I call the meeting to order
Welcome to meeting No. 26 of the Special Joint Committee on Medical Assistance in Dying.
I'd like to welcome members of the committee, witnesses, and those watching this meeting on the web.
My name is Marc Garneau, and I am the House of Commons joint chair of this committee.
I am joined by the Honourable Yonah Martin, the Senate's joint chair.
Today we are continuing our statutory review of the provisions of the Criminal Code related to medical assistance in dying and their application.
I have a few administrative points to make. I'd like to remind members and witnesses to keep their microphones muted unless recognized by name by one of the joint chairs.
I will also remind you that all comments should be addressed through the joint chairs.
When speaking, please speak slowly and clearly for the benefit of the interpreters.
Interpretation services are available for people participating in the meeting both by videoconference and in person. People participating remotely have the choice, at the bottom of their screen, between floor, English and French.
With that, I would like to welcome our witnesses for panel one, who are here to discuss mature minors.
As individuals, we have present with us Dr. Dawn Davies, pediatric palliative care physician, and, appearing remotely, Cheryl Milne, executive director of the David Asper Centre for Constitutional Rights. As well, from The Hospital for Sick Children, we have Randi Zlotnik Shaul, director of the department of bioethics.
Thank you, all three of you, for joining us tonight.
We'll begin with opening remarks, followed by questions for the panellists. These are five-minute opening remarks, and I'd like to start with Dr. Davies.
Dr. Davies, if you're ready, you have five minutes for your opening remarks.
Thank you very much, and thank you for inviting me to this hearing.
In addition to being the director of the David Asper Centre, I am a practising lawyer. I have spent many years representing young people at the legal clinic, Justice for Children and Youth, including as an intervenor in the seminal case from the Supreme Court of Canada, A.C. v. Manitoba, so my background includes some knowledge in terms of how the law works with respect to medical decision-making for children.
The Supreme Court of Canada said that a mature young person should be able to make these kinds of decisions, even if the decision has grave consequences, if they have the capacity to do so.
For example, there is legislation across the country that varies in terms of how the young person can make these kinds of decisions. In legislation that articulates a best-interest standard, for example, which occurs in some provinces, that standard should be interpreted so that the choice of an independent minor capable of making decisions must be respected.
In addition to the Supreme Court of Canada, that decision was based upon the Charter of Rights and Freedoms, section 7.
The court also based the decision on the United Nations Convention on the Rights of the Child. The articles that are relevant are primarily article 12, which requires Canada to give due weight to a child's views in accordance with the age of maturity of the child, and article 5, which requires Canada to respect the responsibilities, rights and duties of parents to provide appropriate direction and guidance in the exercise of the child's rights in a manner that is consistent with the evolving capacities of the child.
There are also other articles that add complexity and nuance to those decisions. Article 2 deals with non-discrimination; article 6 is around the survival and development of the child, and article 24 is about access to health care and health services. These are all relevant when looking at the provision of MAID for young people under the age of 18.
In respect of safeguards, article 23 also requires the recognition that children with disabilities enjoy a full and decent life in conditions that ensure dignity, promote self-reliance and facilitate the child's active participation in the community.
One of my primary recommendations—and I think you've heard it before from other witnesses who have come before me—is the need to really address or listen to the voices of children and youth in these circumstances. I know other organizations have recommended something that's called a CRIA, a child rights impact assessment. A CRIA involves both consultation with experts, which we are doing this evening and which you have done up to this time, and also consultation with young people who are directly affected.
I won't go on. My speaking notes talk about different vulnerable groups that you need to specifically address.
I also want to say that in addition to talking to children and youth as a group and consulting with them, we have to remember that we can't really drag this out too long because, in the meantime, there are individual young people under the age of 18 who are potentially suffering and who are being denied this particular treatment so that their individual views and preferences are, right now, not necessarily being considered. While I think consultation with children and youth more generally is essential, we also need to think about the individual young people.
I'll leave it there, and hopefully I can answer more detailed questions for you.
Thank you, Mr. Chair. Thank you as well for the invitation to present to the Special Joint Committee on Medical Assistance in Dying.
In addition to being director of the department of bioethics at the Hospital for Sick Children in Toronto, I've worked as a pediatric bioethicist for more than 22 years. I am also an associate professor in the department of pediatrics at the University of Toronto.
