Medical Assistance in Dying Committee on April 28th, 2026

[The Joint Chair, Liberal, Marcus Powlowski]

I call this meeting to order.

Welcome to meeting six of the Special Joint Committee on Medical Assistance in Dying.

Pursuant to the order of reference of the Senate chamber adopted on February 26, 2026, and the order of reference of the House of Commons adopted on February 13, 2026, the special joint committee is meeting to study the eligibility for medical assistance in dying for those whose sole condition is mental illness.

Today's meeting is taking place in a hybrid format, pursuant to the Standing Orders. Members are attending in person in the room and remotely using the Zoom application.

I'd like to confirm that sound tests have been done successfully. Before we continue, I would ask all persons participating to consult the guidelines written on the cards on the table. These measures are in place to help prevent audio feedback incidents and to protect the health and safety of all participants, including the interpreters. You will also notice a QR code on the card that links to a short awareness video.

I'd like to make a few comments for the benefit of witnesses and members. Please wait until I recognize you by name before speaking. For those participating by video conference, click on the microphone icon to activate your mic, and please mute yourself when you're not speaking. For those on Zoom, at the bottom of your screen, you can select the appropriate channel for interpretation: floor, English or French. For those in the room, you can use the earpiece and select the desired channel.

All comments should be addressed through the chair. For members in the room, if you wish to speak, please raise your hand. For members on Zoom, please use the “raise hand” function. The clerk and I will manage the speaking order as best we can. We appreciate your patience and understanding in this regard.

Tonight I would like to welcome a whole bunch of new Liberals: Greg, Wade, Élisabeth and Peter. Welcome to the committee.

Some members are here permanently, and some are not here permanently. It gets too complicated, so I'm just going to forgo explaining all that.

For the first hour, we have two people testifying.

In the room is Professor Brian Mishara, director of the Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices, Université du Québec à Montréal. Online, from the Centre for Addiction and Mental Health, is Sanjeev Sockalingam, senior vice-president of education and chief medical officer.

You will each have the floor for approximately five minutes, and then there will be a series of questions. Since there are only two witnesses, you can go a little bit over. I will raise a piece of paper when you have about 30 seconds left, so you know your time is coming to an end.

With that, we'll start with Professor Mishara.

Professor Mishara, you have the floor.

[Prof. Brian Mishara, Director, Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices, Université du Québec à Montréal, As an Individual]

Honourable senators and members of the committee, I've spent my life working in suicide prevention. I was president of the Canadian Association for Suicide Prevention and the international association. I am founder of the Quebec association for suicide prevention. I also work with the World Health Organization in training, research and policies.

I believe MAID should be available when suffering is not remediable by other means. However, in the case of mental illness, this is not possible to determine. I believe suicides are preventable, even in seemingly hopeless situations. I agree with the position of the International Association for Suicide Prevention that the overlap between MAID requests and suicide makes it impossible to distinguish between them and that MAID for mental illness will undermine suicide prevention by communicating that death is a viable alternative to treatment.

I don't think I have to say much about irremediability. Other people have talked about its impossibility to be determined with mental illness. No one can accurately predict whether a patient who failed to respond to multiple past treatments will respond to the next treatment or not. Mental health diagnoses change. They are, unfortunately, unreliable. With common diagnoses like schizophrenia, if you ask two psychiatrists to independently make a diagnosis, in about one out of seven patients they will make different diagnoses. That means many people will get the wrong treatment unless or until their diagnosis is corrected. Over the course of 34 years, 86% of mental health patients have at least two diagnoses. According to research, virtually no one gets and keeps one pure diagnosis type.

We have an obligation to provide access to mental health treatment before providing access to MAID. In 2025, the Canadian Institute for Health Information found that 41% of adults with a mental illness said that their needs were met not at all or only partially, while 52% of young adults reported being able to obtain not any or only limited help for their mental illness. One out of three Canadians said they did not have access to mental health services because they were unable to pay the cost.

Some believe that requests for MAID are more reasonable or rational and that this can be distinguished from suicide. However, there is no discernible difference between the reasoning in MAID requests for mental illness and justifications given for suicide. Both people feel that their suffering is interminable and intolerable. Moreover, most important human decisions are emotional and not rational or reasoned. What are the most important decisions we make? They are who we marry, our career choice and even what type of car we buy. We cannot expect that while we are suffering from a mental illness, which can cloud one's thinking, things should be any different from other important decisions we make.

I held the Bora Laskin Canadian national fellowship in human rights research to study euthanasia in the Netherlands, where MAID for mental illness was legalized in 2002. Each year, only one or two requests were approved. However, recently, after news stories about people with depression who received euthanasia, requests skyrocketed in 2023, with 138 deaths. In 2024, it went up 60% more, with over 7,000 requests and 219 deaths. Most of the people who died and who requested it were depressed women living alone under the age of 24.

