Medical Assistance in Dying Committee on March 24th, 2026

[Dr. Mona Gupta]

That's a really good point. People always have a choice, if they are capable, to refuse a recommended treatment. That is the state of consent and capacity law in this country, but that doesn't make the person automatically eligible for MAID, if that's what you're getting at.

[Andrew Lawton, Conservative, Elgin—St. Thomas—London South, ON]

Would it make them ineligible for MAID, though, if they did not want to try a treatment that a psychiatrist thought could help them?

[Dr. Mona Gupta]

Again, I think we're in a hypothetical here. If, in the context of a clinical conversation about treatment, it was clear that electroconvulsive therapy, or ECT, was an appropriate treatment for that person's condition, they hadn't tried it, there was no reason not to go forward, the person was saying that under no circumstances would they have it, and they insisted on having MAID, I think it would be fair for the assessor to say, “I can't find you eligible in this circumstance. Perhaps at a later time we can talk about this again.”

On the other hand, if there was a good reason not to go forward with ECT—there were some risks in terms of the person's health or, to take a hypothetical scenario, the person was a lifelong activist against ECT—would it be reasonable to force that person to do something that they, for moral or other reasons, were just in disagreement with? That might be a situation where you would say, no, it's not reasonable to try to force that person to undertake that.

I think there's a lot of individual variation here.

[Andrew Lawton, Conservative, Elgin—St. Thomas—London South, ON]

We've each done a hypothetical now.

Thank you.

[The Joint Chair, Liberal, Marcus Powlowski]

Thank you.

The next round of questioning goes to Dr. Jaczek from the Liberal Party.

[Helena Jaczek, Liberal, Markham—Stouffville, ON]

Thank you so much, Chair.

Thank you to our witnesses today.

In a sense, I'm following up on how Mr. Lawton approached his questions.

Supposing we take a case of a schizophrenic who has tried many different medications and has severe side effects. You talked about looking at clinical circumstances. If someone in a situation like that came to you, could you lead us through how you would actually assess their situation, so we can get a real picture of how a practitioner would approach such a situation?

[Dr. Mona Gupta]

I'd start by pointing out that these processes have been elaborated on in a number of different clinical guidance documents, so what I'm going to describe to you is both my opinion as a practitioner and also something that the clinical community has developed together.

When somebody makes a request for MAID, first a conversation needs to be had: Why now? Where did this come from? What's going on that led them to this request? In my experience, people don't wake up one morning and say they want to have MAID. It's usually something that they have thought about for a long period of time. They've talked to their loved ones or those in their social circle about it. They will usually explain those things.

You would begin by discussing what the process involves, which, for somebody whose natural death is not reasonably foreseeable, would likely be a fairly lengthy process that may involve seeing not only the two assessors as required but also a third consultant if neither had expertise in the person's condition, and indeed any other consultants who were necessary. For example, in my program, sometimes the social worker will come with me to see the patient, and sometimes she'll see the patient on her own. That, of course, isn't required by law, but if I need that assistance, then I will ask for that assistance.

As I mentioned to you in my description in my introduction, I am a consultant. Mental disorder as a sole condition is not permitted, but my colleagues will say, “You know what? This person has had a psychiatric history. We'd really like to get a psychiatrist involved.”

We would spend time gathering the necessary consultations. We would certainly gather their past medical records. That would include the medical reason they were asking for MAID, as well as the other medical problems they were experiencing. We would get in touch with their primary care provider and the specialists who had been involved in their care, if there were some.

Then, most importantly, we would get involved with the people who were actively treating them, and not just doctors. In the case of mental disorders, there's often a clinical team involving nurses, occupational therapists, social workers, etc., and we would discuss it with them.

Last but not least would be people in their social circle who really have a deeper lived understanding of what this person is going through, whether they're in a state of decline and how that has evolved over time.

It's an elaborate process that involves multiple visits and a lot of conversation and dialogue. It's not simply an encounter between two people.

