Hon. Julie Miville-Dechêne: Honourable senators, I rise in support of Bill C-62, which proposes a three-year extension to the temporary exclusion of medical assistance in dying eligibility for persons suffering solely from mental illness. In the interest of full disclosure, and specifically for the benefit of our recently arrived colleagues, I’d like to remind you that three years ago, I voted against the Senate amendment that extended MAID to psychiatric patients. At the time, there was no consensus among experts on this social issue, and that is still the case today.

Although defending minority rights is at the heart of our mandate, the Senate is not a court of law. While some may argue that denying access to MAID violates the constitutional rights of those with mental illness, this conclusion is far from clear. In its Charter statement, the Department of Justice spells out the competing rights and values at stake, including the autonomy of individuals versus the protection of vulnerable people from any incentive to end their lives. The Department of Justice adds:

 . . . feelings of hopelessness and the wish to die are common symptoms of some mental illnesses, which can make it difficult for even experienced practitioners to distinguish between a wish to die that is fully autonomous and well considered and one that is a symptom of a person’s illness.

After analyzing international science-based evidence for a year and a half, the Council of Canadian Academies’ expert panel found no evidence that the irremediability of mental illness could be predicted. Some mental disorders may even impair a person’s decision making and increase their risk of incapacity.

The fact that provincial governments aren’t ready is another compelling argument. We mustn’t forget that the provinces deliver medical care and have jurisdiction in this area. It would be a mistake to equate their serious concerns with an ideological objection to MAID in every case. Take Quebec, for example, a place I know better than others: It was a frontrunner in expanding medical assistance in dying and even holds the world record for this practice. Last year, MAID accounted for 5,200 or 6.8% of deaths in Quebec, a 42% increase in a single year. Of that number, a disturbing 16 cases failed to meet all the criteria specified in the act.

Last June, Quebec amended its Act Respecting End-of-Life Care to legalize advance requests related to cognitive illness leading to incapacity, but it excluded patients who exclusively suffer from a mental disorder. This decision was based on a report by Quebec’s end-of-life care commission, published in December 2021, which concluded, and I quote:

Medical aid in dying is care of last resort for persons whose illness cannot be cured and whose decline in capability is irreversible. Given the lack of consensus in the medical community on the incurability and irreversibility of mental disorders, a strong doubt remains as to whether medical aid in dying is appropriate care. In this context, the risk that this gesture be premature appears very real to us. We are faced here with the grim prospect of individuals obtaining medical aid in dying rather than appropriate medical follow-up that would favour a fully satisfying life.

I share those very same concerns. Some have argued the following — and I’m quoting the report of the Special Joint Committee on Medical Assistance in Dying:

 . . . there is no consensus on many existing medical practices, and that this is not generally considered a justification for prohibition.

I think that it’s inappropriate to equate MAID with a simple medical practice, as though this were about a hormone treatment or taking antibiotics. We have to have the honesty or lucidity to come to grips with this. This is about helping a person to die. It is irremediable.

Another sensitive aspect is the fact that, in the report of the Special Joint Committee on Medical Assistance in Dying, witnesses observed that the eligibility criteria for MAID didn’t require people with mental disorders to have exhausted all reasonable treatment options. Bill C-7 only required that the patient be informed of treatment options. In theory, this would mean that the patient could receive MAID even if he or she hasn’t had access to adequate care. This is particularly worrying in a country like ours, where the shortage of psychiatric care is an established fact.

In Belgium and the Netherlands, where psychiatric patients have access to MAID, more robust safeguards exist.

According to the submission of Professor Scott Kim from the University of Michigan, 1,150 applications for MAID were made in the Netherlands in 2022, which is quite a lot. However, only 5% to 10% were granted. Belgian and Dutch laws require doctors to agree with the fact that there are no options other than MAID in each case, so MAID really is a last resort. I’m aware that the right to refuse all treatment is well established in our country, and it is a paramount right, but it seems to me that the exercise of this right, combined with a life-ending medical intervention, is a sensitive issue that warrants further consideration.

Bill C-62 will do just that. It will allow time for such careful consideration of the state of our knowledge and the scientific and ethical grey areas.

Obviously, I’m aware that there is intolerable mental suffering that is as great if not greater than the suffering associated with physical illnesses, but we can’t expand access to MAID any further until we’re able to confidently assess the applicant’s incurability, the irremediability of their condition, their capacity and their suicidal tendencies.

The severe shortage of psychiatric care and services must be at the heart of this reflection on the health care systems’ state of readiness, or at least that’s what I think. We can’t focus solely on the fact that there are protocols for administering MAID. That is not enough.

Finally, the precautionary principle applies when lives are at stake. Thank you.

[English]

Hon. Julie Miville-Dechêne: I rise to speak briefly in support of Bill C-39 at third reading. The bill delays, by one year, eligibility for medical assistance in dying in cases where mental illness is the sole underlying condition.

As my colleagues Senator Manning and Senator Kutcher have mentioned, this is a very difficult issue. It’s not easy to talk about medical assistance in dying. I’m feeling quite emotional after listening to my colleagues, so I will continue.

I support this delay, which will give experts another 12 months to try to refine the guidelines around this extremely rare practice globally. More fundamentally, however, I don’t see any need to act too quickly on such a serious issue, especially in light of the critical shortage of psychiatric resources.

