November 18, 2020 To the Standing Senate Committee on Legal and Constitutional Affairs: I am submitting the following for your consideration as you study Bill C-7, which expands the eligibility criteria for Medical Assistance in Dying (MAiD). I had previously submitted for your consideration the maid2mad.ca declaration that I co-authored, on behalf of over 1000 medical signatories who have concerns with Bill C-7. I am now submitting the following information from the perspective of an individual psychiatrist on the personal, societal, and systemic impact of Bill C-7 without amendments. Bill C-7 in its current form would facilitate the deaths of people whose death wishes may stem not primarily from their co-morbid physical illness, but from unaddressed psychological distress. Under the current bill, patients may be approved for MAiD without necessitating assurance of access to adequate care, nor requirement to undergo standard medical treatment before receiving MAiD. This opens access to MAiD to a much larger proportion of the population, and the consequence of this reality on vulnerable populations needs to be fully appreciated. There will inevitably arise a case where even the most willing practitioner of MAiD will wonder about the appropriateness of the request for death. For the safety and well-being of patients, and in order to continue providing appropriate medical care, health care professionals must be given freedom to maintain their professional autonomy in declining to become involved in requests for death that they deem inappropriate. Under the current legal framework, I may be sanctioned for declining to facilitate my patients’ request to end their life. As a psychiatrist, this places me in a precarious predicament – my work to preserve the life and safety of my vulnerable suicidal patients is incongruent with current expectations under the law to facilitate their suicide. Despite assurances that amendments to the criminal code in Bill C-14 adequately protected the rights of health care professionals to decline participation in MAiD for reasons of conscience, the reality is that physicians in Ontario can now be penalized by their regulating college for declining to participate in arranging and facilitating the deaths of patients. Being coerced to unwillingly be complicit in the chain of events leading to the death of another human being is understandably severely distressing and deeply offensive to the integrity of one’s character, conscience, and medical ethical morals. If the status quo remains, the State is essentially being permitted to compel an unwilling practitioner to engage in an action they believe to be harmful to another person, and effectively sets up the conditions for inflicting moral injury upon health care professionals. The concept of moral injury is a recognized syndrome that has recently been applied to healthcare professionals during the covid-19 pandemic amidst scarcity of resources in providing care[i]. Moral injury is defined by Jinkerson (2016) [ii] as a “particular trauma syndrome including psychological, existential, behavioural, and interpersonal issues that emerge following perceived violations of deep moral beliefs by oneself or trusted individuals (i.e., morally injurious experiences). These experiences cause significant moral dissonance, which if unresolved, leads to the development of its core symptoms.” These core symptoms may include guilt, shame, spiritual/existential conflict including subjective loss of meaning in life, and a loss of trust in self and others. It may further lead to depression, anxiety, anger, re-experiencing of the moral conflict, self- harm (i.e., suicidal ideation/behavior, substance abuse, self-sabotage), and social problems. The testimony of physicians in Ontario give evidence to moral distress arising as a result of the effective referral requirements in Ontario[iii],[iv] (see first attachment “Freedom of Conscience in Ontario” for excerpts). In order to preserve the health of our medical workforce, it would be in the government’s and society’s best interest to prevent moral injury in our medical workforce while implementing the legal provision of MAID services. The recent decision of the Superior Ontario Court to uphold the effective referral policy for MAiD by the College of Physicians and Surgeons of Ontario amply demonstrates the inadequacies of conscience protection in law; the ruling opposes recommendations made by the Canadian Medical Association[v] and standards raised by the World Medical Association[vi] to respect freedom of conscience of physicians with respect to euthanasia and assisted suicide. To date, Canada has failed on the global stage to provide a safe and level field for patients and physicians to work together with mutual respect in this regard. Clear amendments must be enacted if Bill C-7 is to proceed. For the sake of our patients and the health of our medical workforce, I am, therefore, respectfully appealing to the Canadian Senate to ensure that there are adequate amendments to the Bill that would explicitly safeguard the ability of medical professionals to continue providing care without undue coercion to engage in life-ending interventions that they find morally and ethically unacceptable. I also urge you to support recommendations that would ensure that all patients have access to good medical, palliative, and mental health care, as well as access to other social supports such as affordable accessible housing and home supports, before pursuing a life-terminating pathway. I refer you to a WMJ article[vii] that reviews the effect of MAID on healthcare in Canada, and the Australian Voluntary Assisted Dying Act (2017)[viii] which outlines much more stringent legal protections for patients and health care professionals. I would welcome an opportunity to answer any questions and thank you for your consideration. Sincerely, Sephora Tang, MD, FRCPC Staff Psychiatrist, Department of Mental Health, The Ottawa Hospital, General Campus University of Ottawa, Faculty of Medicine, Department of Psychiatry, Site Education Director & Lecturer References Hosseiny, F. (2020). Moral Stress and Moral Injury Amongst Healthcare Workers. Ethics Rounds. The Royal Ottawa Mental Health Centre. Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology: An International Journal, 22(2), 122-130. Legislative Assembly of Ontario Second Session, 41st Parliament. Official Debates (Hansard) March 23 and 30, 2017. Standing Committee on Finance and Economic Affairs. Medical Assistance in Dying Statute Law Amendment Act, 2017. Sean Murphy, Legalization of Assisted Suicide and Euthanasia: Foundational Issues and Implications, 31 BYU J. Pub. L. 333 (2017). Available at: https://digitalcommons.law.byu.edu/jpl/vol31/iss2/3 Canadian Medical Association’s Submission to the College of Physicians and Surgeons of Ontario (CPSO) – Consultation on CPSO Interim Guidance on Physician-Assisted Death, January 13, 2016. (see attached) WMA Declaration on Euthanasia and Physician-Assisted Suicide, October 2019 (see attached) Herx L, Cottle M, Scott J. (2020). The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues. World Medical Journal. (see attached) Voluntary Assisted Dying Act 2017, Authorized Version No. 004 (June 19, 2020). https://content.legislation.vic.gov.au/sites/default/files/2020-06/17-61aa004%20authorised.pdf .