Hon. Stan Kutcher moved third reading of Bill C-39, An Act to amend An Act to amend the Criminal Code (medical assistance in dying).

He said: Honourable senators, I rise today to speak at third reading of Bill C-39, which extends by one year the implementation day for medical assistance in dying — mental disorder as the sole underlying condition, or MAID MD-SUMC. Once again, I would like to acknowledge that our debates which address sensitive issues such as suicide can be distressing to some and that seeking help when you need it is a sign of strength.

During second reading, I spoke to the scope and purpose of the bill and the reasons why the extension is necessary. Today I will remind us of those reasons, and I will also spend time addressing some of the misinformation that has coloured public understanding of the complex issues surrounding end-of-life choice and has sadly crept into medical professional and parliamentary discourse on the topic of MAID MD-SUMC.

The one-year extension will allow for readiness within our health care systems through cooperation between federal, provincial and territorial governments, regulators and providers. In my opinion, readiness means that four conditions have been met: one, that the model practice standard is finalized, published and distributed to regulators in each province and territory; two, that the certified MAID training program has been completed and is available for access by MAID practitioners; three, that the updated reporting requirements have been fully implemented, and the government has begun to gather the data that will be critical for ongoing assessments of the MAID system in Canada; and four, that the government has had the time needed to review the report of the Special Joint Committee on Medical Assistance in Dying.

Colleagues, we are addressing one of the most important legislative challenges that Canadians have faced and, as Senator Martin said in her second-reading speech, a “complex and deeply personal” issue. We are dealing with an issue that will go down in our history as a touch point in the evolution of our understanding of the individual rights and autonomy of those who are living with a mental disorder. This is of the same depth, complexity and nature as two other health-related issues that we have previously grappled with: contraception and women’s reproductive rights. This evolution in our thinking reflects a movement towards a more compassionate society in which we respect and value each other regardless of who we are, who we love or how we choose to die.

This evolution also reflects how Canada is moving to health provision in which the traditional autocratic paternalism of the past is being replaced by patient-centred care. Now we expect that health care providers collaboratively work with patients to create the compassionate conditions in which competent individuals can make free and informed decisions about their own bodies in life, as well as when contemplating death.

The complex issues that we are dealing with in MAID MD‑SUMC require careful critical thought, respectful discourse, a deep understanding of the nuances involved and a willingness to put the interests of those who are intolerably suffering ahead of unbending ideology or political expediency. Addressing these complex issues also requires us to avoid creating or spreading misinformation and to call it out when we encounter it. We can respectfully disagree with each other. After all, that is an integral part of democratic discourse. That said, this is not the same as misinforming ourselves and each other.

Since the coming into force of Bill C-7, my office and I have been following the public discussions about MAID for mental disorder as a sole underlying condition in mainstream and social media. We have also carefully reviewed all the debates on Bill C-39 recently held in the other place. Personally, I have had the privilege of being part of the joint committee on MAID, as a number of other senators here have also had, and being privy to the many hours of witness testimony and the reading of many briefs.

As a result of this research and deep exposure to the complexities and nuances that surround MAID MD-SUMC, I have identified three areas of misinformation that have characterized public and parliamentary debate in the last year. I will share those with you, as engagement with this issue will not likely end with the passing of Bill C-39. As we all go forward, knowing what some of the common types of misinformation are can help us in our research, discussions, deliberations and in our conversations with each other, regardless of what viewpoints we may hold. They are the following: MAID is replacing access to mental health care; MAID MD-SUMC is a slippery slope; and MAID is another name for suicide. I will take each and examine their origins.

Before doing so, however, let us be clear about how misinformation arises. Some of it is deliberate, initiated by actors who do not like how our society is evolving and who respond to this by the creation and distribution of misinformation. Some of it may be inadvertent, where well-meaning people are swept up into an emotional state and accept what is being promoted without a deep understanding of an issue and careful consideration and critical analysis of what information they are sharing.

I discussed the false statements that have been made about MAID MD-SUMD replacing access to mental health care and that individuals in an acute crisis can access MAID in my second-reading speech. Let me be very clear. People who are suicidal or in an acute mental health crisis will not qualify for and will not receive MAID.

Individuals who request and receive approval for MAID MD‑SUMC will have experienced a substantial amount of different kinds of mental health care for a prolonged period of time. They can also withdraw their consent at any time during the minimum 90-day period. Their intolerable suffering is not because they could not access mental health care; it is because none of the many interventions that have been tried over long periods of time have worked sufficiently well to alleviate their intolerable suffering. Sadly, for mental illness, as for other types of illnesses, not every person who is severely suffering finds the relief that they seek with any of the treatments that we have. Thankfully, this is a very small number of people, but it is still a group of individuals who suffer intolerably.

