Medical Assistance in Dying Committee on May 26th, 2022

[Dr. Mona Gupta]

That is interesting. As you have already heard from the other witnesses, there is debate in the scientific documentation as to whether the desire for MAID is the same thing as being suicidal. Some say it is, others say it is not. In the report, we noted this difference of opinion in the scientific documentation. Setting aside my role as panel chair, I would like to talk about my own work as a researcher in our research group. I will not analyze the question that way, that is, by trying to determine whether one can make a distinction between these two states of mind. I will ask instead if we know how to respond when we deem someone at risk for suicide and when that is not the case.

To answer your question, I will draw on other areas of medicine. For instance, some patients make choices that will certainly lead to the end of their lives, such as stopping treatment. Should all those patients be considered suicidal, hospitalized against their wishes, and forced to continue their treatment? In some cases yes, in others no. On which principles and practices should we rely in making those decisions?

Returning to my role as panel chair, we use these same principles and practices to evaluate a person requesting MAID. Should we take action, even if it is against the patient's wishes, or rather should we assess their ability to make that decision?

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

Okay.

[Dr. Mona Gupta]

That is how we approach it.

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

That is interesting because it leads me to the issue of what is irremediable. Among psychiatrists, those opposed to MAID often say that we cannot define irremediable in the case of mental disorders. It seems that is not possible in psychiatry. In your presentation, however, you said that someone suffering from long-standing mental disorders who has received all the necessary help would be eligible for MAID.

I would point out that this is related to the Supreme Court decision in Carter, which launched MAID in Canada. The Supreme Court noted that “the term ‘irremediable’ does not mean that the patient must undergo treatments that he considers unacceptable”.

As a lawyer, I wonder how we can reconcile this recommendation from the Supreme Court with the field of psychiatry.

[Dr. Mona Gupta]

Okay.

Your question touches on various aspects. I will try to answer it as best I can.

First of all, the panel's position is that the term “irremediable” is not a clinical term. It is a term found in the Criminal Code that is based on three sub-criteria: the incurability of the condition, advanced and irreversible decline in capability, and suffering. All of these terms have a clinical meaning. So we can try to understand these terms and define them in a way that is meaningful to clinicians and that is consistent with what we do in our practice and the treatments patients receive.

I think a large part of the debate between those who say that an illness cannot be deemed irremediable and those who say it can is the result of the fact that they use different definitions. That is why, in the report, the panel tried to offer a definition of an “incurable illness” for mental disorders that would be meaningful in a clinical context.

Of course, we know there are illnesses that we will never be able to cure. We are 100% sure of that. Yet there are many other illnesses that we know less about, especially as regards their long-term evolution. In such cases, what is the degree of certainty required? The devil is in the details. On the whole, that is our view. If we think about what an incurable condition is and draw a parallel with other chronic illnesses, we can say that the threshold is met once all the conventional treatments have been exhausted. This relates to your comment about the decision in Carter.

As Dr. Maher said earlier, we will certainly not force people who are fully competent to do things that are unacceptable to them. Equally, if I note that someone has an incurable illness, how do I proceed if the patient has not tried any treatments? How many treatments do we have to try? It depends on what the clinician and the patient have negotiated.

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

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

We will now go for five minutes to Mr. Thériault.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

Thank you for being here, Dr. Gupta.

I read your report with interest a number of times, and I would like to share my chief concern.

I thought your mandate would include the broadening or banning of MAID in cases where a mental disorder is the only medical problem involved. Why was that not part of your mandate? I understand that you worked from the assumption that this broadening was necessary, and that you sought to determine how to proceed.

If you could answer briefly, please, because I have several more questions for you. Why was that not part of your mandate? Were you surprised by that?

[Dr. Mona Gupta]

I will answer fairly quickly to save on your speaking time. I think this should be a question for the government, because that is where our mandate came from.

I assume that is because that access is already included in bill C‑7, effective March 2023.

[Luc Thériault, Bloc, Montcalm, QC]

In the review of the act, however, we had to determine whether to apply the sunset clause or whether that option should be entirely removed. I think it would have been helpful for the expert panel on mental illness to have that discussion. As a result, Quebec cannot proceed. If it did proceed, it would probably have application problems on the ground. We shall see what happens.

