Question Period Note: Medical Assistance in Dying (MAID)- Report of the Special Joint Committee on MAID

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• On February 2, 2023, the Government of Canada introduced legislation, Bill C-39, to extend the exclusion of eligibility for MAID where a person's sole underlying medical condition is a mental illness for an additional year, until March 17, 2024. Bill C-39 received Royal Assent on March 9, 2023.
• On February 15, 2023, the Special Joint Committee on Medical Assistance in Dying (AMAD) tabled its second and final report in Parliament entitled Medical Assistance in Dying in Canada: Choices for Canadians.
• The Government will be tabling a response to AMAD’s Report no later than June 15, 2023, in order to meet the parliamentary 120-day deadline provided to respond to the report’s 23 recommendations.
KEY MESSAGES
• On February 15, 2023, the Special Joint Committee on MAID (AMAD) tabled its second and final report, which focused on a number of issues related to MAID, such as supporting the implementation of the MAID framework, Indigenous engagement, access to palliative care and disability supports, and potential legislative amendments.
• We know that this inquiry and resulting report has required a significant amount of time and effort. We are deeply appreciative of the Committee’s outstanding work on this matter.
• The Government’s Response to AMAD’s Report will be tabled in the House of Commons no later than June 15, 2023.
IF PRESSED ON THE EXTENSION OF THE TEMPORARY EXCLUSION …
• On March 9, 2023, our Government passed legislation to extend the temporary exclusion of eligibility for MAID for persons suffering solely from a mental illness to March 17, 2024.
• Much progress has been made to ensure the system is ready, including the launch of a Model Practice Standard on March 27, 2023. Delaying eligibility allows time for dissemination and uptake of key resources, such as the model practice standard, by the medical and nursing communities.
• A national accredited MAID curriculum is also expected by the end of 2023.
IF PRESSED ON INITIATIVES THE FEDERAL GOVERNMENT IS UNDERTAKING TO SUPPORT SAFE MAID IMPLEMENTATION IN THE HEALTH SYSTEM …
• Health Canada convened a task group to develop a Model MAID Practice Standard that includes important regulatory content to support the assessment of complex MAID requests, including those involving mental disorders, which was released on March 27th.
• We are funding the Canadian Association of MAID Assessors and Providers to develop an accredited MAID training curriculum. All modules will be available by the end of 2023.
• Furthermore, we are engaging with Indigenous Peoples, collecting more information on MAID in Canada and supporting research.
IF PRESSED ON THE QUESTION OF MAID FOR PEOPLE WITH MENTAL ILLNESS AS THE SOLE UNDERLYING CONDITION …
• Some MAID practitioners have already assessed and have experience with cases that involve mental illness when these occur alongside other conditions.
• Our Government is working to support practitioners who receive MAID requests from persons where death is not reasonably foreseeable, and eventually, from those with mental illness as a sole underlying medical condition.
• In March 2023, a Model MAID Practice Standard was released to support medical and nursing regulators. A new comprehensive MAID training curriculum will launch in the summer and be available by the end of 2023.
IF PRESSED ON CONCERNS THAT PEOPLE WILL SEEK MAID AS A FORM OF SUICIDE, ESPECIALLY THOSE WITH A MENTAL ILLNESS …
• The availability of MAID has not been demonstrated to have an impact on suicide rates.
• The legislation sets a high bar for access. Only individuals with severe, long-standing and treatment-resistant mental illnesses will be considered for MAID.
• Based on a recommendation from the Expert Panel on MAID and Mental Illness, the Model MAID Practice Standard indicates that assessors and providers should ensure that a person’s request is consistent, unambiguous and rationally considered during a prolonged period of stability, and not during a time of crisis.
IF PRESSED ON THE GOVERNMENT’S REACTION TO MEDIA STORIES ALLEGING THAT PEOPLE ARE SEEKING MAID DUE TO LACK OF NEEDED SERVICES
• Although a person may express a desire for MAID due to inadequate services, the eligibility criteria and safeguards provided by the law are robust. Two independent practitioners must determine
eligibility, and the available services and support measures must be presented for review by the individual in question.
• Improving access to social and health services remains a priority.
• For example, the Government has introduced Bill C-22 to create a new Canada Disability Benefit. The Bill is currently being reviewed by the Senate.
IF PRESSED ON INDIGENOUS ENGAGEMENT ON MAID …
• Health Canada is working with Indigenous partners to gain further insight into Indigenous People’s beliefs surrounding end-of-life care and perspectives on MAID to support culturally safer MAID practices.
• This important work is guided by principles respecting the Government of Canada’s relationship with Indigenous peoples, and based on recognition and respect for the right to self-determination.