That is why for those who suffer intolerably, decisions as to MAID MD-SUMC eligibility must be made on a case-by-case basis. As I discussed on Tuesday, there is no “cookbook recipe” for determining if a person’s suffering is irremediable and intolerable. There are substantive clinical considerations for sure, and these have been identified in the expert panel report and in the model practice standard. Psychiatrists, using a two-stage Delphic process have also reached a consensus on what this means clinically. The regulatory bodies will further address these in their MAID practice standards, just as they do for all medical care.

It is essential for us to understand that clinical interventions for complex medical conditions are always done case by case, using evidence-based medicine and patient-centred care. Decisions on how and when to intervene eventually come down to a jointly made agreement between the one who suffers and those doing what they can to help alleviate that suffering. That is how modern health care is meant to work. The phrase “to cure sometimes, to relieve often, and to comfort always” aptly captures this patient and healer collaboration.

Another common misinformation argument made about MAID MD-SUMC is that it is a slippery slope — a classic example of a logical fallacy. Of the three different types of slippery slope fallacies, the causal slope variety is the one most frequently found in MAID MD-SUMC discourse. This is defined in the following way:

Causal slopes . . . revolve around the idea that a relatively minor initial action will lead to a relatively major final event.

While the outcome of this so-called slippery slope is not clearly identified, the presumed conclusion is that if MAID is offered for MD-SUMC, then in a short period of time, very large numbers of individuals who suffer with mental illnesses will receive MAID and/or that other horrific and untoward events will occur. A key component of this type of fallacious misinformation argument is that no evidence is provided to prove that what is predicted to happen will actually happen. Furthermore, it often confuses the expected and usual uptake of a new intervention as proof of the existence of a slippery slope and substitutes emotional angst and fear for rational consideration.

Here is what an expert review of the slippery slope fallacy had to say:

In general, slippery slopes are primarily associated with negative events, and as such, slippery slope arguments are frequently used as a fear-mongering technique. As part of this, slippery slope arguments often include a parade of horribles, which is a rhetorical device that involves mentioning a number of highly negative outcomes that will occur as a result of the initial event in question.

Unfortunately, the slippery slope fallacy has been perpetuated in media, in speeches in Parliament and during testimony provided to the joint committee on MAID.

The slippery slope fallacy also “. . . ignores or understates the uncertainty involved with getting from the start-point of the slope to its end-point.”

Therefore, the person making the argument has no idea what will actually happen. But they are certain that what they fear will happen will certainly happen and on this basis they promote this argument.

The misinformation distributed using a slippery slope fallacy can be substantial and have harmful impacts on the health and well-being of individuals and populations. It needs to be countered by pointing out the logical fallacy that this argument is based on and by providing data that addresses the fear that the argument is meant to encourage.

Let’s unpack the slippery slope fallacy as it pertains to MAID MD-SUMC in Canada. In the case of MAID MD-SUMC in Canada, we can look to evidence from other jurisdictions to determine the truth of such arguments. We can study jurisdictions that have introduced MAID MD-SUMC to determine if there is an ever-increasing and very large proportion of the population that is receiving MAID for a sole mental condition.

There is data to examine from the Netherlands and Belgium. In those jurisdictions, MAID MD-SUMC was introduced over a decade ago. We can examine the percentage of people accessing MAID for mental and behavioural disorders as a proportion of those accessing MAID once the pattern of use has been established.

Here is what the data shows us. In Belgium, in the last five years — for which the Library of Parliament was able to provide data to me — the proportion of people who accessed MAID for mental disorder as the sole underlying medical condition was as follows: 2017, 1.7%; 2018, 1.4%; 2019, 0.8%; 2020, 0.9%; 2021, 0.9%.

Let’s put these numbers in a different perspective. In 2021, the population of Belgium was 11.59 million. The total number of persons receiving MAID MD-SUMC was 24 — that is 0.00020% of the population. Clearly, there is no slippery slope in Belgium.

In the Netherlands, the numbers are as follows: 2017, 1.2%; 2018, 1.0%; 2019, 1.0%; 2020, 1.2%; 2021, 1.5%. Again, I’ll put these numbers in perspective. In 2021, the population of the Netherlands was 17.53 million. The total number of persons receiving MAID MD-SUMC was 115, that is, 0.00065% of the population — no slippery slope in the Netherlands either.

