44th Parl. 1st Sess.
February 13, 2023 11:00AM
Mr. Speaker, I would like to inform the House that I will be sharing my time with the member for Thunder Bay—Rainy River.
I am pleased to rise today to speak to the government's proposed Bill C-39, which seeks to extend the exclusion clause for those requesting MAID and whose sole underlying medical condition is mental illness.
I would like to take a few moments to draw our attention to the MAID monitoring regime and what we know about MAID cases to this point.
Canadians hold personal and very strong views on medical assistance in dying. They deserve accurate and reliable information to inform their decisions and their opinions. This is why we are working to ensure that our public communications are clear and comprehensive through our annual reports.
We know that a lack of accessible information opens the door to misinformation about evolving MAID systems. To be clear, while the proposed legislation would not impact the monitoring regime directly, a year's delay could bring the added benefit of more time to collect and the ability to report on important data regarding those complex cases where death is not reasonably foreseeable.
Putting this into perspective and context, our government acknowledges the importance of the data and reporting in relation to MAID, so much so that the original 2016 legislation obligated the minister of health to collect the necessary information and report annually on MAID activity.
This formal monitoring system is important to informing our understanding in three ways: who applies for MAID in Canada, medical conditions prompting requests and trends in MAID cases since the 2016 legislation.
As such, we have been working in collaboration with provinces and territories, as well as other health care partners, to ensure a robust monitoring system. It is important to understand that this is a significant, collaborative commitment.
Let us begin with a glimpse into what we know right now. As of December 31, 2021, there had been a total of 31,664 MAID deaths in Canada. This is the total number of MAID deaths since the law permitting medical assistance in dying passed in 2016.
MAID deaths represent 3.3% of all deaths in Canada as of 2021. This is very much in line with jurisdictions that have MAID regimes similar to Canada's.
The proportion of all deaths attributed to MAID varies across the country, with the highest rates reported in Quebec and British Columbia, and lower rates in the remaining provinces and territories.
Conditions include multiple comorbidities, cardiovascular disease, organ failure and respiratory illnesses.
Although the current sample is small, 2021 data also shows that, where death was not reasonably foreseeable, 50% of individuals were approved for MAID, compared to 81% of cases where death was foreseeable.
Each MAID request where the person's natural death is not reasonably foreseeable is complex and unique, and early indicators show that approvals for MAID in this stream are much lower than when the person's death is reasonably foreseeable, 50% versus 81%.
The assessment process for a person whose natural death is not reasonably foreseeable is often much more challenging due to the nature and complexity associated with medical conditions of this population. These assessments require detailed clinical analysis of each one of the elements of the eligibility criteria, which define a grievous and irremediable medical condition.
Let us spend a little bit of time talking about the human aspect of this data collection.
We should acknowledge that behind every data element in our annual report is, indeed, a human story. Implicated in each case is a group of people, their families, MAID assessors and providers, health care teams, and most importantly, the person making the request for MAID. The data we collect comes from thoughtful and compassionate conversations involving people who are making the most important decision of their lives and the MAID practitioners. The practitioners are responsible for assessing the requester in accordance with the person's wishes and the law. Through these discussions and the recording of information arising from them, we have a robust monitoring and reporting system for MAID in Canada.
MAID practitioners must ensure that every requester is aware of the services available that might relieve their suffering. This includes exploring treatment options, facilitating referrals and following up on the outcomes. When faced with a MAID request where death is not reasonably foreseeable, assessors spend much more time gathering the necessary information about the person and their condition. The process often involves a review of many years of treatments, surgeries and/or medications, as well as consultation with one or more experts in order to exercise due diligence in making a decision regarding eligibility.
New regulations for the monitoring of medical assistance in dying came into force on January 1 of this year. The MAID monitoring system will report on an expanded set of MAID data points that are collected according to these new regulations. The additional information should provide a greater understanding of persons applying for MAID whose natural deaths are not reasonably foreseeable, as well as their associated circumstances.