With today's special panellists, I also had the honour of being a member of the Council of Canadian Academies MAID expert panel mature minors working group, and have collaborated with dedicated child and family-centred colleagues at SickKids and beyond, grappling with questions associated with MAID and mature minors.
A bioethics lens can be helpful when a decision has to be made and values at the heart of the decision may be pulling a decision-maker towards different choices. For such challenging issues in health care, the aim is to carefully and accountably consider all relevant information, relevant law, clinical evidence and ethics literature to make a decision that best reflects the values one considers most important, and to minimize resulting harms.
Through legal decisions from our country's highest courts and the checks and balances associated with enacting law, MAID is legal in Canada for those suffering from a grievous and irremediable medical condition, in an advanced state of irreversible decline, and experiencing enduring suffering where natural death is reasonably foreseeable and voluntarily requested by a capable person 18 or over, informed by the means available to relieve suffering.
From an ethics point of view, Canada’s framework for MAID is supported by considerations of beneficence and nonmaleficence, the duty to provide benefit and avoid harm, and respect for autonomy and justice. At this point, the question seems to be, is there anything about MAID that should require a different approach from that which already enables mature minors to make other health care decisions for themselves, even those that may not extend life? Here, examples may include a mature minor opting for palliative care or declining yet another round of chemotherapy where it holds out very little chance of success.
In thinking through these answers, one can want to respect the autonomy of mature minors while also wanting to be confident that appropriate safeguards are in place. The current framework for accessing MAID has safeguards built into it that would apply to mature minors if access were expanded.
For example, to be found capable of consenting to MAID, a person must be able to understand what MAID entails and appreciate the implications to themselves of consenting or refusing the procedure. The implications of capacity being decision specific is that the more complex a decision and the more serious the consequences, the higher the level of cognitive development and maturity needed to be found capable of making the decision. These requirements are built-in safeguards, ensuring that only those who meet all the stringent requirements necessary for MAID and have the sufficiently high cognitive ability and maturity would qualify for access.
I would add two additional recommendations.
The first would be increased access to palliative care, so that it is available to all in need as a possible alternative to MAID. That being said, my understanding from outstanding and experienced palliative care colleagues is that in rare cases, even what palliative care has to offer may not be enough to address irremediable suffering in a way that is acceptable to the patient.
Finally, while the report of the CCA was excellent, working group members acknowledged that there was insufficient analysis of the views of young people related to MAID to feel confident that the perspectives of those most impacted by expansion of access have been considered.
Missing are perspectives of youth with a range of relevant life experiences: indigenous youth, youth living with disabilities, youth in the child welfare system and youth living with terminal illnesses, as well as their families. In keeping with the previous testimony from Franco Carnevale and Mary Ellen Macdonald, respecting our responsibilities to young people would include studying their perspectives and bringing their voices into deliberations about expanded access.
Thank you for the opportunity to share these considerations. I would be happy to do my best to answer any additional questions.
Dr. Davies, I have only about two minutes left, so I'm going to load you up with a couple of questions.
First of all, do you have any thoughts on some supports that may be needed, or that we need to address, for indigenous, racialized or disabled youth? When I look at my riding out on Vancouver Island, I have a very high indigenous population. I know there are definitely some gaps in access to health care services there. Can you offer any thoughts on that?
Also, we heard that this should be brought in through a staged approach. It's probably preferable to start with track one, but this committee also has to grapple with how this issue of mature minors crosses over to our earlier discussion on mental disorders as a sole underlying medical condition. We heard from a number of people who say that even in adults it's hard to make a determination. We know with children how rapidly the brain develops. It goes through different stages.
If you could offer any expertise based on your personal experiences on that subject, that would be helpful, please.
Thank you very much, Chair.
Thank you so much to our witnesses. I think your thoughtful ideas here about addressing track one have been very helpful to the committee, so I thank you for that.
Currently the Canadian Association of MAID Assessors and Providers is developing a training program, which should soon be finished, on MAID assessment and provision. It will be certified by the Royal College, The College of Family Physicians of Canada and the Canadian Nurses Association.
Are you aware of that program and whether it addresses the issue of mature minors in its totality?
If you're not aware, or if it doesn't, do you think something like this should be developed for mature minors, perhaps under the auspices of the Royal College as well as the Canadian Paediatric Society, something so that we would have comfort that MAID assessors and MAID providers dealing with mature minors really are meeting a particular standard of professional competency?
