The Dutch warning: Why Canada should pause on MAiD for mental illness

Added: 2026-05-15

[00:00:00]Now, we welcome to our our witnesses today, all of them all the way from Holland. I believe you may have a World Cup team that's coming over here and and um but but up until then, we're friends until we actually pose each other on the on the field. Um so, I'd like to specifically welcome Dr. Jim Van O, professor of psychiatry. Dr. Wilbert Van Ru, I I I apologize if I mispronounce your name. Um, again, another psychiatrist and Dr. Cisco Vanvine. Yet again, a psychiatrist. And I'm sorry that's all the information they sent us.

[00:00:38]Um, and maybe I could first start with you, Mr. Van O. I will hold up a piece of paper. I don't know whether you'll be able to see it there when there are about 30 seconds left. Try to finish your remarks within five minutes. So to begin with, again, Dr. Van O, five minutes, please.

[00:00:59]Thank you very much honorable committee members. Uh thank you for inviting me. I am a professor of psychiatry at Utrex University Medical Center and a fellow of King's College in London. I advise the Dutch government on the current transition of our mental health services and in that capacity I lead social trials of a new form of mental health care in a direction that bears directly on the question before this committee.

[00:01:27]The Dutch experience, in my opinion, offers a warning for Canada. For 20 years, our euthanasia law left psychiatric cases largely untouched.

[00:01:38]However, over the past decade, a small group of activist physicians and organizations built a practice through sustained media campaigns. In 2024, the Dutch Euthanasia Expertise Center received around 5,000 requests, roughly 1,000 on psychiatric grounds. Among people under 30, requests rose from about 30 per year to nearly 900 in six years. Completed euthanasia rose fivefold.

[00:02:12]This pattern has been widely interpreted as a so-called suicide contagion effect amplified by the institutions that should safeguard against it.

[00:02:24]A contrast this committee perhaps should keep in mind under Dutch law physicians must agree that there are no reasonable options. Euthanasia is in principle the very last resort. Canadian law does not work this way. In Canada, patient choice trumps the physician's professional judgment. So, a doctor cannot insist that other options be tried first. That single difference will, in our assessment, drive Canadian numbers beyond ours. In 2024, the UN Committee on the Rights of Persons with Disabilities warned that the Dutch practice was unsafe. Persons with psychosocial disabilities have a fundamental human right of protection against premature death. Euthanasia for mental suffering cannot be cleanly separated from physician performed suicide. It is in many cases suicide carried out by a psychiatrist.

[00:03:26]Our research and clinical work reveal a minefield on every side. Autonomy. Most who request euthanasia for mental suffering are traumatized, marginalized, often living in poverty without prospects. Mental illness by definition compromises autonomy. Calling such a request a free expression of choice ignores the substance of the suffering.

[00:03:56]Discrimination. The argument that refusing euthanasia for mental suffering is discriminatory equates psychiatric suffering with terminal cancer. It is a false equivalence. Cancer with a two-month prognosis is linear and progressive. Mental suffering is not.

[00:04:17]Recovery happens often unexpectedly through relationships, purpose, meaningful work, bonding with another person, or even an animal. The patient recovery movement insists that recovery is possible for everyone. Plasticity is the rule. Criteria: Clinicians do not agree on iriability, on futility, on competence. The result is something like a lottery. Whether you receive suicide prevention or a lethal injection depends on which clinician you meet.

[00:04:58]Substance. Recent Dutch analyses show that many who receive euthanasia are women with unadressed trauma. Their unconscious self-destructive dynamics get enacted in the procedure. The psychiatrist becomes recruited into a deadly outcome. Toffrey Wayne and colleagues describe how in the Netherlands people with autism spectrum traits increasingly receive euthanasia for what is at root social suffering framed in medical language. The intervention should be social and existential, not lethal.

[00:05:39]Psychiatry claims it can both prevent suicide in one patient and helps finalize suicide in another with the same suffering. That is incoherent. It is not autonomy.

[00:05:51]It is not anti-discrimination.

[00:05:54]It is a contradiction at the heart of our profession.

[00:05:59]My message to Canada, do not expand. The evidence is not there. The UN, the International Association for Suicide Prevention and our lift experience point the same way. The social trials that we run in the Netherlands show another path. Care that builds relational continuity, hope and connectedness.

[00:06:25]That is the system worth building, not procedural pathways to death.

[00:06:30]>> Thank you. Thank you, Dr. O. Van O. Um, next Dr. Van and maybe you can correct me Ruiz.

[00:06:42]>> Thank you, Mr. Chair. My name is Wilbert Van Roy. It's like yeah, R Oi. Um, when it's Yeah. pronounced. Um, yeah, I will start my statement now.

[00:06:55]Honorable committee members, thank you for inviting me. I'm a Dutch psychiatrist. For nearly 30 years, I've worked with people with severe psychiatric disorders.

[00:07:07]In that time, I've seen mental health services in the Netherlands steadily erode, especially for those with the most complex conditions.

[00:07:17]This deepens despair and contributes may contribute to a wish to die in some patients.

[00:07:25]Since utinasia was legalized in 2002, psychiatric utia or mate has gradually become normalized in the Netherlands.

[00:07:33]And this trend has rapidly accelerated in the past decade. In my practice, I now meet more vulnerable, often relatively young patients who are in principle treatable.

[00:07:48]Yet they request euthanasia because timely and adequate care for them has been eliminated for political economic reasons.

[00:07:58]At the same time, a small group of activists physicians has adopted an increasingly permissive approach to mate often justified in the language of autonomy and compassion.

[00:08:10]In 2024, with several colleagues, I raised the alarm about how broadly the legal due care criteria are being interpreted in psychiatric cases.

[00:08:22]The resulting debate revealed deep division and a lack of consensus among Dutch psychiatrists.

