Welcome, everyone. Appreciate you're staying late today, after three days already, I guess, of going to various seminars and sessions. So I'm glad also that you found us, because this was a presentation that was put together rather late, so it didn't make it into the actual hardcover drive, but it is on the app, so I'm glad to see a good turnout. And is Dr. Brindel here, or did she leave? Anyway, I want to thank her. There she is. Hi. So Dr. Brindel, who is the president of APA, this was her idea and her brainchild, and I really want to thank her for pushing this forward as a presentation today at the meeting of the APA. I think it's an important topic, and we have a really good fortune of having our colleagues and friends from Canada here who will be part of the presentation. And in simplistic fashion, what we really want to do is give you a sense of the contrast between what's evolved and what's happened in Canada versus the ways in which medical aid in dying has evolved and is operational in the United States, so we've got a great opportunity to compare those and ask a lot of questions about it. I'm not going to give extensive introductions, because I want to save time, but I put this up here, who's on the panel. Myself, Richard Martinez, I'm the director of forensic psychiatry at the University of Colorado. I'm also the chair of the APA's Council on Psychiatry and Law, and as I was sharing with a colleague before I became a forensic psychiatrist, I was involved in medical ethics issues and end-of-life issues in the first half of my career, so this has been a continued interest of mine. We're going to have Dr. Elliot Krueger, who is the director of ethics policy and secretary from CJA at the AMA, which is the Council on Ethical and Judicial Affairs at the AMA. Thomas Strauss, Dr. Thomas Strauss, who's coming up from LA, he's the Maddy Katz Chair in Palliative Care Research and Education at the UCLA David Geffen School of Medicine, and Dr. Strauss is going to share with us perspectives from the California operation of medical aid in dying. My good friend Charles Dike, who is the chair of the ethics committee for the APA, is also going to be talking. He's also the president-elect of the American Academy of Psychiatry and Law, and he's also the chief medical officer in Connecticut Department of Mental Health and Addiction. And we have Dr. Allison Freeland from Canada. Welcome, Allison. She's an associate professor, Department of Psychiatry, University of Toronto, and in her role here, she's the board chair of the Canada Psychiatric Association, and she also chairs the Canada Psychiatric Association of Professional Standards and Practice Committee, and has been very involved with some of the evolution of policies and procedures, as you'll hear about, in Canada dealing with medical aid in dying. And then lastly, another colleague and friend, Dr. Gary Chemowitz, also from Canada. He's a professor of psychiatry at McMaster's University, and he's the current president of the Canadian Psychiatric Association. So I thank all my colleagues for coming today. So I'm going to start with a little bit of an introduction and sort of lay the groundwork a little bit. Our goals today are hopefully to help you appreciate the clinical, legal, and ethical complexity of medical aid in dying, understand the laws in the U.S. and Canada related to medical aid in dying and how these are different, how do concepts such as terminal illness versus irremediable illness and suffering differ, if you will, two definitions that our colleagues will talk about a bit, grapple with the distinction between suicide and medical aid in dying, what are the implications for certain mental illnesses in the role of psychiatrists, how should we think about competency assessment and voluntary choice in medical aid in dying, and lastly, hopefully, get each of you to think a little bit about the resources that are available to you in whatever jurisdiction you're coming from, especially if it's a jurisdiction where medical aid in dying either is legal or is currently in front of your state legislature. So some definitions to start out, withdrawing, withholding life-sustaining treatment, these are processes that involve taking away or not giving certain treatments with the expectation that the patient will die, euthanasia is the act or practice of killing someone who is very sick or injured in order to prevent any more suffering, suicide is the act of killing oneself because of a desire not to live, and lastly, medical aid in dying is the act whereby a qualified ill patient self-administers a life-ending medication provided by a physician. What's in a name? So many of you in the audience probably have been around long enough to see the evolution in what we call this thing, this process, this phenomena, and we've heard terms like physician-assisted suicide, I'm old enough to remember, of course, Dr. Gavorkian back in the 80s and the controversies around early issues dealing with this topic, but there's many things this is called and I would suggest that what we call it is very important, lawful physician hastening death, physician assistance in dying, aid in dying, medical assistance in dying, medical aid in dying, mercy killing, and euthanasia. When you look at the nomenclature, there's been an interesting change in how this is referenced in scholarship and in the media and in the literature so that the terms physician-assisted suicide have gradually, if you will, lowered as the terms medical aid in dying and medical assistance in dying have increased. Overview internationally, I'm not going to talk much about it and maybe our colleagues from Canada will have more to say about this, but euthanasia or physician aid in dying is legal now under certain circumstances in all of these countries and here's a map internationally to give you a sense. I'm not going to go into the details here, but it's broken up between areas where prescriptions of lethal drugs for self-administration are legal versus prescriptions plus active participation by physicians in other jurisdictions. And then there are jurisdictions where technically, legally, it is still, quote, illegal in some fashion, but they've developed in those countries processes and procedures that if the physicians and the patient follow those procedures, if you will, there's a promise of not being prosecuted for this. The traditional arguments for medical aid in dying, usually we talk about respect for patient autonomy, support the patient's dignity, control and peace of mind during the final days with family and loved ones. It's seen those that advocate as an act of compassion and nonabandonment. This is certainly was the position of Timothy Quill, who was kind of the counterpoint to Kevorkian in the 1980s. Protections in all jurisdictions to ensure patients remain the driving force in end of life discussions. So putting up boundaries around these procedures in some fashion by including multiple physician involvement and opinions, second opinions about terminal illness, the issue of mental competence and voluntariness and building in waiting periods, for example. And of course the arguments against traditionally. The traditions of the health professions promote care and comfort. There's a prescription against intentional ending of a person's life. Physicians are asked to breach specific prohibitions and duties of beneficence and nonmaleficence, thus violating the historical role of physician as healer and comforter. I'm not going to review Hippocrates going all the way back, but I'm sure most of you are familiar with that. And then of course there's concerns of coercion in vulnerable populations. In the U.S. now we have 11 jurisdictions where this is legal. One state, most of these come from citizen petitions that then get translated into legislative changes in those states. Colorado, where I'm from, is one of those states. We made this citizen vote in I think 2016 it was. And then the legislature followed suit and drafted, if you will, a procedure and policy for the state of Colorado. One state, Montana, it was through a Montana state Supreme Court ruling, which the state legislature is still struggling with in Montana. But technically in Montana right now it is legal based on the Supreme Court decision, but they don't have procedures and policies in place. And interesting, just in the last months, 10 or so states have taken up medical aid in dying legislation in those states. I don't have an update on where it is, but you can check this out afterwards. Here are the states and the means by which medical aid in dying came into play in all of those jurisdictions. Oregon, of course, was the first with the Death with Dignity Act in 1994, which then I won't go into the background, but they had to revote for it and actually revoted for it in 1997 and passed it even at a higher majority. So here is a map of 2022, and this is what's interesting. So if you take the populations of all these states and you add them up, so 22% of Americans now have access to medical aid in dying. And New York is one of the states that's taking up legislation right now, so I don't know what the outcome will be there, but you can imagine this 22% is going to be increasing pretty dramatically this year, perhaps. Main diagnosis for asking in the U.S., there's many, many studies we can look at, this is just kind of a summary, but cancer in 70 to 80% of the case, and I'll ask Dr. Strauss and others to correct me if I get any of this wrong, ALS and neurocognitive disorders tend to be the second most common diagnosis. And what's really important is that consistently pain has not been the reason for people asking for medical aid in dying or participating in medical aid in dying, that was often a misconception for many, many years and studies really have not bared that out, including the data from Oregon. Now physicians can be involved in many ways, it's a continuum, so it may be as something as just having a discussion with a patient, you could be a psychiatrist in the office with a patient with cancer who wants to talk with you about it, to making referrals to those people who do participate or have chosen to participate and may have expertise. You may serve as a made consultant, developing your own expertise and at least consulting and if you will, working with an individual about this decision in some fashion. And then of course serving as a prescriber and actually attending to the participation of medical aid in dying, and lastly, for this audience, we want you to think a little bit about this issue of how should psychiatrists, how should mental health professionals be involved or not be involved. We realize this is an extremely controversial issue and of course some people may out of for a number of reasons decide it's not appropriate for you to participate in some fashion and we're going to talk a little bit about that further. Physician attitudes have really evolved dramatically. Back in 2010, just 13 years ago, only 45 percent for and 41 percent against, pretty evenly divided, but what we've seen is increasing trends that physicians across the United States have been more supportive, not necessarily that they themselves feel like they want to participate, but recognizing that this is something they want available as a public policy within their states. Lastly, getting close to the end, Oregon data from 2021, just to remind people, the number of prescriptions always outpaces the actual use of the prescriptions in the United States. This Oregon data is pretty typical in that sense. Usually we think about this as people who are suffering terminal illness, want to get the prescription, go through the procedures and the protocol, they get the prescription and if you would, it gives them an increased sense of control that they can decide to use it, but the reality is the data says that not everyone actually uses the prescription. These are just some general issues, I take some of this from Colorado, but this is generalizable to most of the 11 jurisdictions. There's usually an age limit. The person has to be capable of making and communicating an informed healthcare decision, must be voluntary. In the United States, different than you're going to hear from Canada, we use the criteria of terminal illness, of course that can be a moving target, obviously someone with pancreatic