Medical assistance in dying, or MAID, is expanding in Canada in ways that many people are perhaps not even aware of. Do we really know what we re getting into here? Shouldn t we perhaps talk this out a little bit more as a nation? To help us understand the complexity of these issues, where we re at in the situation here in Canada, and where we may be going awry, we are joined by Dr. Sanu Gand, a professor at the University of Toronto and the Head of Psychiatry at Humber River Hospital, where he is the physician chair of the Medical Assistance in Dying Committee.
00:02:05.120Thanks for joining us for the latest episode of Full Common.
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00:02:10.720Medical assistance in dying, MAID as it's called, is expanding in Canada.
00:02:16.220In ways that a lot of people are perhaps not even aware of.
00:02:20.080Laws were first introduced permitting MAID in Canada just over five years ago.
00:02:23.540But in early 2021, the categories and situations were broadened in ways that are concerning to a number of experts.
00:02:31.620Do we really know what we're getting into here?
00:02:34.020Shouldn't we perhaps talk this out a little bit more as a nation?
00:02:36.940To help us understand the complexity of these issues, where we're at in this situation here in Canada, and where we may be going awry, we're joined today by Dr. Sanu Gand.
00:02:46.720Dr. Gand is a professor at the University of Toronto and the head of psychiatry at Humber River Hospital, where he is the physician chair of the Medical Assistance and Dying Committee.
00:02:55.620Dr. Gand, thanks so much for joining us today. We appreciate it.
00:02:58.880My pleasure. Thank you both for having me and also, more importantly, for your interest in this challenging and complex topic.
00:03:07.300Yeah, challenging indeed. And there's definitely a lot of perspectives, both professional perspectives, but also very raw opinions out there that a lot of people are sharing.
00:03:17.600I'm kind of surprised to find us so suddenly back at this conversation, as I know it was a national conversation about five years ago, following a court ruling.
00:03:25.520A lot of people said, well, it's a slippery slope. Watch out.
00:03:28.940We said, well, OK, you know, take it one step at a time.
00:03:31.180But it looks like recently we have gone a further step, which I guess requires a subsequent conversation.
00:03:37.060Yes, and this is why I'm so appreciative that you're taking the time to look at this issue, because I honestly believe that the vast majority of Canadians are completely unaware of just how far things have gone and in such a short time.
00:03:56.320So I think there are a lot of misconceptions out there about where our current expanded policies are going and how we've come to be where we are.
00:04:06.060Well, can you explain to us how things first sort of developed back around 2016 when there was, I guess, a court ruling saying medical assistance in dying would be allowed to end the suffering of terminally ill adults?
00:04:20.560What were the confines of that? How did that sort of work practically?
00:04:25.000So what happened was in 20, the court ruling was from 2015, and it led to laws that were implemented in 2016.
00:04:33.920And the ruling was in a case called Carter versus Canada.
00:04:38.800And in that case, there were two plaintiffs, two people who were, they were fighting for the ability to have a medically assisted death.
00:04:49.080And each of those people had what we call a neurodegenerative illness, meaning an illness that has known progression and a known course to it, and it was known that they would not be able to improve.
00:05:04.880One of them had ALS, and the other had spinal stenosis.
00:05:09.160So what the Supreme Court found in that case was that the up until then blanket prohibition the country had against assisted dying, that the blanket prohibition violated our charter.
00:05:22.300And what that means is they said that you can't just say that you're unable to provide assisted dying in any situation.
00:05:31.040It may be suitable in some situations.
00:05:33.480Now, keep in mind, that prohibition was actually in the criminal, in our criminal law, is the law that needed to change.
00:05:41.100So what changed in 2016 to conform with that ruling was that the government brought in Bill C-14, which allowed for assisted dying in certain circumstances.
00:05:55.180And one of the safeguards that was required was that a medical condition that was grievous, meaning really serious, and irremediable, meaning it will not get better, that we can predict it won't get better, that you needed to have a grievous and irremediable medical condition.
00:06:14.040And one of the safeguards was that natural death needed to be reasonably foreseeable.
00:06:19.660And so that's what the initial framework was based on in 2016.
00:06:26.640What was the response among the medical community to this ruling?
00:06:30.060Was there the sense that, yes, we need to provide these opportunities for people, that this is a gap?
00:06:34.800So there was, I don't know if relief is the right term, but a general agreement with this?
00:06:40.580What was the level of acceptance to resistance, would you say?
00:06:43.400It's a controversial area in some ways, but I do think that the ruling at that time, which was framed in the context of providing assisted dying when someone is already dying, that's a key distinction, because death needed to be reasonably foreseeable.