BILL C-7, AN ACT TO AMEND THE CRIMINAL CODE (MEDICAL ASSISTANCE IN DYING)
On September 11, 2019, the Superior Court of Québec ruled in favour of two plaintiffs (Jean Truchon and Nicole Gladu) who had challenged the Criminal Code eligibility requirement that an individual’s natural death be reasonably foreseeable and the more stringent provincial requirement for a person to be at the end of life. The governments of Canada and Québec did not appeal the decision.

On February 24, 2020, the federal government tabled proposed amendments to the 2016 Criminal Code provisions on MAID (Bill C-7) in response to Truchon. The Bill was terminated with the prorogation of Parliament but was re-introduced on October 5, 2020 (its content was unchanged). It received Royal Assent on March 17, 2021.

The 2021 MAID legislation:
• removes the requirement for a person’s natural death to be reasonably foreseeable in order to be eligible for MAID
• introduces a two-track approach to procedural safeguards based on whether or not a person’s natural death is reasonably foreseeable
o existing safeguards are maintained and, in some cases, eased for eligible persons whose natural death is reasonably foreseeable
o new and strengthened safeguards are introduced for eligible persons whose natural death is not reasonably foreseeable
• temporarily excludes eligibility for individuals suffering solely from mental illness for 24 months*, and requires the Ministers of Justice and Health to initiate an expert review tasked with making recommendations within the next year on protocols, guidance and safeguards for MAID for persons suffering from mental illness
• allows eligible persons whose natural death is reasonably foreseeable, and who have a set date to receive MAID, to waive final consent if they are at risk of losing capacity in the interim
• requires expanded data collection and analysis through the federal monitoring regime to provide a more complete and inclusive picture of MAID in Canada

DELAY OF THE SUNSET CLAUSE ON THE EXCLUSION OF MENTAL ILLNESS
On March 9, 2023, the Government of Canada passed legislation to extend the temporary exclusion of eligibility for persons suffering solely from a mental illness from March 17, 2023 to March 17, 2024. The Government, in collaboration with provinces and territories, and their medical communities have made important progress in preparing for the original March 2023 deadline. This delay allows more time for dissemination and uptake of key resources by the medical and nursing communities.

In September 2022, Health Canada convened an independent MAID Practice Standards Task Group, comprised of individuals with clinical, regulatory, and legal expertise, to develop a practice standard to provide regulators and clinicians with guidance on MAID assessments for complex requests, including those that involve mental disorders. The Model MAID Practice Standard was published on March 27, 2023. The Government is also funding the development of an accredited Canadian MAID curriculum to support clinician education and training.

IMPLEMENTING KEY RECOMMENDATIONS OF THE EXPERT PANEL ON MAID AND MENTAL ILLNESS
As a requirement for former Bill C-7, an Expert Panel was appointed by Ministers of Justice and Health to conduct an independent review to consider protocols, guidance and safeguards to apply to MAID requests by persons who have a mental illness. The final report of the Expert Panel on MAID and Mental Illness was tabled in Parliament on May 13, 2022. It includes 19 recommendations that provide guidance on the interpretation of the MAID eligibility criteria, application of the legislated safeguards, and the assessment process, as well as advice on measures to improve the functioning of Canada’s MAID regime more broadly.

A key conclusion of the Panel was that the existing MAID eligibility criteria and safeguards, when interpreted appropriately and buttressed by existing laws, standards, and practices in related areas of healthcare, can provide an adequate structure for assessing those more complex (track two) MAID requests, including where a mental disorder is the sole underlying medical condition.

On July 26, 2022, the Ministers of Health, Justice and Disability Inclusion issued a news release on the Government’s progress in implementing several of the Panel’s key recommendations to help prepare the MAID practice community in assessing these complex MAID requests. This progress included: developing a practice standard for MAID; developing a nationally fully accredited MAID curriculum; enhancements to the data collection system under the Regulations for the Monitoring of MAID; plans for Indigenous engagement; and, federally-funded qualitative research on MAID.

PARLIAMENTARY REVIEW OF MAID LEGISLATION
The 2021 legislation also required that a Parliamentary Review be initiated within 30 days following Royal Assent of the legislation flowing from former Bill C-7. The Parliamentary Review must address (but not necessarily be limited to) the topics of mature minors, advance requests, mental illness, the state of palliative care in Canada, and the protection of Canadians with disabilities.

The Special Joint Committee on MAID (AMAD) held three meetings before dissolution. The committee reconvened in April 2022 and, on June 23, 2022, submitted an interim report, specifically focused on MAID where a mental disorder is the sole underlying medical condition. The interim report made no formal recommendations but urged the federal government to support the timely implementation of the recommendations of the Expert Panel. AMAD’s final report, containing 23 recommendations on all topics under its remit, was tabled on February 15, 2023. The Government will table its response no later than June 15, 2023.