This data lines up with the recent study by Jordan Potter, published in Medicine, Health Care and Philosophy in 2018, titled, “The psychological slippery slope from physician-assisted death to active euthanasia: a paragon of fallacious reasoning.” Professor Potter concludes:

. . . (1) employing the psychological slippery slope argument against physician-assisted death is logically fallacious, (2) this kind of slippery slope is unfounded in practice, and thus (3) the psychological slippery slope argument is insufficient on its own to justify continued legal prohibition of physician-assisted death.

Colleagues, as practitioners of sober second thought, it behooves us to call out this misinformation based on the fallacious slippery slope argument when we come across it. Indeed, we could identify the phrase “slippery slope” as a yellow light warning us that what follows could be a fallacious argument.

A third area of mushrooming misinformation directed toward MAID MD-SUMC relates to the issue of suicide. Here the logical fallacy called the “jingle fallacy” — yes, there is a logical fallacy called the jingle fallacy — has been extensively used to muddy the reality and to call into question the primary purpose of MAID itself: an end-of-life choice made by a competent person who is suffering intolerably and who meets all requirements established by law.

A jingle fallacy is the erroneous assumption that two things are the same because they bear the same name — Logic 101, I remember. With MAID MD-SUMC, commentators using this logical fallacy state that MAID is suicide either because this medical practice had previously been called “physician-assisted suicide” or because, for their own reasons, they are using emotional rhetoric to activate the fear factor in others.

A very recent example of this is found in a media story on MAID MD-SUMC in which the following quote appears:

. . . when you introduce legislation that allows someone to prematurely end their life with the assistance of a medical practitioner, that is then doctor assisted suicide. By definition, that is suicide.

In this case, nomenclatural confusion may have contributed to the ease with which this type of misinformation has spread. Indeed, it was the 2016 joint House and Senate report that reviewed many of the terms used to describe this end-of-life intervention and settled on the term “medical assistance in dying,” possibly to avoid this confusion.

As a reminder to us all, the 2016 joint committee report was titled Medical Assistance in Dying: A Patient-Centred Approach. Those who have not yet had the opportunity to read it may want to do so. Those who have read it will recall that the third recommendation was:

That individuals not be excluded from eligibility for medical assistance in dying based on the fact that they have a psychiatric condition.

This committee also grappled with and accepted a definition of “grievous and irremediable,” which is similar to what the expert panel recommended in 2022.

If we listen closely to the suicide misinformation narrative, we will find that at no time is there any attempt made to critically parse how MAID and suicide are the same. The statement is simply made that they are, and that is that. So instead of blindly accepting this statement as truth, let us compare death by suicide and death by MAID. If MAID is indeed the same as suicide, these two types of events should have many similarities.

Suicide is often impulsive. MAID MD-SUMC requires a minimum of 90 days’ waiting and is not impulsive. Suicide is often violent, resulting in traumatic experiences for family members or first responders who come upon the body. MAID MD-SUMC does not result in that type of traumatic experience.

Suicide is a secretive and lonely act, often committed by an individual in desperate circumstances. Family and friends are avoided, not included. MAID is not a secretive and lonely act and usually occurs in the presence of family and/or friends.

Suicide often results in unresolved grief and lasting mental anguish for those left behind. Rates of depression, psychiatric admission, suicide attempts and death by suicide are increased in family members who are in bereavement from a suicide. For families involved in MAID, this experience results in grief and feelings of loss that are similar to those of families involved in palliative care experience and does not mirror the negative outcomes found in families who have experienced the loss of a family member to suicide.

Colleagues, you can decide for yourselves how these two items are similar or different. In my estimation, they do not share the same characteristics and are clearly not the same.

Perhaps, however, there are other ways that suicide and MAID could be the same. Let’s explore this possibility. If suicide and MAID were the same phenomenon, they should be similar in their population demographics. Further, if suicide and MAID affect the same population, the introduction of MAID should decrease rates of suicide. If, on the other hand, as some have argued, the availability of MAID will increase suicide rates in the population, the introduction of MAID should be followed by increased rates of suicide. Let’s check these possibilities out.

First, regarding the assertion that MAID and suicide affect the same populations, this is false. The age distribution of MAID deaths and suicide deaths is different. The gender distribution of MAID deaths and suicide deaths is different.

Second, the assertion that MAID will increase or decrease suicide rates in Canada is also false. The suicide rates in Canada did not increase or decrease significantly since the introduction of MAID. This difference in MAID as compared to suicide demographics in Canada and the lack of MAID impact on suicide rates in Canada strongly suggests that the population that chooses MAID and the population that dies by suicide are not the same population. This data simply does not support the contention that MAID and suicide are the same phenomenon.

