Thank you.
Evidence of meeting #7 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 euthanasia.
A recording is available from Parliament.
Evidence of meeting #7 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 euthanasia.
A recording is available from Parliament.
Liberal
Yonah Martin Senator, British Columbia, C
Thank you very much, Chair.
Good evening, colleagues.
Thank you so much to the witnesses. I know it's very late for you, so we really appreciate the expertise you are sharing.
I know that Dr. van Veen commented on the importance of having MAID available to those suffering from mental illness, and it would be a small group, but in your account, Dr. van Os, Dutch psychiatric euthanasia became normalized gradually. Then it was accelerated. The numbers are more alarming now, with a small group of activist physicians helping drive that shift.
Can you explain how that happened in practice? Why should Canada take warning as to what could happen should we consider expanding MAID?
Professor of Psychiatry, As an Individual
Thank you very much for this question. I think what you would like to happen in a country is that if there is a shift in practice, particularly one like euthanasia, you want it to be well reasoned, well prepared and safe. What happened in the Netherlands was that the law, as it was formulated in 2002, was open to all sorts of uses that I don't think were initially seen as possibilities.
What you will see with euthanasia is that individual clinicians often differ wildly in what they think they see before them in terms of suffering, irremediability, futility, autonomy, etc. This is what we've seen in the Netherlands. If there is a media campaign that will sway a group of physicians who really think they are following their instincts of mercy and then expand their practice, society is not able to keep up with that and to control, deliberate and assess what is happening.
With such a difficult issue, where there's no consensus on the criteria, it's not about being against euthanasia; it's about who can address the fluctuating opinion surrounding these criteria. For example, you should have a transparent public body for oversight with representatives of disability, palliative care, psychiatry—and, in your case, indigenous and lived experience communities—and not just the activist providers. It was proposed in the Netherlands as well to have a committee of wise, experienced individuals from all corners of society to do more oversight and lead the debate.
Professor of Psychiatry, As an Individual
This is what we haven't done.
Yes, thank you very much.
Liberal
Rosemary Moodie Senator, Ontario, ISG
Thank you, Mr. Chair.
Dr. van Veen, your current research focuses on the intersection between psychiatry and death. You study suicide prevention, assisted death for psychiatric suffering, advanced care planning by patients with a psychiatric disorder and psychiatric complaints in terminally ill patients.
Based on your research that has studied suicide prevention, medically assisted death and psychiatric suffering, in your opinion as an expert in this area, what is the relationship between suicide prevention and medically assisted death for people with mental health illnesses?
Psychiatrist, As an Individual
The short answer is that it's very, very complex the relationship between suicidality and psychiatric MAID. Even the language is complex. We've seen suicide, almost by definition, as something pathological but, if you talk to patients, especially ones with persistent suicidality, what they are mostly saying is that they miss a good conversation about their death wish, about wanting to die. They don't want psychiatrists or other physicians to act on it immediately through coercive protection in the form of MAID. They want to have a connection to talk about their death wish and not have it waved away immediately.
I think it is irresponsible to call MAID a form of suicide prevention, but there have been cases where people have requested MAID and got denied or where there is a delay in the system, and people end up dying through suicide, but I do not think we will see that in the numbers. Framing MAID—
Senator, Ontario, ISG
Can I ask another question?
Is it impossible to distinguish between a rational request for MAID and the suicidality that may be present in someone with a mental disorder?
Psychiatrist, As an Individual
I do not think it's impossible. I think it's complicated, but I think we have clear clinical guidelines. Competence is a construct, and we have good internationally agreed-upon rules on how to establish competence. I don't see any reason why that should not be possible for patients requesting MAID. In clinical practice, this is sometimes challenging but often something that we can do.
Liberal
Flordeliz Gigi) Osler (Senator, Manitoba, CSG
Thank you, Mr. Chair.
Thank you to all the witnesses who are here today.
My question touches on the question Senator Moodie just asked. My question is for Dr. van Veen.
This committee has heard from psychiatrists who have said that it's impossible in clinical practice to distinguish between a rational request for MAID and the suicidality that may be present in someone with a mental disorder. You answered it a bit in your response to Senator Moodie, but I'd be interested to hear more about how that differentiation is handled in the Netherlands.
