44th Parl. 1st Sess.
February 15, 2024 10:00AM
Mr. Speaker, I am thankful for the opportunity to speak about Bill C-62 and the extremely important issue of medical assistance in dying, or MAID, and mental illness.
I think all members can agree that this is a highly complex, quite sensitive and emotional issue, that raises divergent and deeply held views from the medical community, experts and the public at large. The questions of whether, how and when to expand eligibility for MAID to persons whose sole underlying medical condition is a mental illness are difficult; they do not have easy answers.
The federal government believes that eligibility for MAID should be expanded to such persons. However, such an expansion should not be rushed and should not occur before the health care system is ready to safely provide MAID in all cases where it is requested on mental illness grounds. This is why we have introduced Bill C-62, which proposes to extend the temporary mental illness exclusion by three years, until March 17, 2027. The bill also includes a provision requiring a parliamentary review prior to that date.
As members will recall, in 2015, the Supreme Court of Canada concluded in the Carter case that the Criminal Code’s absolute prohibition on physician-assisted death was unconstitutional. The Supreme Court held that physician-assisted dying must be permitted in some circumstances, namely, for competent adults who clearly consent to the termination of life and who have a grievous and irremediable medical condition. This decision led to the legalization of MAID in Canada one year later, in 2016, through Parliament’s enactment of former Bill C-14. Our original MAID law limited eligibility for MAID to competent adults with an eligible medical condition whose natural death was reasonably foreseeable. Our MAID framework was added to the Criminal Code and was made up of a stringent set of eligibility criteria, as well as procedural safeguards to prevent error and abuse in the provision of MAID.
A few years later, the “reasonable foreseeability of natural death” eligibility criterion was challenged in Quebec; in 2019, it was declared to be unconstitutional by the Superior Court of Quebec in the Truchon decision. As this was a trial-level decision, it was only applicable in Quebec. Nevertheless, the Attorney General of Canada did not appeal the decision; instead, the federal government made the policy decision to expand eligibility for MAID. This led to Parliament’s enactment of former Bill C-7 in 2021, which expanded eligibility for MAID to persons whose natural death is not reasonably foreseeable. This resulted in the removal of the eligibility criterion that a person’s death be reasonably foreseeable and the creation of two sets of procedural safeguards for the lawful provision of MAID.
The first track of safeguards applies to persons whose natural death is reasonably foreseeable; the second, more robust, track applies to persons whose natural death is not reasonably foreseeable. This second set of safeguards was created in recognition of the fact that requests for MAID by persons who are not at end of life are more complex. This is why a minimum of 90 days must be taken to assess a person for eligibility for MAID when their natural death is not reasonably foreseeable. This is not a reflection period; it is a minimum assessment period. This safeguard aims to respond to the additional challenges and concerns that may arise in the context of MAID assessments for persons whose natural death is not reasonably foreseeable. This includes whether the person’s suffering is caused by factors other than their medical condition, as well as whether there are ways of addressing their suffering other than through MAID.
This second set of safeguards also requires that two practitioners be satisfied that the person meets all the eligibility criteria, and if neither of them has expertise in the medical condition causing the person suffering, one of them must consult with a practitioner who does. Involving a practitioner with the relevant expertise aims to ensure that all treatment options are identified and explored.
Practitioners are also required to inform the person of available counselling services, mental health and disability support services, community services and palliative care; to offer them consultations with the relevant professionals; and to ensure that the person has given serious consideration to such alternative means to alleviate their suffering. Although this does not require a person to undertake treatments that may be unacceptable to them, it requires that they fully explore and weigh the risks and benefits of available treatment options.
Former Bill C-7, as originally introduced, permanently excluded eligibility for MAID on the basis of a mental illness alone. This was not because of the incorrect and harmful assumption that individuals who have a mental illness lack decision-making capacity or because of a failure to appreciate the severity of the suffering a mental illness can cause. Rather, this was done because of concerns about the inherent risks and complexities of permitting MAID for individuals who suffer solely from mental illness.
