Evidence of meeting #6 for Physician-Assisted Dying in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was nurses.
A video is available from Parliament.
James S. Cowan Senator, Nova Scotia, Lib.
Thank you for your presence tonight and the information you provided to us.
My question has to do with advance directives. If we were, as a committee, to recommend that advance directives should play a part in this legislative regulatory regime that Parliament will bring into effect, what additional precautions or protections should we build in when we're dealing with mental illness as opposed to physical illness?
President, Canadian Psychiatric Association
Again, I'll go back to the principles that we're talking about when mental illness is present, and that is the need for a very careful assessment to understand what is influencing the patient's decision-making process. It's not a question of making a value judgment on their decision but a question of evaluating the rationality of all of the pieces that are in the process going toward making the decision. That would need to be brought in at any point where someone is providing a directive. Again, if mental illness is present, then we think any decision needs to be properly evaluated.
I just want to clarify one point. I don't want my prior comments to be misconstrued as a suggestion that a psychiatrist needs to be involved in every decision. We were saying that when mental illness is present, a psychiatrist needs to be involved.
Senator, Nova Scotia, Lib.
It would be the same as if it were a physical illness, I suppose. You would call in the specialist in the physical illness that was causing the distress.
President, Canadian Psychiatric Association
Yes, although in the case of mental illness being present, it is about how it affects the thought process. In some other illnesses it might be not as much of an issue and would be more about assessing the suffering and irremediable nature of it.
Senator, Nova Scotia, Lib.
Do you consider that to be more difficult from the point of view of a trained professional with respect to mental illness than it is with respect to physical illness, or does it just require a different skill set, different experience?
President, Canadian Psychiatric Association
It requires a different skill set with awareness of how the mental illness itself could affect the person's thought processes. That's the difference. If I have an illness in my heart or if I have diabetes, I may well have symptoms from it and I may suffer from it and it can be problematic, but it doesn't necessarily affect how I think about what I have.
President, Canadian Psychiatric Association
Exactly. With mental illness, you have the presence of both suffering and symptoms, and you also have influence on the person's thought processes. Teasing that apart is challenging, but we do capacity assessments like that already—not for this purpose, but we do capacity assessments.
Senator, Nova Scotia, Lib.
Of course. You do it for all kinds of other reasons apart from that. This would simply be another action, perhaps more finite or final, but you're called upon to make capacity assessments every day for other legal action to be taken by your patients.
Senator, Nova Scotia, Lib.
You may have answered this earlier, and if I missed it I apologize. I'm wondering whether there is a need, in your view, to define those terms that are used in Carter, or whether those are terms that physicians—in your case, particularly psychiatrists—are trained in and are familiar with. Do professionals know when those conditions, those thresholds, are met from a professional point of view? Can you comment on that?
President, Canadian Psychiatric Association
That's an excellent question, because that gets to the heart of actually some of the other questions about this.
In some areas, when we're looking at the impact of suffering and how a person is perceiving and experiencing it, yes, clinically we are often able to do a thorough assessment and tease apart the impact on them. Terms like “irremediable”, again, are more in the legal framework you're looking at. I actually think that people will need some guidance on what level of irremediableness the framework is asking for.
Senator, Nova Scotia, Lib.
Is it a medical assessment, a professional medical assessment, or is it only a legal definition issue? I can appreciate the need for clarity, but are you looking to Parliament for that clarity, or would you be looking to the college of physicians and surgeons in your province?
President, Canadian Psychiatric Association
I don't have the best answer for you on that right now. It's the most challenging question right now: what threshold should be required for defining something as “irremediable”?
Senator, Nova Scotia, Lib.
The term “grievous” is easier to comprehend, is it?
President, Canadian Psychiatric Association
“Grievous” suggests a degree of severity. “Irremediable” is on or off. It either is or is not. It's a dichotomous definition, whereas most of the things we do in medicine, and certainly these assessments—
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
Okay. Thank you, Dr. Gaind.
Mr. Arseneault, go ahead.
Liberal
René Arseneault Liberal Madawaska—Restigouche, NB
Thank you, Mr. Joint Chair.
Dr. Gaind, as your testimony is really important, I will ask my questions quickly.
I would first like to know whether we could have access to your introductory document.
President, Canadian Psychiatric Association
By introductory document, do you mean the speaking notes?
January 27th, 2016 / 8:15 p.m.
President, Canadian Psychiatric Association
We can provide it afterwards, but we didn't prepare it in advance for circulation.
Liberal
René Arseneault Liberal Madawaska—Restigouche, NB
Okay. Thank you.
I wanted to talk about the Carter decision, which led to the establishment of this committee and to these meetings.
One of the things established in the decision is that, according to the spirit of section 7 of the Canadian Charter of Rights and Freedoms, we must be able to provide assistance to die. The decision states that, “a competent adult person who clearly consents to the termination of life...”
Could you tell me whether you think that, when we talk about the same individual, the concepts of a competent adult and clear consent boil down to the same thing?
Can we take that view?
President, Canadian Psychiatric Association
No, those are different. You can clearly have a wish for something, but that doesn't necessarily imply that you have capacity or competence for it.
The other issue I'll point out is that capacity assessments—in medicine, we often call them that—are specific to what is being assessed. They're specific to the decision. Therefore, it's conceivable that someone can have capacity to make one decision and lack capacity to make a different decision. The capacity assessments for PAD requests need to be very focused on the nuances of what could be behind the process of making that specific decision.
Liberal
René Arseneault Liberal Madawaska—Restigouche, NB
Let's take for example a typical case, that of an adult with no pre-existing mental illness who has learned that they have an incurable disease. The disease does its damage, and time passes. At some point in their disease and their suffering—you get the picture—they ask to be provided with assistance to die by referring to the Carter decision.
Do you think that Canadian medical professionals can do that analysis? In other words, can they determine whether the adult is capable of deciding and whether they are clearly making such a request?
President, Canadian Psychiatric Association
I believe physicians are able to determine if patients are competent and have capacity. In the example you're giving, if the person doesn't have a mental illness, a psychiatrist may not need to be involved.