Welcome to this meeting of the Special Joint Committee on Medical Assistance in Dying. I would like to welcome members of the committee and witnesses, as well as those watching this meeting on the web.
[English]
My name is René Arseneault, and I am the House of Commons joint chair of this committee. I am joined by the Honourable Yonah Martin, the Senate's joint chair of this committee.
[Translation]
Today, we begin our examination of the degree of preparedness attained for a safe and adequate application of medical assistance in dying, where mental disorder is the sole underlying medical condition, in accordance with recommendation 13 of the committee's second report.
[English]
I would like to remind members and witnesses to keep their microphones muted, unless recognized by name by the joint chairs. I remind you that all comments should be addressed through the joint chairs. When speaking, please speak slowly and clearly, and as near as you can to the microphone for the interpreters. Interpretation in this video conference will work like in an in-person committee meeting. You have the choice at the bottom of your screen of floor, English or French.
[Translation]
With that, I would like to extend a virtual welcome to our witnesses for our first panel.
From the Canadian Psychiatric Association, we have Dr. Alison Freeland, chair of the board of directors and co-chair of the MAID working group.
[English]
We also have the Canadian Bar Association, represented by Ms. Shelley Birenbaum, chair of the end of life working group.
Thank you for joining us, Ms. Freeland and Ms. Birenbaum.
We'll begin with opening remarks by Dr. Freeland, followed by Ms. Birenbaum.
I will be very strict with the time for everyone here tonight because we'd like to have at least two rounds. If you ask a question with 10 seconds remaining in your time, there will be no answer. I'd ask everyone to try to be as tight as you can on your time. Then we can have two rounds of questions for everyone.
Dr. Freeland, the floor is yours for five minutes.
My name is Alison Freeland. I am a psychiatrist, and I am here in my capacity as chair of the board of directors of the Canadian Psychiatric Association and co-chair of the CPA's medical assistance in dying working group to provide you with the CPA's perspective. Thank you for the opportunity to be here today as you consider the degree of preparedness attained for a safe and adequate application of MAID for MD-SUMC.
As the national voice of Canada's psychiatrists and psychiatrists in training, the CPA's mission is to promote the highest quality of care and treatment for persons with mental illness and to advocate for the professional needs of our members by promoting excellence in education, research and clinical practice.
The CPA does not take a position on the legality or morality of MAID, nor has the CPA taken a position on whether MAID should be available where mental illness is the sole underlying medical condition. However, the CPA does believe that any legislation must protect the rights of all vulnerable Canadians without unduly stigmatizing and discriminating against those with mental disorders solely on the basis of their disability.
The CPA's primary contributions towards preparedness have focused on providing feedback and input on national standards and the training curriculum, facilitating member awareness and education on MAID and contributing to the literature regarding MAID. Through our working group, the CPA provided feedback on the MAID practice standard prior to its release last March. The CPA was also part of the national MAID curriculum steering committee, which supported and enabled the development of a training curriculum for assessors and providers that was released in September. In addition, several CPA members have been part of the CAMAP working groups that developed individual curriculum modules.
The CPA regularly informed members about the development of the practice standards and their contents as well as the curriculum through our weekly members newsletter. We continue to keep our members abreast of and facilitate relevant MAID training opportunities.
At our 2022 annual conference, we held a panel discussion for 140 participants that explored ethical considerations to guide MAID decisions, assessment of capacity and voluntariness, and suicide versus MAID. More recently, our annual conference last month included a plenary that discussed the need for a national MAID curriculum and outlined its development. More than 300 conference delegates participated in this session.
In conjunction with the conference, we also hosted a facilitated session of the MAID and mental disorders curriculum module for CPA members who are licensed clinicians. It's my understanding, from informal discussions with systems partners, that approximately 100 psychiatrists are now registered for the MAID curriculum. We continue to promote future educational opportunities for this training through our newsletter.