During its consideration of the bill, the Senate made an amendment that added a sunset provision that would repeal the mental illness exclusion 18 months later. The House of Commons accepted the amendment in principle, but changed the date of repeal to two years; in other words, the provision of MAID based on a mental illness alone was set to become lawful on March 17, 2023.
The decision to temporarily maintain the exclusion of eligibility was based on the recognition that additional study would be required to address the risks and complexities of permitting MAID in these circumstances. This is why the former bill also included a requirement for an independent expert review respecting recommended protocols, guidance and safeguards to apply to such requests for MAID.
Former Bill C-7 also required the creation of a joint parliamentary committee tasked with conducting a comprehensive review of the Criminal Code's MAID provisions and other MAID-related issues, including MAID and mental illness. The committee undertook this important work, and its interim report, which focused on MAID and mental illness, was tabled in June 2022. It urged the federal government to collaborate with regulators, professional associations, institutional committees and the provinces and territories to ensure that the recommendations of the expert panel were implemented in a timely manner.
The committee's second report was tabled in February 2023. The majority view expressed was that eligibility for MAID on the basis of a mental illness alone should be permitted. However, the final report also raised a key concern that more time was needed for standards to be developed and training to be undertaken before the law should permit a mental illness to ground a request for MAID. The federal government recognized the significant progress that had been made by the provinces and territories, stakeholders and the medical community in preparing for the expansion. However, it ultimately concluded more time was needed.
This is why we introduced Bill C-39, and Parliament enacted it. It extended the exclusion by one year, until March 17, 2024. This extension aimed to provide additional time for the dissemination and uptake of key resources by the medical and nursing communities. We thought it essential to prepare for the safe assessment and provision of MAID in all cases where a mental illness grounds a request for MAID. The committee expressed support for the extension in its second report.
I want to take a moment to recognize the work that the federal government has done during this extension to support the fulfillment of some of the expert panel’s recommendations. For instance, we amended the regulations for the monitoring of MAID last year to ensure comprehensive data collection and reporting. Such changes allow for data collection related to race, indigenous identity and disability of persons requesting MAID. These changes came into force in January 2023, and the first set of data will be captured in Health Canada’s 2024 annual report on MAID.
Moreover, Health Canada convened an independent MAID practice standards task group to develop a practice standard for MAID. In March 2023, the model MAID practice standard and supporting documents that provide guidance to support complex MAID assessments were released. Finally, Health Canada supported the Canadian Association of MAiD Assessors and Providers in the development of a Canadian MAID curriculum, which was launched in September 2023.
In Canada, certain aspects of MAID fall under federal jurisdiction and others fall under provincial and territorial jurisdiction. The federal government is responsible for the criminal law aspect, whereas the provinces and territories are responsible for the implementation of MAID within their health care delivery systems. Impressive progress has been made in preparing for the expansion by the March 2024 deadline. However, the provinces and territories have all expressed that they are not yet ready. For this reason, we are proposing to extend the temporary mental illness exclusion for another three years, until March 17, 2027.
The extension would allow more time for the provinces and territories, and their partners, to prepare their health care systems by implementing regulatory guidance and developing additional resources for their medical and nurse practitioners. It would also provide more time for medical and nurse practitioners to become familiar with the available training and supports. Our ultimate goal is to help ensure that the necessary protections are in place to protect the interests of individuals who may seek MAID on the basis of a mental illness alone.
We believe that this issue should not be rushed. Eligibility for MAID should not be expanded until the health care system is ready to safely provide MAID in these complex circumstances. I urge all members to support the bill so our partners can get this right.
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Mr. Speaker, I obviously agree with the member. The dog that ate the government's homework has been fattened up over the last nine years, because it had a lot of homework to eat that the government has not done or pretends not to have done.
