round with three minutes for both Conservatives and Liberals and two minutes for Bloc Québécois and NDP. We have never gotten to the second round, but because we have one and a half hours, we'll be able to do the full order.

Dr. Gupta, we welcome you and the expertise that you bring to the table. You have five minutes to address our committee. The floor is yours.

[Dr. Mona Gupta, Associate Clinical Professor, Expert Panel on MAID and Mental Illness]

Thank you, Madam Chair.

I am pleased to appear before you to represent the Expert Panel for MAID and Mental Illness, which was created under Bill C-7 and whose final report was tabled in Parliament on May 13, 2022.

I am a psychiatrist and regular researcher in philosophy and ethics of psychiatry at the Centre Hospitalier de l’Université de Montréal. In my clinical practice, I work in the area of consultation-liaison psychiatry, the subspecialty devoted to the psychiatric care of the medically ill. I have also been involved in cases of persons requesting MAID, primarily as a psychiatric consultant and sometimes as an assessor.

In these opening remarks, I will provide a brief overview of the reasoning behind the panel’s recommendations. I can elaborate upon this reasoning in more detail during the discussion period as needed.

Just a quick note about terms: although our mandate used the expression “mental illness”, we chose to use the term “mental disorder” since this is standard terminology in medicine. Hereafter, I will use the expression “mental disorder”.

Our mandate was to make recommendations for safeguards, protocols and guidance for MAID requests made by persons with mental disorders, not to debate whether such persons should be permitted to have access. Nevertheless, we took the concerns raised by those who are opposed to this practice very seriously. By these concerns, which are addressed in the report, I mean incurability of a medical condition, irreversibility of decline, capacity, suicidality and vulnerability.

As we undertook our work, our first observation was that people with mental disorders are requesting and accessing MAID now. This group includes a range of requesters, from people whose mental disorder is stable, to those whose psychiatric and physical problems are active and together motivate the request for MAID, all the way to those whose requests are largely motivated by their mental disorder but who happen to have another qualifying condition. These requesters may have long histories of suicidality. There may be questions about their decision-making capacity. They may also be in situations of structural vulnerability.

A second and related observation the panel made is that there are people requesting and accessing MAID now whose medical conditions are difficult to assess with respect to incurability and irreversibility in decline—for example, some requesters with chronic pain.

Based on these observations, the panel concluded that there is no single characteristical problem that attaches to all people with mental disorders and only people with mental disorders. “Mental disorders” is merely an imprecise proxy for these concerns. If the hope is that by excluding people with mental disorders as a sole underlying medical condition from accessing MAID we can avoid having to deal with these difficult issues, clinical experience with MAID shows us that this is not the case. We are already facing these problems in practice. That is why the panel's approach is to try to address these problems head-on.

When we looked carefully at the concerns raised about MAID for mental disorders, we found that they were clinical in nature, meaning that the difficulties arise when clinicians have to apply legal terms to MAID assessments—for example, interpreting the word “incurability” for a particular medical condition or assessing chronic suicidality.

What seems to be required to address these concerns is greater elaboration about the applicability of the eligibility criteria and the best approaches to adopt in assessing specific challenging issues in clinical practice. The panel has tried to provide this elaboration and specification in our recommendations.

This process of elaborating and specifying has also allowed the panel to clarify that, in order for a mental disorder to be a grievous and irremediable medical condition in the sense of the Criminal Code, it must be of long standing and the person must have had an extensive history of treatment and social supports. MAID is not intended for people in crisis or those who have not had access to health and social resources.

With that, I will stop. I would be very glad to continue on in discussion with you.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much, Dr. Gupta.

We will begin round one with Mr. Cooper.

Mr. Cooper, you have five minutes.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Thank you, Madam Joint Chair.

Thank you, Dr. Gupta, for being here.

I note that on page 21 of your report, it says that a “consensus-seeking approach was adopted” during the panel's deliberations and that the authors had reached “unanimity” in the recommendations. I would note that's not entirely true, as two members of your panel resigned. Isn't that correct?

[Dr. Mona Gupta]

It's true in the sense that they were no longer members. The authors of the report supported the report unanimously.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Can you elaborate on why those two members resigned or left the expert panel?