In conclusion, we are committed to transparency and accountability across all levels of government to ensure public confidence in the MAID regime. We are honouring this commitment by providing Canadians with accurate and reliable information on MAID as it continues to evolve in this country.
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Madam Speaker, I was very surprised listening to my colleague talking about the numbers they have. In 2016 there were 1,200 cases of MAID. That doubled in 2017 and doubled again in 2018. It was over 10,000 in 2021. That is nearly 30 people dying in this country every single day. That is more than double all the deaths from breast cancer or all the suicides in this country. We were promised a process to make sure we were not implementing a regime that was doing this without really strong checks and balances.
I find it staggering that the member could say this thing is working when we see such massive increases, much higher than in Europe or anywhere else, in medically assisted death in this country.
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Madam Speaker, let me clarify and reiterate what I said in my intervention. I talked about the total number of MAID-related deaths in 2021 being 10,950, of which 2% related to MAID for individuals whose deaths were not reasonably foreseeable. The numbers the member is quoting might be accurate, but that was not the point I was trying to make. As I also indicated, the total was nearly 30,000 since 2016, when the legislation came into force.
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Madam Speaker, I just want to follow up on the statistics my hon. colleague from Timmins—James Bay pointed out from across the way. They are staggering. When we begin to consider them, it should cause all Canadians to pause, reflect and say that the legitimate concerns many of us raised in this House when this was first proposed continue to this day. There are inadequate safeguards in place to protect those who are struggling with mental illness and have other ailments in their lives that have challenged them for a particular season. MAID opens the door to a decision of such finality that it can cause grave consequences for many Canadians and their families.
What safeguards are going to be put in place to stop this from being abused any further?
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Madam Speaker, first of all, I do not think that MAID has been abused, especially as it relates to mental health. As I intervened, I lost my father to cancer back in 2016. At that time I wished the MAID option were available to us. Having said that, we have felt in our government that the base of 219 cases is not representative enough of the data that we want. We want to ensure that the safeguards we should have are in place and strengthened. This is the fundamental reason that we are extending the timeline by a year and introducing this bill. If this bill is to protect those individuals who are dealing with mental illness, then they need all the supports to be able to make that decision.
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Madam Speaker, I listened with interest to the member about what further things we need to be considering and thinking about. Could he elaborate a bit more on what he thinks are the most important factors that we need to be thinking about in this place as we consider this legislation?
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Madam Speaker, aside from the timeline that we have set to make sure that we have more data to be able to analyze the situation, it is also important to work with the provinces and territories to ensure that they have the processes, guidelines and support system they need. Then they can help those individuals who are in the process of making that decision to receive the support they need to come to the right decision.
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Madam Speaker, I support this legislation putting a one-year hold on allowing MAID for mental illness.
We need to hold off on this until we have a broader consensus as to if and how we are going to do this. We need more safeguards in place. If we are going to do this, we need to make sure that we do it right. I do not think that we ought to have an automatic start date in one year as is planned.
To be clear, yes, I support this legislation in that MAID for mental illness will not be allowed beginning in March. However, from my perspective, we ought to make this hold indefinite. I know there are a lot of people out there who are really worried about this legislation because they have loved ones who are going through a hard time and they think, probably rightly, that some of those people will want to access MAID.
There are parents, siblings, partners, spouses and friends who are worried. Parents touch my heart the most because they are worried that the lives of their children could be affected. I can certainly sympathize with this because I have six children of my own. One does not have to be a parent to realize that almost everyone goes through a difficult time at some point in their life, hence our concern.
I know there are also a lot of psychiatrists out there who are really worried about this. There are psychiatrists who know that if their patients were to have more treatment, they would probably get better, but they are requesting MAID at this time.
Both these groups have legitimate concerns about this legislation. At the moment, I do not think the safeguards are in place, and if implemented now, the law would end up affecting a lot of people in a way that was not intended.
What is the intention of the law? I would submit that the intention of MAID for mental illness is that it should only apply to a very small group of hard-core cases. This seems to be the case in Holland, where only one in a thousand people, I am told, who apply for MAID for mental illness are actually granted it.