00:07:02.340There has been a shift towards greater acceptance that that is appropriate in some situations.
00:07:12.040I don't think there's 100% agreement on either side in this complex debate.
00:07:17.440But it is something that shifted over time.
00:07:19.580And to put that in context, you know, there had been a previous Supreme Court ruling in a case about 20, in the 1990s, in 1993, a different case challenging the same law.
00:07:33.600And that was a case also of a woman, Sue Rodriguez, who had ALS.
00:07:37.700And in that ruling, the Supreme Court upheld the existing law through a split decision.
00:07:42.740And in the 2015 ruling, the Supreme Court unanimously ruled that the law violated the charter.
00:07:51.680So even that represents some sort of shift in what society and people seem to think was acceptable.
00:08:00.420The concern became, though, that some people did not agree with it.
00:08:07.000And it did allow the option for people to be what are called conscientious objectors, meaning if somebody did not want to participate on the medical side, that they shouldn't be compelled to.
00:08:21.260But there were others who were not conscientious objectors, but they had concerns about further expansion.
00:09:35.700My background is psychiatry and psycho-oncology.
00:09:39.660In other words, when patients have cancer as well.
00:09:43.200And the MADE laws that we have had up until now, because that reasonably foreseeable death, safeguard had been there, and mental illnesses on their own do not, by and large, lead to death, sole mental illness conditions have not been things that have really been open for getting MADE for.
00:10:06.640So people could apply for MADE if they have a mental illness, plus another condition that had been leading to foreseeable death.
00:10:15.300But mental illness conditions alone generally would not qualify for that.
00:10:20.060And as a result, in terms of my role, we haven't had applications for sole mental illness.
00:10:26.620So as a psychiatrist, I wouldn't have a role in doing the clinical assessment of whether somebody's ALS is irremediable, for example, or whether their lung disease is irremediable.
00:10:38.080So it's more of an oversight role where we would review things as a team.
00:10:42.540But again, we so far have not had MADE for sole mental illness, by and large.
00:10:48.540So now we're in a situation, March 2021, the law further amended by Bill C-7, which has expanded the situations and categories where MADE is made available to patients.
00:11:03.120In what sort of scope has this now changed?
00:11:06.940So if I can take a second, I'll rewind a little bit.
00:11:11.280In order to get to that question, because you mentioned at the beginning that some people had concerns there could be a slippery slope, and others were saying, no, there's no need to worry about a slippery slope.
00:11:39.840So before even getting to the expansion in C-7 from 2021, before getting there, let's just talk for a minute about what has been happening with MADE under the old system, when death needed to be reasonably foreseeable.
00:11:55.680And this is part of what I think many people don't understand.
00:11:59.420When death needed to be reasonably foreseeable, it did not mean that you only had two weeks or two months or even two years left to live.
00:12:07.440It was generally acknowledged through other case law that occurred during that time, that even if someone had up to a decade to live, up to 10 years to live, that could qualify and would qualify and did qualify for getting MADE.
00:12:22.880So we're not talking about people right on death's doorstep, even under the old system.
00:12:28.040I wasn't aware of that, to your point about Canadians not really understanding.
00:12:32.620Yeah, and so what that means, quite literally, is that even age ended up becoming a potential quote-unquote qualifier, because the issue of age and frailty did come into play.
00:12:47.440And so if you could say to anyone that, yeah, we think it's reasonable that you might have 10 years or a bit less to live, they actually would have qualified under the old system without expansion.
00:12:58.460Now, under the old system, let's look at briefly what the numbers were, that the country gets national statistics.
00:13:06.560The way we've compiled them, there's always a bit of a delay in the national reporting.
00:13:12.660So I'm going to give you two years of national reporting.
00:13:15.280The latest national reporting we have is from 2020.
00:13:22.800But I'm going to talk first about 2019.
00:13:25.320So in the year 2019, which was just a few years after MAID came in in 2016, in that short time, our national death rate from MAID was 2%, meaning that 2% of all deaths in Canada by 2019 were by MAID.
00:13:44.520Some provinces were quite a bit higher than that.
00:13:48.060So Quebec was at almost 2.5% and BC at about 3.3%.
00:13:53.380Over the next year, so into 2020, again, before expansion of C7, the death rate in every single province went up.
00:14:03.140They quite remarkably called the term a growth rate.
00:14:05.680They called it a growth rate in the death rate by MAID.
00:14:09.300And so by 2020, 2.5% of all Canadians dying that year died by MAID.
