Thank you, Chair and members of the committee, for the invitation to appear today.
My name is Dr. Sanjeev Sockalingam. I'm the chief medical officer, the senior vice-president of education and a senior scientist at the Centre for Addiction and Mental Health, CAMH.
CAMH is Canada's largest mental health teaching hospital and one of the world's leading research centres in this field. I also oversee our medical assistance in dying service here at CAMH.
Over the past number of years, CAMH has made several submissions to government committees related to mental illness and medical assistance in dying. Our position has been, and remains, that we are concerned about the expansion of MAID to people whose sole underlying medical condition is mental illness.
We want to be clear that this position is not based on the belief that suffering caused by mental illness is not comparable to suffering caused by physical illness. The grievousness of an illness is subjective, and there is no doubt that, for some people, mental illness can be grievous and can cause physical and psychological suffering.
The irremediability of an illness, however, is an objective determination that must be based on the best medical evidence available. There are currently no established criteria or consensus among psychiatrists about whether or when a mental illness should be considered irremediable. That is because there is no evidence in the mental health field, at this time, to predict the trajectory of any one person's mental illness and to ascertain whether an individual has an irremediable mental illness. This has been discussed previously. Therefore, any determination that a person has an irremediable mental illness for the purposes of MAID would be inherently subjective and arbitrary.
In an attempt to address this problem, the Canadian Psychiatric Association, CPA, recently published initial guidance designed to help MAID assessors identify whether a person has an irremediable mental illness. I know this has also been discussed by this committee. We appreciate the CPA’s efforts to create clarity around the process of assessment; however, it does not address our call for the creation of guidelines summarizing the evidence gap. Specifically, the guidance document does not offer MAID assessors evidence-based criteria that could be used to determine the trajectory of a person’s mental illness. The CPA guidance only provides recommendations on a process to follow for assessing a person’s mental illness. This leaves the guidance open to individual interpretation and could put people with mental illness at risk of accessing MAID when they do not actually meet the eligibility criteria.
The lack of evidence for how to objectively determine the irremediability of an individual’s mental illness is the primary reason we remain concerned about the potential for MAID to be extended to people whose sole underlying condition is mental illness.
This concern is compounded by disagreement among physicians on whether or how a request for MAID can be differentiated from suicide intent, which is an extremely difficult task for psychiatrists. In fact, a new review of the research literature found no evidence to suggest that it is possible to reliably distinguish between the factors underlying a request for MAID and those underlying suicide intent.
While the CPA’s first edition of MAID clinical guidance has a section on managing suicide risk across all phases of the MAID pathway, it does not provide concrete methods for helping clinicians determine if the request for MAID is due to acute distress, a symptom of a mental disorder—