However, we had an opportunity to close the door completely with the bill from the member for Abbotsford, Bill C-314. I think it was a grave mistake of the House not to have voted in favour of it. There would have been no expansion of MAID to those with mental illnesses. The House and future Parliaments could have reviewed the situation and redecided on the matter in five, 10, 15 or 20 years. Then, there would be more data and more people looking at how the system had been used, what the demand was like, and whether there had been advances in the psychiatric and mental health services provided to Canadians. If we do not provide the service at the front end, so that a person could choose to get healing and have the ability to live a fulsome life the way they want to live it, then we cannot really be pushing MAID on the other side as the only path available to those who are vulnerable or suffering from mental illness.
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- Feb/15/24 1:57:41 p.m.
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Mr. Speaker, I am concerned about it. I do not know what it means and there is much disagreement as to what it means.
I would ask a question of the member, which I know he will not have to answer under the rules. Is he okay with track one MAID? A lot of the psychiatrists who went before the committee who were not in favour of MAID for mental disorders were in favour of track one and track two. I would like to know if the member accepts MAID under any circumstance or not at all.
It is an important ethical and moral decision, I agree, but no one in the House wants people to suffer needlessly, and I think we are all grappling with this on moral and technical grounds. It may not be possible, I cannot say, but we want to separate out suicidal ideation. We want to be able to separate out psychosocial factors as motivating factors for requesting MAID in cases of mental illness, and we are not there yet.
We want to study treatment fatigue to see, if somebody says they are done and cannot take it anymore, whether we can guide them to another treatment. We have looked at treatment fatigue when it comes to HIV and type 1 diabetes patients, but we have not looked at treatment fatigue when we talk about psychiatric illnesses.
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- Feb/15/24 4:03:00 p.m.
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Mr. Speaker, let me start by apologizing to the four or five people who might have listened to my last speech and who are here listening again today, because this is going to sound a little repetitive.
I certainly support the legislation, and I know there are a lot of people out there who are really worried about allowing MAID for mental illness. There are people who are worried about their friends. There are people who are worried about their parents. I am most sympathetic to people who are worried about their children. I have six children, and I know that they are going to, at some point in their life, go through difficult times. I would certainly be a little worried for them if we were to allow MAID for mental illness to be implemented with the current safeguards.
I know that there are also many psychiatrists who are worried about and/or oppose the legislation. In fact, the latest statistic I heard was from a survey that showed that about 75% of psychiatrists were against it. They are worried that their patients who would otherwise get better would instead resort to MAID.
Let me take a step back and look at the arguments coming from the other side. People are going to say, “Why not? Is it not a matter of personal autonomy? Is it not my body and my choice?”. This is not about the state's dictating to the individual what they can do with their own body. It does not criminalize trying to commit suicide or committing suicide. This is about what role, if any, the state should have in assisting people to commit suicide.
I am going to come back to the issue of whether MAID for mental illness is the same as assisting suicide.
The question of whether the state ought to take a role in assisting people in ending their lives is, I think, a little like the question of whether the state should try to prevent people from killing themselves. This is a topic I know something about, having worked a lot of years as an emergency room physician. In that role, my job, if somebody came before me and was suicidal, was to keep them in the hospital, even against their will, to prevent their suicide from happening.
Occasionally people would ask why I should I have that power, saying, “ Is it not my body, and my decision to make?” I think that there are two legitimate reasons for the state to try to prevent people from killing themselves. One is to protect someone from themself. When one is in the depths of depression, they cannot realize that things will get better; that is partly why someone is so depressed and wants to kill themself. The reality for most people is that they do in fact get better.
The other legitimate reason for the state's intervention is to protect the family. The person who commits suicide is dead. The rest of the family lives on and lives with the pain, but it is not only that; they are constantly haunted by whether the death was because of something they did or did not do.
Some people are going to say that, no, MAID for mental illness is not the same as assisted suicide, that we are talking about a small group of people who have intense, prolonged suffering and have tried every form of treatment but nothing has worked, and that it is cruel and unconstitutional to not allow those people access to MAID. I disagree. The Canadian law is far more permissive than, for example, the Dutch law. There is absolutely no requirement that all forms of treatment have been tried and been unsuccessful. Our law does not even require patients to have tried any treatment at all; it requires only that the patient have no other treatment that is acceptable to them. There are going to be people who refuse all forms of treatment altogether.