cancer who chooses not to get treatment, there's obviously some reasonable predictability about end of life within six months, but what about the person with pancreatic cancer who decides to get a Whipple procedure or decides to get chemotherapy, you've got to think about this. Even the concept of terminal illness, although it's more of an objective standard, it's also a moving target to some degree. And then the person has to be physically and mentally capable of self-administering of medication, the diagnosis must be certified by a consulting physician, including that the patient is mentally competent, and usually there's a second supportive opinion in most jurisdictions. And lastly, referral to a licensed mental health professional is elective in most jurisdictions, Dr. Strauss is going to talk a little bit about what happened in California around that, and I'd be interested to hear about what's happening in Canada about that, but essentially one or two of the physicians involved, if they have concerns about capacity, about depression, they can refer in, and really are required by statute in Colorado to refer to a mental health professional, psychiatrist or psychologist for assessment. And this is a definition of mental capacity, in the opinion of an individual's attending physician, consulting physician, psychiatrist, or psychologist, the individual has the ability to make and communicate an informed decision to health care providers. It's pretty generic. Okay, I think I will stop there, and we will hand things over to Dr. Krieger. Thank you. The only thing is you've got to hit it right there to go forward. Okay, great. Thank you. So thank you very much for the opportunity to speak with you this... Yeah, it's always a problem when you're five foot one and the mic is up here. There's no way around this except shorter podiums, and no one seems to be willing to do that. So I appreciate the opportunity to come and talk to you about what AMA policy currently is and a little bit of how we got there. I mean, some of this is going to be repeating what we just heard, right? But... It's a right-hand button, you say. No. Really firmly. Strike it firmly. Thank you. Okay, so I'm not going to go through this discussion of AMA policy, but you will notice if you look at the dates that most of them actually date in substance to the 1990s. And what we found is that... What I found looking back through the reports and the justifications for policy was that basically the AMA was tracking the debates that were common across the country, right? So what we had... Try this again. Was a focus first on terminal illness and care of the dying, then a report on euthanasia, mercy killing, which then came to be discussed in terms of causing to die versus allowing to die and a patient's right to refuse life-sustaining treatment, on then into assisting the patient in hastening his or her own death. But all of these basically, the substance of current guidance from the AMA, both in terms of House of Delegates policy and in terms of the Code of Medical Ethics, dates... Is 30 years old. Which suggests that the issues perhaps have not changed as dramatically as some would like to think. But one thing I would want to point out to you is that it's important to understand the difference in AMA policy... Between... Closer, sorry. There's also a bunch of cable here that I'm trying not to stand on. To say that AMA policy is... It comes in two different chunks. The policies of the House of Delegates are treated differently than the reports and policies of the Council on Ethical and Judicial Affairs. And it's CJA, the Council that creates and sustains the Code of Medical Ethics. CJA reports cannot be amended on the floor of the House. They have to come back to the Council for further consideration. There can be no tinkering with the language. None of that. It's just back to the Council to reconsider based on testimony heard. Which does mean that Council reports tend to be... How shall we say? Longer in development than policies adopted on the floor of the House, which can be adopted the day they're presented, right? So I think that that's important for another reason. The Council's reports deal strictly with the ethics of particular questions. They don't deal with public policy. They try very hard not to say how something should be implemented or whether something should be implemented in some cases. But if we do, if the Council does deal with implementation, it's to think in terms of what are the key questions that need to be asked to implement this in an ethically justifiable manner. So we don't... Far less than I think the Council used to when it was the Judicial Council and largely staffed by the Office of General Counsel, doesn't have a right answer necessarily, but it has a series of questions you have to ask. So keep that in mind when we talk about AMA policy. I will simply point out that the end product for the Code of Medical Ethics, the discussions of euthanasia and assisted suicide with the exceptions of the definitions and one further qualification in the euthanasia opinion are absolutely identical. So they are a difference that is not recognized effectively even in policy, I think. I should at this point confess I trained originally as a discourse linguist, and I first joined the staff of the Hastings Center back when they were developing guidelines on the termination of treatment and care of the dying. So this has sort of been in my wheelhouse for almost 40 years. But the more interesting point, I think, is that in 2016, the House revisited these questions about specifically assisted suicide. There's agreement that euthanasia is not acceptable. We're not debating that any longer, at least in the AMA context. We were asked, the Council was asked to study aid in dying with the thought that it would return a report to the House on whether AMA should formally adopt a neutral stance. And then in the following June in 2017, there was a second resolution adopted by the House asking CJ to clarify the difference between physician-assisted suicide and aid in dying. To sort of get their, begin their deliberations, the Council in this case gave very extensive opportunities to the House of Delegates to give it input before it ever actually wrote a report. So we had three different CME sessions of varying forms. And I think it's interesting just to note that the first one, we convened a panel of non-AMA physicians who were opponents of assisted suicide, although I will say that Dan Sulamese, who was then at the University of Chicago, is now back at the Kennedy Institute for Ethics and recently appointed to the Council on Ethical and Judicial Affairs, argued against assisted suicide. Marcia Angel argued in favor. And Chair of the Ethics Committee at the American Academy of Hospice and Palliative Medicine argued for a neutral stance, which the Academy had just taken. And I apologize, I forget the physician's name. When we held the second session, it was more a listening opportunity so that delegates could come and just tell us what you think and they told us in no uncertain terms what they thought and we still saw very diametrically opposed positions. The third time around in November and I believe the slides may be in error on this now that I see it, in November of 2017 we convened another CME session where we asked participants to break out into small groups and deal with very particular questions about assisted suicide so that we began, they began funneling down to think about how the council was thinking about this, what kinds of questions the council was asking itself so we tried to model the deliberative process in that way. By June of 2018 we were able to put a report forward which the house promptly returned and then finally in June of November of 2018 with a modified report the house adopted and what I really want to focus on are the the distinctions between those two reports if you will. They hinge on an opinion that the council issued in 2014, a report that was adopted in 2014 on physician exercise of conscience which recognizes that physicians are not only professionals bound to professional ethics and professional commitments they are also moral agents in their own right as human beings. They have identity conferring beliefs and opinions and commitments that they bring with them into the clinic and that there has to be some way to enable physicians to live in both those worlds simultaneously and what the council heard from participants in our listening sessions and from the literature and discussions within the council and I should say the discussions within the council were painful. The council was as divided as any other group in the country about whether physician assisted suicide was in any way permissible but the recognition that there were irreducible moral tensions among the council within the general population and that persons with equally good intentions and well considered perspectives were simply never going to inhabit the same moral space or the same moral perspective and how are we going to live in that world because we don't have a choice but to live in that world. That's when the council turned to its opinion on the exercise of conscience which tries to delineate the ways in which physicians can exercise that right and yet not override a patient's right or override their commitments as healers so what again what are the key questions you have to ask yourself. I think the most important part for policy on assisted suicide is the recognition that physicians bring moral perspectives that are not strictly out of the profession into their professional lives into their relationships with patients and this is where the council ended up. It's a compromise position. It's what we put we drew on the philosopher Martin Benjamin's notion of an integrity preserving compromise. No one gets exactly what they think they should but everyone can live with the end product even if you have to hold your nose even if it's not what you would have chosen yourself you agree for reasons of having to live in some form of collaborative or some form of community that everybody gives up a little for the benefit of all but I think the important thing to note here and I actually I'm going to read this out to you because it really does matter. Instead of amending existing guidance in the code of medical ethics the council crafted a preamble that explains what this moral tension is. Thoughtful morally admirable individuals hold diverging yet equally deeply held and well considered perspectives about physician assisted suicide. Nonetheless at the core of public and professional debate about assisted suicide is the aspiration that every patient come to the end of life as free as possible from suffering that does not serve the patient's deepest beliefs and self-defining beliefs. That supporters and opponents in fact share a fundamental commitment to values of care, compassion, respect, and dignity. They diverge in drawing different moral conclusions about action from those underlying values in equally good faith. Guidance in the code of medical ethics encompasses that irreducible moral tension at stake for physicians with respect to participating in assisted suicide. Opinion 5.7 very powerfully expresses the perspective of those who oppose assisted suicide while opinion 1.1.7 which is the opinion on conscience articulates the thoughtful moral basis for those who support assisted suicide. That is now a preamble that comes with the opinion on assisted suicide which would otherwise prohibit it on the basis of it being difficult to control as public policy acknowledging that there are concerns about vulnerable patients. There's nothing different than that than in any other access to care issue right fundamentally from an ethics perspective. So that's where the council ended up and I think what is often not not appreciated or sometimes misread sometimes intentionally misread about the AMA position is that we can have an ethics position that says you you need to make these decisions in the context of a patient-physician relationship one-on-one. Every patient is different every situation is different and physicians who believe that it would be abandoning the patient not to continue on with them not to provide a prescription for lethal medication should be able to do so in conscience with the