Mr. Speaker, in this debate, which can get quite emotional, I am going to try to live up to my riding's name, and I will remain calm.
The bill before us today is really two bills in one. The government proposed that the vote at second reading be split. In fact, I expected the Conservatives to support that proposal, but that does not appear to be the case. Later, at third reading, we can discuss whether it is appropriate to split the vote or even split the bill. However, for now, it seems to me that it would have been wise for everyone to agree to hold separate votes at second reading. The reason is that mental illness raises a distinct set of issues, while advance requests raise a different set of issues altogether. In my opinion, there should have been two separate bills.
As I have said many times, when it comes to a human being determining the conditions of their end of life and determining what they consider to be the threshold of what is tolerable in this process, the law recognizes the principle of self-determination. The Baudouin ruling, which is an interpretation of the Carter decision, makes it clear that, in matters relating to mental illness, a blanket prohibition is discriminatory. What bothers me a great deal today is that, from the very first Special Joint Committee on Medical Assistance in Dying, the question was not whether we should move forward on the issue of mental illness. On the contrary, we said that we would wait and see whether the network, the providers and the system were capable of proceeding safely. That was the issue. It was not about whether we should move forward with it or not. Why were we so convinced of that as soon as we saw the first report from the late Marc Garneau, who was the chair of the committee? It was precisely because a blanket prohibition is discriminatory in nature.
I heard all sorts of things about mental illness: astonishing intellectual shortcuts, horror stories and anecdotes. People are basing their positions on absolutely nothing. If what some are describing is actually happening today in the context of mental illness, that is, if people are being encouraged under the current law to choose medical assistance in dying, or if it is being suggested to people with mental illness, that is a criminal offence. It is that simple. One calls the police and reports it, because the Criminal Code already governs such situations. When witnesses come before committee and tell us anecdotal stories of that nature, I ask them whether they reported the matter to the police, because those cases are already covered by the Criminal Code.
However, if we have legislation that sets out all the safeguards needed to ensure that things are done properly, that is quite a different matter. I heard all sorts of claims. The point, here, is not to suddenly allow a suicidal or depressed minor access to MAID. Such a person would not even be assessed for that purpose. Simply making a request does not make someone eligible. Some witnesses came and told us that if the bill had been passed, they would not have been there, in front of us. What basis do these people have for making such claims, given that the assessment process is precise and rigorous?
The unfortunate thing about this debate is that very few lawmakers here have carefully read the experts' report laying out all of the safeguards that would be needed to safely provide medical assistance in dying for people with mental disorders.
Some will tell me that psychiatrists cannot assess irremediability. Fine, but they assess people's decision-making capacity every day. There are people with mental disorders who also have cancer, and their capacity to consent, or not consent, to MAID based on their cancer can be assessed. Everyone is capable of doing that. Psychiatrists do this regularly, but if a mental disorder is the sole condition, suddenly opponents say they cannot do that. They say that psychiatrists cannot accurately determine a prognosis or a diagnosis and that this justifies a blanket prohibition for all individuals who are unresponsive to all the available treatments for their mental disorder. These are individuals who have never refused a treatment that could improve their condition and who, after several decades, sometimes 25 or 30 years, have come to the conclusion that they would like to end their lives with dignity, following a proper assessment, and certainly not when they are in distress or experiencing a suicidal crisis.
A suicidal crisis is actually sometimes part of the expression of a mental illness or disorder. The fact remains that irremediability is a chronic condition established over time. That is a far cry from the scenario of a young man suffering from a broken heart who decides to put up his hand and say that he wants MAID. If the law were to pass, what would happen? By raising his hand, he would be raising a red flag, and instead of attempting suicide, thinking he is entitled to access MAID, he could be treated. He could be taken care of. However, right now, with a blanket prohibition, there is no preventive aspect in terms of there being a law to deal with the issue of mental disorders. As I said, this is unconstitutional.
Going back to my first point, the government had five years, since the first Special Joint Committee on Medical Assistance in Dying, to ask the Supreme Court for an opinion. The government could have clarified whether the blanket prohibition imposed in the Carter decision unconstitutionally infringes on the rights of patients with a mental disorder and is therefore unconstitutional discrimination. However, it did not do that. It did not summon the courage to do so, and right now, if we decide to uphold the indefinite exclusion, it means there will be no more debate on this matter here. No future government would reopen the debate on this.
What is happening? The burden is being placed on vulnerable patients. The government says it wants to protect vulnerable patients, yet there is a contradiction there. The government says that these patients are vulnerable and lack the capacity to make decisions about their own end of life in the circumstances I have described, even after a comprehensive and rigorous assessment. However, the government expects them to navigate the legal system and take their case all the way to the Supreme Court to defend their rights. To me, that shows disregard for human dignity. To me, that shows cowardice, parliamentary cowardice. It is cowardice because Parliament has never been proactive throughout this entire debate on MAID. Now, suddenly, when it comes to mental illness and advance requests, Parliament has decided to be proactive. I will come back to that, but colleagues can surely understand why I find this somewhat surprising.
