Front Burner - MAID and mental illness: Will feds hit pause?

Episode Date: December 6, 2022

With concerns mounting over the upcoming expansion of medical assistance in dying to include mental illness as the sole condition in March 2023, we ask Liberal Member of Parliament Marc Garneau if the federal government will listen to growing calls from mental health experts and hit pause on the controversial change. Marc Garneau is the Member of Parliament for Notre-Dame-de-Grâce—Westmount and the co-chair of the Special Joint Committee on Medical Assistance in Dying. It’s a committee that is looking into this issue for the federal government.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Jamie Poisson. You know, I have become comfortable with providing MAID for patients, and I recognize that it's something Canada, by and large, supports for those who are dying. I am increasingly, myself, becoming uncomfortable with the expansion and the lack of consistency

across the country and about who is now accessing MAID. There are cases that I think aren't being assessed in a thoughtful way. I hope that the legislators are listening to this interview. That's Dr. Madeline Lee in November, talking with me about medical assistance in dying,

known as MAID. As a psychiatrist and a MAID provider, Dr. Lee has overseen hundreds of cases and administered deaths directly to patients. And as she just said, she's a supporter of MAID as an option in Canada. But she also says she's become increasingly uncomfortable with how MAID's recent

expansion to include cases that no longer require a person's natural death to be reasonably foreseeable. So a chronic pain condition, for example, is being applied across the country. Several cases have recently popped up where people have requested to die in part because they don't have proper housing and can't afford to live with their condition. Dr. Lee is also part of a growing group of health experts urgently calling on the federal government to delay a controversial upcoming expansion of MAID to include mental illness as the sole underlying condition. Just a few months from now, on March 17, 2023,

Canadians who suffer from mental disorders like depression or schizophrenia might qualify for a medically assisted death. It's a massive change, and Dr. Lee's providers are simply not ready. Not everyone agrees with that, but there is demand for the government to ensure MAID protects vulnerable people better.

To talk more about this, I'm joined by Mark Garneau. He's a member of Parliament for Notre Dame de Grasse-Westmount and the co-chair of the Special Joint Committee on Medical Assistance in Dying. It's a committee that is looking into this issue for the federal government. Mr. Garneau, thank you so much for joining me today. Good to be with you, Jamie.

So I wonder if we could start with the upcoming expansion of MAID to include mental illness. Dr. Madeline Lee, the psychiatrist and MAID provider that you just heard in the intro, when I spoke with Dr. Lee last month, she was imploring the federal government to push back the expansion of MAID to include mental disorders. And she is someone who, as you heard, generally supports MAID. And I have another clip of Dr. Lee I'm hoping that you could respond to if you just want to take a listen to this. I think the healthcare system isn't adequately prepared right now. So the biggest challenge is that education hasn't happened yet. And I don't think can be adequately rolled out before March. I think that we don't have this oversight process in place yet. I think Canada hasn't infested enough in the last couple of years that we've had in preparation to increase access to mental health resources.

The pandemic has driven the demand for mental health resources to a crisis level. And we haven't, Canada hasn't put in anything to meet the supply end of that. And so in addition to people needing mental health resources because they're requesting MAID, we haven't got an answer for that in Canada. I also think we haven't had the chance to put in the infrastructure for providing this. We haven't had the ability to, you know, at the time to put together a panel of clinicians who will do this work. And I know that every province is thinking about this, but nobody has really, we're just at the beginning of starting this, and I don't think we can do it by March. So Mr. Garner, I want to pull apart some of what Dr. Lee said there today.