Our peer-reviewed journal, The Canadian Journal of Psychiatry, has published a number of articles that seek to clarify aspects of MAID, including original research by van Veen and colleagues that establishes 13 consensus criteria for determining irremediability in the context of MAID in the Netherlands. While psychiatrists diagnose, treat and assess capacity in people with mental disorders on a daily basis, we will soon publish a paper on the capacity to consent in the context of MAID in The Canadian Journal of Psychiatry, and this will offer further guidance to our psychiatrists. Our MAID working group continues to be active and will meet shortly to consider further topics where members would benefit from additional guidance.
The CPA also has some knowledge of health systems readiness gained through members of our working group as well as from our Council of Psychiatric Associations, which facilitates an exchange of information on issues of national importance by assembling the presidents of the various provincial psychiatric associations.
As a national member organization, our role is to listen to and dialogue with our members. While some psychiatrists do not support MAID, others are interested in learning more and will choose to be involved with MAID as consultants or assessors and possibly providers. Psychiatrists' expertise is important when it comes to MAID, but we do not practise in isolation. We work in interprofessional teams that centre the voice and lived experience of the patient and their family to balance treatment, care and hope for recovery with a capable person’s right to make health care decisions.
Thank you, and I would be happy to answer questions.
:
Good evening, Chairs and honourable members of the committee. My name is Shelley Birenbaum, and I am chair of the end of life working group of the Canadian Bar Association. Thank you for the opportunity to address your committee.
The CBA is a national association of 37,000 lawyers, Quebec notaries, law teachers and students, with a mandate to promote improvements in the law and the administration of justice. The CBA end of life working group comprises a cross-section of members drawn from diverse areas of expertise, including constitutional and human rights law, criminal justice, health law and child and youth law.
Medical assistance in dying, or MAID, is complex and raises vital issues and diverse views and the need to balance the competing values of autonomy and protection of those who may need it. At the same time, we must realize that the suffering of individuals with mental illness is no less real than that of individuals affected by physical illness, and persons with mental illness should have the same agency to determine their health care treatment as persons with physical illness, as long as they meet the requirements to do so.
We make three main points for this committee to consider. First, a total exclusion from MAID for all persons suffering from mental illness as a sole condition is likely to be constitutionally challenged as violating the equality, security and liberty guarantees in the Canadian charter. Second, there are already legislated procedural safeguards in the Criminal Code to protect those with mental illness as a sole condition and who may be vulnerable. Third, additional guidance, as pointed out by Ms. Freeland, is available for health professionals and has been developed to help clinicians.
To give more detail on constitutionality, a general exclusion of all persons suffering from mental illness is likely to be constitutionally challenged as discriminating against those with mental illness and denying them equality under the law, contrary to section 15 of the charter. A blanket prohibition increases suffering and will likely result in breaches of the rights to security of the person and liberty, that is, the ability to make decisions regarding bodily integrity guaranteed to us under section 7 of the charter.
There are existing legislative safeguards. The Criminal Code already establishes a robust series of procedural safeguards that must be met before a person is considered eligible for MAID, including decisional capacity, two independent assessments and informed consent. The safeguards for track two, where death is not reasonably foreseeable—and most mental illnesses would likely fit within that category—are even more rigorous, requiring a prescribed and robust informed consent, consultation with an expert in the field, a reflection period and a determination that there has been a serious consideration of options.
Health care practitioners are already legally required to assess capacity prior to treatment, and psychiatrists regularly make capacity determinations for persons with mental illness, provide prognoses about mental illnesses and assess risk of suicidality, which are different than MAID. Any additional safeguards must not unduly prolong the suffering of those who are otherwise eligible for MAID and should align with current best practices in mental health care.
We understand that there have been many tools developed, and many recommendations of the expert panel on MAID and mental illness are being implemented to ensure a state of readiness. We are aware of the “Model Practice Standard” and “Advice to the Profession” documents that have been developed, as well as the comprehensive Canadian MAID curriculum, with a specific module on mental illness and MAID. In addition, provinces and territories and regulatory bodies may continue to develop guidance and tools in their role in regulating health and health practitioners.
MAID where mental illness is the sole condition has been under consideration for almost nine years and has been delayed twice. We are of the view that eligibility should no longer be delayed and that the planned March 2024 implementation date should be respected.