understanding that there may be consequences to that decision depending on where they're they're living what jurisdiction blah what jurisdiction they're in and at the same time as a matter of public policy be very concerned about legalizing physician assisted suicide for all the reasons that have been mentioned about ensuring that it is not used against vulnerable persons that it is a free and fully informed decision all of those good reasons that there are the policy considerations are different from the decision-making considerations in the patient-physician relationship. So you can cite the AMA and say yeah the AMA completely opposes physician assisted suicide but it's not strictly accurate either so I think what the council managed to achieve was a situation that brings some nuance that acknowledges the complexity excuse me of the situation and requires everyone involved in it to be very very intentional very deliberate very careful and there's still always the principle in the Code of Medical Ethics that when physicians find law is not in the best interest of patients they have a responsibility to advocate for change in the law but no one is going to be required to participate or ideally forbidden from participating at least on the grounds of decision-making with patients. Thank you. So Dr. Strauss is next. Sure Good afternoon. Tom Strauss. I'm a psychiatrist and palliative care physician and I really appreciate the chance to be here and speak with you. I guess I will open by simply saying what is implicit. There's lots of points of view about this. Myself after 30 years as a psycho-oncologist and palliative care doctor have concluded it's appropriate for me to participate but I recognize that many others including perhaps folks in this room might not agree with that. I respect that perspective and you know because you've been hearing about the sort of neutral or against stance most of our professional organizations have taken. I'm gonna try to cover this outline quite quickly where I'm repeating what's already been said. I will go even faster. You've seen this map so I will not belabor it. I do want to share with you Governor Jerry Brown's signing statement. Some of you know Jerry Brown trained as a Jesuit before becoming a politician and a lawyer. In the end he wrote I was left to reflect on what I would want in the face of my own death. I do not know what I would do if I were dying in prolonged and excruciating pain although as you've heard that's generally not the motivator for people to pursue medical aid in dying. I am certain however that it would be a comfort to be able to consider the options afforded by this bill and I wouldn't deny that right to others. As you might imagine he took a fair amount of heat for writing that out and signing the bill. So this is the bill that he signed it was called AB 15 as you can see it was passed in 2015 and became law in 16. So in California qualified patient has to be terminally ill, has to make a non-coerced voluntary request, has to be 18 or older, must be a California resident, must register his or her request twice verbally, initially separated by 15 days as you'll see California recently shortened that in fashion of other states to 48 hours and has the ability to self-adjust. What you may not know is that another Jesuit trained scholar and politician Janet Politano was president of the University of California at that time and she issued a letter soon after Brown signed the bill that directed all of the University of California health units there were five at the time UCLA where I am, UC San Francisco, San Diego, Davis and Irvine to participate to create their own policies and procedures for adhering to the law in effect the UC was opting in where a number of faith-based organizations explicitly opted out and I was part of the work group at UCLA that wrote our policy and procedure which was ready when the bill became active in 2016. As Rick mentioned UC San Francisco opted as an institution to create a higher standard at least they thought of it as a higher standard at the time which was to say that any patient requesting medical aid in dying UCSF would be required to have a formal mental health evaluation to assess the elements that we will soon discuss. That was well much higher bar than what the law called for which was as you'll see when evidence of mental disorder is is noted by either the attending or the or the consultant. I will tell you so that you're not sitting here in intolerable suspense that after a few years of experience UCSF has now abandoned that practice and now simply proceeds along the lines of the law and their reasons for abandoning although I'm not among them were essentially that they did not change outcomes and they concluded that it was creating an obstacle for patients that indeed did delay access on occasion led to patients dying prior to getting access that they felt was not appropriate. So more on that later perhaps and this is the most recent update so the the waiting period as you can see is reduced from 15 days to 48 hours and a few other odds and ends including gender-neutral terminology. I don't want to bore you with the details but I'm very proud of this because for those who would suggest that this is sort of a overly brisk careless process that does not attend to the needs of patients and families I will tell you that that's not what happens at our place. In fact sadly what I mean it's wonderful but it's sad what happens at our place is that patients contemplating the mortality get the level of attention that all people contemplating mortality should get in the form of really deep and broad psychosocial assessment opportunities for family to talk about taboo topics like mortality frequently associated with actually the abandonment of the request oh I got to talk to my family about dying I guess that means I don't have to hasten my death because it turns out they want to care for me during my last months really you know very profound extraordinary extraordinary things so again this is wonderful details available if you want them. Under the California law when is it mandatory for the attending physician to refer to a mental health professional in quotes if there are indications of a mental disorder rather anachronistic old-school language the physician shall refer the individual for a mental specialist assessment and nothing can happen no drugs can be prescribed until that assessment occurs what is the task of the mental health specialist to determine that the patient has capacity to make medical decisions which most of us in psychiatry recognizes a pretty standard activity for a psychiatrist working in medical settings and is not suffering from impaired judgment that's what ID stands for except there should be a J in council my abbreviation is wrong impaired judgment due to mental disorder that's a little bit trickier right I don't think any of us was trained to find impaired judgment due to mental disorder even our forensic colleagues right there's not a recipe for that one is there not exactly yeah okay and that could be a psychiatrist or a licensed psychologist and this is a rather boring summary of what that includes so this is my reasoning therefore my job and this is the job that I do I'm not a prescriber but I am a mental health professional who does these evals when asked to is first to discern whether the patient has capacity to make medical decisions which I'm generally pretty comfortable doing to discern whether the patient is suffering from impaired judgment due to a mental disorder which first of all requires me to determine whether mental disorders are present again I'm generally fairly comfortable doing that and then to assess for impaired judgment and then to link the two causally that's challenging this is the state medical board offered to some guidelines which included using evidence-based measures like the MacArthur capacity assessment tool for treatment and of course various mood and cognitive measures which you generally do what might be some examples of impaired judgment due to mental disorder these are made-up examples so perhaps a severely depressed person who has delusions of deserving punishment or death I would say we would not disagree that that might impair the person's judgment about requesting access a lethal prescription perhaps someone who's demented who cannot weigh the risks and benefits and alternatives ingredients of capacity perhaps somebody who's chronically hypomanic who is impulsive and has inability appreciate the consequences of various and other and diverse actions or perhaps a polysubstance-dependent person who's been impaired enough in recent years by addiction so as to have been unable to make other important life decisions I have not encountered those patients those are not real cases but just hypotheses so really quickly through the California data all the states that have laws require annual reporting this is thought to be a both a protection and a way of helping the public and the scientists understand what's going on as Rick said earlier the majority of Californians in the most recent data indeed had cancers followed by some neurologic diseases and other illness the majority of those cancer patients had lung and bronchus cancer or pancreas but as you can see it's fairly spread out in California about little under 60% of those who received lethal prescriptions are known to have used them so by no means does everyone do so and then there's the artifact of you know you might have gotten your prescription in December of 21 but you might have taken it but not till February of 22 so that wouldn't be reflected in the 21 data what does this tell us and this is a theme again that is repeated among the states that do this the folks that pursue medical aid in dying tend to be older tend to be whiter they tend to be have more advanced education they tend to be more affluent they tend to have health insurance they tend to be enrolled in hospice some would say they tend to be folks who have had many of the privileges of power and sort of a sense of agency in their lives and indeed when you look at the sort of people's reasons and this this you see this in Oregon you see this in Washington this is not about having intractable pain this is about being unwilling by the way they also tend to be male people who are not going to lie passively dependent on others my own experience is part of what propelled me to do this work and to conclude that for me this is an appropriate activity when I was a full-time palliative care cancer doc was two violent suicides among older white guys who sound exactly like that narrative right these were not people who are gonna lie passively dependent this was before the law was available essentially the message when they tried to talk with us about helping them in their lives was we can't help you you're on your own and they took care of business but in a way that I think was the worst outcome for everyone so that again is my that's my story that's why I'm here but we could talk more about that later so oh I'm sorry the other thing that you know people point out you saw the stats right so something like 79 million Americans live in a made legal state 40 million of those live in California that's more than half California is ethnically culturally much more diverse than Oregon and Washington so there was a lot of interest in what will California tell us about whether underrepresented groups groups that have good reason to be skeptical about the health care system groups who have reason to maybe not be as trusting as locus of control affluent generally white people will they utilize this and the answer is I'm not sure we really know yet although the case vignettes that I'm going to show you happen to reflect women and two women of color who were among the first patients I evaluated at UCLA this is just sort of again a personal ethics trajectory Tim Quill is the lead author this is from the New England Journal or excuse me from JAMA a few years back just helping us think where we might place ourselves I just want to mention to you that medical aid in dying is perhaps you know the far extreme of potential ways of hastening death voluntary stopping of eating and drinking generally uncontroversial completely legal and something that there is now a definitive medical textbook on this is why I show