And the first issue I want to address is a major one that's come up in conversation, and that is access to mental health. So the Canadian Mental Health Association is calling for the government to first increase mental health care funding before expanding MAID to include mental illness. There's a concern that people are going to choose to die because they can't access treatment. And how is the government ensuring that people have more access to mental health supports before this March 17th deadline? Well, it's a very good question. And by the way, I think we interviewed Dr. Lee as one of our

witnesses. Certainly, people have experts and witnesses that we have heard in the past seven months on various topics related to MAID, including mental disorders, have asked whether or not we will be ready when this comes into effect on the 17th of March. And that's something that we have to take into consideration. There have been witnesses who have said that sometimes somebody may have a mental illness that they may request MAID because of other structural problems, such as access to shelter and access to a psychiatrist, access to other forms of treatment. Those are all things that we've listened to and take into account. And those will play into the recommendations that we have to decide about to make to the government by next February. Are you going to recommend that more

resources be put into mental health? Or are you going to recommend that the government should hit pause on this expansion until mental health resources are improved? Well, I can't divulge to you what the committee is deciding. It's a committee of 15 people, five senators and 10 members of parliament. We have to make that decision in terms of the recommendations we will put to the Minister of Justice and the Minister of Health. But I can't let the cat out of the bag at this point because this is confidential. But let me just say that we have heard and listened to testimony such as that of Dr. Lee. And we know that all of these are important factors that play into the recommendations that we will make. failing people who can't access these important services to the point where they might be considering ending their lives because they don't have access to mental health supports?

Well, we wouldn't want that to be the reason that they decide to request MAID. We would want it to be for the reason for which MAID was intended. But we're fully cognizant of the fact that there are always things that can be improved in our health care system. We're hearing a lot about that these days, particularly in light of the pandemic. But in a more general sense, there is always room for improvement in terms of the health services that are provided, in the case where natural death is not reasonably foreseeable, which could be applied in the case of people with mental disorders, that other supports have been provided to them and that they're not driving factors in their decision to request MAID. So, we're very conscious of that. And so improvements in health care

are factors that everybody is aware of. Just a few weeks ago, I was listening to this Toronto Star podcast with Althea Raj called It's Political, and Justice Minister David Lamedi was on it. And she was asking him about this very issue that people may access MAID because they don't have access to proper mental health supports. And I just want to play for you part of what Mr. Lamedi said here. Remember that suicide generally is available to people. This is a group within the population who, for physical reasons and possibly mental reasons, can't make that choice themselves to do it themselves. And ultimately, this provides a more humane way for them to make the decision they otherwise

could have made if they were able in some other way. So several people were upset with this statement. Some psychiatrists said Mr. Lamedi sounded like he was encouraging suicide. And actually, Althea responded by saying, you know, should the government be facilitating suicide? And do you think that that's the way the justice minister should be talking about medical assistance in dying? The intent of MAID is to allow people to make informed decisions, if they have the capacity to make that, people who are suffering grievous and irremediable illness. This is part of a freedom that we have in our charter for them to make those informed decisions. We as a government and the medical profession obviously will try to do everything possible so that we can avoid that situation. That can be either through additional structural supports,

it can be through better health care access. Those are the kinds of things that we need to work on in parallel. But ultimately, a person who is suffering unbearable pain on a constant basis and it's judged to be, assessed to be irremediable, has the right to make that request in our society. And we have to look at that very, very seriously to make sure whether it is justified, whether the person has the capacity to make that informed decision. That's our job.

And the vast majority of people who have access to MAID, the process has gone the way it was intended to go and has achieved its purpose, which is to allow those people to make their decision about dying at a specific time, you know, with a sense of dignity and surrounded by their loved ones. And that is its intended purpose for those who make that decision. And nobody, of course, is forced to make it, and nobody should be forced to make it. But can you see what people are saying here, which is the idea that it feels like we aren't doing those other things in parallel, particularly giving people proper access to mental health

supports? Can you see why people are so upset about that? We can always improve what we are doing, but the process of eligibility in the case of mental illness, mental disorder, when the assessor looks at that person, they have to be satisfied that everything has been done to try to alleviate or lessen the condition that the person is living. And in some cases, that can be through additional treatment, mental health treatments that have not been explored. And in some cases, it can be through social supports that may help to relieve the pain and suffering that they are going through. And yes, we need to be working towards both of those things. But ultimately,

we also in parallel have to respect a person's decision. And the vast majority of people make that decision because they have come to terms with the fact that they feel that MAID is the option they choose to leave life. I want to go spend a bit of time talking about that criteria, like how you decide whether someone is eligible for MAID. So as I understand it, a person with a mental health, because we're talking about mental health right now, it has to be decided that the medical condition is irremediable, right? That it won't improve. And I've gone through a bunch of expert testimony from your committee, and there seems to be no agreement among experts on how to determine whether a mental illness won't improve much harder to do than a terminal cancer diagnosis, right? And actually, an expert panel was put together by the federal government to give