Alarmed psychiatrists petitioned the government to stop this practice. They said, “Introducing euthanasia as a sanctioned outcome reframes suicidality from a symptom requiring containment into a potential treatment endpoint, an acceptable 'treatment plan.'” I don’t want this to happen in Canada.

[The Joint Chair, Liberal, Marcus Powlowski]

Thank you, Professor.

Dr. Sockalingam, you have five minutes.

[Dr. Sanjeev Sockalingam, Senior Vice-President, Education, and Chief Medical Officer, Centre for Addiction and Mental Health]

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—

[The Joint Chair, Liberal, Marcus Powlowski]

I'm sorry, Dr. Sockalingam, but I believe there's an issue with translation.

[Greg Fergus, Liberal, Hull—Aylmer, QC]

Yes, Mr. Chair. I would like the witness to slow down a bit, because the interpreters are having trouble keeping up.

[The Joint Chair, Liberal, Marcus Powlowski]

Could you slow down a little, please, Dr. Sockalingam?

[Dr. Sanjeev Sockalingam]

I'm sorry. I'll slow down a bit.

[The Joint Chair, Liberal, Marcus Powlowski]

Thank you. We'll give you a few extra seconds at the end.

[Dr. Sanjeev Sockalingam]

Thank you. Would you like me to repeat the last paragraph? Would that be helpful? Okay.

As I was saying, a new review on the research literature found no evidence to suggest 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 includes 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 or an enduring desire to die.

Finally, but of utmost importance to extending MAID to people whose only medical condition is mental illness, there is the state of mental health care in Canada. We've heard that mental health has been and continues to be significantly underfunded compared to physical health care in our country, making it difficult for people to get the right care when and where they need it.

Demand for care continues to grow, while service capacity does not. One in three Canadians reports that their needs for mental health care are unmet or only partially met. In Ontario alone, over the last four years, mental health service volumes have increased by 66%. Access to mental health treatment also remains inequitable. That is why investing in mental health care and support should be the priority before any consideration is given to moving ahead with implementing a track to choose MAID.

In sum, only when we have evidence-informed, consensus-based criteria for determining the irremediability of a person's mental illness and for distinguishing between a request for MAID and suicide intent—and only when such criteria can be introduced into a well-resourced mental health system—would it be possible to offer safe, adequate and equitable MAID services to people whose sole underlying condition is mental illness. That is why CAMH recommends that the federal government delay indefinitely the extension of MAID eligibility to people whose sole underlying condition is a mental illness.

CAMH is happy to offer expertise to government, including sharing our recent evidence synthesis on irremediability, suicide and MAID and the gaps in the evidence base, when it's available.

Thank you.

[The Joint Chair, Liberal, Marcus Powlowski]

Let me say that if you want to submit that, I think we'd be happy to receive it.

Now we go to our first round of questioning, with Mr. Lawton for the Conservative Party for five minutes.

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

Thank you very much, Mr. Chair.

Thank you, witnesses, for your very fascinating and well-informed testimony.

I'll be devoting my time to asking you questions, Dr. Sockalingam. I want to put a fine point on how you ended there. Your position, or CAMH's position, rather, is that we should delay indefinitely the expansion of MAID for mental illness as the sole underlying criterion. Is that correct?

[Dr. Sanjeev Sockalingam]

That is correct.

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

We have heard testimony—overwhelmingly from psychiatrists, in particular—that has alluded to the very things you've alluded to here: that there is no reliable way to distinguish between suicidality as a symptom of mental illness and a good-faith request for MAID. We've heard about the impossibility of coming up with a standardized framework that would assess irremediability for mental illness.

Would you say from your experience that we have as close to a consensus as possible from mental health care practitioners on these points?

[Dr. Sanjeev Sockalingam]

I would say so. Again, we've done our own assessments within our institution, and this is what has come forward as a majority in terms of some of the concerns.

Again, I would say it's due to the lack of evidence that we have to really delineate between suicide intent and a request for MAID. Also, as you articulated, our ability to prognosticate irremediability is significantly limited, given changing diagnoses, diversity and access to treatment based on geographic region or socio-demographic factors, but also in terms of predicting response.

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

Obviously, on a very charged subject, it can be very difficult to find consensus, but we do actually have a fair amount of consensus to delay the expansion.

My question for you is in terms of looking at what CAMH said ahead of 2024, which was that 2024 was too soon, and the government delayed it and delayed it again, and here we are with an extension yet again to 2027. You're saying that we should delay indefinitely. Is it your view that these issues can never be resolved? Or should we really be looking at a permanent cessation of this, ending this practice of kicking the can down the road, and just saying that, by design, this could never work?

