Evidence of meeting #2 for Medical Assistance in Dying in the 45th Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was case.
A recording is available from Parliament.
Liberal
The Joint Chair Liberal Marcus Powlowski
Thank you, Dr. Gupta.
We will go to Senator Wallin for three minutes.
Pamela Wallin Senator, Saskatchewan, CSG
I have three quick questions for Dr. Gupta. You know that our time here is short.
We've all read your CV, and you've been involved in this intently. Based on your experience, if MAID is approved for patients whose sole underlying condition is mental illness, do you believe we have standards and practices and clinical assessments that will protect patients with mental disorders?
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
Yes, I do.
I think the clinical community has worked very hard to develop standards. I think we have devoted more time and attention to people with mental disorders than to any other patient group. I think that's a good thing. I think that's something we should be proud of, and I think we are ready to move on to the next phase.
Senator, Saskatchewan, CSG
As my second question, I just want to confirm something that you mentioned, which is that some mental disorders are considered irreversible and that this condition can be assessed.
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
Yes, the guidance document that the Canadian Psychiatric Association has developed gives clinicians a strategy for reasoning clinically about whether a person's condition is a grievous and irremediable medical condition.
Senator, Saskatchewan, CSG
I know you can't actually answer my last question based on evidence, because this is not a legal practice in Canada at this point, but is there any evidence in other quarters that the marginalized or those living in poverty or those with life problems are more likely to access MAID or have MAID offered to them than those who have better incomes and live in better conditions?
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
Thanks to the excellent data collection that has been happening through Health Canada, the best data that we have in fact indicates the opposite—that MAID is accessed to a greater extent by people who are better off, who are white and who are in better social situations.
In some ways, it's not surprising, because it's true in general in health care that people who are better off tend to access it, and the same is true for MAID.
Senator, Saskatchewan, CSG
In terms of readiness, you think the providers and assessors are in a good place to take this on, should they be asked to do so.
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
Yes, I do. I think it's like any new practice in that not everybody will rush out and start doing it. People who are more experienced—we've had MAID for 10 years now—will take a leadership role. They will supervise and mentor newer and younger and less experienced colleagues.
Liberal
The Joint Chair Liberal Marcus Powlowski
Thank you, Senator Wallin.
Senator Wells, you have the floor for three minutes.
Kristopher Wells Senator, Alberta, PSG
Great.
Dr. Gupta, the purpose of this committee is to study readiness across the country. Can you talk to us about the elements of clinical readiness and what we should be assessing?
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
Essentially, clinical readiness involves the things I mentioned earlier. It involves training that somebody can undertake in order to obtain a competence they need in order to do a clinical activity. It involves clinical guidance, if that's necessary, in the form of guidelines or documents that explain more technical points, if that's needed. Most importantly, it involves a community of practice of other people who are doing the same activity that can provide sober second thought—no pun intended—on your practice and to whom you can go for advice and assistance and to discuss challenging cases in real time so that you can get feedback on them. It requires supervision, if needed, for newer and inexperienced colleagues who need to have direct guidance in real time.
Those are the elements of introducing any new practice into medicine.
Liberal
The Joint Chair Liberal Marcus Powlowski
Thank you.
We'll go on to the second round.
Ms. Jansen, you have three minutes.
Conservative
Tamara Jansen Conservative Cloverdale—Langley City, BC
On behalf of my mom and dad and sister, Dr. Gaind, I'd like to ask you a question. You mentioned that the idea that we can reliably separate suicidality from a MAID request, or even predict that a mental illness is truly irremediable, is, in your words, “snake oil”. That's a pretty serious warning.
Can you walk us through what the evidence actually shows? How often do doctors get these predictions wrong? How much overlap is there between someone who is suicidal and someone who would qualify under psychiatric MAID?
Professor of Psychiatry, Faculty of Medicine, University of Toronto, As an Individual
What the actual evidence shows—again, reassurances aside—is that even with our best precision modelling, for something as severe as treatment-resistant depression for potential MAID assessments, assessors would get them wrong more than 50% of the time. A study done by Marie Nicolini showed 47% accuracy, which is interesting; it's actually worse than flipping a coin.