some advice on this. So for example, they couldn't say how many times a person should be treated before a decision is made that they can't be cured or their mental illness symptoms can't be alleviated. And like, do you think it's responsible for the government to push forward with this March 17th deadline when experts are so far apart on this? when experts are so far apart on this? Well, there's a range of opinions with respect to experts. And that is one of the reasons why when we changed the law with Bill C-7, which allowed access to MAID in cases where natural death was not reasonably foreseeable, that is the reason that we put additional safeguards

in place compared to what we call track one, people who are in imminent threat of dying, such as with cancers. So those additional measures that were put in place to have two people assess a 90-day reflection period, bringing in additional experts if required if the MAID assessors are not convinced or are not able to make the decision about whether the person truly understands and is in a situation where every other option has been explored in terms of treatment. It's been going on for years or decades. The person is not at that time going through a suicidal crisis because that immediately disqualifies them at that particular time. All of those safeguards are put in place. And that's why the expert panel made 19 recommendations. And those 19 recommendations are things that were received by the government

last May, and which they are looking at to provide specific standards and protocols associated with the assessment process, looking at the issue of training for MAID assessors who can be physicians or nurse practitioners, looking at oversight to make sure that it's being done the proper way, looking at research in particular areas, and looking at data collection so that data is collected so that we have a more fulsome picture of how MAID is being administered, not only in the cases of mental disorders, but in all other applications where MAID is invoked. Right. But this panel, I just want to talk about that panel for a second. Like, this panel itself has been criticized. Like, two people resigned from the panel. One member said there was a lack of transparency from the panel in publishing dissenting views. Another said the process was rushed and that, quote, panel members simply did not want to put forward any serious safeguards that would require the law to change. These seem like pretty serious concerns to have with a panel that is supposed to be

providing a roadmap here, no? Anytime you're looking at something as complex as this particular issue with a panel of 12 people, you're going to have differences of opinion or variations on the same opinion. That is inevitable. But to focus on one or two people out of a group of 12 that may have had differences to the point of, in one case, leaving, is to forget that there was large consensus amongst the majority of the experts that were on that panel. And that is pretty typical when you're studying anything as complicated as made. And so it's important also to focus on the overwhelmingly large area of agreement with respect to mental disorders from this panel, as opposed to just focusing on somebody who, for whatever reason, had their own different views and did not feel comfortable with the panel.

But there are lots of experts who disagree with the conclusions of the panel. I know that they made recommendations, but they did not recommend that any changes be made to the law. And there are experts who clearly feel that the law needs to do more here. So, for example, in the Netherlands, doctors must report every death to a regional review committee. Have these topics come up? the course of our examination of this, and those are things that the committee takes into consideration and decides whether or not it will move forward with recommendations. There are also fairly large groups that are asking for the government to take a pause here. The Association of Chairs of Psychiatry in Canada, which represents the lead psychiatrists of Canada's 17 medical schools. The Center for Addiction and Mental Health, CAMH in Toronto. And why not just recommend that the government hits the pause button? This is such a high stakes issue here. Like, why even wait for your report to come out? We're aware of everything that is being said about this particular subject. And I'm certainly very aware of the different bodies that have

given the position that this should be delayed. All of those things are factored into our deliberations as a special joint committee and play into what will be in the final report, which I can't describe in substance at this point, but that will be, of course, be made public in February when it is tabled in both houses. The other issue I wanted to bring up with you briefly, you know, you talked about training. It just, it also feels like there are a lot of components of this that have been delayed here. Like your own committee was supposed to have released this final report by now, and you have not done so yet. The expert panel, it was late delivering its report. Federally funded physician training for MAID and mental health is also late. It was supposed to be released in the new year, but now it's not coming until next fall after this March 17th deadline. So if all these important components have been late,