[00:08:30]I speak today out of care and responsibility to warn of the dangers when structural shortages in mental health care and ideological convictions begin to shape decisions about life and death for some of the most vulnerable people in our society.

[00:08:49]Allow me to frame this with a story older than any of our laws.

[00:08:56]When the Greek hero Odysius finally sailed home, he was exhausted and wounded after years of war in Troy.

[00:09:07]On the last stretch, he faced the sirens, voices promising peace and an end to suffering. He knew that if he listened freely, he would perish.

[00:09:21]So he asked his crew to bind him to the mast.

[00:09:25]Not because he was weak, but because he understood that the urge to escape pain can peak precisely when judgment is most vulnerable.

[00:09:38]As a clinician, that image returns to me when I consider euthanasia for psychiatric patients.

[00:09:45]I have sat with many people who are tired in this odysian way, worn down by chronic depression, trauma or personality disorders.

[00:09:57]When they say to me, "I don't want to live anymore." In most cases, they are not asking to die.

[00:10:04]Often they are asking for pain to stop, for meaning to return, and for someone not to give up on them.

[00:10:14]For doctors, the central question can shift from, "Is there still hope?" to, "Have we followed the steps."

[00:10:22]Suffering becomes something to be assessed, documented, and ultimately validated by death.

[00:10:31]Psychiatricia increasingly involves young people with conditions that fluctuate over time.

[00:10:38]These are not terminal illnesses. their lives with uncertain trajectories.

[00:10:45]Yet utia requires certainty, a remedial suffering and in psychiatry that certainty is often an illusion.

[00:10:56]Moreover, vulnerability is not evenly distributed.

[00:11:00]In the Netherlands, women, young adults, and people with trauma histories, autism, intellectual disability, or personality disorders are over represented among those requesting and being granted psychiatric utia.

[00:11:16]These are often people whose agency has been eroded by life experiences.

[00:11:23]And to call this pure autonomy is clinically naive.

[00:11:29]As a psychiatrist, I'm trained to tolerate despair without endorsing it.

[00:11:34]To stay present and still say, "I don't know the answer yet, but I'm not done with you."

[00:11:43]That stance is not paternalism.

[00:11:46]It's fidelity.

[00:11:48]It's what kept Odysius alive until the voices had passed.

[00:11:55]Canada now stands at a similar narrow strait.

[00:11:59]If you extend euthanasia to psychiatric suffering, you will not simply add an option. You will reshape the moral landscape of care.

[00:12:10]You ask clinicians to decide not only when life can no longer be cured, but when it no longer should continue.

[00:12:20]That is a burden psychiatry was never designed to carry.

[00:12:24]I ask you to pause to listen not only to legal arguments but to clinical experience to those who have seen safeguards scratch criteria soften and procedural replace presence binding ourselves to the mast is not cruelty sometimes it's the most humane act we have >> thank you doc >> please do not ask psychiatrists and doctors to become the siren for people who need our compassion Care and protection. Thank you chair.

[00:12:55]>> Thank you Dr. Van Roy. Dr. Vanvine for 5 minutes.

[00:13:07]>> Still Dr. >> Thank you for inviting me. I'm Cisco Vanvine. I'm a psychiatrist from the Netherlands experienced in assessing psychiatric mate requests. As an empirical ethicist, I've been studying mate for psychiatric suffering for 10 years now and I'm currently the head of the end of life psychiatry research group at the Amsterdam University Medical Center. Also, I have a re research appointment at our national suicide prevention center and I'm the chair of the committee tasked by the Dutch Psychiatric Association with updating the clinical guidelines for psychiatric mate. I've been following the debate in Canada closely over the past years. But as a disclaimer, I would like to state that I've learned that when it comes to this topic, it's virtually impossible to maintain a detailed understanding of another country's legal, cultural, and ethical context because it's continuously shifting. So, for the remainder of my time, I'll focus on the Dutch situation and what universal lessons can be drawn from that. Major psychiatric suffering has been legal in the Netherlands for decades. first on the basis of juristprudence which was codified into law in 2002. Our first guideline for psychiatric maid stems from 1998 and describes uh a rigorous assessment procedure.

[00:14:23]However, in clinical practice, it remains extremely rare. Only zero to five cases were reported annually and it was barely a topic for patients and clinicians alike. This changed around 2010 when the possibility to request made for psychiatric suffering became more salient. A few years later, the expertise center euphania, the ECE, was formed, which quickly became the center where most patients with psychiatric m request were referred to.

[00:14:52]With this, the cases started to increase over the years with about 8% annually until 2024.

[00:15:00]This is of course significant uh raise but it's also important to mention that psychiatric mate to this day remains relatively rare at about 2% of all mate cases. The increase of cases eventually led to long waiting list at the ECE which in turn was reason for a small group of pro-made psychiatrists to seek publicity and call on their colleagues to perform psychiatric maids more often.

[00:15:25]In my view, this mainly caused a strong resistance among among Dutch mental health care professionals, which in turn was a fertile soil for a fierce and equally public counter reaction, deepening the polarization further. This dynamic has soured the debate and may have contributed to the 21% drop of psychiatric mate cases we have seen in 2025, which in itself of course cannot be seen as a bad thing. Together with different stakeholder groups, including the Dutch Psychiatric Association and the National Foundation of Patient Representatives, we are currently working on getting the discourse back on track in the Netherlands to a more nuanced and constructive conversation.

[00:16:05]This is important for for there are still many clinical and ethical challenges that require our continuous attention which I'm happy to discuss further if asked.

[00:16:16]Let me continue with my more universal moral view on psychiatric mate. Drawing on a decade of clinical and research experience, I've come to the following view. Although respecting autonomy is of course a fundamental justification for a mate, mercy is even more important.

