Evidence of meeting #5 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 access.
A recording is available from Parliament.
Registrar and Chief Executive Officer, College of Physicians and Surgeons of Nova Scotia
Chair, if I may speak, at the beginning, you introduced me as speaking on behalf of the Federation of Medical Regulatory Authorities of Canada. I was invited as the registrar of the College of Physicians and Surgeons of Nova Scotia only.
The Joint Vice-Chair Hon. Pierre Dalphond
I wish to welcome our witnesses who are with us tonight for our third and last panel for today.
Appearing as individuals, we have Dr. Jitender Sareen, head of psychiatry and professor in the department of psychiatry at the University of Manitoba, and Dr. Sandip Singh Gandham, assistant clinical professor in the department of family medicine at the University of Alberta. Representing the Ontario Hospital Association, we have Melissa Prokopy, vice-president of policy and advocacy, and Dr. Kevin Young, vice-president of medical affairs.
Dr. Sareen, you have five minutes.
Jitender Sareen Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
Thank you, Chair and members of the committee, for the invitation to appear today.
My name is Dr. Jitender Sareen. I am speaking as department head of psychiatry at the University of Manitoba and as a provincial specialty lead for mental health and addictions at Shared Health. I have practised adult psychiatry for more than 25 years. My perspective today reflects my clinical, research and system experience, rather than a philosophical or conscientious objection to MAID itself.
MAID for mental disorders has been a difficult issue in Canada, and there are thoughtful perspectives on both sides. I respect concerns about autonomy and suffering associated with mental disorders. However, after a careful, unbiased review of the international literature, I believe Canada should not expand MAID to include mental disorders as a sole underlying condition.
First, prognosis in mental disorders is often uncertain. Individuals can remain severely ill for long periods and still improve, particularly with changes in treatment and psychosocial situation. There is no international standard that defines irremediability in mental disorders. When you're regulating something, unless you have an international standard to hold somebody accountable, you cannot regulate it.
Second, there is also no clear and reliable way to distinguish a request for MAID from suicidality when mental disorder is the sole underlying condition. Unlike physical conditions, suicidal ideation is part of the diagnostic criteria for many mental disorders, including depression, post-traumatic stress disorder and borderline personality disorder. This goes to the core psychiatric practice, which is grounded in assessing and treating hopelessness and preventing suicide.
I know you have been reassured by some other witnesses that psychiatrists are trained to make distinctions between MAID and suicide, but psychiatrists and psychiatry residents nationwide are not being taught how to distinguish MAID from suicidality, because there's simply no way to do it. Most academic chairs of psychiatry departments across Canada have similarly recommended against the expansion of MAID because of these concerns.
Third, most international professional associations and people with lived experience groups have clearly recommended against providing MAID for mental disorders. In 2025, the American Psychiatric Association's position paper explicitly opposed this, citing the difficulty in defining irremediability, the unpredictability of prognosis and the concern that mental disorders themselves may influence decision-making. The International Association for Suicide Prevention has also expressed opposition to MAID.
In Canada, both the Canadian Association for Suicide Prevention and the Canadian Mental Health Association have raised concerns about expansion, alongside organizations representing people with lived experience and disability advocates, such as Inclusion Canada and Indigenous Disability Canada.
In 2023, Quebec passed Bill 11, which established that a mental disorder other than a neurocognitive disorder cannot be an illness for which a person may request MAID. This year, Alberta has proposed Bill 18 to exclude MAID for mental illness and to restrict access to MAID to individuals with a foreseeable death in the next 12 months.
As for Manitoba, when this issue was brought to our provincial psychiatry leadership council in 2022, and again in 2026 in the context of operational planning, the council reached a clear consensus on both occasions that expansion to mental disorders should not proceed.
For these reasons, I respectfully urge this committee to recommend an indefinite pause on the expansion of MAID for mental disorders.
Thank you.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you very much.
Now we'll go to Dr. Gandham.
Sandip Singh Gandham Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
Honourable Chairs, thank you for inviting me to appear before you today. I appear before you as an individual.
I'm a family physician with experience working in addictions medicine, mental health and end-of-life care. My perspectives are shaped by providing care for those with profound suffering, including an expressed wish to die. I've also worked as a MAID assessor and provider since 2016. I come to the discussion not as an ideologue, but as a clinician who has sat with suffering in many forms—physical, mental, existential and social.
I want to begin by acknowledging something very important. Suffering associated with severe mental disorders can be unbearable. Those of us who provide care for those with severe chronic mental illness know this first-hand. Their suffering is real. It is not less real because it is psychiatric rather than physical.
Recognizing this suffering is one of the reasons that many support MAID where mental disorder is a sole underlying condition. The potential benefit, ethically speaking, is the respect for autonomy and also equal treatment. If grievous and irremediable suffering is the foundation of MAID eligibility, some argue it would be discriminatory to categorically exclude those whose suffering is solely from mental illness.
There's also an argument rooted in compassion. For a small subset of people whose suffering may truly be enduring, refractory and intolerable despite years of care, MAID may be seen as a last resort to relieve their suffering where other medicine has failed to relieve them.
