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.
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
I've reviewed the CPA MAID guidance document. On the front page, it says it has not been peer-reviewed. I'll stop there.
I will add that the CPA says on their website that they don't have a position on MAID. You've heard testimony from a number of people saying that there's no international definition around irremediability and differentiating MAID from suicide. That guidance document is not peer-reviewed. It's from a small group of people.
Conservative
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
No.
Conservative
Michael Cooper Conservative St. Albert—Sturgeon River, AB
Are you aware of other heads of psychiatry being consulted?
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
No.
Conservative
Michael Cooper Conservative St. Albert—Sturgeon River, AB
It copies and pastes Health Canada's model practice standard with respect to irremediability. Do you see that as appropriate criteria, or is that problematic?
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
No, I don't see it as appropriate criteria. That's what the chairs of psychiatry have also submitted—a briefing to this committee saying that they don't support expansion.
Conservative
Michael Cooper Conservative St. Albert—Sturgeon River, AB
Would you agree that you can look at past treatments, but the most important question is what is going to happen in the future? That's something that the practice standard criteria do not address.
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
Exactly.
Conservative
Michael Cooper Conservative St. Albert—Sturgeon River, AB
What about on the question of suicidality? We heard testimony from the head of chairs of psychiatry that it actually creates clinical confusion. Would you concur?
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
Yes, I agree.
I'll repeat that the CPA guidance document has not been peer-reviewed. Internationally, the document that I've referenced—the American Psychiatric Association document—has been peer-reviewed and approved by the APA board and the International Association for Suicide Prevention research as well.
I don't support the document from the CPA.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you.
We now go to Mr. Fergus for five minutes.
Liberal
Greg Fergus Liberal Hull—Aylmer, QC
Thank you, Senator.
First, I want to thank our witnesses for being with us today to share their views and speak to the committee about a very sensitive issue.
I'm brand new to the committee, and in the little testimony I've heard so far, one of the things that's come through is the lack of consensus. Some health professionals are saying that they're ready, that the rules and guidelines are in place, whereas others are telling us that they aren't ready. Some are saying they have the capacity to provide the service, while others are saying they don't.
Dr. Gandham, I very much appreciate that you recognize the gravity of mental illness and what a very serious condition it is for some Canadians. I also appreciate how candid you were, explaining that while the issue deserves serious consideration, you personally believe we still aren't ready and you don't agree with moving forward.
I want to step back a bit and ask all of you this question: Regardless of our capacity to handle these requests or develop guidelines to ensure that the process is carried out properly, do you think Canadians are ready for MAID in this context?
You can go first, Dr. Gandham.
Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
I wonder, in this case, if we're putting the cart before the horse. When we look at any sort of illness, when you want to treat it, you have to look at the root cause. That's what we're taught. If you really want to cure it, you have to look at the root cause. When you look at mental illness, it's not something that just arrives out of the sky. There are lots of deep, complex, intertwined causes for it.
Working in addictions for the last seven to eight years, I've yet to see somebody with severe substance use disorder who did not have some very difficult, traumatic childhood experiences or adverse childhood events, to varying degrees. They impact your ability to cope—your coping mechanisms and all that.
When we're talking about readiness, I think before our treatments...we're probably not even there.
Liberal
Greg Fergus Liberal Hull—Aylmer, QC
Excuse me, Dr. Gandham. I'm not asking whether health professionals are ready. I'm asking whether you think Canadians at large are ready to accept this change.
Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
It's hard for me to answer. I can't answer for the population and if they're ready. It depends on from what perspective. If the question is whether the majority feels this is appropriately ready and this is the right thing to do, in that sense, it would be hard to say.
I don't want to speak for the majority. I have my own, individual opinion, but if they knew the full facts, I do not think they would be ready.
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
The Canadian Mental Health Association, the Canadian Association for Suicide Prevention and Inclusion Canada all have said that we're not ready for MAID for mental illness. They've said that publicly.
It can be theoretically thought about, but in reality, to make it available in Canada...you can't differentiate MAID from suicide.
Liberal
Greg Fergus Liberal Hull—Aylmer, QC
I'm going to ask this of you, Ms. Prokopy and Dr. Young, very quickly because I have only about 30 seconds for both of you. Do you think your neighbours are ready? I have to sell this at the doors. Do you think the people you meet every day and talk to at the grocery store are ready for this?