[00:16:33]Because of this, I think it's hard to justify excluding patients with psychiatric disorders whose suffering can be immense or in other words, unbearable. I do think that made for terrible illness uh is fundamentally different from made for chronic suffering. Made for terminal illness is a way to prevent a terrible death. Made for chronic illness can be seen as a way to end a terrible life. Both situations require different due diligence approaches and I think your two track system reflects that better than our Dutch system which does not make this distinction. I also think that med should be accessible for people suffering from chronic illness because by definition death will not end uh a suffering that is not terminal.

[00:17:17]Although I see a lot of difference between chronic physical and psychiatric suffering. I do not think these differences are sufficient to justify a complete ban of psychiatric patients.

[00:17:29]Uncertainty about irdiability is a big challenge in almost all cases regarding psychiatric suffering, but it can also be an issue in some forms of chronic physical suffering. I would also argue that adopting a retrospective view on iriability is more suited for patients with psychiatric and chronic physical illness. This means that a physician isn't asked to judge whether a patient will never recover, but that the physician is asked to judge together with the patient that they have suffered enough.

[00:18:00]Finally, a short word on media dynamics.

[00:18:03]It is my experience that media and social media play a profound polarizing role in debates surrounding psychiatric mate. This worries me a great deal for large groups of both in both our countries. This is not a merely mere theoretical ethical problem. It's a debate with real life concerns of real people who are in vulnerable positions.

[00:18:25]These people deserve that we remain curious about each other's viewpoints and commit ourselves to a respectful, responsible and constructive debate.

[00:18:34]Thank you for your invitation to contribute to this conversation. I'm happy to answer all your questions.

[00:18:41]>> Thank you to all the um witnesses. It's now for the first round of questioning.

[00:18:46]Miss Jensen for five minutes.

[00:18:48]>> No, >> I think it's you first.

[00:18:50]>> Thought it was me.

[00:18:51]>> You first. Sorry.

[00:18:52]>> Mr. Cooper, you got this totally wrong.

[00:18:54]>> No, you got the second hour.

[00:18:56]>> Oh, that's the second hour. Okay.

[00:18:57]>> Thank you, Mr. Chair. I'll start with Dr. Van O. Uh, Professor Joselyn Downey from Dying with Dignity claimed at this committee that if there is a delay or indefinite pause on the expansion of made for mental illness that quote people will die by suicide, impliedly asserting that made for mental illness will reduce suicide rates. But empirical data doesn't demonstrate that, does it?

[00:19:31]Yes, you are correct. Uh at the population level, there's not uh a correlation or an inverse correlation between euthanasia and suicide rates in different countries with different levels of both these practices uh and also at the individual level.

[00:19:52]uh it is not it's not possible to say that euthanasia is necessary to prevent suicide because even in patients requesting euthanasia the rate of suicide is very low. Uh so that uh you would need uh to uh actually uh have you have a number needed to treat of 10 and a number needed to harm of nine. So meaning that 10 young people must undergo euthanasia to prevent one suicide and nine die without any preventive purpose being served. So in short, such an intervention would result in far more deaths than it could possibly save.

[00:20:36]>> Yes, that is correct. I have published this in the British Psychiatric Bulletin last month.

[00:20:42]>> Okay. And looking at the experience in the Netherlands, you noted that there has been a substantial increase in made cases where mental illness is the sole underlying condition in recent years. I I thought you had said there had been a uh fivefold increase. Is that right?

[00:21:00]>> Five-fold increase in those under 30 years of age. And uh since uh 2020 there's been a 200% rise in psychiatric euthanasia cases compared to a 40% rise in total euthanasia cases in the Netherlands.

[00:21:19]>> Okay. And a disproportionate number of those cases involve women. Do I have that right?

[00:21:27]>> Yes. This is seen in many countries. So uh there's uh women are far more likely to request euthanasia for psychiatric reasons than men.

[00:21:38]>> And uh now despite a growing number of made cases of a suicide rate among women particularly young women has gone up not down in the Netherlands. Correct.

[00:21:50]>> That's correct. Yes. There's a tendency for it to go up and not down.

[00:21:54]>> Okay. Thank you for that. Now moving on to Dr. Van Roy. You spoke about vulnerability not being evenly distributed that women, young adults and persons with trauma histories, autism and personality disorders are over represented among those who seek maid where mental illness is the sole underlying condition. Can you elaborate on the experience in benevolence with respect to vulnerable populations?

[00:22:23]Yes, thank you um honorable committee member for this uh very um important question. Um there have been some studies by our um u official u um bodies uh installed by the government uh who are uh keeping statistics of the people who um receive utasia solely on the basis of medical grounds and um a lot of patients um being granted utia they come from different from from certain groups as I mentioned the foremost women uh young women uh people with autism are on the rise. this very big population of autistic patients asking and being granted euthanasia in the Netherlands and also worrying what came from uh the the British research from um professor Tuffrey Wine in London she revealed that in many cases even intellectual disability is not an exclusion criterium anymore for receiving um utanasia and that's particularly worrying because when you read the um uh the statements the doctors gave to justify these um these these these utas they are quite worrying and professor Tury Winer who's of Dutch descent by the way she was quite shocked when she read those reports by the um body that does the uh supervision over the over the utavia.

[00:23:56]She said for example that uh a lot of patients they receive euthanasia not based on any medical condition or something but mainly on the basis of their social position of situations like demoralization or a lack of social uh integration in society.

[00:24:15]>> Thank thank you Dr. Roy. Um we've run out of time for that um round of questioning. Um next Mr. Fergus for five minutes.