What about other countries in which MAID is available? Are they the same as Canada or different? Here the data supports the same conclusion: They are not the same. I will quote from a review of this data in Belgium and the Netherlands by Dr. Tyler Black, who was a witness at the special joint MAID committee:

The following is a comparison between countries that enacted death with dignity legislation (Belgium and the Netherlands) and neighbouring countries that did not. Comparisons between countries have several challenges, but there is no empirical support for the notion that suicide rates increased or differed in MAID-legislated countries versus those that didn’t.

This had a control group in it. Again, it’s not the same there either.

Another component of this MAID-is-suicide misinformation is falsely arguing that suicide is unique to MAID MD-SUMC, a comment that is easily debunked by simply turning to the facts. For example, in the same recently published media article, a self‑identified opponent of MAID MD-SUMC stated:

The traditional form of MAID with a reasonable foreseeability of death allowed MAID to actually operate on a plane that didn’t intersect with suicide.

So let’s look at this assertion. I addressed this during my second reading speech on Bill C-7 and will quote myself:

. . . the presence of a severe and chronic illness is, by itself, an elevated risk factor for suicide. This elevated risk is not only found in persons with a sole mental disorder.

For example, the Canadian Community Health Survey found that, in young adults, attempted suicide was four times higher in those with chronic illnesses such as asthma and diabetes. Suicide rates in persons with cancer are twice as high as in the general population and eight to ten times higher in persons with Huntington’s.

In a study of suicide and chronic pain, Fishbain et al. found that the rate of suicide in chronic pain patients was two to three times greater than in the general population. Tang and Crane, in a global review of suicide and chronic pain, found that the risk of death by suicide is at least double in those with chronic pain.

A similar pattern of significantly increased rates of suicide in chronic illnesses occurs with other chronic illnesses, including cancer. A recent global meta-analysis published in Nature Medicine in 2022 by Heinrich and colleagues reported that the suicide rate was 85% higher for people with cancer than in the general population.

Colleagues, according to Health Canada data for 2021, over 65% of all people who chose a MAID death had cancer as the underlying condition. Remember, suicide deaths in cancer patients are 85% greater than in the general population.

It is false to say that chronic diseases that are not mental illnesses do not have similar concerns about suicide. That is just completely wrong. So why is this misinformation being spread? Whatever the reason may be, our role in providing sober second thought behooves us to follow the data, not pontifications or personal opinions.

As I wrap up this speech, I will turn to another issue that, in my opinion, has been poorly addressed in all these discussions: that of the need to improve rapid access to effective mental health care for all who require it. This is something I fought for my whole professional life and continue to do so.

When I graduated medical school in the 1970s, the number one mental health care need was rapid access to effective care for all those who required it. When I completed my residency in psychiatry in the 1980s, the number one mental health care need was rapid access to effective care for all those who required it. When I entered the Senate, the number one mental health care need was rapid access to effective care for all those who required it. According to the World Health Organization, the expenditure for mental health care should be about 10% of the total health care budget. The Canadian Mental Health Association calls for that number to be about 12%.

This is not solely a federal government issue. Provinces and territories set budget allocations for health and mental health. In my research, the proportion of health care budgets allocated to mental health care fall between 5% and 7% in most provinces and territories — well below required amounts.

We keep hearing that mental health care is on a priority list. Well, colleagues, let’s take mental health care off the priority list and put it on the equitable funding list.

We currently have a national push and environment to move beyond talk to implementation. There is now a federal Minister of Mental Health and Addictions. There is discussion of a targeted mental health transfer fund. Perhaps this will result in the federal government providing more support for improving rapid access to high-quality mental health care for all who need it.

Perhaps this will be the impetus that provinces and territories require to step up their investments in mental health care and also to invest in what works and not what ticks a box.

Honourable senators, we need to keep up the pressure on all levels of government to equitably invest in improving rapid access to effective mental health care for all Canadians. But this pressure is not because of MAID MD-SUMC. It is because we need this to happen, MAID or no MAID.

As we prepare to go to a vote on Bill C-39, I thank you for allowing me to share concerns I have about the misinformation surrounding MAID MD-SUMC and for your continued support for doing better for those Canadians living with mental illness. They deserve compassionate, equitable treatment throughout their life journey, and that includes the end of life.

Colleagues, thank you for your attention and your careful consideration to the complexities and nuances of the MAID MD‑SUMC debate.

For the many reasons that we have discussed this week, in my opinion, it is the right thing to do to delay implementation for MAID for mental disorder as a sole underlying condition by one year.

Wela’lioq, thank you.