you this which Tim Quill also helped write okay this is actually the first person I ever evaluated as a psychiatrist in the mental evaluation so this is a woman who had widely metastatic breast cancer she'd had breast cancer for more than a decade when I saw her she had metastases to bone and and her other breast and to her lungs and to her brain and her abdomen and again this was early on right so the medical oncologist somebody I worked for for many many years referred her to me not because she thought she was depressed but because she had been on Prozac for 20 years and therefore it raised the question of whether there was a mental disorder as opposed to a remitted depression I evaluated her and I think the important point is this is somebody for whom Medicaid and dying was part of long-held personal health values she had been thinking about this since actually before her diagnosis of her what turned out to be her terminal illness she had very clear criteria about when she would dose if she had access it was if she couldn't do the things that gave her life meaning and purpose like gardening and socializing and reading and pursuing her personal spiritual practice which she was doing gangbusters when I saw her and all she had brain metastasis she scored 30 out of 30 on a mocha and really she had no evidence of either impaired cognition or evidence of mood symptoms and really passed any formal assessment of capacity with flying colors she ultimately got a prescription and about six months later took it and had a very peaceful death which was judged by all of her community as a wonderful thing this is another case this is a black woman who was a nurse who had come back to California as her disease progressed she had been hospitalized at one of our hospitals for hypercalcemia many of you know a common complication of advancing breast cancer and had brain metastasis her family had really intensely wanted to honor her request to pursue medical aid in dying so I actually went to see her at home a couple days after her hospital discharge she was deeply comatose never to wake up couldn't demonstrate capacity clearly was not a candidate died peacefully a few days later and just to remind all of us how we're surprised by clinical experiences that turned out to have been one of the most profound clinical experiences of my career because it was so important to her family that that evaluation had taken place even though they were completely unsurprised by the outcome so you know really glad I did that should made requests to be subject to different or similar capacity standards as other medical decisions I think that's a fair topic for debate this is just me you know spitball in here so you know I often point out in discussions that the patient has a very specific goal when they pursue made which is controlling the time and circumstance of their death generally when patients are seeking other interventions they have a different goal whether it's you know getting an antibiotic for their viral respiratory infection that we think is inappropriate or whether you whether it's doing something that might make us also uncomfortable like having a tenth cosmetic facial surgery that we think might be disfiguring but it's it's a different situation generally well and by law the patient initiates the discussion when it comes to made generally in most other circumstances patients are making a request excuse me generally another circumstance of clinicians are making requests if it's something we think should happen that patients may not know about is there a formal capacity consent process there is generally not outlined in law for most other things. Is there a mandated reporting? There is, not generally the case in other circumstances. Is there a mandated consultant? There is, generally not the case in others. And is there a mandated mental health evaluation? Yes, there is when there's evidence of mental disorder, generally not the case. Although, again, some of us in CL do end up seeing transplant candidates or candidates who are pursuing that empteenth cosmetic surgery when the surgeon is really uncomfortable. Okay, so what's kind of on the frontier? And then this is my last slide. Waiting periods, as you see, are being shortened, equalizing access for patients with disabilities. We haven't touched on the fact that there are disabilities groups advocating, for example, for patients with ALS or patients with dementias, patients with ALS who may not be able to self-activate, self-administer, patients with dementias who generally are gonna lack capacity when the time is relevant for them to want to get access. Waiving residency requirements. Vermont now has waived its residency requirement, broadening the scope of providers who can prescribe, including advanced practice nurses, refining the pharmacologic cocktail, which is really happening, and the question of, well, will the U.S. support Supreme Court weigh-ins? So, sorry for the sprint, but look forward to our discussion. Thank you. Thank you. Hi, everyone. I'm gonna try to also, I'm looking at the time, I'm gonna skip some of the things that have already been spoken about. I'm gonna try to also talk maybe about the law or the legal aspect a little bit more. And everyone knows that the, I'm just gonna decide the discussion points. I don't know if I can get to all of them, but obviously, we have time to talk and questions and answers. This is what people who support, who are against this always point out, that the Hippocratic Oath says that we shouldn't do this, but we also know that it also says we shouldn't do this, but we do it anyway. I mean, some areas do this. So, it's kind of a, point those things out to tell you that this is a, not necessarily a concrete final statement or comment on this, because we've moved a little in some other areas. I don't know if, when I made a difference, if we had said that, I mean, I don't know how Hippocrates or the oath itself would have considered the fact that if a pregnant woman's life was at risk or in danger, would they have done anything about it? I don't know if that should have been, it's not part of the discussion, but it's certainly some things we think about in ethics as to the limitations at the time versus where we are now. We also want to just talk a little bit about the principles of medical ethics, where we say that the physician-patient relationship is central, is the core of all the ethics. We also say that this is driven, or at the core of it is the patient's best interest, which is anything that would do good for the patient and not harm the patient. The arguments, of course, is that even physician aid in dying can be in the patient's best interest. So there are arguments in this area that you just need to be aware of, that those strong arguments can have counter on the other side. It's important to note this issue of duration of the patient-doctor relationship, because in some other areas, the duration can be pretty brief, and somebody just comes in and makes a decision. It's completely different from someone who's been working with somebody for a long time, and I think these are sort of pitfalls that might be there in some areas. There's a question of autonomy versus non-maleficence, which is the autonomy of the patient to decide what they want for themselves and their lives versus our duty to not harm patients, and that's a tension that's out there. Sorry, have I done something wrong here? I have done something wrong. Okay, goodness, I've done worse. All right. Okay, there's also the issue of informed consent versus capacity assessments. I mean, you know, we've heard our colleagues talk about accurate capacity assessments. I wish that was the case in every other areas that's concerned that the capacity assessments are actually not good enough, and so balancing the patient's informed consent, ability to give informed consent, which you determine through capacity assessments, and it's not always as good as it could be, and there's this issue of justice. Who has access? The dramatic, what number of people I saw there were very small minority individuals versus large. The access issues can also be even more than just racial. It can go in so many different areas, but that's a question of justice. The issue of inaction versus action. Withdrawing life-sustaining treatment was considered, and you'll see when I talk a little bit about it in the legal opinions as inaction, but is it really inaction if you don't remove something? In medical school, there's something we used to know, we used to call masterly inactivity, which is part of treatment. You're just masterfully not engaging at this point, but anyway, inaction versus action. Prescribing medications that could assist patient commit suicide versus actually be the one who administers something to cause death. And we can debate the differences of all of this in a minute. Now, let me just talk about this right to withdraw life-sustaining treatment, which is enshrined in both legal and ethical opinions. And if you're going back to 1914, when Justice Benjamin Cardoso said that every individual of adult years and a sound mind has the right to determine what happens to their body, and this is an argument for refusal of treatment or refusal to accept treatment being a function of an informed consent process. And therefore, if you administer treatment to someone who's refusing, you could be held for battery or some other malpractice and so on and so forth. And in the legal decision of Cruzan, it was also actually quoted in some ways that relate to that where it says the 14th Amendment provides that no state shall deprive any person of life, liberty, or property without due process of the law. And this principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medication or medical treatment may be inferred from their previous decisions they have made, including Justice Cardoso's comment above. And the issue of a physician's intent in removing treatment in these situations is to respect the person's autonomy. This is a respectful person's principle in the ethics guidelines. Therefore, honoring somebody's decision to not accept treatment, which might ultimately lead to their death, is respecting the person's autonomy, is respecting the person's personhood, as opposed to any other legal considerations. But the right to assisted treatment, on the other hand, according to the law, is slightly different. The US Supreme Court framed the question whether the liberty protected by due process clause includes a right to commit suicide, which in itself includes a right to assistance to suicide. And it tries to distinguish between death from aggressive treatment for pain versus death from assisted suicide. And these are all nuances, they are very minute differences, but maybe if we have time, we can talk about that a little bit. It boils down, according to as far as they are concerned, to the MD's intention. Because if your intention is to relieve suffering, versus the intention is actually to commit to lead to somebody's death, causation versus intent. If a patient dies from aggressive pain management, for example, the intention in those situations is not to commit suicide or to aid in dying, but to relieve suffering. That's how they looked at that. A doctor who assists a suicide, however, must necessarily, so they're very clear that you are intentionally leading to somebody's death. The Supreme Court concludes that everyone, regardless of their physical condition, is entitled, if competent, to refuse unwanted life-saving medical treatment. No one is permitted to assist a suicide. I believe I've missed a few slides here, but we can talk about them later on. Death after withdrawal of treatment follows a withdrawal or inaction, and is usually ascribed to the underlying disease. So they try to differentiate between letting die and killing. In other words, if we withdraw treatment from someone and they then die, they are seeing that as the individual died from their illness. They did not die because you withdrew treatment, but they died because of the underlying illness, as opposed to the other situation where in the assisted suicide, either the lethal medications you've given that led to somebody's death is the ultimate cause of the person's death. So it is killing, as opposed to the other situation where it is letting die from an