Those arguments deserve serious consideration, but so too do the risks. In my view and from my clinical experience, the risks of proceeding currently outweigh the potential benefits. These risks are not just incidental; they're fundamental.
It begins with the concept of irremediability. In many physical illnesses where MAID is currently provided, prognosis may be difficult, but it is often more knowable. In psychiatry, by contrast, predicting that a person's suffering is truly irremediable is far from certain.
Recovery in mental illness can be non-linear and surprising. Patients who at one point seemed like they were beyond hope may later improve from treatment, sometimes because their circumstances change—housing stabilizes, trauma is addressed, substance use remits, relationships repair or hope returns—and sometimes simply from the passage of time itself. I've seen patients who had once believed death was their only relief find stability, meaning and reasons to live later. That uncertainty matters deeply when the intervention being considered is irreversible.
A second concern is that many features of severe mental illness can directly affect the wish to die. Hopelessness, self-destructive thinking, impaired future orientation, and suicidality can all be symptoms of the illness itself. Particularly in addictions medicine, I see how suffering can distort what appears to be a settled wish for death. Distinguishing a sustained, autonomous wish to die from a treatable expression of an illness is not a simple assessment challenge. It is often the core clinical question.
I worry that in some cases, we may not be responding to an autonomous, enduring request for assisted dying, but rather to the voice of the illness itself. That is not a distinction we can afford to get wrong.
My third concern is that I'm deeply concerned about structural vulnerabilities. Requests for death don't arise in a vacuum. They may emerge in the context of trauma, poverty, isolation, inadequate housing, long ways for treatment, and lack of access to care and supports. If people seek MAID because they cannot access the conditions necessary to live with dignity, that is not a triumph of autonomy; it is a failure of care. In such cases, the suffering may be real, but its drivers may be remediable through social response rather than death as a medical intervention.
That raises a profound ethical concern: Are we offering MAID in some cases because a person’s suffering is truly irremediable or because our systems have been unable or unwilling to provide what people need to live? I would submit that Canada has not yet demonstrated a mental health and social care system robust enough to assure those alternatives are meaningfully available.
Some may still argue that this is discriminatory. I would respectfully suggest caution is not discrimination when it arises from genuine clinical uncertainty and concern for protection of the vulnerable. Equal respect does not always require identical responses when the underlying clinical realities differ.
For me, the question is not whether some people with mental illness suffer grievously—they do. The question is whether we can reliably distinguish in practice those rare cases where suffering is truly irremediable from those where despair may yet be treatable. I am not persuaded we can do so with sufficient confidence.
Where doubt exists in matters of life and death, where prognosis is uncertain and where vulnerability is profound, caution is not paternalism. It is an ethical responsibility.
Thank you.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you very much.
We'll go now to Ms. Prokopy.
Melissa Prokopy Vice-President, Policy and Advocacy, Ontario Hospital Association
Good evening, Mr. Chair. Thank you so much for today's invitation.
I am Melissa Prokopy. I'm the vice-president of policy and advocacy at the Ontario Hospital Association. The OHA represents Ontario's 135 hospitals. Our membership includes a diverse representation of hospitals of various types and sizes, including mental health and addictions hospitals. I'm joined today by Dr. Kevin Young, who's the vice-president of medical affairs and chief of staff at the Waypoint Centre for Mental Health Care in Penetanguishene, Ontario.
Today, we'll share with you perspectives from the hospital sector about the Ontario health care system's readiness for the proposed expansion of MAID where mental illness is the sole underlying medical condition.
I want to outline three key concerns we have heard from our hospital members with respect to the proposed expansion: existing challenges to access to mental health care services more broadly, the impact of inequities in accessing these services by different parts of the population, and broader system readiness by health care providers to deliver MAID.
I'm going to ask Dr. Young to outline these access and equity points in more detail.
Kevin Young Vice-President, Medical Affairs, and Chief of Staff, Waypoint Centre for Mental Health Care, Ontario Hospital Association
Thank you, Melissa.
With respect to access to mental health care services, there are still significant barriers in Ontario and across Canada. Recent data from the Canadian Institute for Health Information reveals that 41% of adults aged 18 or older who were diagnosed with mental health disorders say that their needs were only partially met or were completely unmet. These challenges are relevant not just on a patient level but also when looking at overall system readiness.
For example, in 2024, the OHA commissioned a study with the University of Toronto that examined the expected impact of chronic illness on the health care system in the next 20 years. Mood and anxiety disorders and substance use disorders were noted to be contributing to the rise in chronic disease among young Canadians. This means additional strain on the health system and an increased need for improved access to mental health care.
Additionally, we heard that existing challenges to accessing care can complicate the provision of MAID. They also present challenges for health care providers in eligibility assessments. Health care providers must be assured that MAID is not chosen by patients simply because they cannot access necessary mental health care.
Clinical challenges caused by inadequate access to mental health care can cause further system impacts. For example, a patient might be found to be ineligible for MAID but continue to have issues accessing mental health supports. Practitioners may be required to address access issues in the MAID application process through facilitating consultations or seeking expedited treatment for applicants, which may be the best course of action for a particular patient, but this could also create the risk that the process becomes a means to access mental health care more quickly, which can then further increase inequities in accessing care.