why are we still hurtling towards this March 17th deadline? I think that people should take comfort in the fact that the expert panel took the time necessary did its work, released its report last May. And we in the special joint committee of senators and MPs have delayed our report because we wanted to hear from additional witnesses. So this should give some comfort to Canadians that we're not rushing the process, and hence the reason for the delay. And we now have had the opportunity to hear from them, and the February 17th deadline is the one that we feel that we can meet with our report. But then what about the argument that the March 17th deadline is now rushed and people aren't ready? I'm not saying that these delays shouldn't have happened. And of course,

this feels like a topic that everybody should take their time on and get right. So we're very much aware that the 17th of March is a month after the 17th of February. So we're very much aware that the 17th of March is a month after the 17th of February. So we're very cognizant of that fact. In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization. Empowering Canada's entrepreneurs through angel investment and industry connections. Hi, it's Ramit Sethi here. You may have seen my money show on Netflix.

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just search for Money for Couples. You know, we talked before about access to mental health and how there are concerns that people might be accessing MAID because of their inability to access mental health supports. And you mentioned, we talked about that there's also concerns that people are already accessing it because they have a chronic condition, that they might not die imminently, but they're in pain. And also because of other factors, like that they might not be able to afford housing.

And so there have been quite a few controversial stories that have come up in the news lately. For example, Amir Farsoud, a man from St. Catharines, who started the process of applying for medically assisted death, not just because of his constant back pain, but also related to his fears over being homeless because he couldn't really make ends meet with his disability checks. And I think it's worth mentioning that he changed his mind after an outpouring of support here, but he was able to get a signature from one doctor. And as you mentioned, you need two. And Dr. Lee pointed out to me in our conversation that a person can basically keep asking doctors until they get the signatures.

And this sounds a lot like doctor shopping, right? And is this something that concerns you? So the additional protection measures, I believe at this point that the expert panel recommended, the two MAID assessors and, if necessary, additional experts to look at the case, I think indicates that we have to be obviously very careful and very thorough in making a MAID assessment. It's important. We are hearing the stories in the media about the example

that you brought up, where in some cases a person has said, well, if I had access to certain supports, I might feel differently about it. Those are important for us to hear as a society, but also as a committee looking at this. And as again, as I've said before, it points to the need for us to always find ways to improve our health services and social services and supports in this country. At the same time, and that we've heard very clearly in the committee, at the same time, there have been now many years of MAID in place, and we have gained a lot of experience in terms of looking at it. The majority of requests for MAID have been for the so-called track one, where the end of life is foreseeable.

But there have been track two, which is the case we're talking about here, where the end of life is not foreseeable, where we have gained a certain amount of experience, and where we have learned a number of things. This is something that's new to Canadian society, medical access, medical aid and assistance in dying. So as we are going along, we have to be very careful. We have to learn from the things that we're hearing about and the experiences. That's one of the reasons we need to improve our database. It's one of the reasons why we are sensitive to the fact that the person making that decision must not only have capacity, but they must be making it primarily because they have decided that their suffering is unbearable and irremediable. And it's not because of other factors that they're making that decision.

That's important for us to bear in mind all the time. And it's important for us to bear in mind one fundamental point here, and that is that ultimately it is an individual decision that the person makes. And in some cases, we've heard from people who have said they resent being told by outside so-called experts how to live or to end their life. They don't want to be treated as people who are, quote, vulnerable. They are people who are in full possession of their faculties in some cases and are saying, I've had enough. I am the one who has been suffering all of these years. And for somebody else to tell me, no, no, no, you are not allowed to do it because certain things have not been done properly. That in some cases,

we heard testimony of people who were very resentful of that. So that's the kind of balancing that we have to do with respect to medical assistance in dying in the case of mental disorders. It's not an easy task. This idea that this needs to be a person's very personal and individual decision, of course, this is incredibly personal, but I want to bring up another example related to that. Which is sometimes forgotten, if I may say, which is sometimes sort of swept away and forgotten