On behalf of the CBA, thank you again for the opportunity to speak today. I look forward to answering any questions you may have.
I thought my question was simple. You're not in a position to give me a yes or no answer. I understand that.
In a number of writings, it is said that, roughly speaking, 50% of psychiatrists are reluctant to make medical assistance in dying available to people with mental disorders. In the brief you submitted to the joint committee in May 2022, you wrote:
… it is essential that at least one independent psychiatrist who has expertise in the mental disorder in question completes a comprehensive clinical assessment to validate whether the patient has received an accurate diagnosis and if they have had access to evidence-based mental health assessment, treatment and supports for an adequate period of time based on generally accepted standards of care.
This view, that an independent psychiatrist with expertise in the mental disorder in question is needed, is also found in recommendation 10 of the final report of the expert panel on medical assistance in dying and mental illness.
Do you think we have the necessary resources to implement that recommendation?
:
Do you think so? I'm sorry. The committee's final report in February 2023 noted, “there has not been sufficient time to develop the standards of practice” that “are key to ensuring a thoughtful, consistent approach to MAID”.
I have found, in all my years of Parliament, that things don't move very fast. To suddenly go from February to now and say we're ready...I have a really hard time buying that. We were given an arbitrary date on this by the unelected Senate, which threw in March 2023. Then the Liberals moved it to 2024.
Can you tell me with assurance that I can go back to the people I represent and tell them not to worry, that if their loved one who's severely depressed decides he's going to end his life, it will be done right with all the provisions and protections? Can you tell me that I can tell people those protections are in place now, because in four months this will become law?
:
That's crucial. We're supposed to know it's going to be “rationally considered during a period of stability, not during a period of crisis”, which may require serial assessments.
That sounds great, but that is not like anything I've ever seen in the real world. We deal in our office with people who have severe depression. We deal with families that deal with loved ones who are in a deep, dark, black hole, and we deal with the fact that many families don't have doctors or have never seen a psychiatrist.
In four months, thanks to how this has been set up, this becomes law and someone who's in a deep, dark depression can end their life. How do I tell their family that everything was done to make sure they had all their agency? How do I tell them not to worry, that if this person who's in a deep, dark depression decides to end their life, the process is there to protect them?
The point here is that we're on a trajectory for creating competencies. I know of no speciality in medicine where all the competencies are done on day one. We have a huge trajectory for creating competency. We have to be careful not to give an improper idea about medical training.
I'll go to Ms. Birenbaum.
We're seeing some confusion in the committee about assessing readiness between provincial jurisdiction and federal jurisdiction. Our job as the federal government is to assess readiness solely in terms of steps within the federal government's jurisdiction.
I'm wondering whether you think the exclusion of people is a limit on charter rights. What prospects do you think a claim of lack of readiness would have as a justification for a limit on rights? How would the Supreme Court look at a justification of provincial non-readiness?
I know there have been questions about readiness, and there is concern about the overall readiness. You've responded to some of the questions about the lack of....
I'm curious about a survey from October 1, 2023, of psychiatrists in Manitoba. Only 33% of them responded that they were in favour of the legislation and legalizing MAID for mental illness. In that same survey, 65% of respondents said they do not have enough awareness or understanding of MAID. This speaks to the lack of readiness or concerns of readiness.
Would you first speak to the 33% of psychiatrists who are in favour of the legislation?
:
Thank you very much, Madam Chair.
I want to thank our witnesses for being here. We have such a narrow mandate that you'll be hearing, and are already hearing, a bit of repetition and a bit of different phrasing of some of the questions. The narrow mandate, of course, is just to verify the degree of preparedness attained for a safe and adequate application of MAID.
I've always supported MAID. Every time there was a MAID vote, I voted for it. I support the safeguards and I certainly support the Charter of Rights.
Dr. Freeland, your organization takes no position, but perhaps I can ask you this as an individual: Do you think the health system is ready for an expansion of MAID eligibility for individuals whose sole underlying medical condition is a mental disorder?
:
Thank you for that question. I'm just reflecting on it as an individual.