illness that exists. Now, the status that, actually, I wanted to go back to tell you what the exact question the court was trying to answer in all of these three cases that I put up in previous slides, which for some reason they skipped all of it here to this point where we are. But the question really was whether or not the prescribing of medications, in this particular case, they concluded that prescribing physicians from... The issue in two cases, one was Washington, one was in New York, was that the law said that prescribing medications to lead to somebody's death or assisted suicide was against the liberty interest of the state. The state had an interest in preserving life. And therefore, anyone who prescribed medications that led to that was actually bridging the liberty interest of the patients. I think it would be better for me to just go back a few slides and come back here. So here are the three decisions, the three court decisions that override a lot of our discussions today. And the overriding question was, is there a constitutionally protected liberty interest in determining the time and manner of one's death? Is there a liberty interest, protected liberty interest? And I think the final decision here is that there isn't. Therefore, the law still, to this point in time, prohibits us from assisted suicide, according to the Supreme Court judgment. The AMA opinion, I'm not going to go into that because I think we have already talked about those. The APA talks really along the same lines with the AMA in terms of stating very clearly that, I think you said it, that medical euthanasia, the debate is dead. We consider that as unethical. But the other opinions about lethal injection for execution says nevertheless, overriding meaning of this principle, which is a treatment of patients with compassion and dignity, which is arguments that people have advanced for utilizing assisted treatment, that that treatment, the physician-psychiatrist is not a killer, no matter how well-purposed the killing may be, which is a really powerful statement that says that we can't participate in activities that might lead to somebody's death. The APA then goes on into a very comprehensive discussion about how psychiatrists can engage in this process, because we are trained to handle sensitive and difficult discussions with patients. We are trained to identify and treat common psychiatric and neuropsychiatric symptoms at the end of life, and to address the psychological suffering that accompanies the potential stigmatization and marginalization of those nearing end of life, to balance information regarding end-of-life care with accurate knowledge of patients' preferences, provide sufficient information, and so on. But here's the thing I wanted to point at the end there, where I don't know how far California is from other areas. The number of people who've been referred to psychiatrists in this end-of-life discussions have been very small. Four to 5% of people are the ones who actually get to see a psychiatrist, who get to have this capacity assessment done, and you can imagine the potential risk in all of these areas when others are involved in these decisions. The American Academy of Psych and Law does not actually have any specific statement or comment about this. However, they have comments about legalized, authorized executions, which are not the same, but I just want to point out the language there that it's unethical to participate in legally authorized execution. That's an AMA, also a principle, but it's not unethical to conduct competency to be executed evaluations, which is a really interesting point, because if you then decide that somebody is competent to be executed, what exactly are you saying, or are you doing? Essentially, you're saying that you're giving the courts freedom to do that, and obviously, just like the debates that went on in CJER, a lot of this kind of debate will be happening at the Apple about this comment here, and finally, they decided that psychiatrists should never be forced to do this. If you are not comfortable doing competency to be executed evaluations, you should be allowed to do that, but if you did it, it wasn't unethical, even though the outcome might be you finding someone competent to be executed. So you can see we're all struggling with this whole idea of where we should fall in. Just want to spend a few seconds talking about alternate views. Even though the Supreme Court in both Glucksburg and Verco were very clear that physician-assistant suicide or medical aid in dying was against the law, they were very clear about it on no uncertain terms, there were some other comments that kind of challenged and projected how things might change in the future. At least two of the justices had, in their concurring opinions, they were supporting it, but while they were supporting it, they were telling us that the doors to having these discussions might be happening at the state level, and they foresee a future where discussions around physicians participating in end-of-life decisions or made, as we call them, they see a future where it might happen at states. So they're opening the door a little bit to allow states to continue to have those discussions, including the participation of psychiatrists, even as they are concurring with the opinion that at this particular point in time, it's against the law to do that. Now, some other ethicists also have their challenges to this whole idea of the decisions from the Supreme Court, like withdrawal of life-sustaining treatment, which some of them have called passive euthanasia. Actually, they are making a comment that you're participating in the care, in the dying of somebody, that withdrawal of life-saving treatment and injection of lethal drugs to cause death are the same, and the distinctions that they are talking about, the distinctions are really what they refer to as moral fictions, which are four statements endorsed to uphold cherished and entrenched moral positions that we all hold in our ethics. And essentially, what we are saying is that these are four statements that we make to help our cognitive dissonance when it comes to managing these type of issues. So we split the hairs by saying withdrawal of treatment is different completely from actually giving treatment to help somebody die. The area that is also really interesting is the statement that we can give you an excessive amount of medications to take care of your pain, in the understanding that you might die in the process, but that is fine. The intention at that time was not to kill you, but to relieve suffering. And therefore, the whole idea of intention becomes very, very questionable. And the ethicists in these positions are saying that regardless of whether you are withdrawing treatment at the patient's request, or you are offering treatment to lead to someone's death, the physician bears the responsibility as far as they're concerned. So they don't really entertain this whole difference that the Supreme Court was making. And then some other ethicists and clinicians also talk about the doctrine of double effect, which is a harmful effect of treatment, such as the high doses of medications to relieve suffering can also lead to death. But in those situations, where the ethics permits you to do that, even though somebody, the outcome might be death. And the question whether that is a partial intention as opposed to a full no, when you say the intention is to relieve suffering, is there a partial intention to actually cause death as well? So these are arguments that people have made to fight, to question the idea of permissive treatment to kill patients. I'm sorry that I rushed through this because I saw that the time was really gone. And I wanted to be sure that we had enough time for our Canadian colleagues. Thank you. Thank you. So we're gonna now have Dr. Chemowitz, Dr. Freeland from Canada to give us the Canadian perspective. We're running a little late, but we're gonna go ahead and take full time for you guys. And then we will, if we have to go beyond 515 for some questions, I'm sure people can stay. It's the end of the day. Thanks, Rick and good afternoon. Just a disclaimer before I start. I'm not an assessor or provider of MADE in Canada. So my name is Gary Chemowitz. I'm the president of the Canadian Psychiatric Association and a forensic psychiatrist. And I'll be joined today by my colleague, Allison Freeland, who's the chairman of the board of the Canadian Psychiatric Association. I think what you'll hear from us today is perhaps a little different in that we also have MADE for people who don't have deaths that's foreseeable. And there's a consideration of MADE where mental illness is the sole underlying condition, obviously a controversial issue. So what I'm gonna do and what we're gonna do today is review the legislative history of medical assistance in dying in Canada, which we refer to as MADE, and we'll give you a sort of a window of insight into what Canadian psychiatrists need to be aware of when they're dealing with people with mental disorders who've requested MADE. And we'll also delve into what our Canadian Psychiatric Association has done to support the development of guidance, the tools for our colleagues to meet the challenges with MADE legislation. So 50 years ago, medical technology gave us the tools to prolong life in certain circumstances. And increasingly, patients looked to doctors for tools to end their suffering. In 1972, suicide was decriminalized, but doctors still faced criminal charges if they assisted their patients to die. So in 1993, Sue Rodriguez, who had advanced ALS, argued that suicide was legal under the Canadians' Criminal Code, but prohibition of assisted suicide violated her rights under the Charter of Rights and Freedoms, discriminating against her as a disabled person because she was by then physically incapable of taking her own life. In a very close decision, the Supreme Court of Canada ruled against her. In 2015 came the Carter decision. The facts of the case were very similar to the Rodriguez case, but in this case, the Supreme Court struck down the prohibition on assisted suicide in the Criminal Code, saying that in the intervening years, there'd been significant changes in societal and legal framework. The decision limited the right to physician-assisted death to competent adult Canadians who clearly consent to death and have grievous and irremediable medical conditions that causes suffering that is enduring and intolerable to them. The court also noted that properly designed and administered safeguards were capable, so in this case were capable of protecting vulnerable people from abuse and error. In response to Carter, the Canadian government issued, introduced Bill C-14, creating a statutory framework to allow for medical exemptions to the criminal code that criminalized medically-assisted death. So physicians or nurse practitioners who wrote a lethal prescription for the patient to self-administer or provided medications IV to end a patient life could no longer be held criminally responsible if they met all the eligibility criteria. Bill C-14 tried to strike a balance between the autonomy of persons who seek maid on the one hand and the interests of vulnerable people and suicide prevention on the other by adding eligibility criteria to the person's death that had to be reasonably foreseeable. In 2016, to be exempt from prosecution, to be exempt from prosecution, medical practitioners had to ensure that the person was eligible for health services in Canada. This was to prevent maid tourism. They had to be at least 18 years old and capable of making healthcare decisions. They had to have a grievous and irremedial medical condition. The request had to be voluntary and not the result of coercion, and they had to give informed consent. Now, grievous and irremedial was defined as a serious and incurable illness, disease, or disability that resulted in the person being in an advanced state of irreversible decline and capability that caused the person to endure physical or psychological suffering that was intolerable to them, and they could not be relieved under conditions acceptable to them. And critically, their death had to be reasonably foreseeable and there was no requirement, however, for certitude with regard to prognosis. Safeguards included the requirement