I know that there are people who support MAID for mental illness who will say that the safeguards are going to come from the medical profession, that they are going to require someone to have tried all forms of treatment beforehand. Unfortunately, I do not have the same sort of faith in the medical profession's doing that. Why do I not? If we look at what has happened with the MAID regime for people with physical illnesses, we see that there are a lot of MAID practitioners who are very zealous about its being all about one's personal autonomy and saying it is not for them to question someone's suffering, and who are quick to approve people.
Let me give some examples from the media. The Fifth Estate aired a program that said that a 23-year-old diabetic going blind in one eye was granted MAID. Another person, a 54-year-old man, had back problems, but his main problem seemed to be that he was worried about losing his housing and ending up on the street. He too was granted MAID.
CTV published a couple of relevant articles. A 51-year-old woman was actually granted and got MAID for multiple chemical sensitivities. Again, from CTV, a 31-year-old woman who seemed to use a wheelchair from time to time and had multiple environmental allergies, applied and was approved for MAID; again, however, her main problem seemed to be that she could not find suitable housing.
There are those who have such faith in my fellow doctors to come up with the system and all the safeguards, but I do not share the same sort of faith. I, as someone with a lot of children, realize it is inevitable that at times in their life they are going to go through a hard time, the breakup of a relationship or financial hard times. I am really worried that they would walk through the door of a zealous practitioner who will tell them it is all about personal autonomy and is their decision to make, because who is the doctor to question their suffering. There is not any requirement in the current legislation that the MAID practitioner talk to the family or the previous treating practitioner to find out whether in fact the depression was motivated by, for example, the breakup of a relationship.
I also want to talk about what I think is a really fundamental and perhaps fatal flaw in the current regime with allowing MAID for mental illness, which is the problem, the impossibility, of determining irremediability: Who is not actually going to get better? I have spoken previously about the inability of suicidal individuals to appreciate the fact that they are going to get better. Some people would ask whether there are people who are not going to get better, who are irremediable. That is in fact the requirement of the legislation. The problem is that doctors do not have a crystal ball. They are not really good at being able to determine who really is irremediable.
In fact, a recently published study looking at the ability of clinicians to determine irremediability for treatment-resistant depression concluded:
Our findings support the claim that, as per available evidence, clinicians cannot accurately predict long-term chances of recovery in a particular patient with [treatment-resistant depression]. This means that the objective standard of irremediability cannot be met....
Furthermore, there are no current evidence-based or established standards of care for determining irremediability of mental illness for the purpose of [MAID] assessments.
For me, as a long-time medical doctor, it is absolutely mind-boggling that there are medical practitioners and psychiatrists who are not particularly bothered by the fact that they really cannot say whether the illness is irremediable, and would grant MAID. If we allow MAID for one such person who would actually get better, to me it would seem tantamount to the same sort of tragedy as the state's hanging someone who later turned out to be innocent. We in this place cannot let that happen.
Last, let me address the assertion of proponents of MAID who say that it is inevitable that the Supreme Court would find not allowing MAID for mental illness unconstitutional because it is allowed for physical illness. I think that, yes, there would be a finding that such a provision would violate section 15 or section 7, but as always, the question comes down to the section 1 analysis and whether the state's actions constitute a reasonable limitation as prescribed by law that “can be demonstrably justified in a free and democratic society.” I do not think the answer to that is clear. It is not just me; there was a letter written by 32 law professors who came to the same conclusion: it was not clear whether it would be found unconstitutional.
I am not going to say that we should never allow MAID for mental illness; in fact, I know personally of a case where this might have been the ethical thing to do, but I think we are a long way now from being in a situation where we should start to allow it. I would prefer the pause be indefinite, but so be it. We have what we have. Let us look at it in two years and see what has changed. I doubt very much will have changed.