I work in Ontario, which is a complicated province. There are lots of different health care systems there. I think there is still work to be done at a local level to ensure that the entire system has created a coordinated point of access.
The encouraging thing is that where I am, there is now a provincial group looking at a community of practice around medical assistance in dying, particularly for a mental disorder. In Toronto, where I work, we now have a coordinated working group sponsored by the two local Toronto hospitals, which, again, is turning its mind to how to do this. It is represented by a number of different health professionals and includes psychiatry. In fact, the Toronto working group is co-chaired by two psychiatrists.
I think people are working hard knowing that there is a date in mind to get to a place of readiness and knowing that readiness is never going to be perfect. When we think about readiness in this context compared to when MAID came out way back with Bill , there's been a lot more work done on the national approach around standards and available curriculum, and I think many different organizations are engaging health care teams around how to best understand this.
I am definitely not a MAID expansionist. I just truly believe that it's very stigmatizing—and this is my personal belief—to take a group of patients and say to them, “You can't even be considered for something because you have a mental illness.”
I believe that very few people would be found eligible should this go ahead with respect to mental illness. Ms. Birenbaum has clearly outlined all of the safeguards and processes we'd have to get through to get to that point.
Those would be my personal reflections, not the CPA's reflections.
:
Thank you, Madam Chair.
A number of people who talk about mental disorders as the sole underlying medical conditions claim that people who are suicidal and in crisis or are depressed could have access to medical assistance in dying, whereas nothing in the expert report says that. In fact, it says the opposite.
My question is for both witnesses. I would ask them to give a brief answer.
Do you think that expanding medical assistance in dying to people with mental disorders could have a preventive effect in suicidal individuals?
For example, if a suicidal person, the day after the amended act is passed, raises their hand and says that they want to have access to medical assistance in dying, at least we will know that they need help and can be taken care of when, at the moment, they are completely abandoned and could make attempt suicide.
Isn't this a preventive measure?
:
That's a great question, and I think there is a lot of debate about that.
First of all, I think if we were all living in a perfect health care system, we would assume that people have quick access to an assessment at the onset of suicidality and would ensure they have rapid access to treatment and care in the system. I think that's something we all strive for broadly in the health care system.
With respect to people accessing an expert assessment because of an ask around medical assistance in dying, I think there has been some debate about the fact that, when you see a psychiatrist and are able to explore your illness and understand diagnosis and treatment options, many people who get to that stage may in fact not be eligible.
Again, I'm going to put my personal hat on. One of the important parts about readiness—and it's something we've talked about in Ontario—is the navigation back into the health care system. When you look at the standards, there is a requirement to continue to provide ongoing treatment and care for people who are not found eligible for MAID. In this context, there is that opportunity.
:
Thank you, Dr. Freeland.
I want to go back to the question of whether we're ready for March 2024. You said that Canada had decided we were going down this road. I would say that the Senate, which is not elected, threw in a date and told us to live with it, and the Liberal government agreed. That date was March 2023. As it approached, they panicked, so now it's March 2024.
This is a huge Rubicon we're crossing, so what's more important? Is it the date or getting it right? Would you suggest that we take the time to do this right? If it's proven that it's not going to affect a lot of people and that there are going to be all these safeguards, do we need to meet the arbitrary date that was put in between the Liberal government and the Senate, or should we do this in light of the bigger and broader consensus that we need to achieve to make sure people are protected?
I would like to make a few comments for the benefit of the new witnesses.
Before speaking, please wait until the chair recognizes you by name. A reminder that all comments should be addressed through the chair. When speaking, please speak slowly and clearly. I would ask those in the room to speak very close to their microphones in order to help the interpreters.
Interpretation in this video conference will work like in an in-person committee meeting. For those participating by video conference, you have the choice, at the bottom of your screen, of floor, English or French. When you are not speaking, please keep your microphone on mute.
I would now like to welcome the witnesses for the second panel. Joining us by video conference, we have Dr. Mona Gupta, psychiatrist and researcher at the Centre hospitalier de l'Université de Montréal.