for two independent medical examinations, two independent witnesses, a 10-day reflection period between approval for maid and the provision, and the ability to withdraw consent at any time. Bill C-14 also required an expert consultation and a parliamentary review over the subsequent five years to review the impact of C-14 and the issues of mature minors, mental illness, advanced directives in the context of maid. The age and consent requirements of the bill implicitly excluded mature minors and advanced directives, and the criteria of natural death become reasonably foreseeable, made it such that capable adults whose sole underlying condition was a mental disorder would rarely qualify. However, the legislation did not specifically exclude people whose sole underlying medical condition was a mental illness. For an example, somebody with an eating disorder with such an advanced stage they would die as a result could have qualified for maid under Bill C-14. So core challenges sought to clarify aspects of Bill C-14 and in the province of Quebec, the case of Jean Trichon and Nicole Gladue, who suffered from incurable degenerative diseases had sought and were denied maid because their deaths were not reasonably foreseeable. In 2019, the Superior Court in Quebec declared that the federal criterion of a reasonably foreseeable death and Quebec's requirement that the patient be at the end of life as invalid and contrary to their charter rights. Neither government appealed and crafted laws designed to bring them into compliance with the Trichon decision. Bill C-7 became Canadian law in March 17th, 2021, and in general, the criteria remained the same except for the definition of grievous intermedial medical conditions. And the requirement that a natural death but reasonably foreseeable was removed as an eligibility criteria, but a sunset clause was temporarily placed there so that mental illness for the purposes of determining grievous intermedial medical conditions were put on hold for a while. This meant that a person could not be eligible for maid if they had a mental illness as their sole underlying medical condition until March 17th of this year, which time that exclusion would automatically disappear from the legislation. It should be noted that the person can still be eligible for maid and have a mental illness, and that's one of the issues that we struggle with because many people also have mental conditions and have terminal illnesses. But in this case, people had to have another illness, a serious illness, in addition to maid to meet the eligibility criteria. So there were some safeguards that were put in place, and we introduced essentially what we call Track 2. And this was dependent on whether the person's natural death is reasonably foreseeable, and people no longer needed to be essentially at death's door to be eligible for maid. And if they were not, they had to go through a much more stringent set of safeguards in this case. So these Track 2 cases in which, for instance, the sole underlying medical condition could be a mental disorder, or the condition was not remedial, could go through this Track 2. So they had to have all sorts of things in place, lots of safeguards, and I'm not gonna go through all of them. But in addition, Bill C-7 also required the collection of all sorts of data about gender identity, race, indigenous identity, and disability. There was also a 90-day period between first eligibility and the provision of maid. The person must be informed of the means available to alleviate their suffering, and must seriously consider these means. And as you can imagine, when it comes to somebody with a psychiatric condition, these are obviously very important. Bill C-7 also required the federal ministers of health and justice to initiate an independent expert review, respecting protocols, guidance, and safeguards to apply to requests for medical assistance in dying in persons who have an underlying mental condition. And the expert panel on maid was undertaken, had to undertake this particular review. So this was reported on earlier this year, and just found that the debate on maid for mental disorders of the sole underlying mental condition did not only apply to people with mental illness, nor to all people with mental illness. And although their mandate was limited to mental illness, they noted their recommendations against safeguards, protocols, and guidance should be applied to all clinical situations, regardless of the requester's diagnosis, and where there were major concerns about incurability, irreversibility, capacity, suicidality, and or the impact of structural vulnerabilities. So in response to the expert panel's first recommendations, Health Canada convened a task force of clinical, legal, and regulatory experts to develop maid practice standards in advance of what was then the march of this year's point in time where maid SUMC mental condition was going to be in place. And so they put in place a number of things. Health Canada also funded the development and implementation of a national fully accredited maid curriculum to provide high quality training to healthcare providers across Canada. And a soft launch of this curriculum is expected this fall. The modules would then advise and support clinicians in assessing persons who request maid, including those with a mental disorder, complex chronic conditions, or those people who are impacted by structural vulnerabilities, as well as the provision of culturally safe care and the practical application of a maid legislative framework. In March of this year, the SUMC set... In other words, in March of this year, we would have had maid for mental conditions, the sole underlying condition, as part of track two and available to Canadians. That was prolonged for a year to March of next year to allow for the development and dissemination of maid practice standards and the national maid curriculum. Later that month, the model practice standards for medical assistance in dying were released, and that was really there for legislators, but really also assist province and territories, institutions, and programs as they draft or revise maid policy in preparation for the removal of the exclusion of requests where mental disorder is the sole underlying condition. So since the model standard covers aspects of maid practice relevant to requests where mental disorder is the sole underlying medical condition, as well as the content relevant to all requests for maid, particularly track two, where patients' requests are not reasonably sealed, it included a number of regulations. I'm not gonna go through all of them, but some of the things that we struggle with are around confidentiality, the assessment of decision-making capacity, the voluntariness of the request, seriousness and irreversibility, and serious consideration of the means available to relieve suffering. There was a companion document as well that was put in place, but I'm not gonna go through, so I'll leave this to Alison, because she'll probably talk to us a little bit about what the CPA has been doing to get us to this point, Alison. Thank you. Is it this one? The one on the right, yeah. Hi, everyone. Thank you for an opportunity to talk a little bit about the Canadian Psychiatric Association and how we've been involved in medical assistance in dying, particularly as it relates to the issue of mental illness as the sole underlying condition. I will also join Gary in saying that I am not a maid assessor or provider, and I'm in fact a general adult psychiatrist who, along with many of my Canadian colleagues, has been trying to learn, educate myself, reflect and understand the complexity of this issue that is facing Canada and Canadian psychiatrists in particular with this specific group of patients. So what has been the CPA's role during this time? Since the Carter decision in 2015, CPA leadership has been very involved and made appearances before and provided written submissions to various parliamentary committees and expert panels. We have tried to have continued member engagement on medical assistance in dying through surveys, a time-limited task force, repeated symposia at CPA annual conferences, member town halls and written comments from members. We formed a maid working group to develop a discussion paper to support awareness and understanding of key issues relating to the evolving landscape of maid, particularly with respect to SUMD. This was used to solicit further member input. Through its maid working group, the CPA provided feedback on the draft maid practice standards through a rapid review process. And there was a broad consultation which included provincial and territorial physician and nurse regulators, provincial and territorial ministries of health, health professional associations and individual experts engaged in research relating to maid. The CPA has also been part of the National Maid Curriculum Steering Committee with representation there. And this is a committee which is supporting and enabling the development of national maid training curriculum for assessors and providers in Canada. So one of the things at the CPA is that we published a position statement on maid in February 2020, which is updated in November 2021 to reflect the latest legislation, Bill C-7. Our statement set out several principles and considerations regarding maid and psychiatry in Canada and reflected the need to protect and respect the rights and interests of patients with psychiatric conditions in the evolving Canadian landscape of maid legislation. Our position statement says that psychiatrists, of course, need to have a working knowledge of maid legislation. And it's incredibly important that we believe that psychiatrists take time to read and understand what has been going on. Patients with mental illness should not be discriminated against solely on the basis of their disability. And as such, they should have available the same options regarding maid as available to all Canadians where eligibility requirements are determined to be met. Psychiatrists must remain impartial when speaking to patients about maid in these circumstances. But, of course, conscientious objection is permitted, but effective referral is expected as required by the physician's regulatory body. And, of course, rigour and expertise in conducting capacity assessments and identifying treatable symptoms of mental disorder is expected. Our October 2020 survey, with which we had a response rate of 23%, found that 79% of psychiatrists agreed that maid should be available for people who are eligible. 63% agreed that it is possible for a mental disorder to be grievous and irremediable. But only 41% agreed that people with mental disorders as their sole underlying medical condition should be eligible. 9% of respondents said they were conscientious objectors. 