Medical Assistance in Dying committee  Thank you for that question. Clinicians on the ground are going to be drawing upon the work that has been done by the expert panel and the task group to help clarify how to use these terms in practice. Even without that work, I am very comfortable saying that I don't think there are any psychiatrists, physicians or nurse practitioners who think that acute distress is the equivalent of a grievous and irremediable medical condition.

Medical Assistance in Dying committee  In the same logic of the expert panel, we need to focus on what the complexities are and not what diagnosis the person has. I am not part of that association, and I can't comment on any of their internal discussions, but I would say that in order for a person with a substance use disorder to actually fulfill the criteria, they would have to have an extremely severe condition with probably very severe physical comorbidity along with it.

Medical Assistance in Dying committee  A person can make a request and be assessed, but they're not going to be eligible unless they meet the criteria and the safeguards are respected. Most people with addiction who do not have any of the sequelae of chronic and severe substance abuse would not be eligible.

Medical Assistance in Dying committee  It doesn't concern me, in the sense that I don't think anybody knows what it means. We can make all sorts of hypotheses about what it might mean, but nobody really knows. What I would caution you about is drawing inferences, like the one in your question with respect to male-to-female suicide ratios, because we don't know what it means.

Medical Assistance in Dying committee  I'm not inside their minds, so I can't tell you what they're thinking, but I'm really glad you brought that up, because I think some of the voices that are saying we are not ready have contributed nothing to becoming ready. I would submit that one way of assessing whether somebody is sincere about concerns about readiness—as opposed to, as Dr.

Medical Assistance in Dying committee  Is that for me or for Dr. Gamache?

Medical Assistance in Dying committee  I agree. I would say more or less the same thing. In 23 years, I've encountered maybe two people who would meet the criteria.

Medical Assistance in Dying committee  As I said, it's been seven years, and only 2% of all physicians in Canada assess certain patients' eligibility for MAID and deliver it. We need a small number of people who are prepared to work with a small number of patients. Of course not everyone in the medical professions will have the same level of training and be up to date on all practices.

Medical Assistance in Dying committee  No.

Medical Assistance in Dying committee  I know that I personally have never been involved in or aware of any case where a psychiatric consultant was needed to support assessors and it was not possible to obtain a psychiatric consultation. Dr. Gamache has a view of the entire province of Quebec and can probably comment on that better than I can.

Medical Assistance in Dying committee  I think so. I think we have to distinguish between the psychiatrist who acts as a consultant and the psychiatrist who acts as the assessor. Psychiatrists already participate as consultants with the two physicians or two specialized nurse practitioners. They do assessments. This is already being done.

Medical Assistance in Dying committee  I think we can all agree. Whatever views we have about MAID for persons with mental disorders, we can all agree that mental health services and addictions services in this country could stand to be improved, and there could be much greater access. I think what Dr. Gamache is pointing out is that these unfortunate souls who do not have proper access to care will not be eligible for MAID anyway.

Medical Assistance in Dying committee  It is precisely because some people with mental disorders—a very small number, I think—are going to be able to make a capable, informed decision to access MAID despite the fact that they may have also struggled with suicidal thinking over the course of their lives. This is already the case, because people who may have struggled with suicidal thinking over the course of their lives make MAID requests now.

Medical Assistance in Dying committee  There's a full range of experience, just like there is for MAID now. There are some people who are actively involved. There are some people who are not involved. There are some people who are occasionally involved. I would say the same thing is true for psychiatrists. As with any new and complex practice—and this is true for everything that we do in medicine—people who are less experienced aren't the people who are going to start.

Medical Assistance in Dying committee  Oversight, of course, as you know, is a provincial and territorial responsibility. There are differences between provinces and territories in the mechanisms that they choose to deploy for oversight, from Quebec's Commission sur les soins de fin de vie, which is very formal, to coroners' reviews and ministry oversight committees.