All the regulatory bodies told us that they were ready. The Special Joint Committee on Medical Assistance in Dying refused to hear from the Canadian Psychiatric Association, which had established standards of practice. The government paid a committee to set standards of practice. All the practitioners told us that everyone was ready to move forward. In the end, the answer is no because there are some who oppose all forms of medical assistance in dying and who will seize on any anecdote to say that it will become a horror show, that it will be awful, that it will cause harm, and that the system is unable to deliver proper care.
There are indeed mental health challenges. However, when someone has been dealing with a mental disorder for 30 years, in keeping with the definition, I do not want to hear anyone claim that the system is incapable of treating that person and that this is why we have to wait for the system to be able to treat or cure them, especially when some psychiatrists say that no cure is even possible. People are effectively being told to continue suffering within reason. If this constitutes discrimination, does the first clause save the blanket prohibition? Absolutely not. What is really happening is that people are being told to continue suffering until a treatment is found that will finally cure them. These people are being told to be patient, after a lifetime of stigma and discrimination.
Only a small minority of people are likely to request MAID, and the assessment would ensure that they meet the criteria. On top of that, there was an additional safeguard in place for people with mental disorders. Prospective monitoring was advised. During the assessment, when it was time to intervene, a panel would be asked to review the process to see whether it had been properly implemented, which is not currently the case for other scenarios involving MAID. The bill has continued to move forward with regard to advance requests. This was a key recommendation of the first special joint committee. We agreed that while we should delay the decision to see whether the necessary provisions for mental disorders could eventually be implemented in practice, there were no reservations about advance requests five years ago.
It took the government five years to show some courage and do what had been proposed. If it felt that advance requests were a more delicate process, given that the person is assessed when they are incapacitated, all it had to do was set up an additional safeguard, an additional requirement. It was told that since the provinces are responsible for health care, it should require them to develop a “how to” procedure so that this is done by the book, and, that way, debates will take place in each provincial legislature. This could even become an election issue. If, for example, a province decides not to go ahead at all, someone will surely go to the Supreme Court and have the ban struck down or change the government so that the legislature passes a law.
Quebec has implemented a process based on a very interesting approach. First of all, a person is not told that MAID is an option before first undergoing an evaluation. An advance request is made based on a diagnosis, and once care begins following that diagnosis, the patient is given an explanation of the stages of the disease's progression. At some point during these stages, when the person is of sound mind, they sit down with the care team and establish the criteria that correspond to their personal threshold of what is tolerable.
A person might say that they would like to receive MAID when they become doubly incontinent, when they start playing with their own feces, when they resist being fed, when they are no longer able to recognize their own family or even interact with other human beings. There is no automatic threshold. In fact, at a certain point in the progression of the illness, in other words, when the patient has reached a certain level of incapacity, a third person is responsible for informing the care team that they believe the patient should be evaluated. The care team will evaluate the patient and may inform the third party that the patient in question has not yet reached that stage. The process would then continue.
This process is based on the clinical judgment of physicians or other professionals. The Quebec law states that, at the time medical assistance in dying is administered, the person must be “incapable of giving consent to care due to their illness”, they must be “exhibiting, on a recurring basis, the clinical manifestations related to their illness” and they must be in a medical state “of advanced, irreversible decline in capability...that gives a competent professional cause to believe, based on the information at their disposal and according to their clinical judgment, that the patient is experiencing enduring and unbearable physical or psychological suffering that cannot be relieved under conditions considered tolerable.” There is no mention of reasonable means.
My colleague, who was a social worker, told me about a lady who had what is known as “quiet dementia” or “happy dementia”. Incidentally, this is a transitional phase that leads the person towards the end of their life. It is a transitory state. It is not permanent. People with Alzheimer's often die from a secondary condition, because they are no longer mobile, because they are bedridden or because they are confined to a wheelchair. That is why the concept of what is considered tolerable is important. However, in the government's bill, instead of trusting provincial legislatures, it proposes a whole bunch of criteria and the aim is to set aside the criteria that the individual may have put in place, on the pretext that it would lead to MAID being granted in cases of happy dementia.
Let us imagine a woman with an illness who reaches a point where she is no longer aware of her actions and is no longer in her right mind. Let us imagine that she repeatedly undresses in public and smiles while throwing herself at men. She appears happy. Who was this woman? It is very important to understand that someone who reaches that stage of the disease and that stage of cognitive decline is not the same person anymore. This woman was a nun who had spent her entire life observing the strictest standards of modesty. Does anyone think that if this woman had set out her wishes in advance, she would have put up with this situation simply because she seems relatively bothered and even seems happy? The Supreme Court has been very clear. The whole question of dementia, whether or not the person appears happy, should be discussed at the formal meeting where the patient establishes their personal criteria.
A person could very well say at that meeting that if they reach that stage and wish to continue living in that condition, they should be allowed to do so.
I will end here. No one would be forced to make an advance request if they have a degenerative disease such as Alzheimer's or dementia. The Conservatives always make it seem as though it would be mandatory for everyone. It is not a requirement, but merely an option.