22% were involved in assessing maid. And 10% were involved in providing maid. 87%-important number-agreed that more training and education was needed in this area. In August of 2021, as I mentioned, we published a discussion paper written by our maid working group to solicit further input about areas of concern with respect to maids specific to sole underlying mental disorder from our members and from 50 stakeholder organizations. While some psychiatrist respondents remained opposed to any access to maid for those with a sole underlying mental condition, based on the majority of feedback CPA has received, the points raised in our discussion paper reflect the primary areas of concern that our members have raised about this. Many of the concerns highlighted and safeguards proposed by respondents are echoed in the maid model practice standards and its companion Advice to the Profession document, which offers clarification on a number of items in the standard. And I wanted to just mention a few things that our discussion paper and input from our members has been reflected in some of this important national work. One of the issues was that maid assessors and providers must be independent practitioners, in other words, not the treating physician. Reasoning and evidence upon which an assessment of capacity is made must be done carefully and with thorough documentation. The issue that we raised is another one reflected that the decision to request maid must be made freely and without undue influence, and this must be very carefully explored as part of the assessment. That where a capable person refuses consent to obtain their health record and personal data or collateral information or the involvement of other health practitioners necessary to complete a maid assessment, the assessment cannot be completed, and therefore that person cannot be found eligible. And so that really underscores the thoroughness that's expected in the assessment. Another issue raised in our discussion paper and by our members was that in Track 2 cases, where natural death is not reasonably foreseeable, there must be sufficient time for reflection, and that the standard has been set at a minimum of 90 days, allowing more time beyond that if needed. And that 90 days is between the day the first eligibility assessment for a current request begins and the day maid could be provided. Another issue raised was that neither the assessor... If neither the assessor of maid or the provider of maid has expertise in the diagnosis, so expertise particularly from our perspective in the area of mental disorder, they must consult with a physician or nurse practitioner with the required expertise in the diagnosis being considered. Another issue raised in our discussion paper was that the person must be informed of the means available to relieve their suffering and where appropriate counselling services, mental health and disability support services, community services and palliative care consultations must have been offered with relevant professionals and that community services include services related to housing and income supports. That the person has given... It has to be demonstrated that a person must have given serious consideration to the means to relieve their suffering and that this is understood to mean they have exercised their capacity, they have exhibited careful thought and are considered to not be impulsive. And finally, I'll just comment on in the discussion paper and again as part of the standard is that to take suicidality into consideration, assessors and providers must ensure that the person has been informed and they must ensure that the person's request for aid is consistent with the person's values and beliefs and is unambiguous and enduring. They must ensure it is rationally considered during a period of stability and not during a period of crisis and that this may require multiple serial assessments to understand. There's lots more that we could talk about with respect to this issue but what I will say in summary is that this has been for our organization and I think for Canadian psychiatrists a very complex and at times emotionally charged period for those engaged in advocacy and education related to MAID. However, as a national organization representing Canadian psychiatrists, we believe our responsibility is to ensure our members are well prepared to meet the coming legislative changes and in fact we did hear from our members, 87% saying that they wish to have more education in this area. We want to ensure that the safeguards and training being developed around MAID practice are of the highest quality and balance both our duty to protect our patients with our patients' right to choice. As an organization, however, we remain fundamentally committed to ensure that people have access to treatments and services and that is a front and center part of our organization's advocacy. People with psychiatric disabilities must have equitable and timely access to appropriate culturally safe, evident-based care as well as community supports and services and this is to ensure that MAID is not requested as a means to escape social exclusion or a dearth of community support. Thank you for the opportunity to bring our Canadian perspective. APPLAUSE Thank you. Thank you very much. So, we're close to... Oh, what? Say it again? Oh, OK, go ahead. Sorry, I just wanted to make a clarifying comment before we continue with questions and answers. I apologize that in my rush to go through my presentations, I might have made a statement that might be confusing around the Supreme Court. The question before the US Supreme Court was never whether or not these bans were illegal. Those were not the questions. The questions in Glosberg and Quill, which both Washington State and New York State, was whether or not the ban of physician-assisted suicide, those bans were unconstitutional. Those were the questions. Not whether or not they were illegal, but whether or not the bans were unconstitutional. And the Supreme Court in both situations said the Washington State's ban and the New York ban's were not unconstitutional. In other words, not that they were illegal, but that they were not unconstitutional. And also, some other states might decide to approve physician-assisted suicide, in which case that might be constitutional as well. So the issue wasn't about illegality. That question has not come to the US Supreme Court. The question has been whether or not banning physician-assisted suicide was illegal. Sorry, unconstitutional. And the Supreme Court said it was not unconstitutional. Thanks, Charles, for clarifying. We're going to take 15 more minutes. We'll stop at 530. But I want to give you guys an opportunity, obviously. There's probably a lot of questions, and thoughts, and comments. And you can direct a specific panel member, or just open it up. The gentleman in here? Yes, it's very informative. I have a couple of questions. Go ahead and identify yourself at the front end of the room. Hi, I'm Arden Barnett. I'm a psychiatrist in Illinois, Champaign, Illinois. Thank you. I have a couple of questions, two for California, two for Canada. I'll be brief and sit down and listen. In California, has there been any movement to allow MAID for people who are suffering, have insufferable pain, as opposed to similar to what's happening in Canada? Secondly, in California, it says the evaluations should be, PCP should refer for evaluations. Must. It is must? OK, thank you. So just one question for California. In Canada, two questions. What percentage of people are requesting MAID? I know they gave us some numbers for California. Secondly, in Canada, if someone is a guardian of someone who doesn't have agency or has a disability, have any guardians of people who have a chronic disability requested MAID for their wards, you might say? I'll sit down. Just to the issue of guardians, for all requests for MAID, the person has to be capable and freely give consent to that. So in the issue of any incapacity, it cannot be requested through a substitute decision for a guardian. We've been collecting data. 2021, Canada population, approximately 40 million. We've had just over 10,000 MAID deaths in 2021, which was 3.3% of all deaths. Anticipate that number, obviously, to be higher. Clearly, mental disorder is not part of that at this point in time. And track two, we're still waiting for that to play out. And the other question about California and pain. Pain itself would not qualify you. If you have metastatic cancer and happen to have pain, you have to have a terminal illness. And some would argue that intractable pain might be a terminal illness, but that would not qualify in California. Do you agree with that direction, or are you in favor of that direction? I don't. And likewise, not in the direction of intractable suffering associated with psychiatric illness. Thanks. Patricia? Good afternoon. Patricia Westmoreland from Denver, Colorado. I wanted to ask those of you in the United States about medical aid in dying for individuals with eating disorders. Those of us in the eating disorder community are extremely distressed by the paper by Gadiani et al, discussing a construct that she basically put together herself, that of terminal anorexia, which those of us in the eating disorder profession do not necessarily believe is actually in existence, and then proceeded to engage in practicing medical aid in dying for two eating disorder patients. Interestingly, with little to no comment on exactly what all of you were talking about, the ability to make decisions and reason judgments that do not come as a result of a mental illness. So I would really like to hear, especially from you, Dr. Kriegers, what you think about that. Thank you. Definitely going to punt on that question in a major way and say, I'm not a clinician. I am not qualified to speak to whether an individual with an eating disorder could ever reasonably be considered terminally ill. I think that that's something that is unfortunately going to have to be settled within the profession. That said, if that individual can, in fact, make a reasonable decision, understands the consequences, the implications of a request, I don't know that a clinical status alone should preclude that request or should preclude a physician acknowledging that request or acceding to that request. That said, I would want to see all kinds of safeguards put in around that. But from the ethics perspective, if I am competent, if I am in distress and my firmly held beliefs are that this is the best course for me, it's much harder to shut down. But how does somebody with a starving brain able to really make that decision? And as somebody who has worked with eating disorder patients for the better part of 20 years and has written a book on this subject, I find that extremely concerning. Can I ask Dr. Strauss to comment on that a little bit? On the general? On the eating disorder question, yeah. So I think we might agree that there are people who have had eating disorders for long periods of time who do have some of the often fatal schemata that go with that, like cardiomyopathy or repeated infections or a crumbling skeleton, who have opted not to have any more treatment for their anorexia nervosa. And I have seen cases where people like that have been admitted to hospice. Generally, there's not much disagreement. Yeah, and I don't have a problem with that at all. Yeah. And I think some of those patients do demonstrate what one could argue are the ingredients of capacity to make medical decisions. I realize you might say that's not possible. And I think under those circumstances it might be an appropriate thing. But I've not been in a situation like that. OK. Thank you. Thank you. Next. I'm Judy Glass from Montreal, Quebec, Canada, and a former member of the Canadian Psychiatric Association, from which I resigned because of the CPA's position on MAID. I have several questions for you, but I'll ask only two. One is, you mentioned that 79% of the CPA members agreed with the idea of MAID for people with psychiatric illnesses. And I'm curious to know, what percentage of psychiatrists in Canada are members of the CPA? So we have about 4,800 psychiatrists in Canada. About half of them are members of the CPA. I think that kind of reflects regular membership. I think those numbers may be incorrect. I think that 79% are not in favor of MAID. It's actually a much smaller number. It's less than half. It's something on the order of 41%. So the majority of Canadian psychiatrists are not in favor of MAID for underlying medical conditions. As you know, I mean, this has really been a tense and complex issue in Canada that has really divided the profession. Thank you for speaking to that. It sounds like what you're saying, then, is you took a position that actually doesn't represent Canadian psychiatrists. So the Canadian Psychiatric Association doesn't take a position on MAID. We take a position that that is a decision that essentially Canada, our view is that Canada has made that decision, and that we will do what we can to ensure our patients are protected against being taken advantage of, so they can be capable. But they also should have the ability to choose, like any other Canadian. And we're also in the business of making sure that practitioners, in other words, psychiatrists, are educated about MAID. We've developed a curriculum and put in place a number of safeguards. A number of the other things that we've done is we've engaged with a number of committees, expert panels, Health Canada, and provided information to ensure that the safeguards are there, and that we've inputted into a variety of arenas for all of those reasons. But we certainly are very much aware that many people are very uncomfortable with the idea that physicians, and especially psychiatrists, should be somehow involved in this process. Thank you. My