00:14:22.160And we know that even within there, there are pockets that are even higher.
00:14:27.140It's reported that Vancouver Island's death rate by MAID is over 7%.
00:14:33.280And it's been dubbed the MAID capital or assisted dying capital of the world.
00:14:38.660Now, all of that is before Bill C7 expansion.
00:14:43.180Now, let's look at what happens with Bill C7 expansion.
00:14:46.040Can I just ask you one question, though?
00:14:47.920Because I imagine some advocates of this would say that that increase in rates is an indication of what people have always wanted anyway.
00:14:55.340And that it's, while maybe not good news, these are people who are avoiding the great pains that they anticipated at what would be a more natural end of life, where they are allowed a death with dignity now.
00:15:08.320And that that number is something, again, not to be celebrated, but that people got what they wanted.
00:15:13.560How do you respond to that position, which I've heard advocated?
00:15:16.680And I've heard people say, I've heard the MAID advocates for expansion or expansionists, I've heard them say precisely that, that, oh, that's a good thing.
00:15:37.860I've also heard them say that the problem is not that the rate is high in some provinces, it's that it's low in others.
00:15:45.000And that that reflects that there's not enough availability of people to get MAID.
00:15:49.900Now, before kind of saying which way should we fall on that, I have to point out that people need to realize, especially as MAID laws expand, they affect different people and different populations in different ways.
00:16:06.220And we'll hopefully come back to this near the end, because I think this is really a key, key point.
00:16:14.660But when we look at the number of people dying by MAID, we also need to look at who are those people who are dying by MAID and why are they getting it.
00:16:27.880There are some people who get MAID because they want to die with dignity.
00:16:33.220They've lived a life of autonomy, and they want to preserve their dignity and autonomy and die with dignity.
00:16:40.440As we expand MAID laws especially, there is also a second group of people, and evidence shows this, who it's not that they're seeking death with dignity.
00:16:50.820They're seeking an escape from life suffering.
00:16:53.860And life suffering includes social suffering.
00:16:56.280When we look at who's actually been getting MAID when death is foreseeable, right, so if death is predictable and foreseeable, that group does actually tend to be, according to the research, that group tends to be more privileged.
00:17:14.720They come from higher socioeconomic status, and they tend to be white.
00:17:19.380That's the description in the terms of the researchers in multiple places that have looked at this.
00:17:24.980But when you expand MAID, which is now what we're doing, when you expand MAID for conditions beyond death being foreseeable, in other words, when you expand MAID to people who are not dying, then a different group starts to be affected, and they seek it for different reasons.
00:17:43.720They seek it because they are suffering from things like poverty, loneliness, isolation.
00:17:49.460You also see, and I'll talk about this a bit later, a gender gap emerging with twice as many women as men getting MAID for psychiatric euthanasia in the European countries that allow it.
00:18:03.080So it's not just a population number of 2% or 2.5%.
00:18:08.100It is who is getting MAID for what reasons, and then who keeps getting it as we expand the laws more.
00:18:15.140And to me, that shifts the question from not, well, where do we think the perfect balance is?
00:18:22.020It shifts the question to which mistakes do we want to make?
00:18:26.020Do we want to say that somebody, to preserve their autonomy, we want to make it even easier for them to get it, even if they have more than 10 years left to live?
00:18:35.020But by doing that, we also change the goalposts, and we know that others are now going to get it because they've had life-suffering society refuse to help them with.
00:18:48.520Is it preferable to have MAID available for someone who otherwise, and I can't think of a more diplomatic way to say this, would otherwise have just had a messier suicide?
00:19:05.020When we look at the actual evidence, and that is something that the expansion advocates have, or activists, have said is an issue.
00:19:18.180Oh, we're trying to avoid people from having, in the terms you're using, a messier or painful suicide.
00:19:27.920What we actually find is this, that in the, so if we look at psychiatric suicide and suicide attempts, it's an interesting statistic, which is universally, this is repeatedly found, that by a two-to-one ratio, more women than men attempt suicide.
00:19:48.920So they try to end their lives when they have, when they're suffering from a mental illness.
00:19:54.820And the vast majority of them do not end up taking their lives.
00:20:00.040So the initial suicide attempt, they end up surviving it.
00:20:06.500And this is a clear thing we see with the suicide research, that in the vast majority of cases, suicide, in those contexts, is something that there's a lot of ambivalence about.
00:20:19.560But people may have that ambivalence for a prolonged period of time.
00:20:23.740It's not that it's only there for one day or two days.
00:20:28.080And if they get to the point of acting on it, that's when they have a suicide attempt.