[English]
I welcome Dr. Douglas Grant, representing the Federation of Medical Regulatory Authorities of Canada.
[Translation]
Lastly, we have Dr. Claire Gamache, psychiatrist and president of the Association des médecins psychiatres du Québec.
Thank you all for being with us today.
I'll now give the floor to the joint co-chair, Senator Martin.
:
Thank you very much, Madam Chair, and thank you, all, for the invitation to meet with you today.
I'm a psychiatrist and bioethics researcher at the University of Montreal. I've had the opportunity and the privilege to be closely involved in the public conversation about assisted dying for persons with mental disorders as their sole underlying medical condition—MDSUMC for the rest of my remarks—since its beginning.
I served as a member of the CCA working group on MAID for MDSUMC mandated by Bill . I chaired the federal expert panel on MAID and mental illness, mandated by Bill . More recently, I led the work of Health Canada's MAID practice standards task group, and I also led the working group that developed CAMAP's educational module for MAID and mental disorders.
It is from this vantage point that I want to share some observations about readiness.
When the Government of Canada made the decision to include persons with mental disorders as their sole underlying medical condition on equal terms with all other medically ill suffering persons whose natural deaths were not reasonably foreseeable, it committed to do three things: constitute an expert panel on MAID and mental illness, strike a special joint parliamentary committee to further study the matter, and revise its data collection system. As we know, the federal government has fulfilled these commitments.
When the federal government made the decision to extend the exclusion for an additional year, it spoke about the need for extra time to ensure that two major deliverables—the CAMAP MAID curriculum and the model practice standard for MAID—were complete. As we know, these activities are complete. The standard has been in the hands of physicians and nurse regulators since April of this year, and they are adopting or adapting the standard as appropriate within their jurisdiction. The CAMAP MAID curriculum was launched in September 2023 and has been offered already, numerous times, to physicians and nurse practitioners.
Several other initiatives have occurred since December 2022, including a national MAID MDSUMC preparatory workshop with delegates from every province and territory, including MAID assessors, providers and psychiatrists. There has also been a national system readiness workshop to share knowledge about administrative processes.
Most provinces and territories are working with frontline clinicians, regulators and administrative authorities to ensure that clinical processes are appropriately tailored for requesters with mental disorders. I have provided several examples of these activities in my brief.
A few weeks ago, I taught the CAMAP MAID and mental disorders module to a group of about 20 psychiatrists, family physicians and nurse practitioners in Vancouver. Beforehand, the colleague co-leading the session, an experienced family physician and MAID assessor and provider, Dr. Tanja Daws, bounded up to me. Even though MAID MDSUMC is not allowed, she said, I've already had patients with all the same types of issues in the case studies we cover in the module.
What struck me about Dr. Daws' comment is that persons with mental disorders as their sole underlying condition who make requests for MAID will be in the careful hands of experienced clinicians who, over these last seven years, have already handled the full range of complexities in their MAID practice that MDSUMC requests may present. Her comment also confirms what the expert panel concluded, that the complexities so often attributed to mental disorders are not, in fact, unique to mental disorders and are already being handled in our MAID system today.
The work that has been undertaken on MAID MDSUMC since 2017 has been thorough, the processes transparent and collaborative. The Government of Canada has fulfilled every commitment concerning readiness that it made. It has also made unprecedented contributions to health care professional education and regulation, which well exceed the scope of its jurisdictional responsibilities.
As my colleagues Dr. Gamache and Dr. Grant know better than I, the other essential actors in health care and in the MAID system—regulators and professional associations—have been active concerning MAID since 2015. They will continue to fulfill their mandates. In the case of the regulators, this is guiding clinicians towards safe MAID practice in the public interest, and in the case of professional associations, ensuring their members are equipped to participate in MAID if they choose to do so.
By far, more thought, care and capacity building have been done for persons with mental disorders as their sole underlying medical condition than for any others. This is a good thing, and this work will have the added benefit of strengthening Canada's MAID system for all patients.
If you were to ask me what I need if tomorrow I had to assess MAID eligibility for a person with a mental disorder as their sole underlying medical condition, the answer is nothing. The work has been done. We are ready.