second question has to do with the phrase in the legal documents, which is that the condition has to be irremediable. And I'd like to hear your definition of irremediable, because I don't believe that we have a definition. I think you're raising a really great question. And we don't have a definition of irremediable. That is something that, through Health Canada and through the standards and the curriculum being developed, a way of standardizing the assessment of people to drive towards understanding the concept of irremediability against the issue of patient choice and autonomy. And I think, as Canadians, we're on a journey to learn how to do some of this stuff moving forward. With the changes in the criminal code and legislation that's come from our government, I believe, from a CPA perspective, what we are trying to do is understanding that that is coming. How do we ensure that our members, and I would say Canadian psychiatrists in general, step up, learn, reflect, consider about this, and help get involved with that evolving practice that's going to need to have to happen to get to the place of irremediability? But there's a lot of work being done, training, development of standards, development of expertise. And I think it's important, as a psychiatrist, that we lean into that work and figure out how we have our voice and how it's shaped. And that's really what we're trying to do through the CPA. Thank you. I'm struck, just if I can comment. What I find fascinating about the contrast between the two countries is really the way the notion of autonomy, and, if you will, the subjective input of the patient, comes into play. Clearly, in the United States, we've gone down a path of trying to objectify a concept of terminal illness as criteria. Canada has opened this up, as European countries have, to really grapple with the value-laden concept of what is irremedial. What does it mean to have unbearable suffering? And I think this is really, if you will, the tiger that is so hard in this discussion. And then, of course, at the other, or the next level, is whether organizational medicine, how do we participate in this in some fashion, or not participate, push back on it? So I just wanted to clarify those dynamics, because they're so powerful in this contrast. My name is Beth Morris, and I'm from Chevy Chase, Maryland. And I have been involved since 2015 in testifying before the Maryland legislature in support of an aid-in-dying bill. It still hasn't passed. And I've also been involved in advocating within the American Psychiatric Association and the American Medical Association. So I have a lot of experience with the opposition, deeply held opposition, to so many physicians in the US. And I am just curious. I mean, Dr. Martin, I'm kind of following up on your question, is what's the difference between Canada and the US that the path that you have taken is quite different from where we physicians are in the US? And I also would like to know the Canadian Medical Association, I'm assuming there is an entity, and what their position is. I mean, maybe it's an unfair question. You know, I think the one thing I will say, I mean, the difference between Canada and the US, I think Canada prides itself as being a liberal democracy. I think we champion the idea of personal choice and autonomy. And I would say that extends way beyond the aid issue. And I will just say that. And I will just think about the abortion debate that's happening in the US and what that looks like compared to the Canadian culture as well. So where we are right now, that is our culture and our approach to things. So I think that that's one part of it. And again, I think just how this is, because it's unfolded pretty quickly. When you look at the timelines, it's like a lot of change has happened quickly. And I think this is the part of the process has been the court findings, like court findings which have influenced government decision making, which hasn't really been about consultation with the profession. It has been the profession reacting to those things. And I will say, particularly where it becomes to mental disorder, I mean, I would very clearly say it's been a very divisive and contentious discussion in many respects. And again, coming back to this idea of personal opinion or emotional connectedness to an issue, and how do we tease that away from the idea of more of an organizational approach that says, whether you as a person want this or not, it is coming to our country. And we're saying as an organization, we have to step up. You can't not look at it. You've got to learn about it. So that's kind of where we're at. Let me just add a little bit. In terms of the court cases that I was going through, one of the things our Supreme Court has done, it's commented on the cultural and social changes over time. So the same case years later reflected a change in Canadian culture. And as Alison said, termination of pregnancy, when you look back, I mean, I'm old enough to remember those debates. When you look back now and you see how far we've come, Canada also looks, perhaps, more to Europe. So I think you've seen, perhaps, a shift. And maybe you'll see that shift here, but we'll come back in five or 10 years, and maybe we'll, but I think our decisions reflect a cultural and societal shift in our quite diverse liberal democracy. Thank you. So I have one question about that. Quick follow-up, because we've got two more people. That's okay. So the U.S., there are many judges who are strict constructionists in the U.S. Do you have that, you have that less so in Canada? We have 10 provinces, and with the appeal courts, we have a Supreme Court, one Supreme Court, so it's probably a little easier to pull things together and find a commonality of purpose. I mean, having all the states in the U.S. gives you a grand experiment, but it also can slow things down. So I think just the way it's structured, I think, has for us, in this, a bit more of an advantage. Okay, thank you. I just wanna make one quick comment about what happened in Washington State. So despite the court decision from the Supreme Court that says it's not unconstitutional for the state to ban physician-assisted suicide, the next couple of years, it went to the ballot, and the people overturned it in the ballot. So the people says, we won this, and despite what the court was saying, they got it. So it boils down to power to the people, I suppose. Right, thank you. Hi, I'm Anna Kostreski. I'm a fourth-year psychiatry resident, finishing up next month, very interested in this topic. I'm actually giving a Grand Rounds presentation on Thursday about palliative care and psychiatry. Just a quick question, are the slides going to be available? I didn't see them on the app. Are they gonna be available? I don't know. So for other sessions, usually the PDF of the slides is available in the app, but you can just have them upload it, but I think that'd be very helpful. Yeah, I've seen that. This was put together rather late in the program, but I will check with them and see if we can do that. And then just a quick piece of feedback. Just as someone very interested in this topic, I really think that last section of the presentation was really where the interesting kind of more kind of current event type aspect of this presentation was, and I would've really liked to hear a little bit more of that part expanded, just the concept of mental illness as the sole underlying condition. I think that's really applicable to us and kind of very interesting. Especially since we're going over half an hour late. That's just a little bit of feedback. I think that would've been helpful to have a little bit more narrow of a focus. Absolutely. I think we could do an entire presentation just looking at the European models and what data comes out of the European models to address your issue about the mental illness component. And in a number of years, we're gonna invite you back to talk about what's happening in Canada. Next. Chaman Sharma, I'm also a psychiatry resident at VCU. I had a couple questions. So one was with Dr. Strauss. You mentioned that only approximately 60% of patients that were given the medication actually administered it. So I was just curious, is there any policy in terms of recovering those medications if they are dispensed or filled? Because it seems a little bit kind of Dangerous. Dangerous to have such a lethal medication out in the society. Yeah, it's not in the law, but many programs do. And most programs encourage people not to pick up the drug until they're close to wanting to use it and then storing it in a lock cabinet, et cetera. Thank you. Let me just, can I add to that? In Colorado, they actually built into the statute a disposal mechanism for the very concern you're talking about. I see. And then one final question. So this is related to Dr. Freeland. She mentioned with, you know, crack two looking for that period of not being in crisis, but more of in a sustained stability. And, you know, it comes to mind is, you know, if you have a patient with MDD that's recurrent severe, what really defines stability if, you know, you're presenting them with treatment modalities, but they're in this state. So, you know, is it the illness itself that is preventing them from engaging in treatment? How do you kind of delineate and move through those situations? So, sorry, it's a little hard to hear. It's a bit echoey back here. I just want to make sure I'm answering your question. So I think the question you have is around trying to understand suicidality against a sustained request for aid. Is that? Right, right. So like a patient with MDD that's severe and concurrent. So how do you kind of assess if they're in a period of stability? Yeah, that is a great question. And something I believe is a very active topic within the Canadian psychiatry community. And I would say when you ask some psychiatrists, they would say, I can't actually tell the difference in those situations as opposed to others who would say that in their experience working with patients, that there's a qualitative difference between somebody who can clearly articulate a desire to end their life on the basis of the suffering and their experience of the irremediability of their symptoms versus a sort of a more impulsive or acute quality to the suicidal intention. I think part of the discussion is, you know, there's no 100% guarantee that we do anything perfect in medicine. And so some of the ethical debate, I think, rages around that, which is, you know, if we're going to, the challenge is this is such an ultimate decision for somebody who may then end their life. And is that somehow different from somebody who's going to have a very high-risk operation, for example, knowing that they may never get off the operating table? Like, what are the similarities in how we assess and understand and share that information with patients? You know, some people talk a little bit about that. I think the national standards and the modules that are being developed turn their mind to that. And I think it's really important that psychiatrists, who I believe are, if anyone's going to be able to try and sort that out with a patient, it's going to be psychiatrists. And how do we engage psychiatrists to, if they don't want to actually assess for the issue of MAID, which many don't, and I understand that, how can they at least give an expert opinion around the issue of suicidality versus a more sustained request around ending your life? And so how can we contribute to that discussion as well? So those are some of the things that we're thinking about. Just one other quick comment. So there's some creative folks thinking about, you know, modern, rapidly-acting antidepressant therapies, making sure that those might be available. Ketamine, TMS, and even now the breaking wave of psychedelic therapies, which, as you probably know, have been studied in people with end-of-life intense fear, anxiety, et cetera. So I think there's a lot of interesting stuff ahead. Thank you. Well, thank you very much. Thank you, the audience, and thank you to the panel. Thanks.

Medical Aid in Dying

MAID

U.S.

Canada

legislation

ethical considerations

patient autonomy

traditional medical ethics

Oregon model

terminal illness

AMA

mental capacity assessments

court cases

societal attitudes

professional education