00:20:33.540What we're doing with MAID is we are changing a transient suicidality in those situations into a permanent death.
00:20:41.640Because when you look at the European countries that provide psychiatric euthanasia, you see that exact same two-to-one ratio of women to men who actually get their lives ended.
00:20:51.480So in other words, something which they might otherwise have a suicide attempt and survive and then not try again and go on to live meaningful lives.
00:21:02.380We're now making it easier for them in that initial period to actually have their lives ended by us.
00:21:09.000So the data shows that suicide attempts, many of them are cries for help.
00:21:35.280And the help they need, the help they need is help with their illness and help to live.
00:21:42.100And in fact, I've spoken with many people who have said, you know, people who've struggled with chronic depression, who've said, at that point in my life, in the past, I was competent.
00:22:20.960Think about how that makes you feel about whether you want to be here in the context of suffering from mental illness and poverty and loneliness.
00:22:28.720And so in that context, somebody may actually want to end their life and they can't see anything else.
00:22:37.460My role as a psychiatrist has always been to say, you know, I actually know from the evidence and from experience that we actually can help you.
00:22:47.580And I think that's what our role should be.
00:22:52.260There's one fellow who, I won't say his name, but he does talk publicly about this.
00:22:58.640It's actually a bit painful for me to even say.
00:23:01.400I always get a little emotional thinking about this.
00:23:03.780But he struggled with mental illness for many years, chronic depression, sometimes getting better, other times worse.
00:23:10.640And it did have suicidal thoughts for much of that.
00:23:52.120He lived and is living a meaningful, fulfilling life.
00:23:55.640He's actually become a mental health advocate.
00:23:57.360And I don't want to be the person on that bridge that doesn't say, we're going to help you live and find a way to live a meaningful life again.
00:24:07.380And that is what the evidence actually shows the risk is with expanded, made, and psychiatric euthanasia.
00:24:14.080We'll be back with more full comment in just a moment.
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00:25:01.900Dr. Gan, in response to the expanding legislation, would your perspective be that we just need to think this through more and maybe not go ahead with this?
00:25:11.520Or is it that we need different safeguards involved to act as further checks and balances?
00:25:17.640You know, that's an excellent question.
00:25:20.860And one of the fundamental issues here is that if you bypass the fundamental safeguard, no other safeguard means anything.
00:25:32.900One of the fundamental safeguards, this is embedded in our legislation.
00:25:37.360This is what Canadians have been told and sold that MAID is about.
00:25:42.820They've been told that MAID is for a grievous and irremediable condition.
00:25:47.840That is something which for mental illnesses is a fallacy to be able to apply to MAID laws.
00:25:54.700Because mental illnesses can be grievous and absolutely can lead to terrible suffering, as bad or worse suffering than physical or other medical illnesses.
00:26:05.040However, what you cannot do with any mental illness is predict when it won't get better.
00:26:11.340So, the issue of it being irremediable, that's actually impossible to predict.
00:26:47.620The Canadian Mental Health Association doesn't.
00:26:50.820And so, this idea that we're telling people that, oh, yeah, I think you're not going to get better.
00:26:57.100That is not based on any scientific evidence.
00:27:00.400And in fact, the scientific evidence shows we can't make those predictions.
00:27:03.580So, my question is, if we are not providing MAID for when the condition can't get better, when it's irremediable, what are we providing it for?
00:27:13.660And then it opens the door to all of that other life and psychosocial suffering.
00:27:18.420Even groups that support MAID for mental illness, even they acknowledge and admit that you cannot make these predictions.
00:27:32.160So, the Quebec Association, the Quebec Psychiatrist Association, the AMPQ, this was in a paper that was written by their group.
00:27:42.580And it included the author, or as one of the authors, the same person who's currently chairing the federal expert panel on mental illness.
00:27:54.760And that group actually literally said, regarding irremediability and mental illness, it is possible that a person who has recourse to MAID, regardless of his condition, could have regained the desire to live at some point in the future.
00:28:10.700And then they remarkably, in my opinion, remarkably, go on to say that, well, regarding, you know, the certainty and eligibility criteria, assessors will have to answer this ethical question each and every time they evaluate a request.
00:28:25.640And, you know, our law is not that somebody has a grievous and irremediable medical condition if in the ethical opinion of each and every assessor they do.
00:28:35.360So, that opens it up to such non-scientific, non-evidence-based judgments that place our patients at risk of premature death when they're in a state of suicidality.
00:28:49.620Dr. Gant, I want to get your take on a CTV news story from November 2020 that I've never forgotten.