It is not intended for a 25-year-old who was abused as a child and has had intermittent depression ever since. It is not intended for the 30-something-year-old who remains depressed a couple years after the breakup of a marriage. It is not intended for somebody who is schizophrenic and is fine on their medication, but having stopped their medication, now wants to access MAID.
Some out there may say, “Why not? It should be the individual's choice”. As a teenager, I read Jean-Paul Sartre, and at the time, I agreed with him that the ultimate choice in life is being over nothingness. Perhaps I still agree with this. However, neither suicide nor attempted suicide is illegal in Canada. The question today is what role, if any, the state has in assisting suicide.
I worked a lot of years as an emergency room doctor, and I saw many people who were suicidal. My job was to assess whether people were suicidal, and if they were, to bring them into the hospital even if it was against their will. The law gave me the power to do so.
Many people would ask what right I have to tell someone what to do with their body and say that it should be their own choice. My response to them is that I think there are two legitimate reasons for the state intervening to prevent suicide.
One is in order to protect people from themselves. When someone is in the depths of depression, they do not see a light at the end of the tunnel. They cannot contemplate the possibility, let alone the probability, that they are going to get better. That is the nature of depression. That is what makes someone suicidal. Most of us know that, eventually, with a change of circumstances and enough time, people actually do get better.
The other legitimate reason for the state to interfere is to protect loved ones. A person who commits suicide is dead; they feel no pain. However, the loved ones continue to live the rest of their lives with the anguish of losing someone, often haunted by feelings that perhaps it was because of something they did or did not do.
The suicidal individual's inability to appreciate the possibility that they might get better should certainly make us reluctant to allow MAID for people with mental illnesses. Some people would ask whether there are people who really will not get better and who are irremediable. That is the requirement of law: The illness has to be irremediable.
The problem with that is that doctors are not really good at determining who is irremediable. Doctors do not have a crystal ball that can predict the future. In fact, studies show that doctors are not good at determining who is irremediable.
A recently published study by Nicolini et al. looked at clinicians' ability to determine irremediability for treatment-resistant depression. It reviewed 14 different studies. I will cite its conclusion: “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 for 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.
As a long-time doctor, I find it absolutely mind-boggling that there are practitioners out there who are willing to administer MAID to someone knowing that perhaps with a bit of extra time the person would have gotten better. Good doctors worry about making mistakes. Good doctors do not want to kill off their patients. It seems to me that if there is even one person who is administered MAID and who, if they had not been given MAID, would have gone on to a happy life, that is a horrific tragedy. I would say it is something akin to capital punishment when it turns out the person was actually not guilty of the crime. If this happens, it is certainly on the conscience of every one of us in this place.
The number of people we can confidently say are irremediable is probably small. Some would say no, but I would offer a few comments. One is that anyone under 40 should never be considered irremediable, and in fact anyone under 60, unless they have had ongoing years of illness. I would also suggest that somebody who has not tried every kind of treatment and has not seen a lot of doctors and therapists should not be considered irremediable. Who is left? Perhaps if there is some 75-year-old who has no family and who has undergone many years of illnesses, tried every sort of treatment available and seen numerous doctors and no one can help, then maybe, and I emphasize the “maybe”, they should be considered for this.
Do I believe that the law, as implemented now, would really be confined to that small number of cases? No, absolutely not. Like a lot of members, I have been paying attention to the media and have heard of the many cases where we are just left shaking our heads that somebody would allow MAID for that. The reality is that there are a lot of practitioners out there with a very liberal approach to allowing medical assistance in dying, who seem to be willing to base it on perhaps just a phone call, practitioners who do not think it is necessary to talk to the family, to get to know the patient, or to consult someone who knows the patient.
Some people will say that the decision about standards of care and safeguards should be left to the colleges of physicians and surgeons. As a 35-year member of the College of Physicians and Surgeons of Ontario, I totally disagree with that. This is not the kind of decision that is normally left to the colleges, nor should it be; this is the kind of decision that should be left to the elected representatives, who in turn are accountable to the people.