:
Thank you. It's a privilege to speak to the committee.
I'm Dr. Douglas Grant. I'm a registrar of the college of physicians in Nova Scotia. I'm a family doc and a lawyer, and I represented the Federation of Medical Regulatory Authorities of Canada at the Health Canada working group.
My approach to the question is that all readiness must be built on regulatory readiness. My respectful submission is bluntly this: Regulators are ready for this. We don't need any more time. We're not coming for more time.
We will be ready for many reasons.
The first is that most of the hard work has been done. The model practice standard developed by the Health Canada working group is the best synthesis of the law with the input of all necessary stakeholder voices. I know I speak on behalf of my fellow registrars that we see these as very useful documents. The document can be adopted in whole, which Nova Scotia will do—and I can tell you that we will be adopting it in whole in other Atlantic provinces as well—or used as a template to build a professional standard upon. The supporting documents provide à la carte language that could be plugged into existing college standards.
At the end of the day, what will happen in March 2024 is that all medical regulators will have guidance and professional standards in place that are built from or informed by the model practice standard developed by the Health Canada working group. With exceptions for style and format, there will be substantial consistency between provinces.
The second reason why the regulators will be ready in March is that we have a solemn and legal duty to be ready.
There may be some slight variations in provincial legislation, but all medical regulatory colleges have a mandate to regulate the medical profession in the public interest. That mandate means we're in service to patients. In this case, we're in service to the specific patients who are suffering, who are being denied a form of care to which they are entitled in law, and who, as a class, have been suffering and denied this care since 2015.
Finally, our duty extends to physicians themselves who look to provide this care, who are entitled to a clear articulation of regulatory direction and expectations. I'm here to say that the regulators will meet their duties.
The fact that we're here implies that you have heard voices from non-regulators implying that the regulators are not ready. I would like to unpack those concerns.
First of all, they are not supported by history. At each step of MAID's evolution, there has been a chorus of voices asking whether the regulators were ready. After the one-year implementation period was coming to an end following Carter, there were calls of unreadiness. At the time, I was the president of the Federation of Medical Regulatory Authorities of Canada, and I made submissions to a joint committee like this—I don't think it was in this room—indicating that the regulators were ready. We were ready.
We were ready when the law evolved to include eligibility for patients whose natural death was not reasonably foreseeable. Then we were ready again when Audrey's amendment, which enabled a waiver of final consent to eligible patients at risk of a loss of capacity, came into law.
I guess I would like to say that this is par for the course. Medicine constantly evolves. MAID will evolve and the medical regulators will respond, because we have a duty to be nimble.
I hope that the concerns of unreadiness are not in response to silence on the websites of colleges like my own. That would be a mistake. Professional standards serve many purposes. They declare the regulatory expectations, direct the caregivers, and also serve a public purpose. They advise the public of what it is entitled to expect. Rooms like this indicate that the situation is fluid. The regulators in the college in Nova Scotia, which I run, will wait until the path forward is settled and political debate has stopped. The medical regulators have no desire to mislead or confuse the public.
I would encourage this committee to be disciplined in its efforts to distinguish opposition to MAID from accusations of unreadiness. In my experience, the choir of voices making accusations of unreadiness has been entirely composed of voices that are opposed to MAID. With the courts having made their final decision, opposing voices cannot advance arguments to stop MAID.
I would ask the committee to ask whether the accusations of unreadiness are a genuine argument or simply an attempt to buy time for the sake of time, when no time is needed—at least not from the regulatory perspective.
:
Good morning, everyone.
My name is Dr. Claire Gamache. I'm the president of the Association des médecins psychiatres du Québec.
We thank the House of Commons for the invitation and the opportunity to discuss these sensitive issues.
The Association des médecins psychiatres du Québec, or AMPQ, is one of the 35 associations affiliated with the FMSQ, the Fédération des médecins spécialistes du Québec, which represents 1,200 psychiatrists.
The association is a union that strives for optimal conditions of practice for its members, but since its inception, the association has been interested in the organization of care, access to mental health services, and the improvement of public literacy on mental disorders.