According to the Canadian Psychiatric Association, and based on your report, to determine that a person with a mental disorder meets the incurability criterion, three criteria must be considered: the chronic nature of the condition, the scope of previous treatment attempts and thus the effectiveness of treatments, and the person's refusal of treatment. I assume you have to evaluate whether there have been repeated refusals or refusals that have affected the required assessment.

Some people say there are no incurable mental disorders, under any circumstances. Clearly, that is not what you are saying. Nonetheless, all patients have the right to refuse treatment. What role does that right play in your assessment of whether a person meets the incurability criterion? In the case of a patient who has refused or refuses treatment, can one conclude that the person has not done what is necessary to be cared for? In that case, would the patient not be eligible?

In some instances, it is said that a mental disorder is incurable. That also entails some suffering.

[Dr. Mona Gupta]

Thank you very much for your question.

If I may digress a bit, I want to broach a more clinical and technical topic.

In the case of certain paradigmatic illnesses, such as advanced cancer, when there is a clear diagnosis from a biopsy or MRI, for instance, we can get an idea of what will happen to the patient from the outset.

In the case of other illnesses, however, we cannot know how things will evolve when the diagnosis is made. It depends on the treatment the patient receives, their response to the treatment, and the side-effects, among other things. We cannot predict much without trying treatment.

That is why, in the report, we try to align the need to try treatments in order to establish that the trajectory of the illness is bleak, with the need to respect the fact that a person has already tried many treatments and has had enough. Where exactly do we draw that line? I think it will differ from one person to another. We also have to consider their general health and the circumstances in their case.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

I have a fear related to the reliability of the assessment process. I do not think there are a lot of psychiatrists who are assessors or MAID providers in Quebec. There are family medicine providers who are trained to do the assessment, but I know full well that some are very opposed to expanding MAID to persons suffering from a mental disorder alone. You said it takes at least one assessor with expertise in the “condition”. Can you tell me what “the condition” means?

As well, the assessor with expertise in “the condition” has to be a psychiatrist who is independent from the treatment team and provider—and we already have problems with access to psychiatrists. Could you please explain.

Are all the criteria set out in recommendations 10, 11 and 12 realistic?

[The Joint Chair, Hon. Yonah Martin]

Be very brief, Dr. Gupta.

[Luc Thériault, Bloc, Montcalm, QC]

Will we be ready on March 17, 2023?

[Dr. Mona Gupta]

I will answer briefly, but we can come back to this.

I think it is feasible. Right now, when a person with a complex illness requests MAID, we seek the opinion of specialists.

Let me give another example, to which we can draw a parallel.

In the case of evaluations for institutional commitment, the law requires the opinion of two psychiatrists, not just one psychiatrist, regardless of whether it is during the day, during the week, or on the weekend, and we make sure that is done. Those patients are ill and are the most vulnerable. In my opinion, we can create a structure that will properly accommodate their request.

[The Joint Chair, Hon. Yonah Martin]

Thank you, Dr. Gupta.

Next we will have Mr. MacGregor to finish off this first round.

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

Thank you very much, Madam Joint Chair.

Dr. Gupta, thank you so very much for joining our committee today and helping guide us through some very difficult issues. I appreciate the report that we now have to refer to as we commence our study.

I've been a member of Parliament since 2015 now. I was there for the Bill C-14 and Bill C-7 debates. For me, the problem with this whole process is that it seems, with the amendments that were made by the Senate to C-7, which effectively are going to allow for mental illness as an underlying condition by March of next year, it's also a situation where we've put the cart before the horse. We're involved in this very in-depth study, but we're working with an impending deadline that is now less than a year away. You've talked a lot about the fact that we need to make sure every option is available.

Before I get to supplementary questions, though, my first question to you is this: What was it like for the expert review panel working under the knowledge that you had this deadline? Did you feel a sense of pressure? How did that inform your work, knowing that in March of next year this is now going to be a part of the Criminal Code and allowed?

[Dr. Mona Gupta]

Thanks so much for the question. I appreciate the opportunity to have a chance to discuss these issues with you.

I think it was Dr. Wiebe earlier today who talked about the commonality between chronic physical conditions and chronic psychiatric conditions, so I think I would start my answer there by saying that it was not so much the March 2023 legislative deadline that put pressure, because I think that we see a lot more commonality between psychiatric disorders and physical disorders, as I said in my opening remarks, which are already being structured under the track two safeguards. Our task was really to say, let's take a look at these safeguards. Are they doing the work that we want them to do in situations of mental disorder as a sole underlying medical condition?