In summary, if we are going to allow medical assistance in dying for mental illness, it should be to an exceedingly limited number of people. If we were to implement the law as it is now, I think a lot of people would be getting it whom the law was not really intended for, nor do I think we are that close, so I think there should be no fixed date on which this law comes into effect. When are we going to know we are ready to do this? I would suggest it would be when there is some consensus from the psychiatric community. From all the surveys I have seen, the majority of psychiatrists are against this, which is certainly one indicator.
We need to take however much time is necessary to do this right. This is not like other decisions made by the House of Commons. If we mistakenly take a life, all of the politicians in this room, all of the bureaucrats in Ottawa and all of the Supreme Court justices cannot bring that life back.
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Madam Speaker, I really appreciate my hon. colleague's perspective. I heard a lot about the intention, and sometimes we have intention versus impact, so I am curious what he thinks the impact would be of just extending the deadline, as opposed to actually throwing out the legislation or supporting Bill C-314.
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Madam Speaker, the question before us now is really the coming date for implementation, which is mid-March. The intention of the legislation right now is to give us more time, and that is entirely appropriate.
We pride ourselves on making our decisions based on evidence. If we are going to make decisions based on evidence, then this certainly has to be given more time, which means that there has to be a delay on this so that it does not come into effect in March. What comes after is for us to determine. I personally think there ought to be indefinite time until we get this right.
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Madam Speaker, my colleague from Thunder Bay—Rainy River is well aware of my great respect for him. However, in listening to his speech, I found it riddled with confusion.
I wondered whether he read the expert panel's report on mental illness as the sole underlying medical condition. I believe that our thinking may not be quite so different. I think that his practice has shown him the need to take care in adopting such an approach. However, in reading the report, he will see that there are many precautions in place and very specific guidelines.
Indeed, just because there are not very many mentally ill people experiencing tremendous suffering does not mean we must not move forward. One person experiencing unimaginable and intolerable suffering is, in my opinion, one too many.
I would like to know my colleague's thoughts on this.
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Madam Speaker, I have not in fact read the report. At the moment, the problem is that we have 10 provinces and three territories that are all expected to come up with the appropriate safeguards, and I do not think any of them have actually publicly come forward with those safeguards.
I would further suggest that it ought not be the colleges of physicians and surgeons that are put in the position to have to put those safeguards in. It is up to us, the elected representatives who are accountable to the people, who ought to be the ones making those decisions, not the colleges of physicians and surgeons.
I would agree with the member that one person who stays in suffering is too many; however, I would also suggest that one person whose life is taken prematurely because of an overly liberal approach to MAID and the pain that that causes, particularly to the family, ought to be something we consider before making any decision that would allow that to happen.
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Madam Speaker, when we voted on this legislation, we were told that Parliament would be able to review so we could tell whether or not we had overstepped and whether or not it had worked. We were never given that right. Instead, this was handed over to the unelected senators, who got it into their head that people who are depressed or who have a few problems should be able to die. We have to fix that. We never got to address whether or not these provisions were working, whether or not there need to be proper guardrails in place.
Would it not be better if this bill would just park this, stop it dead, until we can actually find out how this process is working for the people of Canada?
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Madam Speaker, my guess is that if this were to go to the Supreme Court, it might well say that this kind of difficult decision, which involves balancing competing ethical values, is best left to the elected representatives, who are accountable to the people. We are the elected representatives, not the Senate. I have a lot of sympathy with what my colleague has to say.
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Madam Speaker, I rise today to speak to Bill C-39, an act to amend an act to amend the Criminal Code (medical assistance in dying), introduced by the Liberal Minister of Justice. This is obviously a particularly delicate subject.
The bill corrects a mistake made by the Liberal government. Another mistake, some will say. This government makes hasty, last-minute decisions and, as usual, has to backtrack. It is correcting one of its mistakes, but in doing so it will make another.