Psychiatrist, As an Individual
In clinical practice, every psychiatrist is trained to assess suicidality. That's also a continuously changing field. We are now recognizing the fact that we are really bad at predicting suicidality, but it's even more fundamental than that. I think that what we call suicidality matters, and there's not an agreed-upon definition of suicidality internationally.
It appears to me that, in the Canadian context, suicidality is synonymous with an irrational death wish. If that is the case, if that's the way we define suicidality, then it's possible to distinguish a rational death wish or a competent death wish from an incompetent death wish that is the result of psychiatric order. We have guidelines to do that, and physicians all over the world are able to do that.
Flordeliz (Gigi) Osler
That was my question. Can you tell us a bit more about the guidelines? How are the psychiatrists in the Netherlands differentiating...?
Psychiatrist, As an Individual
You have the Appelbaum and Grisso criteria, which are well known and internationally recognized, to guide the competence assessment. They are really cognitive, so a patient has to be able to make a decision, explain their decision and use all of the needed information and apply it to themselves.
There are supplements in the Netherlands in our MAID guidelines with an assessment of the emotional congruence of the decision. Especially in the context of eating disorders, we are asked to see if there aren't any pathological values involved in the decision to choose death. In short, that's how we do that. There are pretty extensive, comprehensive guidelines for how to do that.
Liberal
Kristopher Wells Senator, Alberta, PSG
Thank you.
I have a quick question for Dr. van Veen.
Have you had a chance to look at the Canadian psychiatric guidelines that were developed? If so, do you have a comment on those, as an expert?
Psychiatrist, As an Individual
Yes, but there are a lot of guidelines. I've reviewed the 20-page guidelines that were published last year, based on the Delphi study. I think they're pretty comprehensive and pretty close to our Dutch guidelines. There are small differences, but I think they're pretty thorough.
Senator, Alberta, PSG
Thank you. I appreciate that.
This question is for Dr. van Os.
In your commentary copublished in the Psychiatric Times, titled “Psychiatric Euthanasia in the Netherlands: Young People, Procedural Medicine, and the Limits of Psychiatry”, you wrote about an increasing number of youth in the Netherlands who are seeking medical assistance in dying. However, you also say in the article that “rejection and withdrawal rates remain substantial”.
You got that from the American National Library of Medicine's data that studied the requests for medical assistance in dying by young Dutch people with psychiatric disorders. That same report concluded that although there was an increase in young persons seeking MAID MI-SUMC, “Only 3.0% of all applications by young people resulted in MAID, which is lower compared with the acceptance rate for MAID-PS among adults in the Netherlands. One in 4 applications was halted by the patient even before medical files had been assembled.” Of the files that continued to be accessed, 60% were rejected due to eligibility screening. That was in your article.
Wouldn't this data which you've cited in this commentary suggest that the system developed in the Netherlands to protect against unlawful cases of MAID for mental illness as the sole underlying condition is actually working?
Professor of Psychiatry, As an Individual
No. Actually, I would not agree with that, because while, of course, 3% sounds like a small number, it's a relative number. In fact, there's been a growth of about 500% over five years in the number of young people getting MAID. That may still be 3% in a pool that is ever-increasing.
What happens in the Netherlands.... To clarify, we have 90,000 people, mostly young girls, presenting at the first aid departments of hospitals with non-lethal suicide attempts, and it is this pool that is more and more drawn to formulating their suffering in terms of a euthanasia request. Euthanasia requests are actually increasing to the GP, in the psychiatric practice and with the school counsellor, so we've seem an enormous increase in requests.
The 3% may be 3%, but there's a background of an increasing number of requests.
Senator, Alberta, PSG
We're running out of time. Perhaps you could send those numbers, if you have the peer-reviewed information making those comparisons. They don't add up with the numbers that we see.
Liberal
Professor of Psychiatry, As an Individual
This is of course a big topic, but not every time a GP gets a euthanasia request it is recorded somewhere in the Netherlands.
