Evidence of meeting #6 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 research.
A recording is available from Parliament.
Senior Vice-President, Education, and Chief Medical Officer, Centre for Addiction and Mental Health
Do you mean adequate decisions about MAID for mental illness?
Senior Vice-President, Education, and Chief Medical Officer, Centre for Addiction and Mental Health
Yes. I actually sat on our provincial committee to tackle this question with our government, our centre of excellence for mental health and addictions and a local network as well—a committee of our major hospitals—to tackle this very question. I co-chaired that local committee. In fact, we advocated for consideration when there was a high likelihood, or a push, to consider MAID for mental illness implementation a couple of years ago. We were worried. We really wanted safeguards in place, and resourcing, because of the concerns I'm expressing today. There was not a willingness to put resources forward.
In fact, one of our other concerns is that this pathway, if it were to come to fruition, would be a way for people to bypass the long wait-lists for mental health treatment to get assessment. They would actually get assessment faster, in some cases, than those waiting years for mental health assessment and treatment. We really need to think about the pressures in our health care system. How are we prioritizing something like this versus providing and rolling out treatments that are effective for treatment-resistant depression, for example, which really links to irremediability? These are the kinds of ethical but financial considerations we have to make in the system.
Liberal
The Joint Chair Liberal Marcus Powlowski
Thank you.
Mrs. DeBellefeuille, you have the floor for five minutes.
Bloc
Claude DeBellefeuille Bloc Beauharnois—Salaberry—Soulanges—Huntingdon, QC
Thank you very much, Mr. Chair.
My questions are for you, Mr. Mishara. I imagine you will understand what I am trying to convey.
If I have a chronic, incurable and persistent illness, I can choose to die with dignity by requesting medical assistance in dying. If I receive a diagnosis of dementia or Alzheimer's disease and I'm a Quebecker, I can write advance requests to remain and die with dignity, rather than living in a CHSLD, where I might no longer recognize my husband and children, would be incontinent, and would have a very poor quality of life, even in a highly supervised environment like a CHSLD. I have the right to make a choice; the act allows me to do that.
However, if I'm schizophrenic, if I have access to a psychiatrist, if I'm properly medicated, if I receive intensive mental health follow‑up from my CLSC, if my loved ones are by my side and if, despite all of that, I have been suffering for many years, I come to the conclusion that I don't have the same rights as other citizens who are experiencing suffering. This is because psychiatrists and physicians can't agree on a clear framework for determining whether my recovery is still likely and whether there are still further treatment attempts that could reduce my suffering.
What bothers me, Mr. Mishara, is that we're creating categories of citizens who don't have the same rights. I understand that it is more difficult to determine, based on a person's history, whether someone can obtain medical assistance in dying when their only underlying medical condition is a mental health disorder. However, there are people, as we speak, who would meet all the criteria but don't have the same right as others. That troubles me.
What can you tell me that might convince me that these people are not being discriminated against?
Brian Mishara
It's not true that there is no research being done at present. There's a great deal of research, but all the research to date indicates that no one is able to say with certainty that, in six months or a year, or with another treatment, this person won't be glad to be alive. In addition, given the very limited access to mental health treatment, we have an obligation to do everything possible in terms of suicide prevention. Anyone who attempts suicide thinks in exactly the way you describe. The person believes that they can no longer endure their suffering, that death is the only way to put an end to end it and that nothing can be done. However, we are almost always able to prevent suicide.
Bloc
Claude DeBellefeuille Bloc Beauharnois—Salaberry—Soulanges—Huntingdon, QC
I'm not talking to you about cases of suicide; I'm talking to you about a person with schizophrenia, for example, who has been receiving ongoing care for 25 years, who is medicated and who is well supported by those around her. As a legislator, I feel uncomfortable not taking her wishes into account and not listening to her when she says that she has had enough and that she suffers every day, despite all the assistance she receives. I wonder what to say to these people.