00:28:57.580It surprised me and shocked me for a number of reasons.
00:29:01.320I'm sure you're aware of these incidents.
00:29:20.340It was the exact opposite of the lonely months of lockdown she had suffered through in a retirement home where she had lived for several years.
00:29:26.580The story goes on to talk about her life.
00:29:29.120It says the lockdowns were so crushing for her.
00:29:33.540And there's so much that can, of course, be said about our treatment of elderly, long-term care homes, retirement homes, pandemic rules, which were legitimate, which weren't.
00:29:42.240But when I read this story, I remember a year and a half ago, I thought I didn't think this was what medically assisted dying was for.
00:29:52.600I appreciate that she's a 90-year-old beyond normal life expectancy, but she was also not facing an imminent death from a deteriorating health issue.
00:30:02.060Yeah, you know, I actually, I think you've struck the nail on the head.
00:30:09.680Because this is not, it's not what I signed up for when I got, when I actually believed in the value of assisted dying in some situations.
00:30:20.960It's not the sort of thing that I think most people, most Canadians would think made should be for.
00:30:28.040And unfortunately, that actually is what this expanded made is exposing people to.
00:30:36.060And I believe the way we got here is, you know, there are a number of myths that have fueled what has led to expanded made.
00:30:45.920As I said at the beginning, most people don't even realize that even before expansion, if somebody had even up to 10 years of life left, they probably would have qualified.
00:30:56.980But I think the key myth that allows this to perpetuate, and this is very sad to me.
00:31:03.520I see so many of the expansion activists repeatedly saying that, oh, made is about autonomy.
00:31:11.040They're telling people it's about your autonomy.
00:31:13.000Well, and that's very appealing, because people say, of course, autonomy is good.
00:31:19.240And if we have more autonomy, all the better.
00:31:22.700Well, when we actually look at the stories you're talking about, about who are some of the people getting made, and this is from work that continues to come out.
00:31:33.000This is from December of 2021, looking at psychiatric euthanasia.
00:31:38.240What kind of suffering is actually leading to these people getting it?
00:31:42.260There's a range of it, but it includes things like perceived failures to live up to the expectations of others, and societal standards and norms.
00:32:03.220You know, I was on a podcast with Canada Land, I think it was, in October.
00:32:08.140And the heading of that podcast was a woman in our country, in B.C., saying, I die when I run out of money.
00:32:15.020The, this has, as it should, it's attracting international attention.
00:32:23.660You know, Canada prides itself, as a Canadian, I like to pride our country as being one that's on the forefront for social justice.
00:32:31.740In this area, I think we're taking a huge step backwards, and to be blunt, I think we're implementing policies of privilege that actually embed ableism, ageism, racism, and sexism, and expose the most marginalized to unnecessary premature deaths for this autonomy myth.
00:32:52.560And I'll get back to that in a second, but in terms of the international headlines, there was a piece in the UK Spectator, just in the past week or two, titled, Why is Canada Euthanizing the Poor?
00:33:05.380And it goes through some of the things there now.
00:33:08.280Now, in terms of autonomy, as I mentioned before, you will have a group that has lived well, and now will have the chance potentially to die more on their own terms.
00:33:25.400Although I honestly think that even in that group, most people don't realize that they would have been able to get made even if they had 10 years of life left, even before, before expansion.
00:33:34.980But let's say, let's say the expansion does increase the autonomy for some who have lived well, and now want to die well.
00:33:44.160Well, these other things I was talking about, about people getting it for life suffering, that's not autonomy.
00:33:57.240And so this myth of autonomy, it's a specific type of autonomy.
00:34:01.180It is what I would call privileged autonomy.
00:34:04.980Dr. Gand, I must say, I myself am conflicted on this, because I have always approached so many life choice issues from a very libertarian perspective, where I say, ultimately, even if it's something that I don't agree with, I wouldn't do myself, I wouldn't want people I love doing it.
00:34:22.860What place do I have to tell a consenting adult what they can and can't do?
00:34:28.840And this issue, hopefully, we are dealing with poverty issues so that nobody even has that thought.
00:34:34.760Hopefully, we are dealing with mental health challenges.
00:34:37.120Hopefully, we are providing all the other exit ramps.
00:34:39.600But ultimately, if someone has thought through this, hopefully thoroughly, hopefully at length, who am I ultimately and who are we as society to ultimately limit this option?
00:34:48.540How would you respond to people such as myself who are conflicted because of that very thought process?
00:34:59.040And I agree with you that when people have true autonomy, we should support them in the decisions that they make.