That is for any one of the witnesses.
I just want to say thank you. I'm not sure who said it, but I think the most powerful statement today is that delay is not a neutral decision. That applies to the entire discussion we've been having, for years now, in this country.
What I hear in this conversation is that we're trying to deal with our own concerns. As legislators and as medical professionals, we want to make sure we're doing the right thing when this is really about mature minors, the child and the young person's capacity, and it's their call.
My question is about this process of hearing their voices. When the numbers are so small in the first place and we're talking about funding projects and going out and giving voice, I am just afraid this is another example of pushing this down the road when, in fact, delay is not neutral. We have some kind of agreement here on track 1.
I'll start with you, Dr. Davies. Does it concern you that we will just push this further down the road?
I welcome the second panel.
We have the issue of a vote at 8:30, with bells going off at 8:00. Is there unanimous consent for us to go for 20 minutes after the bells?
Some hon. members: Agreed.
The Joint Chair (Hon. Marc Garneau): Thank you. Very well.
We'll have to be very disciplined on the time.
With that, I'd like to make a few comments for the benefit of our new witnesses.
Before speaking, please wait until I recognize you by name.
I will remind you that all comments should be addressed through one of the joint chairs.
When speaking, please speak slowly and clearly for the benefit of the interpreters.
You have the choice of interpretation in this video conference. At the bottom of your screen there is a choice of either floor, English or French audio. There will certainly be questions in English and in French.
When you are not speaking, please keep your microphone on mute.
With that, I would like to welcome our witnesses for panel number two, who are here to discuss mature minors.
They are all appearing as individuals.
We have Caroline Marcoux.
We also have Professor Roderick McCormick with us.
We have Timothy Ehmann, who is a medical doctor and a child and adolescent psychiatrist.
All three are appearing by video conference.
Thank you to all of you for joining us.
We'll begin with your opening remarks, which should be limited to five minutes.
I'll ask Ms. Marcoux to start off, followed by Dr. McCormick and then Dr. Ehmann.
Ms. Marcoux, you have five minutes. Please go ahead.
Good evening, everyone.
My name is Caroline Marcoux. I am the mother of the gorgeous Charles, whom I have with me, right here.
On July 30, 2019, Charles received a diagnosis of osteosarcoma, a cancer of the bones, in his right femur. At that time, Charles was 15 years and nine months old.
Over the next year, he went through a whole series of chemotherapy treatments and had major surgery on his leg to remove the mass. Charles was always cheerful, optimistic and smiling, as you can see. He was an exemplary and very resilient patient during his illness.
A few months after the treatments ended, he was told the cancer had returned, in both his lungs. He had surgery on each of the two lungs to remove the metastases, but in spite of this, the disease came again immediately after, not just in both his lungs, but also in his knee. Once the cancer had recurred twice, we know that the disease was irremediable and nothing more could be done to halt it. That was in January 2021.
As always, Charles accepted what was happening to him. Psychologically, he still felt well, but his physical health started to decline, bit by bit. He had less and less energy, less and less appetite, and more and more pain. In fact, from January onward, he was having about one good day out of two.
Still, he proudly completed an important milestone in the life of a 17-year-old young man: he got his driver's licence. At that point he was missing one lung, because his left lung was full of liquid and there was nothing more to be done for it. His driver's licence meant that he was able to enjoy his autonomy about three or four times in the week that followed. That was all. After that, he was no longer in shape to leave the basement of the house.
Starting then, and even a little earlier, all the medical care, emergency services and drug dosages were handled by the palliative care team. The team did its best, within the limits of the options available to it, but was never able to completely relieve the pain. That is without mentioning the side effects: Charles was hot all the time and slept very badly. The drugs were not doing the job. He took Dilaudid, morphine, fentanyl, methadone—everything he could get to relieve the pain. The number of drugs he was taking kept going up, because the pain and the symptoms were constantly increasing. His lungs hurt, his shoulders hurt, and he had a distressing loose cough. His condition was not improving.
At the beginning of July, shortly after he got his driver's licence, he was barely getting out of the hospital bed that was brought to the basement for him anymore. Most of all, he was fed up: fed up with doing nothing, fed up with watching television, fed up with being sick and fed up with not having any quality of life. That was his situation. He started worrying about death. He wondered when death was going to come, whether he would be alone when it did and how it would happen. He was calm and collected by nature, but he started having anxiety attacks, anxiety and panic attacks, which showed how completely powerless and at the end of the rope he was.