Vice-President, Medical Affairs, and Chief of Staff, Waypoint Centre for Mental Health Care, Ontario Hospital Association
I can't speak for my neighbour, of course, but I can tell you that the members we heard from, from our hospitals, feel very strongly that they have a duty of care to have guidelines that are consensus-based, to know how to apply these things and to know that people have equitable access to care and are able to get the mental health care they need. In the absence of those things, people feel like they're not able to provide that service knowing that all of those gaps exist. That's important to consider.
The Canadian public would want to know that the people who are providing that care feel secure in their ability to do so and that the necessary infrastructure is there for them to do that.
The Joint Vice-Chair Hon. Pierre Dalphond
Thank you, Dr. Young.
We now go to Mrs. DeBellefeuille for five minutes.
Bloc
Claude DeBellefeuille Bloc Beauharnois—Salaberry—Soulanges—Huntingdon, QC
Thank you, Mr. Chair.
Dr. Sareen, I don't think there's a consensus on expanding MAID access to those whose sole medical condition is a mental illness. Nevertheless, there seems to be a consensus around the table, as well as in each province, about the lack of mental health services and supports. To fix that, the federal government has to increase its transfers to the provinces, which struggle to fund the necessary services.
The fact remains that people suffering from an enduring and incurable mental illness should have the right or freedom to make their own choices, live independently and, above all, live in dignity. They should be able to make the same choice those suffering from a chronic illness can.
What I want you to understand is this: In my view, people with an enduring and incurable mental illness who have received years of care and have the necessary support and services should also have the right to make their own decision in the end, to make a free and informed choice about what happens to them.
Dr. Gandham, in your practice, have you come across a patient with a mental illness who had no other way to end their suffering, so you would understand why that person would want to avail themselves of MAID and you would grant their request?
Head of Psychiatry and Professor, Department of Psychiatry, University of Manitoba, As an Individual
As I said in my statement and as the American Psychiatric Association position paper states, in the moment, with regard to whether it's suicidal ideation or a MAID request, a clinician cannot differentiate whether this is part of a person's mental health or a psychosocial issue. You can have 100 treatments for years before, but that doesn't tell you what's going to happen in the future. That is very important.
As others have stated, the majority of Canadians don't have access to appropriate, evidence-based psychotherapy.
Bloc
Claude DeBellefeuille Bloc Beauharnois—Salaberry—Soulanges—Huntingdon, QC
Sorry to interrupt, Dr. Sareen, but I know that not everyone in Quebec or the other provinces has equal access to the same care. However, I think that someone with an enduring and incurable mental illness has the right to choose what's right for them. We've got two types of patients, and we're discriminating against one of them. That's how I see it.
I agree that there isn't a consensus and that this may not be the right time to expand MAID eligibility to people with a mental illness, but we need to get ready. People with an enduring and incurable mental illness are going to ask for MAID, and we need to be able to alleviate their suffering.
Dr. Gandham, what are you doing to advance your thinking on the issue and move towards clinical readiness, since this decision is probably coming at some point? What are you doing to get ready for the clinical decision to provide this care to people with an enduring and incurable mental illness?
Assistant Clinical Professor, Department of Family Medicine, University of Alberta, As an Individual
What have I been doing? I think my position over the last eight or nine years working in addictions has changed. It's evolved. I am still a supporter of MAID, and I do it regularly.
The premise here that we have to look at is about what's incurable. What are we basing that on? What is the standard definition we have for “treatment resistance”, which is often used—treatment-resistant to what? Treatments have been offered. Is that enough? Were they culturally specific? Were they trauma-informed? You have individuals who have all these issues, and they're not going to engage....
Dr. Neufeld, a couple of days ago, talked about the therapeutic alliance. Just because something is offered.... If there's no connection, where is the person in their trajectory? Are they pre-contemplative or contemplative? Do they believe in it? All those factors are known. Research shows whether a treatment would work or not. Are we accounting for all that?
When we look at any treatment, to be treatment-resistant.... We talk about a biopsychosocial treatment for all psychiatric issues. Yes, we give biological medications, but are people actually following them? Are they compliant and adhering to them? For psychological therapy, do people have funding to get that therapy? Do they actually access it? If they're single parents, do they have the money for it and do they have the time for it?
The final part is social. That's usually a little footnote. If you look at most of the psychiatric assessments—it's not because they're faulty; everybody is intentional—you see that those are out of the grasp of the psychiatrist or the treating physician. In many of those cases are the fundamental routes for many of these ailments. We're saying they're incurable, but we haven't given equal time, effort and resources to the biopsychosocial side, so how can we say they're incurable?