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- Feb/15/24 4:15:01 p.m.
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Mr. Speaker, I am not against MAID for physical illnesses. That is a totally different situation. The problem with MAID for mental illness is the inability to determine who is not going to get better. The unfortunate reality is that there are a lot of doctors who have a very cavalier attitude toward taking someone's life, and that there are people who could or would get better with a little time and with better treatment who would otherwise have their lives foreshortened by one of these zealous practitioners.
Certainly it is very different from, for example, the Carter situation, or someone who has ALS and is terminally ill with a neurodegenerative disease. That is a totally different story, and in those cases I certainly approve of MAID if that is what the person wants.
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Mr. Speaker, I will be splitting my time with the member for Pitt Meadows—Maple Ridge.
Bill C-62, no. 2, suggests that we pause the expansion of medical assistance in dying, known as MAID, to people suffering from mental illness. The Liberals have shown time and again that they consistently pass legislation without the careful consideration needed for such significant changes to our society. This discussion is not just legislative; it is about how we value human life and the impact of the government's choices on all Canadians. In thinking about extending MAID to include mental illness, there is a need for a deep understanding of the complexities and uncertainties in diagnosing and predicting mental health outcomes.
Evidence to the Special Joint Committee on Medical Assistance in Dying showed a worrying truth: Clinicians often struggle to predict whether mental health conditions are irremediable, and they have a 50% chance of being wrong. This alarming fact points to a big problem with the proposed expansion; this is the chance of making permanent choices based on uncertain medical opinions. Mental health involves biological, psychological and social elements. Recovery is not always straightforward, and what seems irremediable at one point may improve with treatment.
Basing MAID on the idea that a mental illness cannot be cured shows a misunderstanding of the changing nature of mental health recovery. As the member for St. Albert—Edmonton put it, it is like flipping a coin on matters of life and death, a practice that is ethically troubling and goes against the idea of patient-focused care. Moreover, we cannot discuss MAID and mental illness without considering the wider issues of access to quality mental health care in Canada.
When people such as Canadian Paralympian and veteran Christine Gauthier are offered MAID from the government when simply requesting help with a wheelchair lift, it shows a worrying trend of suggesting MAID as a fix for systemic failures to providing proper care and support for those with disabilities and chronic conditions. This is not just one case. It reflects a larger problem, wherein essential services and supports are lacking; this drives people to consider MAID not because they want to but because they feel neglected by the Liberal government.
The risks of broadening MAID to include mental illness alone are complex, going beyond clinical doubts to wider social and ethical issues. It makes us question our dedication to mental health care, the value we place on lives touched by mental illness, and the kind of society we want to have. Do we face challenges with empathy, support and a commitment to better care, or do we settle for solutions that ignore the struggles Canadians face?
The Liberal government's approach to expanding MAID shows a wider trend of hasty law-making that leads to policies being introduced, then pulled back or changed after facing reality and public criticism. From errors in firearms legislation to heated debates on the carbon tax, the government often acts first and thinks later. This not only damages our law-making process but also lowers public trust in our ability to govern wisely and carefully.
The rush to include mental illness in MAID, without proper evidence or full discussions with mental health experts, ethicists and affected groups, shows a lack of regard for the careful and expert-led discussions that such a major policy change requires. The need to pause and rethink this expansion, via the bill, is an admission that the government's actions have been rash and poorly thought out.
This legislative step back, marked by two delays in implementation, is not just a minor issue; it is a clear sign of the dangers of choosing political speed over solid, evidence-based policy-making. It raises serious doubts about the government's commitment to responsible governance, which includes the need to fully explore, understand and foresee the effects of laws before they are passed. In this critical discussion on MAID, we must also consider the perspective of those directly affected by such policies. The voices of individuals and families living with mental illness must be central to our legislative process.