[Dr. Sanjeev Sockalingam]

You're asking me to prognosticate on the research and science of mental health conditions. I don't think I can definitively say what the timelines are for us to really tackle and articulate some of these key things, particularly irremediability, for example.

For irremediability, I would say that we do not have sufficient evidence to prognosticate. There are still debates on differentiation of diagnoses among psychiatrists, and assessment.... Until we have solid research to identify people's trajectories and biomarkers and to improve our diagnostic and clinical assessment tools, the notion of providing safeguards for MAID for mental illness.... It will be severely limited. We're saying “indefinitely” because the timelines for the evidence to mature—to have that stability and safety.... It will take a significant amount of time.

I don't think kicking the can down...another three years, as you said, will substantially make a difference, because we need to invest significantly in research.

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

Thank you.

Some of the testimony we've heard is from people who are not on the front lines of seeing patients with severe mental illnesses, as you are. Some witnesses have approached their testimony more from the realm of legal theory, saying that we can't discriminate between physical illness and mental illness.

In its 2023 submission, CAMH said, “health care...for mental illness is not comparable to...care...for physical illnesses.” I don't take, from this, that the two are unequal on a moral level. Rather, in a practical sense, there are significant differences there.

In the 30 seconds I have left, could you please elaborate on that, in this context?

[Dr. Sanjeev Sockalingam]

I'll be very brief on that.

For some physical health conditions, there are diagnostic markers and lab tests we can do to confirm a diagnosis and prognosticate someone's response to treatments.

We are not there with mental health and mental illness. A particular mental illness is defined more by differences in equities, in terms of access to treatments. These are probably more pervasive, given the nature of the illness and the social or demographic factors that are impacted.

[The Joint Chair, Liberal, Marcus Powlowski]

Thank you, Mr. Lawton.

Now, for five minutes, we have Ms. Tesser Derksen.

[Kristina Tesser Derksen, Liberal, Milton East—Halton Hills South, ON]

Thank you very much, Mr. Chair.

Thanks so much to the guests who are here today.

I want to follow up on what Dr. Sockalingam was talking about with respect to the CPA's guidance document, which I reviewed.

In particular, I want to talk about section 2, “Guidance for Assessing and Managing Suicide Risk of the Requester”. I've written down a portion of the document here.

It notes:

Jurisdictions that allow assisted dying for persons with mental [health] disorders as the sole underlying medical condition have found that most Requesters have a history of suicidal ideation and (or) suicide attempts; however, the presence of a history of suicidality does not prevent the Requester from being eligible.

In your opinion, Doctor.... You touched on this a bit. My question is, do clinicians and providers have the tools available to make these assessments and to determine them with some degree of accuracy, particularly given a historical context of previous suicide attempts?

[Dr. Sanjeev Sockalingam]

That's a great question.

In the context of previous suicide attempts, much of our assessment is retrospective, as it relates to mental health conditions and prognosticating from that standpoint. From the standpoint of past suicide attempts or suicidality, I think it is difficult to untangle what a current request for MAID is from an active suicidal ideation or intent, because that's so intricately embedded in some of the major mental illnesses, like depression. There are high rates of suicidality in patients with schizophrenia or psychotic illness as well.

I would say that this is difficult for us to untangle on the front lines—whether someone's request for MAID is, in fact, no longer part of a past suicide intent or part of their current suicidality. It's really difficult on the front lines, and this is validated by experience in our clinical settings.

[Kristina Tesser Derksen, Liberal, Milton East—Halton Hills South, ON]

Thanks for that.

You mentioned how, with respect to understanding irremediability or untangling suicidality from a more reasonably based request, the research is still out.

Is there research under way? Is there a plan? Are researchers looking at these biomarkers and different things? How developed is the research right now? Is this something we're not going to see for decades?

[Dr. Sanjeev Sockalingam]

That relates to the previous question as well. I think we have some signals of where we might be able to do research. We continue to request more funding and resources to do that research and to advance it, but it is still in the preliminary phase. That is why, for it to be widespread in clinical practice, we are recommending suspending this indefinitely. It's because of the time needed for that research to evolve.

[Kristina Tesser Derksen, Liberal, Milton East—Halton Hills South, ON]

You mentioned funding. Oftentimes, some of these discussions come down to that. It's been a particularly important scope of this committee to determine whether or not provinces and territories are ready to offer these services and provide the assessments where they have capacity to do the assessments. On that basis, aside from funding, have you seen a willingness, in your opinion, in the provinces and territories, including Ontario, where you have experience, to address this, or does it appear that they are still far away from implementing the systems and guidance needed for clinicians and providers to make adequate decisions?