In about mid-July he started talking about medical assistance in dying. He talked to me about it and he talked to the social worker and the doctor. He could not go on suffering and waiting for death any longer. We knew that the end was imminent; that was not the issue. He would have liked to have the choice and control over the time of his death. That would probably have reassured him. What he said was that he would have liked to have control over the disease, in at least that respect, because he had not had any control for the previous two years. He had never talked about death before that point. He had always been positive. When he made that request, he was already in the terminal phase. We knew that death was imminent, but he had to wait, because he was then 17 years and nine months old.
It is inhumane for a mother to hear her child say: "Mom, do something, I can't take any more." I accompanied him in it, in his suffering, to the end. I would have liked to do as he wished and do everything I could to calm his anxiety and his pain. All the doctors could do, again, was increase the medication. He was having trouble talking, because he was very medicated. He wasn't eating. At least, he was able to express his needs and tell us what he wanted.
The only possible solution, at that point, was palliative sedation. One day, he asked for it. He was completely fed up and just wanted to sleep and not be aware of his condition. So he went into the hospital pediatric ward, because that is what he wanted. He was put into a state of induced sleep. We watched over him for 24 long hours, and his sleep did not seem peaceful. Again, it was as if the drugs were not enough to calm him, any more than they had been enough to relieve his pain before. He did not seem to be comfortable. As a mother, I had to see him in that state, not being able to understand his needs, waiting for him to be completely unconscious. It took 24 long hours.
He died on July 30, 2021, exactly two years to the day after his diagnosis. So he was 17 years and nine months old.
I lost my boy, but I hold onto the two promises I made him. First, the promise to go on the trip of his dreams to England. And second, at the point when he asked for medical assistance in dying, I promised him that I was going to do everything I could to campaign, or at least to speak up as I am doing tonight, so that it would become accessible to young people like him would like to have it.
Charles was a very mature young teenager, even before his illness. He lived with his disease for the last two years of his life, with a serenity that gives me the strength to get through this period, through his loss. I cared for him until the end, and I would have done it as long as he needed. I didn't want to lose my boy, certainly, but I could not see him suffer any longer, nor could he suffer any longer. He had truly reached his physical and psychological limits. I would have cared for him to the end, but I hoped not to have to care for him when he had reached a stage when he had lost his dignity. I hoped not to have to change his diapers and see him grow thinner until he was a walking corpse. I would have gone there, but I hoped that it would not be the case. Fortunately, when he died, he still had his gorgeous chubby cheeks, so we were spared that, but he was truly at the end of his rope.
I know that the decision to expand access to medical assistance in dying to mature minors is not to be taken lightly, nor did Charles, from the height of his 17 years, at the end of his life, take it lightly. It might not have hastened his death by much, since he was already at the end of life. The date he would have set might have been a few days after July 30. But he was ready and he deserved that choice. It would have been his decision, in the end. It would have been he who chose the time to leave and the people who would be with him. That is the only choice, or at least the last choice he would have been able to make in his life.
My name is Dr. Rod McCormick. I'm Mohawk, or Kanien’kehá:ka. I'm also a professor and research chair in indigenous health at Thompson Rivers University. I live on my partner's first nations reserve of Tk’emlúps te Secwépemc, in Kamloops, B.C., and I'm the director of the indigenous research centre called All My Relations.
I'd like to thank the committee for the invitation to provide input once again on Bill . Previously, I testified on the implications of Bill C-7 for those suffering from mental illness. I'd like to extend those views as they pertain to MAID for mature minors.
The expansion of MAID is occurring at too rapid a pace, in my opinion. I've learned through painful experience that when you're on a slippery incline or hill, or in this case a slippery slope, the best way to avoid falling is to take small, careful steps.
As I'm an indigenous health professor and research chair who has also had approximately 35 years of experience as a mental health service provider for indigenous people, my testimony will be from an indigenous mental health perspective.
I should start by saying that I have grave concerns over the extension of MAID for minors, and I use the term “grave” in a purposeful manner. As my partner and kids are members of Tk’emlúps te Secwépemc and I live in their community, I experienced first-hand the impact of the announcement of the 215 children's graves on the grounds of the residential school. I can clearly see the residential school from the windows of my house and can make out a glimpse of the fields in which the 215 children were buried in shallow graves.