AMENDMENTS TO MAID REGULATIONS
On November 9, 2022, the Regulations Amending the Regulations for the Monitoring of Medical Assistance in Dying were published in Canada Gazette, Part II, and came into force on January 1, 2023. The regulatory amendments support Canada’s MAID regime by allowing for enhancements to data collection and reporting through the federal MAID monitoring regime to provide a more comprehensive and inclusive picture of how MAID, with expanded eligibility, is being implemented in Canada.

On January 1, 2023, expanded data collection requirements commenced and the information collected will be reflected in the federal annual report on MAID in Canada for 2023, to be publicly released in the summer of 2024.

INDIGENOUS ENGAGEMENT
Throughout various consultative and Parliamentary discussions on MAID, Indigenous participants, as well as several Parliamentarians, spoke about the lack of and need for meaningful engagement with Indigenous peoples on the topic of MAID to understand their diverse views and perspectives. This view was most recently echoed by the May 2022 final report by the Expert Panel on MAID and Mental Illness, and AMAD’s interim and final reports. These calls for engagement come from the concerns raised around the potential impacts of MAID on Indigenous peoples, such as:
• Undermining of suicide prevention efforts;
• Straining already inaccessible culturally-safe health care services, including palliative care; and
• Exacerbating systemic racism experienced by Indigenous peoples in the health care system.

As such, the Government launched an engagement plan with Indigenous Peoples in spring 2023 to gain further insight into Indigenous People’s beliefs surrounding end-of-life care and perspectives on MAID to support culturally safer MAID practices. We anticipate a What We Heard report late in 2024.

FUNDING FOR MAID INITIATIVES
Expanded access to MAID (as codified in the new legislation) increases the complexity of eligibility assessments and requires the administration of the enhanced safeguards aimed at protecting vulnerable people who might be induced to seek an assisted death. Budget 2021 provided $13.2 million to Health Canada over five years, beginning in 2021-22, with $2.6 million per year ongoing, to support the development of training and guidance materials for practitioners, as well as a policy driven research agenda. This investment will contribute to an enhanced knowledge base to support safe, sensitive and consistent implementation of the MAID legislation and safeguards across the country.

• Former Bill C-7, which received Royal Assent on March 17, 2021, included a sunset clause excluding persons with a mental illness as a sole underlying medical condition from seeking MAID until March 17, 2023. During the two-year exclusion period, the Ministers of Health and Justice were required to launch an independent expert review on the topic of MAID and mental illness.
• The expert review was led by the Expert Panel on MAID and Mental Illness which released its final report in May 2022. The report contained 19 recommendations respecting protocols, guidance and safeguards to apply to MAID requests from persons with mental disorders. The first recommendation calls upon FPT governments to facilitate the development of MAID practice standards for use by health professional regulatory bodies. Most of the remaining recommendations provide guidance on MAID assessment and provision in complex cases, while others focus on broader measures to improve the functioning of Canada’s MAID regime, through training, oversight, data collection, research, and Indigenous engagement.
• Former Bill C-7 also required a parliamentary review of the MAID law. A Special Joint Committee on Medical Assistance in Dying (AMAD) tabled an interim report in June 2022. The interim report focused on the topic of MAID and mental disorder and the implementation of the recommendations of the Expert Panel on MAID and Mental Illness. Its report noted concerns around practitioner and health system readiness for March 17, 2023 (when MAID for persons with a mental disorder as a sole underlying condition was to become lawful prior to the passage of former Bill C-39).
• On October 20, 2022, the Government tabled its response to the AMAD interim report. In the response, the Government noted it was actively supporting the practitioner community in ensuring the safe and consistent implementation of MAID through practice standards, accredited MAID training and a strengthened monitoring system.
• Despite the work already underway to support system readiness, concerns about lack of preparedness for March 2023 were echoed in the media by a number of mental health and disability stakeholders, some Parliamentarians, and some individuals in the MAID community.
• On February 2, 2023, the Government of Canada introduced legislation to extend the temporary exclusion of eligibility for persons suffering solely from a mental illness until March 17, 2024. This legislation received Royal Assent on March 9, 2023.
• On February 15, 2023, AMAD’s second and final report was tabled including 23 recommendations. The report’s main themes focus on supporting the implementation of the MAID framework, ensuring Indigenous engagement, addressing the importance of access to palliative care and disability supports, amending the legislation to permit requests by mature minors and advance requests for MAID, as well as creating a new expert panel to address the unique needs of individuals with disabilities in relation to MAID.
• The Government’s Response to AMAD’s Report will be tabled in the House of Commons no later than June 15, 2023.