[Helena Jaczek, Liberal, Markham—Stouffville, ON]

Would it also include questions around thinking of suicide and whether they had had that type of thinking or had attempted suicide? Is that part of what you would see as an assessment?

[Dr. Mona Gupta]

That's absolutely part of any standard psychiatric consultation, really, but also for any evaluation for assisted dying.

I'm glad you raised this, because I think it's really important to remember that suicidality and suicide risk does not attach only to mental disorders. People who do not have mental disorders can be at risk and can complete suicide. It is very well documented that people in the first months after diagnosis of certain types of cancer have a higher rate of completed suicide than those in the general population. In fact, suicide risk evaluation is relevant to all of MAID assessment, not only for people with mental disorders as their sole condition.

It's also important to remember the opposite: that simply having a mental disorder does not necessarily make you at risk for suicide. There are people with mental disorders who have never had suicidal thoughts, who have never made a suicide attempt and who have never contemplated it in any way.

Again, to come back to the other gentleman's question, I can tell you about these things in general, but so much depends on the individual and their circumstances, and the assessment process has to be individualized to their needs.

Absolutely, suicidality is part of an assessment. For someone for whom it's a prominent problem, the guidance that we have in this country is that interventions that target suicidality ought to be tried. Certainly, for somebody who's in a crisis, it's not even time to be talking about a MAID assessment. That's not going to happen. Things need to settle down. That person needs to be looked after. Things need to be safe before that can even be contemplated.

[The Joint Chair, Liberal, Marcus Powlowski]

Thank you, Dr. Gupta.

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

[Luc Thériault, Bloc, Montcalm, QC]

I’ve heard this line of argument before: that our opponents and their views with which we don’t agree are merely ideological, whereas we base our position on science. From an epistemological point of view, it’s not particularly convincing.

That said, Dr. Gupta, we often forget that making a request does not automatically mean one is eligible for medical assistance in dying. We overlook the entire process that determines eligibility or ineligibility. That is the subject of today’s discussion.

A report by the expert panel has suggested conditions under which MAID could be extended to mental health conditions where these represent the sole medical issue cited. The fact that a patient makes a request does not automatically make this person eligible.

These conditions apply in particular to patients contemplating suicide or to newly admitted and diagnosed patients whose request is based on structural vulnerabilities. When a suicidal patient requests medical assistance in dying, at the very least, we have the opportunity to raise a red flag and treat that person.

This was made very clear in your expert report. The patients’ circumstances and context are taken into account. One recommendation even stated that, if a link could be established with structural vulnerabilities, proceeding with the request would be out of the question. You even go so far as to suggest providing them with financial assistance, helping them find accommodation, and so on.

These conditions apply if patients refuse, without justification, all treatments that could improve their condition, even though accessible and effective treatments are available, and if the assessors are unable to reach a conclusion on all or some of the criteria. Some say that a psychiatrist cannot make reliable diagnoses or prognoses, and they wonder whether, ultimately, it really is a science.

If a patient cannot meet all or some of these criteria, that person is not eligible.

Am I wrong?

[Dr. Mona Gupta]

Thank you for your question.

You have accurately described the process, the criteria, and the fact that all requirements must be met. That is exactly what an eligibility assessment is. This process is an eligibility assessment. It is not intended to provide unconditional access to MAID.

[Luc Thériault, Bloc, Montcalm, QC]

On page 10 of your report, you state the following:

In any situation where suicidality is a concern, the clinician must adopt three complementary perspectives: consider a person’s capacity to give informed consent or refusal of care, determine whether suicide prevention interventions—including involuntary ones—should be activated, and offer other types of interventions which may be helpful to the person.

This is a far cry from the claims made by those who argue that people suffering from depression will be able to access medical assistance in dying.

[Dr. Mona Gupta]

I fully agree that what you have just read is the standard, accepted approach that follows best practice in suicide risk management.