Let us look back to fully understand where we are today. When the government was preparing to amend the medical assistance in dying legislation in accordance with the most recent directives of the Superior Court of Quebec in 2021, the Senate made an unexpected amendment that would allow, starting on March 17, 2023, the provision of medical assistance in dying to individuals whose sole underlying medical condition is a mental illness. The Liberals then said, yes, why not. the Liberal government accepted the amendment, which is now part of the legislation.
The amendment was accepted without study, reflection or any serious consultation. The date set, March 17, 2023, is completely arbitrary. What was the Liberal government's reasoning at the time for accepting this amendment? How did it come up with the date of March 17, 2023? It obviously relied on its political guesswork, and God knows just how much the Liberals govern haphazardly, without a compass, and by improvising in an indecent and dangerous manner. This decision is just one of many very bad decisions made by the Liberals since taking office.
There are two problems with this measure. The first is expanding medical assistance in dying to people whose only underlying medical condition is a mental disorder. The second is setting the date of March 17, 2023, an arbitrary date that was selected without argument or justification.
Let us look at what is being done elsewhere, and not just anywhere. Let us look at Quebec, where the subject of MAID and dying with dignity has seized Quebec parliamentarians for many years. I know, because I was there as an MNA and minister and I voted in favour of MAID. In my soul, my heart and my conscience, I believe that that was the right decision.
With a view to now expanding medical assistance in dying, in its great wisdom, the Parliament of Quebec is taking its time, thinking and studying. The Quebec National Assembly set up a multi-party Select Committee on the Evolution of the Act respecting end-of-life care. It closely examined whether the scope of medical assistance in dying could be broadened. It tabled its report, which was unanimously adopted by the National Assembly in December 2021. This is recent.
Imagine. The Select Committee on the Evolution of the Act respecting end-of-life care does not recommend that medical assistance in dying be made available when a mental disorder is the sole underlying medical condition. It was obvious to the MNAs who sat on the committee that Quebeckers are not there and that there is no social acceptance of this issue.
However, the Quebec committee did not stop there. It went even further. In order to eliminate any possible grey areas, the committee recommended that the Government of Quebec amend its act to specify that medical assistance in dying is not available in instances where a mental disorder is the sole underlying medical condition.
On page 58 of the committee's report, it states, and I quote:
The Committee recommends that access to medical aid in dying not be extended to persons whose only medical condition is a mental disorder; that, to this end, section 26 of the Act respecting end-of-life care be amended.
The committee added:
This recommendation is in line with the precautionary principle that Québec has upheld since the beginning of work on medical aid in dying. We believe that the risks associated with extending access to medical aid in dying to persons whose only medical condition is a mental disorder would entail too many variations and could therefore not be closely monitored.
It goes on to say:
In order to implement this recommendation, we believe that section 26 of the Act respecting end-of-life care should be amended to avoid the possibility that a mental disorder as the only medical condition give access to medical aid in dying.
The committee refused to extend access because of problems relating to incurability, social acceptability, diagnosis and lack of consensus among members of the public and within medical professional organizations.
The committee therefore opted to follow the precautionary principle. As I said before, this is the element that was so regrettably lacking from the Liberal government's decision-making process. Once the Quebec committee completed its work and submitted its unanimous report, the Government of Quebec introduced its Bill 38 in May 2022, which was less than a year ago. The Government of Quebec endorsed the committee's recommendation. To be clear, Bill 38 was never passed because there was an election, so it died on the order paper.
The bill would have amended section 26 of the act by adding a prohibition on administering medical aid in dying to a person whose only health condition is a mental disorder. I will quote clause 13 of the Government of Quebec's Bill 38:
A patient who meets the following criteria may make a contemporaneous request:
(1) be of full age and capable of giving consent to care;
(2) be an insured person within the meaning of the Health Insurance Act...
(3) suffer from a serious and incurable illness or a serious and incurable neuromotor disability;
(4) be in an advanced state of irreversible decline in capability;
(5) experience constant and unbearable physical or psychological suffering which cannot be relieved under conditions that the patient considers tolerable.