I have always believed that the issue of medical assistance in dying for people with psychiatric illnesses can’t be boiled down to just individual rights or a constitutional analysis. Mental illness is more complex than physical illness, because it often progresses slowly and unpredictably. Unlike degenerative neurological diseases, whose course is known and predictable, it is not uncommon for the psychological suffering associated with mental illness to improve over the medium and long terms.

The federal government outpaced the Government of Quebec on this file before conducting a similar review. Less than a month ago, in mid-February, the Government of Quebec introduced a bill that does not extend medical assistance in dying to patients suffering solely from mental illness.

This exclusion was recommended in the report of the Select Committee on the Evolution of the Act respecting end-of-life care, after extensive consultation with the public and experts. The report states, and I quote:

Self-determination is not the only principle that should be taken into account in this discussion. The protection of vulnerable persons, the ability to consent and the risk of abuse are all elements that enter into the equation.

The Quebec report notes that psychiatrists are divided on the incurability and irreversibility of certain mental disorders. That division reflects the complexity of these illnesses, which are more unpredictable than physical illnesses.

Consequently, there is a real risk of making medical assistance in dying available to a patient too soon. Senator Kutcher, I do not believe that I am participating in what you referred to in your speech as a misinformation campaign on this matter by saying that. I think that there are fundamental differences of opinion in the medical profession, which is why we need to be very careful.

The Quebec report cites psychiatrists who explained that suicidal thoughts are inherent to certain mental disorders. What’s more, the response to psychiatric treatments varies. Alleviated suffering can be a long time coming, after months or years of psychiatric treatment, assuming such treatment is available. I will quote another excerpt from the same report:

We heard the testimonies of several individuals who, after years of unsuccessful treatments, managed to achieve a better balance. These witnesses told us that if they had been eligible for medical aid in dying, they would undoubtedly have applied for it at a time when their health condition seemed hopeless. Today, these same persons are doing much better and are able to cope with their illness because they have received a correct diagnosis and appropriate treatment. Thus, the uncertainty surrounding the trajectories of mental disorders prompts us to be very cautious.

The testimony that made the biggest impression on the select committee came from the Association québécoise de prévention du suicide, the Quebec association for suicide prevention. According to the association, expanding MAID would have an impact on people with suicidal tendencies. There is concern that it could send the signal that death is a legitimate or appropriate option for people with mental disorders. This would undermine years of suicide prevention efforts. I should point out that this does not mean that these suicidal patients would access MAID, but their distress could increase. Let me remind you that Quebec is a pioneer in medical assistance in dying, yet Quebec’s elected officials decided not to rush into the specific issue of eligibility where mental illness is the sole underlying condition, because there are too many differences of opinion.

I also want to point out two things that I think reinforce how important it is to take the time to think about these sensitive issues. First, Quebec now leads the world, with 7% of deaths in the province resulting from MAID. That is higher than Ontario and even long-time pioneers Belgium and the Netherlands. The fact that the rise in MAID was markedly faster in Quebec than elsewhere prompted the chair of the Quebec select committee to investigate the cause and launch a consultation, while advocating for better access to palliative care.

Second, it seems as though, in Quebec at least, it is now easier to get medical assistance in dying than it is to get comprehensive palliative care, and yet both of these options should be available under Quebec law, which guarantees all citizens access to both medical assistance in dying and palliative care, whether at home or in a health care facility.

Some tragic events that occurred in Quebec recently exposed flaws in the system. Andrée Simard, widow of former Quebec premier Robert Bourassa, was denied palliative care during the last three days of her life at St. Mary’s Hospital in Montreal. According to her daughter, Michelle Bourassa, with whom I spoke at length, Ms. Simard died in a lot of pain because she was not given any palliative sedation. Ms. Simard forbade her family to use her fame to get preferential treatment. Her daughter chose to fight in memory of her mother so that all dying persons are treated fairly and with humanity, whether they choose palliative care or medical assistance in dying.

That’s why, even though these issues don’t fall under federal jurisdiction, I think that the availability and quality of palliative care and psychiatric services are a prerequisite for expanding medical assistance in dying. We can’t legislate in a vacuum, in the abstract universe of the Charter of Rights, with no regard for what care is actually available to patients. As responsible legislators, we need to think about the applicability and actual consequences of the laws on which we vote. In this case, we need to prevent the current trend of the health care system getting around providing access to care by expanding access to medical assistance in dying. Better access to psychiatric care is a prerequisite for treating people’s suffering. That is also how we show our compassion. For all of these reasons, I will be voting in favour of Bill C-39. Thank you.

Hon. Julie Miville-Dechêne: Senator Gold, the opposition’s question made me think of the debate on medical assistance in dying. I had serious reservations about expanding eligibility to medical assistance in dying to people suffering from mental illness only.

In the past few weeks and days, people have been speaking out against this change, which is set to take effect in mid-March. Some are saying that we are not ready, and it’s not just anybody.

[English]

It includes the Association of Chairs of Psychiatry in Canada, which includes the heads of psychiatry departments at all 17 medical schools.

[Translation]

Are you going to postpone the implementation of this change?