[00:24:27]Thank you very much, chair. I appreciate this session. I'd like to be my questions to the witnesses. But before that, I'd like to ask you a question or to the committee clerk. I received earlier today a letter from the minister responsible for >> the minister responsible for health uh senior citizens and natural caregivers which was written to the minister's federal counterpart concluding that actually that Quebec is not in favor of broadening this issue. And to quote the letter, she says, "Finally, the difficulty of having the right diagnosis for mental disorders is a problem for many health care professionals and social professionals regarding the potential complexity of the relationship, the therapeutic relationship with their patient or patients if MEID is broadened to uh those with only mental disorders. And these are the concerns that were raised in the report. I just wanted to make sure that this letter will be part of the testimony that will be considered by the committee.

[00:25:50]Perhaps the analyst can answer.

[00:25:52]Thank you, chair. This is a letter that we received on Monday in French. It is going to be translated according to the rules of the committee and will be distributed afterwards to all the committee members and then it will be up to the committee members, the members of the special committee to decide how they will handle it. And that letter will be part of the testimony that we received or the documents that we may cite when we draft our report when we get into the drafting process for the report. Thank you, chair. It is a letter that was received in response to the motion by Miss Jensen that was passed where there was a request to produce documents and the letter answers that order response to that order and once again I would mention that the letter will be translated and if the committee deems appropriate to include it, it could be done. Thank you. Thank you very much. Thank you >> to our witnesses today. Uh I have a a couple of questions. Dr. Vanos, um you made some very strong statements. Uh one of them which was suic uh the situation which or the question which is before us is the equivalence of suicide carried out by psychiatrists.

[00:27:19]Um, I'm wondering if you could uh given your experience in the Netherlands, if you could please uh explain why you would consider that to be a fair comment to make or is it an exaggeration?

[00:27:34]>> Actually, uh, thank you very much for this question, honorable committee member. This is not a strong statement.

[00:27:39]This is in fact a a well-known framing of the problem that it is virtually impossible in clinical practice often to distinguish between the symptom suicide and the death with death wish expressed in the form of a usia request.

[00:28:00]And the International Association for Suicideology has attempted to come up with, you know, a a statement trying to guide clinicians to distinguish between a death wish as a symptom of mental illness and a death wish as a rational expression of euthanasia. And in clinical practice and also in in in theory it may exist, but in clinical practice this is very difficult to distinguish from each other. Therefore, uh what often happens is that uh individuals indeed suffer and express a death wish as a result of their mental suffering which results from a mental disorder and are granted euthanasia uh so that the doctor performs the suicide. And this is not a strong statement. This is in internationally accepted uh framing of of the question before us.

[00:28:58]I have very little time left. Dr. Roy, I I'll ask you this. Uh you had pointed out in a case in Netherlands which has had uh this available for coming on 30 years that you said that mental health services are not equally distributed and that would affect therefore um whether or not there is you can make the case for a remediality. Could you could you just talk a little further about that in the Dutch experience?

[00:29:27]Yeah, thank you for that question. It's a very important question. It's more a political question than a medical question in essence. Um what I witnessed the last 30 years is that especially the psychiatric care for the people most severely affected by mental suffering like the population I mentioned earlier the the people with autism, personality disorders, traumatic histories, the care for those patients has been selectivity selectively being um reduced in in the Netherlands and that's part of our healthcare system which is a commercial system. It's run by healthcare insurance companies and for healthcare insurance companies providing care for the most severely psychiatric ill patients is not very uh profitable. So this care in the Netherlands the last 10 years, 15 years has been reduced quite significantly and the patients I could treat 20 years ago quite um adequately quite effectively I see now they are perishing on long waiting lists and these waiting lists get longer and longer in the Netherlands and a lot of patients they come to me sometimes even their their parents or their their family members asking me well if this system can't provide provide proper care to my loved one. Um um I at least ask you as a doctor working in that system to be able to provide euthanasia to this uh uh person to this family member because you can't provide any care anymore and that's causing a lot of moral stress in Dutch psychiatrists as as you can understand and this has made quite an impact on a lot of psychiatrists I speak to on a daily basis who are very very reluctant and very wary about what's happening now in our country. We have to uh be quite clear that people die now who could be treated 10 20 years ago quite effectively. I've done it myself. So it's really it's a shame actually. It's a shame.

[00:31:39]>> Thank you.

[00:31:41]>> Thank you, >> Madame Deel Foy.

[00:31:47]F and you've joined us on the other side of the table this evening only for tonight.

[00:31:56]>> Very well. Thank you, chair.

[00:31:58]Allow me to make a comment.

[00:32:01]I appreciated the testimony of our guests, but I find it curious that we may hear psychiatrists from the Netherlands, but that we were not able to hear from and question the Canadian Association of Psychiatrists. and I'm not a permanent member, but I would like to say sincerely that I have hard time understanding that we're discussing with people from the Netherlands, but we're not able to question our own psychiatrists who have an opinion and I wonder about the responsibility of the chairs or the clerk given that we didn't hear from them and the study is ending this evening. Allow me to say chair that to me >> psychiatrists and psychiatrist associations So I don't know if you gave her the floor.

[00:32:52]>> You have the the floor still. So to me it's not because we're hearing from 10,000 psychiatrist. I said it's a reason not to hear from the Canadian Psychiatric Association. So to me I would sincerely say that I find it completely unacceptable. Now I would like to say that I believe profoundly in the right of the person to decide for himself or herself on the degree of suffering that they want to endure. And my question will be for Mr. Fain. We know that there are people who are in care who receive medication and who are forced to suffer throughout their entire life because psychiatry community support will not remove their suffering.