00:35:06.420The problem is that the things that I make as my decisions in any society, they can also affect other people.
00:35:15.040And the laws that we implement affect different people in different ways.
00:35:18.880So it is questionable whether it's truly an autonomous decision for somebody who's in a state of depression, whose mental illness is affecting how they think.
00:35:29.580They're still capable, you know, they still have legal capacity and competency.
00:35:35.820But as I mentioned before, their thoughts are being affected by I am bad, the world is bad, future will be bad.
00:35:41.740And there are known biological correlates that lead to the sense of hopelessness and despair in depression.
00:35:50.960And suicidality is a symptom of mental illnesses.
00:35:55.160It's actually one of the core symptoms of some mental illnesses.
00:35:57.600And so in that state, to facilitate somebody to end their life, when we cannot even say to them that they won't get better, but we pretend that that's what we're giving it to them for, for an irremediable condition that we can't predict.
00:36:12.160To me, that is morally wrong, because we know from the evidence that most of those people actually will get better and will themselves regain the will to live.
00:36:23.220So it's not about imposing somebody's external autonomy on anyone.
00:36:26.820It's about recognizing that, well, as I expand my quote unquote right for made under all of these other circumstances, it is exposing a different group of marginalized or vulnerable people who are suffering from all sorts of life suffering, who actually most of whom would get better.
00:36:47.860But in their state of transient wishes for death, we'll be facilitating and fueling those.
00:36:55.120You know, there's, and this was actually in the UK spectator piece that I mentioned to you before.
00:37:03.560But there's a quote from a French poet, I think he was, many years back, and I'll just read it to you and you can kind of figure it out for yourself.
00:37:16.300But it's Anatoly France, and he says, the law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread.
00:37:30.140Pointing out that it's the same law, but obviously it affects people in different ways.
00:37:36.500You're probably not going to have too many people who are rich needing to sleep under bridges or beg in the streets.
00:37:42.460And if Anatoly France was alive today, I actually think the ghost of Anatoly France would say this about Canada's current made laws and expansion, that Canada's made law in its majestic equality helps the poor as well as the rich to die for life suffering.
00:38:03.800Dr. Gann, when you talk about vulnerable persons, one category of individuals most people agree are in more vulnerable positions, our youth, our children.
00:38:13.500And when we talk about expanding medical-assisted death, a lot of concerns right away gravitate to what degree does this or does this not involve children or a phrase that's used in the medical context, mature minors, usually referring to teenagers.
00:38:31.000What are your concerns about that category?
00:38:35.900It's very similar to the last question you asked about, well, if somebody in that moment is deemed to have capacity, shouldn't we respect their wish and their autonomy?
00:38:48.700And that argument has been extended to mature minors to say, well, it shouldn't matter what age they are.
00:38:56.300If you've got a 12-year-old who understands what they are asking for and we deem them to have legal capacity or competency, they should be able to get it.
00:39:07.560There are made expansion activists who are seeking precisely that.
00:39:11.980I am highly concerned about that because, once again, I think what it does is in a very, I would say this is an artificial, this entire thing is often an artificially narrow focus on, oh, it's just that person's individual autonomy and it excludes everything else.
00:39:34.400We know that the brain, the human brain, continues to develop in terms of specific things that are necessary for decision-making into our third decade.
00:39:47.460So, by the age of even 25, it may not be fully, the frontal cortex and other key parts of our brains that are involved in decision-making are not actually fully developed in terms of where they eventually will be going.
00:40:05.560I remember that was a concern around legalizing marijuana, the concerns that 18 to 25 bracket there.
00:40:11.700Yeah, that's exactly, I was actually going to go exactly there, that, you know, I find it striking that in our society, I don't have a problem with this other stuff I'm talking about.
00:40:23.100When I say striking, I'm talking about the contrast.
00:40:25.560But I find it striking that in our society, nobody raises concerns, or I won't say nobody, but people generally accept that we can have a legal age for drinking.
00:40:37.220We can have a legal age for voting, we can have a legal age for marijuana, but we can't have a legal age for when we are going to help a non-dying teenager or less end their life.
00:40:55.980And the science and evidence completely doesn't support that, but again, if the only issue that people are paying attention to is, oh, it's that individual's autonomy, let's provide them what they're asking, it's such an artificial argument.
00:41:14.540Dr. Gand, to your point, there are activists who are pushing still for further expansion of this, and also to one of your very beginning points, a lot of Canadians aren't even aware of what's going on now, and weren't even aware of exactly what the 2016 laws brought about.
00:41:31.040You've talked about this being beyond a slippery slope, but are we still falling?