Their experiences and insights can provide invaluable guidance as we navigate the complexities of this issue. By engaging with these communities, we can ensure that our laws reflect the realities of those they impact most and uphold the principles of empathy and inclusion. Furthermore, the debate on MAID expansion underscores the need for comprehensive mental health services.
The government must prioritize the enhancement of mental health care infrastructure, ensuring that all Canadians have access to the support and treatment they require. By strengthening our mental health care system, we can address the root causes of despair and hopelessness that lead individuals to consider MAID, thereby affirming our commitment to life and well-being.
This moment also calls for a re-evaluation of our societal values and the role of government in safeguarding the dignity of every citizen. As policymakers, we have a duty to foster a culture that values every life, provides hope through support and resources, and respects the autonomy of individuals while carefully considering the ethical implications of life-ending interventions. This approach would not only address the immediate concerns surrounding MAID but would also contribute to a more compassionate and just society.
As we think about what this pause means, we must consider the lessons learned and push for a more thoughtful, consultative and evidence-based approach to making laws. The stakes are too high, and the chance for unintended harm too great, to accept anything less. In MAID's case, where ethics, law and personal choice intersect delicately, our responsibility to be extremely careful and considerate cannot be overstated.
The proposal for a pause on MAID's expansion clearly shows that the Liberal government's policy-making has been quick and poorly thought out. While this pause is needed, it points to a bigger issue of governance, where major legislative changes are made without enough foresight, discussion or understanding of the deep ethical implications. This pause reminds us of the dangers of enacting laws that deeply affect Canadians' lives and well-being, especially the most vulnerable. It shows the current Liberal government's failure to engage in a careful, evidence-based legislative process, preferring instead policies that match ideological aims rather than the complex realities of issues such as MAID and mental health.
This should be more than a brief stop; it should be a crucial time to rethink how policies, especially those about life and death, are made and applied. It questions the government's commitment to maintaining the highest standards of care, empathy and respect for all Canadians' dignity. We must demand greater legislative care and ethical responsibility from the government.
The discussion on MAID and mental illness needs a comprehensive approach that puts individuals' well-being and rights ahead of quick political gains.
It is time for a move towards more responsible governance, where policies are made with great care, are based on wide consultation, and reflect our collective values and ethical standards. Sadly, the current Liberal government seems to lack concern for any of these values.
The way forward should be marked by a dedication to thorough research, wide involvement and a deep respect for life's sanctity. Only by such a comprehensive approach can we ensure our legislative actions truly serve all Canadians, embodying the justice, empathy and respect that define our nation.
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- Feb/15/24 4:47:16 p.m.
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Mr. Speaker, this amendment was brought in by the Senate, the other place, in the first place. It was not in the original legislation. It came back here; the Liberals decided it was a good idea, and it got put through the House without any time limit. It was supposed to be law, and then they extended it for a year. They are now trying to extend it for three years. They are relying on the same people who brought in this idea of MAID for mental illness to postpone it for three years.
Does the member think that this is going to be an easy ride through the Senate, or are the senators who brought this in in the first place going to give it a hard ride?
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- Feb/15/24 5:04:18 p.m.
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Mr. Speaker, to our hon. colleague for Kingston and the Islands, our colleague for Sherwood Park—Fort Saskatchewan only said that when speaking of MAID for those with mental illness, how do we differentiate between suicidal ideation and MAID?
Indeed, it is what we are hearing from the experts who said, “There is no evidence that shows we can predict irremediability in mental illness and it is vastly different, vastly different from other medical conditions and neurodegenerative diseases.... We have to remember what MAID is about. MAID is about predicting who will never get better, and we can't do that, and if we can't do that with mental illness, we would providing death under false pretenses.”
This is completely different from what our hon. colleague talked about with this father-in-law, who was struggling with a brain tumour, choosing MAID and those who are struggling with mental illness, which has been associated with flipping a coin on who can get better and who cannot get better.
I ask my hon. colleague this: Is she okay with flipping a coin when it comes to offering MAID to somebody who is wishing to die by suicide.
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