[00:33:38]And if this evening we were to decide to bring to an end this ability of people to request medical assistance and dying if they have a mental disorder, it would mean we're discriminating. We're placing some of the people who have rights, but we're judging that because there's no clinical consensus that they do not have the same rights as someone who has a chronic disease that is incurable or someone who makes an early uh request under a disease such as Alzheimer's. Chair, I find that unacceptable and from that viewpoint, I appreciated the testimony of Dr. Fonfane who said that he thinks or understood that it's not the best idea to remove the right because there are some people who have mental disorders who are entitled to decide for themselves and who have the decision-m ability that I understand correctly Dr. Vonfe that there are some people who are condemned now to suffer throughout their entire life and if what they can look forward to at the end of life is paliotative psychiatric care and it seems to me that in 2026 we have the duty to offer those people an option and that they're entitled to decide that they have suffered enough and to make the decision that concerns them. Do you agree Dr. on fain with my theory that there are people whom we will never be able to remove the suffering that they experience.

[00:35:09]>> Thank you for your comments and uh question. I I do agree that psychiatric maid should be available uh for a small group of patients. I do think there are differences between uh psychiatric and physical suffering but I do not think that they are um fundamental enough and that there's absolutely no overlap so that it uh would justify a total ban of psychiatric mate. I do think we need different due diligence criteria but I've seen some documents from Canada which which uh give me confidence that you are preparing for that.

[00:35:53]>> I'll give you an example Dr. Fonain the report of experts said for example that those under 30 would not be authorized to make the request. It's not because you make the request that you're eligible. So those under 30 in Quebec now th all those who have intellectual deficiency that is diagnosed do not have access to medical assistance and dying.

[00:36:15]So there are limits and criteria placed on them and I sincerely believe that we will never arrive at a consensus that all psychiatrists will agree on. But there's a matter here of maintaining a right of self-determination. And do you agree that the scientific community could agree on fairly restrictive criteria but be able to support a person for example schizophrenic after suffering for 25 years in treatment comes to a conclusion that they don't want to die in conditions of in the conditions that they deem completely inac unacceptable and that the person is entitled to make their own decision. Can we find a criterion or some criteria that would be used to enable a person like that to obtain what they wish?

[00:37:05]>> Um, yes, I think so. I think the criteria in the law uh in the Canadian and the Dutch law can apply to the the kind of patient that you described.

[00:37:16]Um, and I do think there's consensus.

[00:37:18]there's there's pretty much study uh um been performed which shows relatively high acceptance of psychiatric mates in the Netherlands but also abroad. Uh I do think also because of the polarized debate in the Netherlands that we have a silent majority which in essence um is supportive of a restrictive uh option of psychiatric mate. Um so yeah I I I agree with most of your statements. I would argue that mercy is more important than the right to self-determination in the current uh Dutch system.

[00:37:58]uh so self-determination autonomy is scored necessary but insufficient as a as a criterion and I and I think it's it's important especially in psychiatry and for psychiatric suffering to also maintain the criterion of irredability and unbearableness >> mercy madame defor >> next one is senator Don, you have the floor for three minutes.

[00:38:33]>> Thank you for the members of the panel.

[00:38:36]Uh my question would be for Dr. Vanvine.

[00:38:39]uh you were appointed I think in 2024 the chair of the uh of a committee which is by the Dutch Psychiatric Associations to revise the guideline applicable about the mental illness as the uh so where are you at in your review of the guidelines?

[00:39:02]We currently shifted from a total um renewal of the guidelines to a more gradual uh renewal of guidelines modular renewal. We recently finished uh re renewing the modules that were addressing second opinions uh in in there are two second opinions in the Dutch due diligence procedure and we've we've recently uh uh renewed them and we will uh publish them shortly. We've just started the next cycle which we will publish in the spring of 2027 addressing special patient groups uh for instance young patients or patients with autism and some other groups. So I understand that your s your your work is not to uh propose to deny access but to make more more stricter guidelines applicable to psychiatrist before they can agree to provide made to people suffering from mental illness.

[00:40:04]So, because we haven't published the guidelines yet, I'm I'm sorry. I cannot comment too much on the substance, but I don't think we're gonna I can say that I don't think we're going to make it more strict or more lenient. It's just uh uh uh different we we're making different actions in the due diligence procedures at different points of time where the goal always is to find balance between safety and accessibility. Is there an age which is going to be excluded for the youth like 25 or 30?

[00:40:37]>> This is currently under discussion. We we are currently uh examining that module and I cannot tell the outcome of that discussion.

[00:40:47]>> Thank you >> Senator Martin for three minutes.

[00:40:55]>> Thank you very much chair and good evening colleagues. Um thank you so much to the witnesses whom I know uh you it's very late for you so we really appreciate uh the expertise you are sharing. Um I know Dr. Van Van Vin commented about the importance of having made available to those suffering from mental illness that would be a small group but uh Dr. Dr. Van O um Dutch psychiatric euthanasia in your account in your account became normalized gradually and then it was accelerated so the numbers are uh more alarming now. So with the small group of activist physicians helping drive that shift. Can you um explain how that happened in practice and why should Canada take warning as to what could happen should we consider expanding maid?

[00:41:50]>> Yes, thank you very much for this question. So I think what you would like to happen in a country is that if there is a shift in practice uh particularly one like euthanasia um then you want that to be well reasoned and well prepared and safe and this is uh what happened in the Netherlands was that the law as it was formulated in 2002 uh you know was open to all sorts of use that I think wasn't initially uh you know seen as a possibility and what you will see with euthanasia is that you know there's always in individual clinicians they they differ wildly in what they think they see before them in terms of suffering iriability and futility and autonomy etc. uh and this is what we've seen in the Netherlands. If if there is a media campaign that will sway uh you know uh a group of physicians who really think that they are following their instincts of mercy and then expand their practice then society is is not able to keep up with that and to control and to deliberate and to assess what is happening. So I think what should be done in such a difficult issue where there's no consensus for the criteria it's not about being against euthanasia.