00:41:36.040Do we still potentially have more to go?
00:41:38.660Well, I think that opening it up to mature minors, opening it up to sole mental illness conditions that we are pretending we can predict to be irremediable when we can't, I think that those are bridges we should not be crossing.
00:41:55.600So we do have ways more that we could go, but I don't think we should.
00:42:00.980You know, this is actually pretty unusual, I'm pretty sure, for a podcast, but I wonder if you would bear with me for me to read you a two-minute poem that I wrote the night that Bill C-7 passed.
00:42:16.980So just to put this in context, this was in March 2021, March 11th, and Bill C-7 passed with what they called the Sunset Clause that meant that within two years, made for sole mental illness will be provided.
00:42:34.620And incidentally, that Sunset Clause, remarkably, you know, for a year, the government had said we're not going to have made for sole mental illness.
00:42:45.120In the initial draft of that bill, the Attorney General, Minister Lamedi, was giving those assurances repeatedly.
00:42:51.720And then less than a month before this date, in March, the government changed its mind.
00:42:59.900They put in the Sunset Clause that had been recommended then by the Senate Committee.
00:43:05.040And after one evening of debate that the government foreshortened with, I believe, what they call a closure motion or something like this.
00:43:13.200So literally, one evening of debate, this bill with Sunset Clause passes.
00:43:20.040The political background is interesting because the vote was largely along party lines.
00:43:57.480And it's called Last Rites, Ode to C-7.
00:44:00.660So, O Canada, my brave new world, glorious and gore-free, will soon become the land of death on demand, full autonomy, at least for me.
00:44:12.840I've been granted good life, good friends, good wealth.
00:44:17.360Thank you, C-7, for dealing me good, easy death.
00:44:20.740My last rites, my last rite, easing suffering at my choosing, sanitized, beautified, the choice will be mine, my death so peaceful, ready for prime time.
00:44:33.340I hear whispers in the background warnings to not short the price of tomorrow's mornings, that the cost of my saving grief will be those seeking relief from a life lived without my privilege, not dying, but only trying to get by in life.
00:44:51.840Those we won't help live, but will now give, enticed escape from strife.
00:44:59.320But whispers I can ignore if they fall on the shores of those who whisper louder, experts reassuring me prouder.
00:45:09.500It's their task to know full well, but I don't ask and they don't tell.
00:45:15.640And besides, it's not entitlement, consider the enlightenment of those non-white, non-wealthy, and wise, of those marginalized, to finally have a choice to die well, when in life they had no voice, their only choice was living hell.
00:45:34.700So thank you, Canada, powers that be, for ensuring that our smooth passings will reflect the privilege of our life trappings.
00:45:43.000I will soon be free, without anxiety, knowing that with ease I can choose the time of my going.
00:45:50.960And any poor souls sacrificed on this altar of my choice, my voice, there will be no way of knowing.
00:46:03.380Those would be powerful words to end by, but I want to talk about a couple more issues before we go, Dr. Gand.
00:46:11.460And one of them relates to what you said about the vote on all of this, the legislation being a bit more aggressive than it needed to be.
00:46:21.980I know we haven't invited you on as a political analyst, but what is your sense of what people think they're trying to accomplish in bringing in these laws?
00:46:33.960Because, to your point, we're not just following best practices getting up to global standard.
00:46:38.140We're now the cutting edge, if you can call it that, for most jurisdictions.
00:46:44.040It's not something that everybody out there is saying, we need this, we need this.
00:46:47.920Are they, do they think that this is following social progress and just something that inevitably must be done?
00:46:55.580Is this catering to some special interest groups?
00:47:00.160I appreciate the technicalities or a Supreme Court ruling five years ago, but more broadly, how did we get to this point?
00:47:07.340Again, you know, I think that's a really important question, because when we get to this point, when any country gets to a point like this on issues of national importance, you kind of hope that due diligence has been done and that different things have been looked at and weighed before decisions are made.
00:47:27.860That hasn't happened here, so I can't speak to the reasons why, but I can tell you what has happened.
00:47:34.380And, you know, I think there are a couple of important points along this path.
00:47:40.660You know, when the initial law came in, and keep in mind, that was through a different attorney general, right?
00:47:46.640That was back when it was Minister Jody Wilson-Raybould, who brought in the initial law.
00:47:52.000So when the initial law came in that had reasonably foreseeable natural death as a safeguard in 2016, and then that was challenged in 2019 in what was called the Truchon ruling in Quebec.
00:48:04.940So this was a provincial court, and in that ruling, ruled on by one single judge, she overturned or said that the naturally foreseeable reasonable death safeguard is overly restrictive.