because there is a justifiable focus on what other experts are saying, such as the ones that you've quoted to me. But let's just not lose that from sight. Right. I just think, you know, listening to doctors like Madeline Lee, her concern here is that this is pushed too far in the other direction where there's not enough safeguards put around vulnerable people. And so here's another example that I think is relevant here. Like another story about Made in Canada recently made international headlines. A paraplegic former Paralympian

testified that in 2019, someone at the Department of Veterans Affairs offered her in writing the opportunity for a medically assisted death. I have to crawl down the stairs on my butt with the wheelchair in front of me to be able to access my house. If things are so hard at this point and you just can't keep going on, then you know we can assist you with aid to die. The prime minister responded to this. He said it was absolutely unacceptable. We are following up with investigations. We are changing protocols to ensure what should seem obvious to all of us, that it is not the place of Veterans Affairs Canada, who are there to support those people who stepped up to serve their country, to offer them medical assistance in dying

as a matter of course. But Veterans Minister Lawrence McCauley said in testimony that there were four or five cases of veterans being offered the made option by a now suspended veteran service agent, cases which have been referred to the RCMP. And so, like, is this not a good example of how some additional safeguards might have helped here sooner? Like this idea that all cases have to be referred to a special committee like they do in the Netherlands. So two things there. One is, I will echo what the Prime Minister and Minister McCauley said about the example of the person of Veterans Affairs who raised the issue of MAID with a veteran. That is totally unacceptable. And it's important for us to know this and to ensure that kind of safeguard. But that's not against the rules, right? Like, doctors are allowed to do that here in this country.

All right. But as a country, I can certainly tell you that the intention with MAID is never to sort of push it in people's faces. It is a decision that they arrive at by themselves and should not be prodded with respect to that, which appears to may have been the case in the case of Veterans Affairs. But the second point is returning to Dr. Lee's testimony. Based on what she said at the beginning of the program and what you've said, her concern is, are we ready? The concern is not about whether it should be allowed or not. It's about whether we are ready with the safeguards, the protocols, the training, the oversight. And those are things that the expert panel said were very important in their 19 recommendations. And those are things that we have heard, and not only from the expert panel, but from some other people as well.

So all of that plays into the recommendations that we will make as a committee. Right. And just to be fair, I just want to mention, there are experts who think that the expert panel, like I said before, their recommendations don't go far enough. They don't offer robust enough protections for vulnerable people. But before we go, like, one thing I wanted to talk to you about is the communications around MAID and its evolution. So when we were talking with Dr. Lee, she said that some healthcare providers aren't even aware of how medical assistance in dying has broadened in Canada. And it's not just physicians. I know people who really hadn't heard that medical assistance in dying had expanded beyond those foreseeable and imminent death criteria. And they really had no

idea that it was soon going to be expanded to include mental illness. And do you think Canadians have really had the opportunity to grapple with this evolution, to ask these really, really difficult, thorny questions when it comes to the expansion of MAID? Not the original concept that someone with terminal cancer can access MAID, but these much thornier issues around mental illness and issues where death is not imminent. So let me agree with you. Education is fundamentally important here on something like MAID, which is a new concept, a new capability that exists in our country since 2016. People naturally, I think most people would agree with me, don't like to talk about death. They don't like to think about it too much. But it is something that bit by bit is becoming more talked about. There have been, of course, since 2016, some in the area of about 30,000 people who have access made, and there are stories written about it, and awareness is growing. I, for example, in the

past week have seen a flurry of articles about MAID with different viewpoints. And I think part of that is because of the fact that a decision is coming next March. So I think awareness is growing. And even within the healthcare community, I'm talking about physicians and nurse practitioners, they, of course, can have their own personal opinions and decide whether or not they're prepared to become MAID assessors or MAID providers, and nobody is forcing them, of course. But I think even their awareness is growing as it becomes something that is more common in Canadian society over the past seven years, six years. All right, Mr. Garneau, I want to thank you very much for your time. My pleasure, Jamie.

All right, that is all for today. I should note before we go that we've invited both Justice Minister David Lamedi and Health Minister Jean-Yves Declos to join us for an interview. These are the ministers charged with this file. The Health Minister declined our offer and we have not heard back yet from the Justice Minister. For more CBC Podcasts, go to cbc.ca slash podcasts.