[00:43:25]It's about who can address this this fluctuating opinion surrounding these criteria. I think what should be done is for example that you have a transparent public body for oversight with representatives of of disability paliotative care psychiatry in your case indigenous and lived experience communities uh and and not just the activist providers and this is what was proposed in the Netherlands as well to have have a committee of of wise experienced uh individuals from all corners of society to actually do more oversight and uh lead the debate.

[00:44:07]>> Thank Thank you, Dr. >> This is what we haven't done. Yes. Thank you very much.

[00:44:11]>> Thank you. Um Senator Moody for three minutes.

[00:44:16]>> Thank you, Mr. Chair. Dr. Van, your current research focuses on the intersection between psychiatry and death. You study suicide prevention, assisted death for psychiatric suffering, advanced care planning by patients with a psychiatric disorder and psychiatric complaints in terminally ill patients.

[00:44:39]Based on your research that has studied suicide prevention, medically assisted death and psychiatric suffering. In your opinion, what is the relationship between suicide prevention and medically assisted death for people with mental health illnesses?

[00:44:59]Expert in this area.

[00:45:02]>> Thank you. Um so the the short answer is that it's very very complex the relationship between suicidality and uh psychiatric mate. Um even the language is complex. We we've we've seen suicide as something almost by definition as something pathological.

[00:45:25]But if you talk to patients, especially ones with persistent suicidality, what they are um um mostly saying is that they miss a good conversation about their death wish, about wanting to die.

[00:45:41]They don't want psychiatrists or other physicians to act on it immediately.

[00:45:46]both through coercive uh protection or uh in the form of mate. They want to have a connection and to talk about their death wish and and uh not to have it waved away immediately.

[00:46:01]Um I think it is irresponsible to call mate a form of suicide prevention.

[00:46:08]Um but in individual cases uh there have been cases where people have requested made and get denied or where there is a delay in the system and people end up uh uh dying through suicide but I do not think we will see that in the numbers.

[00:46:28]So >> can I ask another question >> framing may >> can I ask another question? Is it impossible to distinguish between a rational request for aid and the suicidality that may be present in someone with a mental disorder?

[00:46:42]I do not think that is impossible. I think it's complicated but I think we have clear clinical guidelines and we competence is a construct and we have good international agreed upon rules on how to establish competence. Uh so I don't see any reason why that should not be possible. uh for patients requesting mate and in clinical practice this is sometimes challenging but challenging but often uh something that we can do.

[00:47:13]>> Thank you.

[00:47:14]>> Thank you Senator Osler for three minutes.

[00:47:17]>> Mr. Chair, thank you to all the witnesses who are here today. Um and my question touches on uh the question Senator uh Moody just asked because um and and my question is for Dr. Vanvine um because this committee has heard from psychiatrists who have said it's impossible in clinical practice to distinguish between a rational request for maid and the suicidality that may be present in someone with a mental disorder. And so you answered it a bit with in your uh response to Senator Moody, but uh I'd be interested to hear more about how that differentiation is handled in the Netherlands, >> Dr. um in in clinical practice, you you every psychiatrist is trained to assess suicidality. Uh um that's also a continuously changing uh uh field where we are now recognizing the fact that we are really bad at predicting suicidality.

[00:48:28]Um but it's it's even more fundamental than that. I think that what we call suicidality um it matters and and there's there's not an agreed upon definition of suicidality internationally.

[00:48:44]It appears to me that in the Canadian context, suicidality is a synony synonymous for an irrational death wish.

[00:48:52]And if that is the case, if if that's the way we define suicidality, then it's it's it's possible to uh distinguish a rational death wish or a competent death wish from an incompetent death wish, which is the result of a psychiatric disorder.

[00:49:10]And we have guidelines to to do that. uh and and physicians all over the world are are able to do that.

[00:49:16]>> So so that was my question. Can you tell us a bit more about the the guidelines like how are the psychiatrists in the Netherlands differentiating?

[00:49:24]>> Sure. So you have the apple bomb and grizzle criteria which are well known and internationally recognized that that kind guide the competence assessment. Um they are really cognitive. So a patient has to be able to make a decision, explain their decision, uh um use all the um needed information and apply it to themselves.

[00:49:47]They are uh supplemented in the Netherlands in our made uh guidelines uh with an assessment of the congruence the emotional congruence of the decision.

[00:50:00]um uh and uh especially in the context of eating disorders uh we are asked to see if there aren't any pathological values involved in the decision making uh to choose death. So yeah that that's really in short how we do that but there yeah they're they're pretty extensive comprehensive guidelines how to do that.

[00:50:24]>> Thank you Senator Wells for three minutes.

[00:50:28]>> Great. Thank you. Um, a quick question for uh Dr. Vanvine. Have you had a a chance to look at the uh the Canadian psychiatric guidelines that were developed? And if so, do you have uh comment on those as an expert?

[00:50:42]>> Um, yeah, but there are a lot of guidelines, but I think uh if I've I've reviewed the the 20page one that was published last year based on the Deli study. Yeah, I think it's pretty uh comprehensive and it's pretty close to our Dutch guidelines. There are small differences uh but I think it's pretty faroh.

[00:51:05]>> Thank you. I appreciate that. My question now is for Dr. Vano. Uh in your commentary co-published today in the psychiatric times titled uh psychiatric in ethanasia in the Netherlands young people procedural medicine and the limits of psychiatry. You wrote about an increasing number of youth in the Netherlands that are seeking medical medical assistance and dying. However, you also say in the article that I quote rejection and withdraw with withdrawal rates remain substantial end quote which you got from the American National Library of Medicine's data that studied the request for medical assistance in dying by young Dutch people with psychiatric disorders. That same uh report concluded that although there is an increase of young persons seeking maid misumc that only I quote 3% of all applications uh by young people result in maid which is lower compared with the acceptance rate for maid PS amongst adults in the Netherlands with one in four applications was halted by the patient even before medical files had been assembled and of the files that continued to be accessed 60% were rejected. due to eligibility screening.