From the outset of the discussions on medical assistance in dying when mental disorders are the sole underlying medical condition, the AMPQ was involved and took part in the conversation.
We participated in the Standing Committee on Justice and Human Rights' consultations on Bill , the presentation of the position statement of the Collège des médecins du Québec in October 2020, the presentation to the Commission on end-of-life care of the AMPQ's discussion paper entitled “Access to medical assistance in dying for people with mental disorders”, at the national forum on the evolution of the Act respecting end-of-life care, and the consultations of the Special Commission on the Evolution of the Act respecting end-of-life care.
In 2020, the AMPQ's board of directors approved the position that people whose sole underlying medical condition is a mental disorder should not be systematically excluded from medical assistance in dying.
At the request of the Collège des médecins du Québec and the Commission sur les soins de fin de vie, the AMPQ published a discussion paper including a proposal on how medical assistance in dying could be organized within the province of Quebec. That brief was produced with the input of a patient partner and a member representing caregivers.
The AMPQ presented its work to its members at its annual meeting in 2021.
To educate its members, the AMPQ offers continuing professional development activities at its annual conferences and a day of update on medical assistance in dying for medical specialists in Quebec. That day will be held on November 17, 2023, with a session specifically on mental disorder as the sole underlying medical condition.
The AMPQ testified before the parliamentary committee responsible for studying Bill 11 in Quebec. During its testimony, the AMPQ advised the government not to include an exclusion clause for persons with mental disorders. A number of professional associations, including the Fédération des médecins spécialistes du Québec, the Fédération des médecins omnipraticiens du Québec and a number of regulatory bodies, including the Collège des médecins du Québec, the Ordre des psychologues du Québec, the Ordre des infirmières et infirmiers du Québec, and the Ordre des travailleurs sociaux et des thérapeutes conjugale et familiale du Québec, as well as the Commission des droits de la personne et des droits de la jeunesse du Québec, have expressed a similar opinion to that of the AMPQ.
In addition to its regular activities, the AMPQ sat on the national steering committee of the Canadian Association of MAiD Assessors and Providers and reviewed the program as a whole.
All of the AMPQ's interventions and participation in the conversation surrounding medical assistance in dying are intended to raise awareness of the reality of people with mental disorders, their loved ones and the caregivers who support them.
Our experience shows that mental disorders remain little-known and that their effects on life courses are poorly understood by the public.
When we talk about MAID when mental disorder is the sole underlying medical condition, we're talking about patients who we've been following for decades who have tried multiple therapies and treatments.
As you heard from Dr. Gupta, psychiatrists on the ground are already involved in assessing, in various forms, a complex clientele in the MAID processes. They participate in second assessments, collaborative assessments with GPs, and as in any new care, there will be graduated skills development through pairing, mentoring, and training.
The main objective of the AMPQ is to combat stigma by using its expertise and experience with the most vulnerable. However, to avoid perpetuating this stigma and discrimination, inclusion is the best option.
:
Thank you very much, Madam Chair.
My questions are for Dr. Gupta.
Dr. Gupta, you said we're ready with respect to MAID and mental illness. I would submit that's tough to accept, given what we've heard in the previous hour about how there's no consensus among psychiatrists. Only 2% of psychiatrists have signed up for the curriculum program, and there aren't enough resources, but you say we're ready. Are we, really?
I would submit that the heart of the issue is the question of irremediability—whether someone can get better and whether that can be accurately predicted. As you will recall, on page 40 of the expert report issued by the panel you chaired, it states that:
There is limited knowledge about the long-term prognosis for many conditions, and it is difficult, if not impossible, for clinicians to make accurate predictions about the future for an individual patient. The evolution of an individual’s mental disorder cannot be predicted as it can for certain types of cancers.
That report was issued in May 2022. Has anything changed since May 2022 with respect to that conclusion?
:
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. The people who are going to start are people like my colleague Dr. Daws, whom I mentioned in my opening remarks. They have a lot of experience and have seen a lot of patients, and they're the ones who are going to do the initial work while, as Dr. Gamache said, they train and mentor others who wish to become involved.