I think the pressure is about wanting to respond in good faith to the concerns that have been raised, which we also shared and took seriously, and to produce something that would work for patients, for families and for practitioners and not just specialists in cities but people who are living in rural or remote areas, where access may be very different from in cities, and for people living in all kinds of circumstances. I think it was inherent to the exercise. That was the pressure.

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

Thank you for that.

In your interventions with some of my other colleagues on this committee, you were talking about our really having to make sure we have resources in there so that patients can avail themselves of every option for treatment. Certainly in previous testimony, we've heard of “groundbreaking research” that's going on with psilocybin as a potential therapeutic intervention to help guide people through mental health problems. I know it's still in its infancy.

I realize that, for future patients who are accessing MAID, there will be the safeguards in place. They will have to have an extensive history. I guess my concern is that I look around in my own community and I see so many people who are living on the street in obvious mental distress. I keep wondering—if they had had early interventions, could that have prevented them from getting to a state where it became so bad that they didn't see a way of pulling out?

I know the Government of Canada has made some commitments to a big mental health strategy, but can you maybe just talk a little bit about how much more is needed to really fill in the gaps? The last two years, especially, have really highlighted this issue in many communities like mine.

[Dr. Mona Gupta]

That's a really good and big question. I want to start by saying that I'm by no means an expert in the administration of mental health services or financing of mental health services.

To connect your question to the topic that we're addressing today, I think we want to be thoughtful of the fact that mental disorders are not a homogeneous group of people. There are subgroups. Quite often in the public and policy debate about MAID, we conflate people with severe conditions who have been ill for decades, who have had a lot of treatment and a lot of follow-up with people who can't get access to first-line resources during times of distress, times of personal difficulty or perhaps at the beginning of a condition when they're not that severely unwell.

I don't think that responds fully to what you're saying, but thinking about what's needed to fill the gaps has to think about these difference subgroups because I think their service needs are quite different. I know it's not popular to say, but I'm going to say it anyway. There are patients in Canada who get excellent care. I'm sure that Dr. Sinyor's patients at a tertiary-level centre in Toronto and Dr. Maher's patients get excellent care.

Part of the problem is homing in on where the deficiencies are and recognizing that it's probably not just a big mental health strategy with a big spend that's needed, but really targeted funding for very different kinds of services for different subgroups.

[The Joint Chair, Hon. Yonah Martin]

Thank you, Dr. Gupta.

I'll now pass this over to our joint chair, Mr. Garneau.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Senator Martin.

We're now going to do a senator round, each for three minutes.

Just before that, Dr. Gupta, your microphone has sloped down a bit. It causes popping, so to minimize that—I know it's hard to keep it in the same place—if you could lift it up a couple of inches, that would be great.

We'll start off with Senator Mégie.

Senator Mégie, you have the floor for three minutes.

[Marie-Françoise Mégie]

Thank you, Mr. Chair.

Ms. Gupta, thank you for being with us today.

I have reviewed the recommendations from the expert panel. Recommendation 16 pertains to prospective oversight, recommendation 18 to data collection, and recommendation 19 to periodic research.

In your opinion, how could the federal government go about this?

Should there be committees responsible for prospective oversight and data collection? The research would be done periodically. What would those periods be?

How could it all be coordinated?

[Dr. Mona Gupta]

Thank you very much for your question.

I think there are various ways of going about it. Research could be centralized at the three offices of the National Research Council of Canada. Calls for proposals could be issued for projects that are open or on specific topics.

That research could be linked to the data collected by Health Canada. In the report, we proposed that the new variables be incorporated into the current oversight system. In the Netherlands, the research is already linked with data collection. To date, the system in Canada has focused more on calls for proposals for projects that are open or on specific topics. So I think there are various ways of going about it.

We say prospective oversight, but oversight falls under provincial jurisdiction. That is how it stands for the time being. I think the federal government could play a coordination role to ensure that the provinces and territories can develop prospective oversight systems. In the report, we noted that this was a request from psychiatrists. That kind of oversight system would allow them to do their jobs well and have a broader view. It would ensure that they have done their assessments correctly, given the complexities.

[Marie-Françoise Mégie]

Thank you.

Mr. Chair, do I have time for a quick question?