[00:52:14]So that was in your your article. Um so my question for you is this. Wouldn't this data that you've cited in this commentary released today suggest that the system developed in the Netherlands to protect against unlawful cases of made for mental illness as the sole underlying condition is actually working?

[00:52:35]Um, no, actually I I would not agree with that because of course 3% sounds like a small number, but it's a relative number. In fact, there's been an an an a growth uh you know uh of of of uh like uh 500% over five years in the number of young people uh getting made. So that may still be 3% in you know uh a pool that is ever increasing because what happens in the Netherlands to clarify we have 90,000 mostly young girls presenting at uh at the first aid departments of hospitals presenting with non-lethal uh suicidal attempts. And uh it is this pool that is more and more uh drawn to actually formulating their suffering in terms of a euthanasia request. So the euthanasia requests are actually increasing at at the at the GP in the psychiatric practice with the school counselor. So we see an enormous increase in requests and then the 3% of course maybe 3% but in the at you know there's a background of an increasing number of requests.

[00:53:57]>> We're running we're running out of time there. If you could actually send those those numbers if you have the peer-reviewed information making those comparisons they don't add up with uh the numbers that we see.

[00:54:08]>> Yes. So this is of course a big topic but but uh you know >> Thank you. We're at the end of our time.

[00:54:14]>> Yes. I'm sure. But you know, not every time the GP gets a euthanasia request, it's recorded somewhere in the Netherlands.

[00:54:20]>> Thank you, uh, Mr. Lton, for 3 minutes.

[00:54:23]>> Thank you very much, chair. I'd like to go with you as well, if I could, please.

[00:54:28]Dr. Ross, you were talking about in in your opening statement this idea of euthanasia as a last resort and the lack of any prescription in Canadian law to mandate that. Uh we had heard uh testimony from an advocate of the expansion earlier, Dr. Mona Gupta, who uh basically said very similar to what you were mentioning there that uh it would not be appropriate to expect a patient to have tried every treatment available to force them to try every treatment uh before going down this road. Just so I understand the situation in the Netherlands correctly. That is the expectation there.

[00:55:07]Um actually this is a complicated question but I'm glad you're asking him.

[00:55:12]Um the issue is that there are many treatments that can bring change in suffering mental suffering. These can be social interventions. These can be existential interventions recover uh uh offered by a recovery academy which is led by peer support workers. It can be a medical intervention uh and it can be a complimentary intervention for example. And the thing is that uh in fact what what we see what is offered to patients is mostly uh like ECT and medication uh and they're not given options to the social interventions that trey Wayne >> uh sorry there's a there's a technical glitch there but I'm I'm limited in my time. I I'll just move on to another section here if I could please. Doctor, uh, we heard on April 21st from Daphne Gilbert. Uh, she said clinicians agree that only a small number of people will ever meet the stringent eligibility criteria and rigorous safeguards if Canada proceeds with the expansion. Uh, we also heard from another witness, Claire Gamash, who said it is a very small number. based on your understanding of it, is there any reasonable uh conclusion that you could draw similar to what they have drawn rather from how Canada's laws are structured on this?

[00:56:40]Um yes, but the dynamics are a bit different. First, I think the problem is not so much how many people meet the criteria, it's that we can't agree on the criteria. Nobody can. That's the first problem. The second problem is that once you have a procedure in place that people can apply for, desperate people will come and ask for it and there will be unbearable suffering because it is so difficult to get the procedure. That's what we see in the Netherlands. A lot of the unbearable suffering in euthanasia procedures is caused by the fact that people think it is an option and then they become they become embedded and and tunnneled in that particular wish.

[00:57:28]>> Thank you um Dr. Van O Mr. Maloney for three minutes.

[00:57:34]Thank you uh chair and I want to thank all of the witnesses particularly given the time uh we've heard from a great number of witnesses with a diversity of opinions uh so your uh voice is very uh much appreciated Dr. Vanvine, I want to start with you, sir. You started by saying or at some point you said autonomy is fundamental. I agree with that. You then went on to say mercy is necessary. I think I got that right. Uh mercy is paramount.

[00:58:04]>> I think I the other way around >> case I agree with both. But then you went on to say that um when a doctor and a patient they have uh they can decide collectively that you've suffered enough on a mental health situation and access made. Did I get that part right?

[00:58:25]>> Yes.

[00:58:26]>> And is is that statement made um disregarding irredability?

[00:58:35]Um no in detail in the Dutch law u in shortand we call it irrediability but the Dutch law uh requires of us that the suffering that the doctor has to establish irrediability and the doctor and patient in shared in the process of shared decision-m have to establish that there are no reasonable other options. So uh shared decision making is uh part of our law.

[00:59:03]>> Okay. Okay. Would you agree with me that uh reaching that cons that consensus or reaching that conclusion of irrediability is based on subjective complaints made by the patient and the subjective analysis uh carried out by the doctor.

[00:59:22]>> So all complaints are subjective uh from the patient side. Uh and I think the >> Thank you doctor. I'm limited in time.

[00:59:31]So see that's the difference between uh mental health cases and terminal cancer as Dr. Van referred to because in the situation you're describing where you're you're some disregard not disregard but you're you're doing this on a subjective basis isn't that really what Dr. Van Oz was getting at when he said made for mental health is suicide assisted by a doctor.

[00:59:56]>> I I cannot comment on Dr. Venos's statements. Uh but the on the side of the doctor it's not subjective it's intersubjective. There are multiple doctors involved.

[01:00:10]Um >> but doctor it has to be subjective because there's no physical tests that I'm aware of that can determine that you have a permanent mental illness. You can't have a CAT scan. You can't have a any other type of test that'll show that.