Brian Mishara
This person needs to be told that we're going to do everything we can to help. That person needs to have access to the right diagnostic services and the right treatments—
Bloc
Claude DeBellefeuille Bloc Beauharnois—Salaberry—Soulanges—Huntingdon, QC
I'm sorry to interrupt you, but I only have five minutes.
You take certain things for granted. I myself have had people come into my office who had been receiving ongoing care and intensive mental health follow‑up for 20 or 25 years, but who were still suffering. Why aren't these people allowed to be considered as full people who can make their own choices, choices that concern them?
When a person has been treated by a psychiatrist for 25 years, is taking medication, receives intense home-based follow‑up, has loved ones around them, and is still suffering, what hope can I offer that person for the future?
Brian Mishara
That person could speak to a number of people who testified before a parliamentary committee in Quebec before Quebec decided not to allow medical assistance in dying for people suffering solely from a mental illness. The committee heard from individuals who were in exactly the situation you're describing. They told the committee that, if medical assistance in dying had been available to people with mental health issues, they would be dead, because they met all the requirements three years earlier. They said that they were now very happy to be alive and that they had received good treatment.
If it were possible to predict who will be happy to be alive in a year or two and who will continue to suffer, that would be different. However, so far, all the research indicates that this isn't the case. Even research on schizophrenia indicates that symptoms lessen with age.
Liberal
The Joint Chair Liberal Marcus Powlowski
Thank you very much.
Senator Dalphond, you have the floor for three minutes.
Pierre Dalphond
Good evening.
Thank you to the witnesses for being here.
Professor Mishara, you concluded your opening remarks by mentioning some data on the Netherlands. You talked about an exponential increase after one, two, three or four cases a year. Now, the numbers may be much higher. Could you give us more details and provide the committee with the source of your information?
Brian Mishara
I will send you the sources.
The Netherlands has a long assessment process. It sometimes takes up to two years. They accept 3% of applications, and even that is controversial.
That said, there's a suicide-related phenomenon that has been well documented for a long time, known as the Werther effect. It's named after Goethe's book The Sorrows of Young Werther. When that book was published over 200 years ago, there was an epidemic of suicides across Europe, in every country where the book was published. These were young people who—
Pierre Dalphond
Excuse me, Professor Mishara, but time is running out. I'd like you to come back to the data you mentioned.
Pierre Dalphond
I understand the phenomenon, I just want you to tell us specifically about the experience in the Netherlands.
Brian Mishara
Okay.
As a result of this phenomenon, when a method of suicide is publicized in a given country, the number of suicides increases among people with mental illness, who are particularly vulnerable and who use that method. It isn't just a substitution effect; these are people who wouldn't have died if there hadn't been that publicity.
What happened was that there were photos and descriptions of the case of a young woman who had received medical assistance in dying for depression, and, since there had been publicity of suicides on the Montreal metro, the Jacques‑Cartier Bridge or the Vienna metro—
Pierre Dalphond
Again, can you give us the numbers and the ages of the people? The numbers are going up and the age is going down—
Brian Mishara
Okay. According to the figures I gave, in one year, the number of deaths went from 2 to 138. The year after that, there were 219.
Brian Mishara
The majority of the people who made those requests were women who lived alone and had been diagnosed with clinical depression.
The message being sent to suicidal people is that this is a way to treat their depression.
Liberal
The Joint Chair Liberal Marcus Powlowski
Thank you.
We would appreciate it if you could send us that study.
Next is Senator Moodie for three minutes.
Rosemary Moodie Senator, Ontario, ISG
Thank you, Mr. Chair.
Dr. Mishara, I have to come back to this, because I'm puzzled by what I'm hearing. I want to put a scenario to you.
This committee has heard testimony that, here in Canada, we should not allow persons with mental illness as their sole condition to access MAID. This applies even when they are suffering intolerably, even if they meet the criteria required and even if they wish to end their lives and would and will do so if they do not get access to MAID.
Do you share this view, Dr. Mishara?