[Dr. Mona Gupta]

Sure. My understanding is that the panel was selected and appointed by both ministers. They sought to ensure that there was a range of views represented amongst the panel membership, including members who had publicly stated that they were opposed to the practice of MAID for mental disorders. As we started working on the report and the recommendations, one member, despite her initial willingness to participate, realized that, given her public opposition, she could not reconcile her personal position with the work of the panel, given its mandate. That was one resignation that occurred in December.

The second resignation occurred at the end of the panel process, at the end of April. Actually, I don't have information about the specifics of why the person chose to resign, but they sent a letter saying that they were resigning their membership.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Thank you for that. Also page 21 of the report confirms that there was no stakeholder or expert consultation. I recognize that the report elaborates that there was some very limited consultation. That is correct; is it not?

[Dr. Mona Gupta]

Our mandate was not to do consultation, but what we did have to do was to try to go out and get some information that was not available otherwise in the public domain. Yes, we elaborated on that in the report. You're correct.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

And that—

[The Joint Chair, Hon. Yonah Martin]

I'm sorry, but may I just interject? There's a note for Dr. Gupta.

Would you raise your microphone a little bit higher, please? It's for the interpreters.

[Dr. Mona Gupta]

All right.

[The Joint Chair, Hon. Yonah Martin]

I've paused your time, Mr. Cooper. You may continue.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Thank you, Madam Joint Chair.

There was no stakeholder or expert consultation and no consultation with indigenous communities. Is that correct?

[Dr. Mona Gupta]

Again, our mandate was not to do consultations through an expert panel, and the panel was appointed with the requisite expertise on the panel to do the work. That said, three members of the panel do identify as indigenous and, therefore, were able to guide us and had sensibilities that we were able to happily take advantage of in reflecting on those issues.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Would you concede that the absence of stakeholder and expert consultations, which I recognize was not part of the mandate, diminishes the weight that should be attached to the findings of the report? Surely you would concede that it would be important in terms of coming up with recommendations.

[Dr. Mona Gupta]

I don't know if “concede” is the right word. I think we were given a task to do as an expert panel and, as I said, I believe the panel was constituted with the requisite expertise amongst the membership when we did that task. Stakeholder consultation, I think, provides a different kind of information that is also valuable, and if the government wishes to pursue that and obtain that, I'm sure that will contribute valuable information as well.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Changing gears, are you aware of any study on the reliability of physicians predicting irremediability?

[Dr. Mona Gupta]

By reliability do you mean that, if a number of physicians assess the same patient, they will come to the same decision?

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Yes, or are you aware, more broadly, of any studies on predicting irremediability?

[Dr. Mona Gupta]

You mean studies about reliability of assessments and then studies about prediction.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Exactly.

[Dr. Mona Gupta]

I am not aware of studies about predicting irremediability. Irremediability isn't a clinical term; it's a legal term. One of the things the panel tried to do was to give it some clinical flesh, if you will, and put it in terms that clinicians can understand.

I'm going to just modify your question slightly, if you'll let me, and say there are studies about predicting, for example, treatment resistance. That's a term that would be more familiar in psychiatry, for example, amongst people with a certain condition who have had certain kinds of treatments. For example, when we do research on treatment resistance, we certainly identify subjects to enrol in those studies, so you could say, yes, the researchers—clinicians often—who recruit patients for those studies come to agreement on who are treatment-resistant patients and who are not.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Next we will have Monsieur Arseneault for five minutes.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Thank you, Madam Chair.

Welcome, Ms. Gupta.

Thank you for providing all that information, as chair of the Expert Panel on MAID and Mental Illness.

The people before you today are members and senators. At the end of the day, we are lawmakers who don't have all of your psychiatric expertise.

Our focus is whether to permit medical assistance in dying when mental illness is the sole underlying condition. I don't know what the split among psychiatrists is on the issue, but we have heard arguments at both ends of the spectrum from members of the profession.

That said, there seems to be a consensus within the profession that it is indeed possible to distinguish between a person who has suicidal tendencies and a person who does not, even if that person is suffering solely from mental illness. Do I have that right?