00:48:34.340I'm not a lawyer, but my understanding is that it's pretty unusual for the government not to appeal such provincial rulings to the Supreme Court.
00:48:46.320I don't even know what this was on, but two days ago, I think it was, yesterday or two years ago, driving home.
00:48:52.000I heard on the radio that there was some provincial ruling on some other issue, and immediately the government has said, we're appealing to Supreme Court.
00:49:00.200In this case, they didn't even appeal it.
00:49:03.740The government did not do a five-year review that it was supposed to, and that mandated review was also bypassed.
00:49:12.120And so in that sense, due process hasn't been done, I think.
00:49:19.760And I will also say that, and I regret saying this, but I honestly believe it's true.
00:49:26.700You know, I'm a past president of our National Psychiatric Association.
00:49:30.240I'm a past president of the Canadian Psychiatric Association, and I've had significant concerns about the input of my own association in this, because I don't think it's contributed necessary evidence in making these decisions.
00:49:47.560So unlike the American Psychiatric Association, or the Irish one, or the Australian and New Zealand one, the Canadian Psychiatric Association's input, they basically framed it purely as an issue of discrimination, in my mind.
00:50:04.080And they said patients with a psychiatric illness should not be discriminated against, and nobody wants to discriminate.
00:50:10.400But then they link it to the assumption that it would be discrimination unless they have the same options available regarding MAID as available to everyone else.
00:50:20.140And they admitted that they had not looked at whether you could predict whether psychiatric conditions could or could not get better.
00:50:27.520And most concerningly to me, you know, throughout this whole process of whatever it was, a year before the C7 consultations or during that public consultation process, in all of that time, in the written and oral submissions from my own expert group, the number of times they even mentioned mental illness, suicide risk, mental illness-related suicide risk, suicide prevention, even said the word suicide literally was zero.
00:50:56.480And to me, and to me, that's like a respirology association, doing public consultations on lung health or lung disease, and never mentioning smoking.
00:51:08.160But what it does mean is that the necessary input into making these decisions wasn't made.
00:51:16.960And, you know, you made the comment about, and I am linking a thread here, you made the comment about, oh, we're at the forefront, you know, kind of, you know,
00:51:27.920One other point I want to make is that, unique to Canada, nowhere else in the world actually has this.
00:51:33.920We have a provision that says that somebody can get made, they can apply for and get made, even if they've never had any attempts at treatment.
00:51:44.820Think about that, especially in the context of, say, mental illness, but even in general.
00:51:49.940So, and the reason for that is there's a qualification in there that things that could make the situation better, they need to be acceptable to the person.
00:52:00.400Now, nobody's talking about forcing treatment.
00:52:03.900But I am saying that if we're now telling people, oh, yeah, we know you're not going to get better, and they may have never even had access to treatment, that's pretty shocking to me.
00:52:15.400In other countries that have previously been considered to be more expansive with MAID, so some of the European countries, even there, there's a requirement that reasonable efforts at treatment have been made before you can say that something won't get better.
00:52:32.480So, what that means is, rather than helping people live dignified lives in the community and providing them the supports that they may need to do that, in a state of immediate suffering and immense suffering, rather than helping somebody live, we might say, we're going to, you know, help you end your life.
00:52:52.100And that obviously has financial consequences.
00:52:54.300You know, this has been looked at pre-expansion and estimates made post-expansion.
00:52:59.560The Parliamentary Budget Office was tasked with doing estimates on how many hundreds of millions of dollars, actually less it costs to provide MAID than to provide medical care.
00:53:11.540And that doesn't even count the social supports that are no longer needed to help a disabled person live in the community with dignity.
00:53:21.020So, what I'm saying is that whether people consciously are thinking about these levers or not, they are all there.
00:53:33.120And in terms of even these financial implications on a strained healthcare system, I mean, you can do the math yourself.
00:53:42.820Yeah. Wow. Dr. Gant, I have learned so much during this conversation right now.
00:53:50.400And it all goes back to your original point that perhaps we are not having an informed national conversation.
00:53:56.280Canadians are not fully apprised of what's going on with this issue.
00:53:59.280Whatever opinions they have, whatever views they end up holding about it, that we need to probably hash things out a bit better as a nation.
00:54:06.720So, I hope our conversation today can at least be helpful in some small way in heading in that direction.
00:54:12.600Dr. Gant, thanks so much for joining us today.
00:54:15.380And thank you so much for your kind of thoughtful consideration of these issues and openness to thinking about the various perspectives.