It's also important to consider equity in access to mental health care. As we know, systemic inequalities such as racism, poverty, homelessness and others can worsen mental health. For example, Statistics Canada reported in 2024 that among indigenous people who required or were seeking mental health care, the vast majority—approximately three-quarters—reported that their needs were unmet or partially met.
The federal government recognizes the significant barriers facing indigenous people in accessing mental health supports. These barriers are rooted in systemic racism, geographic location and other structural factors. Past consultation by the federal government with indigenous people on MAID underscored the need to improve access to mental health services and the need for further consultation on MAID expansion.
Enhancing access to mental health care would help ensure that MAID is truly informed and a voluntary choice. We believe that additional consultations should continue before the government makes any decisions to move forward with an expansion.
I'll hand it back to Melissa now for some more information about system capacity challenges.
Vice-President, Policy and Advocacy, Ontario Hospital Association
Thank you, Dr. Young.
Our final point is that hospitals have identified clinical gaps that constrain system capacity. For example, we have heard that there is still no clear agreement among clinicians about determining eligibility for MAID where mental illness is the sole medical condition. This includes how to decide whether mental illness cannot be treated and how to tell the difference between a MAID request and suicidal intent.
Further, we've heard about the need for clear clinical guidance and training to ensure providers feel well prepared. One of our members, the Centre for Addiction and Mental Health in Toronto, has publicly recommended that guidelines must be consensus-based, given that there is a lack of evidence on this issue.
For these reasons, we believe that more time is needed to develop consensus and ensure system capacity and preparedness.
Thank you again for the opportunity to speak to the committee. We're happy to answer any questions you might have.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you very much for your presentations.
We have agreed to go for only one round, because we're running a bit late. The interpreters are also running late, but they're staying. Each MP will have five minutes or can share their time with another colleague. Senators will each have three minutes.
Mr. Lawton.
Conservative
Andrew Lawton Conservative Elgin—St. Thomas—London South, ON
Thank you very much, Mr. Chair.
Thank you to the witnesses.
As a matter of context, Dr. Gandham, you are a MAID assessor and provider. Is that correct?
Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
That's correct.
Conservative
Andrew Lawton Conservative Elgin—St. Thomas—London South, ON
When you come at your position of skepticism, it's not coming at all from anywhere near a conscientious objection to MAID itself.
Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
Definitely not.
Conservative
Andrew Lawton Conservative Elgin—St. Thomas—London South, ON
Okay. I appreciate that very much.
You've done events with Dying with Dignity Canada. Is that right?
Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
I have done that.
Conservative
Andrew Lawton Conservative Elgin—St. Thomas—London South, ON
Thank you for that.
I'd like to move to our witnesses from the Ontario Hospital Association. This is for whoever would like to take it.
We heard earlier from a witness—who was for the expansion of MAID to people with mental illness—that if individual practitioners don't feel ready, they should simply not be part of the MAID regime. For your member hospitals dealing with the same dissent that we've seen among witnesses on this committee, how could a hospital even begin to move forward with this when there is no consensus among the psychiatric community and no consensus even among the MAID assessment community?
Vice-President, Policy and Advocacy, Ontario Hospital Association
I'm happy to start. Kevin may have something to add as well.
I will reinforce the point I made, which the Centre for Addiction and Mental Health has stated quite publicly, that we need consensus. Part of the OHA's role in supporting 135 institutions across Ontario is to create, from an organizational perspective, a standard and consistent approach to how we navigate access to any service. Given the lack of clinical consensus across the board on MAID at an individual level, we think the focus at this point in time should really be on broader access to mental health services across the health care continuum.
Conservative
Andrew Lawton Conservative Elgin—St. Thomas—London South, ON
I know the system has accounted for individual physicians who don't want to participate in MAID, but at an institution level, if the expansion does go forward, are you convinced that hospitals would have the adequate legal grounds to say that they will not participate because they do not feel ready to offer this, specifically referring to MAID for people with mental illness?
Vice-President, Policy and Advocacy, Ontario Hospital Association
I'll just clarify that the OHA is not a regulatory body. We're an association. Certainly, we represent all the hospitals. We're aware that a number of our hospitals are faith-based institutions. We also know that members are committed to respecting patient choice and providing effective, evidence-based consultations for MAID. Our job is really to support those efforts within the organizations.
Individual organizations make individual choices. Really, from our perspective, our role is to help create a consistent, standardized approach as much as we can.
Conservative
Conservative
Michael Cooper Conservative St. Albert—Sturgeon River, AB
Dr. Gandham, I just want to confirm that you are the provincial medical lead for MAID for Alberta Health Services and have been in that role since 2019.
Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
I am, but I am here as an individual. I'm not representing them.
Conservative
Michael Cooper Conservative St. Albert—Sturgeon River, AB
Thank you.
Dr. Sareen, in your professional opinion, does the CPA guidance have evidence of readiness for the expansion of MAID for mental illness?