There will always be people who don't want to be involved, and that is completely fine. The colleges and the law allow for that.
It's interesting that we're talking about the 2%, because, in fact, only 2% of Canadian physicians are MAID providers, so it's a small number of people who wish to be involved. Those people will continue to be involved, some more than others. That's entirely normal.
:
Thank you, Madam Chair.
I want to thank the witnesses for their clear testimony.
Dr. Gamache, I asked the same question earlier, but I don't know if it was understood.
Do you think that expanding access to medical assistance in dying to people with mental disorders could have a preventive effect on those who, for example, have suicidal ideation and are not currently in care? Would expanding this access allow these people, who may want to request medical assistance in dying, to be taken care of? At the moment, we don't know that they need help.
Thank you, doctors, for your great expertise.
It has been suggested that some of us who were raising questions about being ready want to relitigate MAID. I'm not one of them. I've had some very close friends choose MAID so they could have an end of life that they had control over with their families. These were very profound moments. I respect that. I'm trying to see how.... I deal with families, with people who have deep mental illness and depression. How can I assure them that this process is done with all the care necessary?
Dr. Gamache, you said that those who would be eligible would have been involved in the medical community for decades. If someone comes in with deep and significant suffering, deep depression, perhaps addiction and suicidal ideation, but hasn't been involved for decades, would they still be eligible?
I'm trying to get my head around this issue of discrimination against the right to MAID, or discrimination against the right to proper medical treatment.
Dr. Gupta, you said the federal government had stepped up above and beyond in making sure of everything that was necessary. In the work that I do as a member of Parliament, we're screaming for the federal government to step up all the time on mental health, but it doesn't.
I represent northern rural communities that are isolated, where we have suicide deaths from gunshots. We have people with deep mental illness who just run off into the woods, and the family can't find them. I'm having a problem here with saying that we're ready to have a really clinical, clear process for people to end their lives, but we don't have the tools in place to be ready to keep people through these times of crisis.
You're on the front line. What do you see?
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I appreciate that. I don't know anything about medicine. I dropped out of high school to play in a punk band. My life experience is dealing with families in crisis. That's what I do as a member of Parliament. We deal with this all the time.
It is a very emotional issue for people. I have a really hard time going back to them and saying “Don't worry; there will be a process for MAID” but not being able to tell them there will be a process for their loved one to get treatment.
Who is eligible, and who is not? If it's deep depression, I know people who have had deep depression for years. I know people who have been deeply suicidal for years. I'm reading all the clinical reports on how they should be treated and how they should assessed. To me, it doesn't sound like the real world. It sounds like an ideal situation of someone who sought this, who comes through the door and has made an informed decision. We're dealing with people who live in storms of darkness and upheaval, and then they settle down and their families go with them.
What are the provisions that separate that?
My question is for Dr. Gupta and Dr. Gamache, and I'd like brief answers.
Last year, a psychiatrist appeared before our committee. On the subject of an individual's eligibility for MAID, she said there were so many important criteria to consider that, out of all the cases she had seen in 30 years of practice, she had encountered only three people who were eligible, given the long-term treatment, chronic disease, and so on.
What are your thoughts on that?
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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. We all understand that an incurable condition and an advanced stage of irremediable decline requires, as it currently does under track two for other chronic conditions, a long history of failed treatment and an inability to function in a way that gives the person an adequate quality of life.
As to your question about suicidality, suicidality is already part of MAID assessment right now. When people are in crisis, MAID assessments are either not done—if that's what the person is asking for—or they are put on hold so that the crisis can be attended to. It will be exactly the same thing when a person has a mental disorder as their sole condition.
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Thank you, Senator Martin.
[Translation]
I thank all the witnesses for being here with us, for participating in the process and for answering questions. We know there's never enough time, but those are the rules.
Thank you for coming.
[English]
We will now suspend briefly to move in camera to discuss committee business. For our colleague Mr. Angus, who attended virtually, a Zoom link for in camera has been sent already.
We will take about five minutes.
[Translation]
We'll suspend the meeting.