[Luc Thériault, Bloc, Montcalm, QC]

You have undertaken training, and you mentioned that you had worked alongside Dr. Daws. You said the following on this subject:

What struck me about Dr. Daws’s comments is that individuals whose mental health conditions are the sole medical condition cited when requesting medical assistance in dying will be in the reassuring hands of experienced clinicians who, in their practice of medical assistance in dying over the past seven years, have already managed the full range of complexities that can arise in requests from individuals whose mental health conditions are the sole medical condition cited. Her comment also confirms the expert panel’s findings, namely that the complexities so often attributed to mental health conditions are not, in fact, unique to mental health conditions and are already being addressed within our current medical assistance in dying system.

[Dr. Mona Gupta]

Thank you for the question.

I fully agree that the complexity often attributed to mental health conditions already exists in other conditions for which MAID is sought. I do not believe that any new complexity will arise if MAID is granted for patients whose mental health conditions are their sole medical issue.

[The Joint Chair, Liberal, Marcus Powlowski]

Thank you very much.

Senator Dalphond, you have the floor for three minutes.

[Pierre Dalphond, Senator, Quebec (De Lorimier), PSG]

Thank you, Mr. Chair.

I would like to thank the witnesses for joining us.

My question is for you, Dr. Gupta.

Earlier, you mentioned how the situation has developed since the publication of our report in 2024. That report was based on the report from the expert panel you chaired in 2022. Subsequently, Health Canada also set up a special task force to assist and guide assessors. As I understand it, they do not distinguish between incurable mental illness and other types of illness. Perhaps you could tell us more about that.

Could you tell us about how the situation has developed? Earlier, you mentioned the CPA, which is now more divided than it was when we met with its representatives at the time.

[Dr. Mona Gupta]

Thank you very much for your question.

A number of activities have taken place. I have highlighted a few that have been carried out since the committee submitted its report in 2024. Since the publication of the federal expert panel’s report, several committees have been established, and a great deal of work has been done to assist and prepare clinicians to deal with requests for MAID from people whose sole medical issue is mental health conditions.

Firstly, a working group commissioned by Health Canada developed the Model Practice Standard for Medical Assistance in Dying. The aim was to help provincial and territorial regulatory bodies update their practice standards for MAID to bring them into line with all new clinical situations. I am thinking in particular of patients whose mental health conditions are their sole medical issue. Obviously, it is up to the regulatory authorities to decide exactly how and when they will incorporate this into their standards. However, I note that several have taken note of the model and have amended their practice standards accordingly.

Subsequently, CAAMEP drafted a number of documents containing clinical recommendations for clinicians, particularly regarding the assessment of the criterion of incurability in the case of a serious and incurable illness. This has extended to the full range of medical conditions from which a person requesting MAID might suffer, as well as to the way in which incurability is assessed in the context of various cases. We often think of cancer, but there are many other diseases from which an individual requesting MAID might suffer.

We therefore need to take a different approach, because the term "incurable" is not necessarily the right word. It is used in clinical practice to describe different types of illnesses. As such, we need to adapt and choose between this legal term and the clinical practice standards used to determine whether the person has undergone all appropriate treatments. That's why CAAMEP has produced this document.

Recently—

[The Joint Chair, Liberal, Marcus Powlowski]

Unfortunately, your time is up.

Senator Martin, you have three minutes.

[Yonah Martin, Senator, British Columbia, C]

Thank you.

It is concerning listening to your answers, Dr. Gupta, that these assessors may not have expertise, so I'm wondering about how the training is taking place and what happens when you don't have the expertise to really understand what is happening?

I have those questions, but I have limited time, so my questions are for Dr. Gaind.

Dr. Gaind, when you testified before this committee in November 2023, you described Canada's MAID expansion trajectory as not so much a slippery slope but a runaway train. Do you stand by your characterization of a runaway train? I see the expansion, and where we are today is alarming to me as a legislator. Has anything changed since your last testimony in 2023, and has that changed your mind?