What I am about to say is important:
For the purposes of subparagraph 3 of the first paragraph, a mental disorder is not considered to be a serious and incurable illness.
Canada does not exist in a vacuum, and it is not disconnected from what is happening in Quebec. The difficulties experienced by Quebec exist across the country as well. We are not prepared for this expansion. If we do not take action now, if we do not pass this bill, in less than one month, people living with a mental illness could have access to medical assistance in dying. We do not want that, Quebeckers do not want that, and Canadians do not want that. Canadians would not understand our lack of action. That is why we need to vote in favour of this bill.
However, we will vote for it reluctantly and with heavy hearts. We do not want the change to take effect on March 17, 2023, but there is another catch in this bill.
Bill C-39, introduced by the Minister of Justice, extends the deadline by one year. The bill extends the March 17, 2023, date to March 17, 2024. Why is it one year? Why not push it back two years? Why not suspend or abolish this section altogether? Why rush the expansion of MAID to people living with mental illness when the country does not want it and when doctors themselves are divided on the issue?
I would like to close by saying that medical assistance in dying is a sensitive issue that speaks to our values and our history, too. What we are asking of the Canadian government is not to simply postpone the date. We are asking the government to give us time, as parliamentarians and as Canadian citizens, to take the time needed. I believe that rushing such matters is always ill-advised.
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Madam Speaker, I have read the recommendations of the committee of the Quebec National Assembly. I am interested in this, as the member is a Quebecker who seems to be opposed to it. The perception of a lot of us outside of Quebec is that the greatest support for more liberal approaches to medical assistance in dying is from Quebec. Is this not the case? Would she like to comment on that?
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Madam Speaker, I think Canadians are on the same page as Quebeckers. I think it would be in our best interest to take all the time we need to really think through this very sensitive and delicate issue, which involves very personal and deeply held values, so that we can properly assess all the consequences.
To be honest, I am concerned that the one-year delay will not change anything, let alone address the issues that are already being raised about expanding medical assistance in dying to people living with a mental health condition. Quite frankly, I do not think we are there at all. We would be rushing things if we move forward, and that would be dangerous for our society.
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Madam Speaker, I commend my colleague who is a member of the Special Joint Committee on Medical Assistance in Dying.
I would just like to provide her with a bit of context. Bill C‑7, which is the fruit of a compromise with the Senate, was meant to respond to a requirement in a court ruling to allow Ms. Gladu and Mr. Truchon to have access to medical assistance in dying.
No one in Quebec considered the passage of Bill C‑7, which allowed Ms. Gladu and Mr. Truchon to have access to medical assistance in dying, to be reckless. There was a consensus on it. It needed to be passed. We passed it while creating a special panel of experts that was meant to table a report within two years to inform a joint committee, which was tasked with reviewing the report and making recommendations that would come later.
We have to be careful when we talk about rushing things. Let us take our foot off the gas. By March 2024, we will have been thinking about this for three years.
What is more, when my colleague says that the public is not on board, I would like her to show me some polls to support that claim. In any event, the current problem is that her party wanted the committee to table a report in June because the Conservatives were against giving the joint committee any extensions on its deadlines so that it could do a good job. Each time, we fought for an acceptable deadline to do decent work. I think they are being a bit hypocritical.
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Madam Speaker, I think it would be better for my colleague to choose his words more carefully.
Unless I am mistaken, last week we heard him say in an interview that there was no agreement on the issue of MAID for those with a mental illness. My colleague also went to the trouble of stating that one in two experts did not agree.
I will close by citing the panel he spoke about.
The evolution of many mental disorders, like some other chronic conditions, is difficult to predict for a given individual. 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.
I will stop there.
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Madam Speaker, there is another crisis underlying the discussion we are having right now, and that is the mental health crisis in this country. The government promised to put funding in place for Canadians to get help, but the Liberals have really been dragging their feet on that.
I would like to hear my colleague's thoughts on the current situation. Does she think the government should provide more resources and make sure that mental health issues really are recognized as a serious problem?
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