[01:00:25]>> But there's also another >> effective to some extent.

[01:00:30]you have.

[01:00:30]>> Yes, you can.

[01:00:31]>> There's not a cat scan that can show uh the suffering from cancer for instance.

[01:00:36]So suffering is always subjective.

[01:00:39]>> No, no, but the cat scan shows you has cancer. A cat scan will not show you have a mental illness.

[01:00:43]>> Thank you. Um madame deoy two minutes. Thank you, chair. We'll continue the conversation. Dr. Van Bain I share your opinion on the fact that a person who comes to you who has suffered throughout a large part of their life and was not able to halt the suffering may themselves decide what they want to do in discussion with their doctor experts in Canada in the last report that we saw with the fairly stringent criteria it's almost impossible that someone who is under 30 can be eligible for made because they have to prove that they took medication that they had care and they took therapy and that it was from one failure to another that after a certain number of years of treatment that they it was unsuccessful and that the suffering remains present and that the person is entitled to make their own decision. Now I would like to come back to a subject from my colleague suffering is irreversible.

[01:01:53]If you're schizophrenic and you've followed therapy for 20 years and it gave no result and you suffer, it seems to me that the person is entitled based on a discussion with their physician that they evaluate the person with all the professionals that they're entitled as a patient, as an individual to decide whether or not you want to go ahead with your life in the quality that it exists in. And what I hear a lot from my colleagues or some of the colleagues at the table is that it's a kind of a paternalistic approach not to be able to trust in the decision-making ability of the person concerned. Wouldn't we better be better off to say that we can allow it but with a case-bycase basis because some might be entitled to it and if we don't listen then it's going to be a discrimination against the rights of a minority of people who could end their suffering that's been going on for years >> with not a lot of time to respond. In fact, no time but but I'll briefly give an opportunity for was it who was the po >> for whom was a question for Dr. Vonfe MP de Belf Dr. in that vein.

[01:03:13]>> Yeah, it was uh it was quite a a long statement. Um I I I largely agree. Uh I think and especially so we we're focusing a lot on young women, but if we look at the numbers, the most common uh uh people are people of middle age with depression. So maybe that's a good statement to make there. Thank you, Senator Delon, for two minutes.

[01:03:39]>> Thank you, Mr. Chair. Uh, Dr. Vanos, you said there was an increase of 60% over last year. So, you're referring to what you wrote in an article a few weeks ago.

[01:03:51]It was from 138 in 2023 to 219 in 2024. That's the number of 60%.

[01:04:01]>> Yes. That's the under 30s. Yes.

[01:04:04]>> Yes. Thank you. And and when you refer to the 500% increase, you go back to uh many years back to 2002, I guess, when they were about two or three people uh >> so that's that's the rise from 5 to 30 over 2020 to 2024.

[01:04:22]>> Okay.

[01:04:23]>> That's also the under 30s.

[01:04:25]>> And you refer also to u uh it well suicide. Uh I understand that in 2023 the last numbers we have is 138 cases of futonasia for psychiatric grounds and 1,900 suicide. So it still represent a small portion less than 7% of those that are dying because I understand in your country that's suicide and are part of the same subclass for statistics purpose.

[01:04:57]Well uh in in medicine we consider premature death as as a class because they are related. They're very strongly correlated. Euthanasia is one form of premature death. Accidents and suicide are in the same class and they are correlated. So uh what we see is that uh in the under30s uh euthanasia as a form of premature death is taking an increasingly large proportion of all premature deaths in youth under 30 years >> but it's still less than 10%.

[01:05:34]>> It's less than 10% but it's a lot. It's a lot, you know, for euthanasia to have that that kind of uh proportion.

[01:05:42]>> And the number of suicide is not increasing or decreasing. It's stable.

[01:05:46]>> It's it's increasing a little a little bit in in young people in the Netherlands.

[01:05:50]>> Thank Thank you, Senator. Um and the last two minutes for Senator Martin.

[01:05:57]>> Thank you. Um earlier Dr. Dr. Vanv was asked whether it's possible to distinguish suicidality from a rational request were made. But uh Dr. um Roy it is also then possible for a psychiatrist to you erroneously conclude that it's a rational request for made is it not is that possible?

[01:06:25]>> Thank you for the question. is definitely possible and from a lot of evidence coming up in the Netherlands in the public debate um a lot of pro-outinesia and pro-mate activists have shared a lot of information about patients who received euthanasia and concluding from that a lot of debate arose among Dutch psychiatrists whether the due uh diligence criteria were were observed and um in some case there's serious doubt definitely among psychiatrists. So there's no consensus at all.

[01:07:00]>> Yes. And if there is an error, I mean there's no recourse. The the person is already dead. So exactly >> Dr. Oz, uh very quickly, um >> suicide contagion is a concern. Uh we've heard from witnesses uh particularly in the indigenous communities in Canada. Is this a concern that is being discussed in the Netherlands?

[01:07:20]Yes, it is discussed but belatedly and uh we are now you know imploring the media to not report on euthanasia in a romanticized fashion like they used to with with pictures and and uh using terms like you know it was very courageous and it's beautiful and we let them go in love because we know those have a very strong contagious effect on young women who feel uh trapped or emotionally unstable to adopt a similar death wish in in the form of euthanasia request. Thank you, Senator Martin. And with that, we conclude um this panel and I would very much like to thank all of you from Holland for participating. We realize you've had to stay up late in the night. Um, but we do appreciate um, hearing your evidence and your experience from Holland and I'll take my um, prerogative as chair to also mention I very much like your soccer team um, given their history and their style of play. So I I wish you good luck in that too. Thank you. Good night.

[01:08:33]>> Thank you.

[01:08:34]>> Thank you very much.

[01:08:36]>> Thank you. Goodbye.