This attempt to conceal the bodies is, in a way, symbolic of the numerous historical attempts by Canada to deal with what Duncan Campbell Scott referred to as the need to “get rid of the Indian problem”. Those attempts, as many of you probably know, consisted of forced starvation, forced sterilization, forced relocation to reserves with unsafe, unhealthy and crowded housing, the introduction of liquor, smallpox blankets, forced residential schooling, experimentation with malnutrition in residential schools, ignoring the contagion of tuberculosis in the residential schools, the ongoing child welfare seizure of children and the excessive imprisonment of indigenous peoples in the penal system. The list goes on.
What I'm saying is that because of the multiple ways Canada has utilized to eliminate indigenous peoples and culture, we are overrepresented at every stage of the health care system, including that of premature deaths. This may all seem overly dramatic to you, but do we really need yet another path to death?
My cynicism is partially based on decades of working with indigenous youth to help them attain and maintain a good and healthy life. As I mentioned in my previous testimony, I've worked with many indigenous youth in emotional pain who were able to recover from being suicidal. The common reflection they had upon recovery was one of relief that they did not choose a permanent solution to what proved to be a temporary problem. Getting the proper and timely help is key to survival.
There are many barriers to obtaining that help. Among them are a lack of accurate diagnoses and corresponding treatments, a racist health care system, a mistrust of a health care system that doesn't always have our best interests in mind, jurisdictional ambiguity and the abdication of responsibility by various governments. The big factor is the remoteness of our communities.
Living on reserve and/or in a remote location often means that health services are provided by nurses or nurse practitioners, who are often overworked and ill prepared to provide the range of services that are required. This is especially the case in the near total absence of palliative care services for indigenous children and youth.
In preparing this statement, I scoured the Internet looking for evidence showing that mental illness can be predicted to be irremediable, and I couldn't find any. Shouldn't public policy as important as this be informed by evidence?
Some argue that we'll be discriminating against minors and those with mental anguish if they are not allowed access to MAID. However, without evidence, are we not also discriminating against those very groups in another way?
Currently, I believe the law provides the option for the minor to self-assess as to whether various methods of treatment are appropriate for them, and to refuse such treatment they deem inappropriate. From my clinical experience, most youth are not aware of the diverse treatment options they have, nor do they have an accurate understanding of them. Granted, for indigenous youth, those options might not even be available to them in their communities, but shouldn't equal health care in Canada be available to all Canadians?
Can teenagers whose brains are still developing make such important decisions?
Although I obviously cannot speak for all indigenous peoples, the pattern I am seeing with the introduction and expansion of this legislation is that of an abdication of responsibility by the Government of Canada and, by extension, by the citizens of Canada.
Instead of making every effort to provide the range of mental health services needed by indigenous youth to overcome their pain, we are instead imposing upon them the burden of deciding whether they should choose a government-sanctioned, permanent solution to what could easily be a temporary problem. That is where mainstream Canadian cultural values fail us all. The emphasis on individual rights and individual freedom is not balanced with the need for collective responsibility.
In closing, I would like to read you a statement by the existential psychiatrist, Dr. Viktor Frankl.
Freedom, however, is not the last word. Freedom is only part of the story and half of the truth. Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. In fact, freedom is in danger of degenerating into mere arbitrariness unless it is lived in terms of responsibleness.
I urge this committee to advocate for the Government of Canada and the provinces to accept their collective responsibility to not expand MAID to minors but to instead improve the mental health services available to indigenous youth and all the youth of Canada.
Nia:wen. Thank you.
Thank you for the invitation to stand before this committee.
My name is Dr. Timothy Ehmann, and I have been practising child and adolescent psychiatry for 10 years in a variety of in-patient, outpatient, academic and community settings.
I would like to begin my testimony by stating categorically that to extend the current MAID regime to minors—mature or otherwise—is negligent and irresponsible.
This debate began shortly after I began practice and has been like a dark cloud looming over my early career. I have followed as the Government of Canada has forged ahead despite many warnings to desist. I am adding my voice to say that it would be wise for the government to proceed no further down this dark path.
The proposition that death is a legitimate treatment for any form of suffering is false.
The proposition that the physician community can reliably assess the competence and capacity of minors to consent to death is false. It is not supported by any available research on the subject. Any physician who peddles this message is doing little more than saying, “Trust me; I'm a doctor.”