[K. Sonu Gaind]

I do stand by that characterization. In fact, I'd make it even more specific. It's like the Lac-Mégantic disaster. Not only is it a runaway train, but we have had and are having the warning signs, based in evidence, that if we expand MAID for solely mental illness, we will be providing it to suicidal people who could and would have gotten better. That is a runaway train. In fact, I'm not the only one now making that characterization. That was made a week or two ago in The Atlantic, in the article done by Charles Lane.

I will point out on this front, about its being a runaway train, that I must say I disagree with virtually every single reassurance that Dr. Gupta has given. She has given reassurances that are not based on evidence. One question asked was, “Why are we conflating, so to speak, mental illness with these social circumstances?” I believe Dr. Gupta even said that it diminishes or denies the seriousness of mental illness. It does no such thing. Refusing to acknowledge that people with mental illness have far more psychosocial suffering...that in itself is stigmatizing and denies the reality of mental illness. In fact, the very high rates of social suffering are precisely linked to suicide risk factors.

If you look at the suicide prevention strategy in the States—I have to say “the States” because we lack one in Canada, where we don't have a national suicide prevention strategy and yet we're talking about expanding MAID for solely mental illness—most of those factors relate to the very things I'm talking about to help prevent suicide: social suffering. Only a small number of them relate to illness. This idea that we're somehow discriminating against people with mental illness if we recognize that.... It is backwards.

I will also further point out, in terms of the runaway train analogy, that reassurances are not evidence, and reassurances are not safeguards. When the previous panel, chaired by Dr. Gupta, had its opportunity to recommend specific safeguards in law, they refused to. They said, “We cannot actually say how many treatments, the types of treatments, etc., that someone should have before getting MAID for mental illness,” despite the fact that our country has no due care requirement.

[The Joint Chair, Liberal, Marcus Powlowski]

Thank you, Dr. Gaind, and thank you, Senator Martin.

We go now to Senator Moodie. You have the floor for three minutes.

[Rosemary Moodie, Senator, Ontario, ISG]

Thank you, Mr. Chair.

My question is for Dr. Gupta. I'd like you to outline for us what professional training and supports have been developed, specifically how professional associations have worked to move forward in terms of making their members more familiar and up to the task of clinical assessments and providing clinical care in this area. Let's start there.

[Dr. Mona Gupta]

I want to start by mentioning that all clinicians.... I'm going to say “physicians”, because I'm a physician, so I'm going to speak for my own profession. All physicians have a statutory regulatory obligation to be competent before we undertake any clinical activity.

The thing that prevents me from doing ECT, even though it's something psychiatrists do, is that I'm not trained to do it personally. It is the same thing that would prevent me from engaging in MAID assessment with a patient who had a condition that I was unfamiliar with, or in a circumstance that I was not comfortable managing in my role as a psychiatrist. We already have a basic obligation not to engage in therapeutic acts for which we are not trained. That applies to every single thing we do. That applies to MAID as well.

We have a responsibility to acquire those competencies once we have finished our training, because then we're in the wild and we have to make sure that if we're doing new things, we acquire those competencies.

There are different ways to obtain competencies. One is to follow formal training programs. One is to do it under the supervision and mentorship of colleagues. In the MAID space, in fact, we have both of those things. We have a formal training program that has been developed by CAMAP, the Canadian Association of MAID Assessors and Providers, which covers the full range of MAID activities and is available to physicians and nurse practitioners, but CAMAP is not the only provider of training in MAID. For example, the Université Laval offered a comprehensive MAID training course. Practitioners will get their training from the provider that is available to them, and there are outlets for mentorship, supervision and case consultation should they need it.

I just want to come back to the last point. Senator Martin raised it, and it is the most important of them all. It is that if you do not have expertise in the patient's condition for track 2, you must obtain a consultation with a person who has that expertise. That's not merely a question of clinical judgment; that is a statutory requirement.

I think the combination of the law, professional guidance, training, mentorship, supervision and case consultation through structures that provinces and territories have put in place provide a comprehensive way to ensure that practitioners achieve their competencies and continue to develop in their professional abilities with contact and interaction and guidance from their colleagues.