Nothing has changed in terms of developing more evidence to say that we can make better predictions. In fact, it's the opposite. Even Dr. Gupta has agreed, in a report she chaired, that you can't make determinations of irremediability. She suggested that this should be an ethical decision each and every time by an assessor. I'll let people think about whether they want their physician providing death to make an assessment of irremediability as an ethical decision.
Regarding suicidality, you actually cannot separate those factors, because, as I mentioned, they're the same factors, and we are seeing those, contrary to what Dr. Gupta said. We are seeing those emerge already in track 2 data, which will only get worse if it's expanded to MAID for mental illness.
Conservative
Tamara Jansen Conservative Cloverdale—Langley City, BC
Okay.
Dr. Gaind, I'm trying to understand something else. We heard that currently more women are accessing track 2 MAID. The explanation we were given was that, well, it makes sense; women have more chronic conditions. When you unpack that, though, what it means is that many women are living with such long-term, non-terminal things as chronic pain, disability or ongoing health issues.
If we see more women in that situation choosing MAID, especially when you add on layers of isolation and financial stress, should we be treating that as something Canadians should just expect?
Professor of Psychiatry, Faculty of Medicine, University of Toronto, As an Individual
I would be terrified if we actually fell to that normalization of thinking, that more women than men should get MAID for psychiatric conditions. We know that twice as many women as men attempt suicide when depressed. Most do not die by suicide. Most do not even try again. The obvious concern is about whether we are converting a transient suicidality to a permanent death by MAID. We see that in Netherlands. Again, there's evidence that has not been brought forward here that about twice as many women as men in the Netherlands are getting MAID for psychiatric conditions.
You know, in terms of more women than men having some of these conditions, and that being used as a justification for why we may see some more track 2 women, or even people in socially marginalized situations getting track 2, if a drug company made a pill that mistakenly ended the lives of more women than men and the lives of people who showed markers of suicidality like social suffering, I cannot imagine that we'd say it was then okay that more women were dying since they were more likely to have chronic conditions anyway. None of these women on track 2, or on MAID for mental illness, would have otherwise died. We would be facilitating their death.
Liberal
The Joint Chair Liberal Marcus Powlowski
Thank you, Dr. Gupta.
Ms. Koutrakis, you have the floor for three minutes.
Liberal
Annie Koutrakis Liberal Vimy, QC
Thank you, Mr. Chair, and thank you to our witnesses for being here tonight.
My question is for Dr. Gupta.
As you know, Dr. Gupta, some individuals can currently access MAID when their underlying condition is a neurocognitive disorder, such as dementia or Parkinson's disease, in certain circumstances. Would shifting from the term “mental illness” to the term “mental disorder”, as proposed in Bill C-218, risk inadvertently excluding those individuals from access to MAID?
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
As you may have read in different reports and so on, “mental illness” is not a standard clinical term. The standard clinical term is “mental disorder”, and that includes everything that's in our classification scheme. The one we use in Canada the most is the DSM-5, published by the American Psychiatric Association.
Dementia, which is actually classified as “major neurocognitive disorder”, is always the result of some other condition. If “mental disorder” were to be excluded, then “major neurocognitive disorder”—i.e., dementia—would also be excluded, because it is considered a diagnosable mental disorder.
Liberal
Annie Koutrakis Liberal Vimy, QC
Can you identify a single dataset that tracks outcomes specifically for MAID assessments where mental illness is the sole underlying condition and that we could use to measure whether the system is operating safely if the exclusion were lifted?
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
I just want to make sure, Mr. Chair, that I understand the question.
Do you mean datasets in other countries?
Full Clinical Professor, Department of Psychiatry and Addiction, Université de Montréal, As an Individual
Certainly the Netherlands and Belgium probably have the most robust data collection, because they have an oversight process, similar to what we have in Quebec, through which they review, through a commission, every declaration of a euthanasia death. They would have data on the numbers of requests, those that were accepted and those that were denied, as well as some information about the patients. That's what we can rely upon.
There are growing datasets in other countries that I've mentioned, but some of them are fairly young regimes, and that data takes time to accumulate.
Liberal
Annie Koutrakis Liberal Vimy, QC
In your opinion, or in what you have seen in your studies, are there some provinces or territories in Canada that are better prepared than others?