There does not exist any standardized, reliable and valid assessment for determining the capacity and competence of minors. Research has demonstrated that unaided competence judgments, even from seasoned and otherwise skilled physicians, are unreliable. In a routine medical practice, children are oftentimes incompletely informed, and the communication between an adult physician and child is oftentimes flawed.
There are many systemic influences on a child's decision-making. No decision is made free from influence. This raises the important question of how to evaluate precisely how free the child is in any decision. One new systemic influence just might be the cultural shift that the Government of Canada is propagating, which is moving our society increasingly towards a culture of despair.
The government messaging that it will offer death as a solution to life's suffering is suicide inducement. We are well aware of the phenomenon of suicide clustering in youth, such as on reserves, and that messages of despair increase suicide rates.
It is a difficult time to be a child in Canada.
MAID is not an evidence-based medical practice. As such, compelling physicians to adopt this practice through law sullies and undermines the integrity of the medical profession. Canadian physicians have been trained to practice modern, evidence-based medicine directed by scientific fact, not postmodern, ideologically-based medicine directed by political authorities.
MAID is an experimental practice without pre-existing safety data, adverse outcomes reporting, or adequate safeguards and accountability. The Government of Canada needs to hold itself to the same level of accountability and standard as it would hold any pharmaceutical company before a new drug or treatment is introduced to the Canadian population. We do not subject children to high-risk experiments.
Minors are a categorically vulnerable population. Postmodern philosophies that postulate that to exclude vulnerable populations from their right to death is to discriminate against them are shallow and dangerous. Legislation that is undergirded by these philosophies is a risk to our children.
The Canadian government and its representatives are conducting themselves paternalistically with regard to the MAID regime.
Organizations representing disadvantaged and vulnerable groups within our society that have presented evidence to this committee have been disregarded. These representative groups have asked for either safeguards or exclusion from eligibility for MAID for their communities and been denied such. The Government of Canada has effectively communicated to these groups that the government knows better what is in their interests than these vulnerable populations themselves do.
In modern society, with modern medicine and scientific advances, the need to kill a child does not exist. Why then the Canadian government's headlong rush to open up the MAID regime to minors?
I'm a child and adolescent psychiatrist. Let me share a story with you.
I had a 17-year-old adolescent whom I cared for back in 2018. Her mother had died when she was seven. For the next three years she was sexually assaulted repeatedly by a family member. Between the ages of 10 and 12 she immigrated to Canada. In Canada, after a handful of years, at the age of 15 she was kicked out by her father. She lived independently, went to school full-time, and worked in fast food for pretty much 40 hours a week.
I met her in the emergency department. She was suicidal. I admitted her to hospital. I was the first person that she shared the sexual abuse with. After sharing that with me, she fell apart. She had full-blown PTSD and depression. I sat with that child, day in and day out, with her sobbing, asking, “Dr. Ehmann, let me die. Let me go home. I want to die.” It was the worst psychological suffering I've ever witnessed. It affected me profoundly, personally. She spent six months on our in-patient unit, in and out.
I can tell you, I wondered about that question of what is the right thing to do. At the end of the day, however, when they are faced with their patients who are suffering from a medical condition, a mental health condition or from life circumstances, the physician's rule is always to protect and preserve life—and I am committed to that.
I don't know how she's doing now. I know that she made it through those hospitalizations and recovered, in part because of the service that we provided in the hospital. Because she was there for six months, my colleagues were all involved with it as well.
I should also clarify that I'm not opposed to MAID in track one, in particular for adults. The death of my sister-in-law actually was inevitable and the cancer had spread to her throat, so she was at risk of choking to death when she received MAID.
I am opposed to it for mental illness and for minors, particularly for mental illness.
What we could be doing, first of all, is talking to youth. In talking to indigenous youth without consulting with us properly, there will be legal cases I'm sure, because that is a right under UNDRIP.
But let's spend some money on mental health. This is the poor cousin of the health field. We don't spend money on it. Provide accessible diagnosis and treatment centres and mental health navigators; get rid of the jurisdictional game; fund Jordan's principle properly, provide life skills training to youth on how to problem solve and how to express emotions; provide services that others get, like palliative care, provide training and support to frontline workers, develop peer support programs for youth.
I could go on and on. There is so much that needs to be done, and we don't do it. Everything is at the “postvention” stage, not at the prevention stage. It's a crisis-oriented health care system for indigenous people.