Bill C-14 (Historical)

An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying)

This enactment amends the Criminal Code to, among other things,
(a) create exemptions from the offences of culpable homicide, of aiding suicide and of administering a noxious thing, in order to permit medical practitioners and nurse practitioners to provide medical assistance in dying and to permit pharmacists and other persons to assist in the process;
(b) specify the eligibility criteria and the safeguards that must be respected before medical assistance in dying may be provided to a person;
(c) require that medical practitioners and nurse practitioners who receive requests for, and pharmacists who dispense substances in connection with the provision of, medical assist­ance in dying provide information for the purpose of permitting the monitoring of medical assistance in dying, and authorize the Minister of Health to make regulations respecting that information; and
(d) create new offences for failing to comply with the safeguards, for forging or destroying documents related to medical assistance in dying, for failing to provide the required information and for contravening the regulations.
This enactment also makes related amendments to other Acts to ensure that recourse to medical assistance in dying does not result in the loss of a pension under the Pension Act or benefits under the Canadian Forces Members and Veterans Re-establishment and Compensation Act. It amends the Corrections and Conditional Release Act to ensure that no investigation need be conducted under section 19 of that Act in the case of an inmate who receives medical assistance in dying.
This enactment provides for one or more independent reviews relating to requests by mature minors for medical assistance in dying, to advance requests and to requests where mental illness is the sole underlying medical condition.
Lastly, this enactment provides for a parliamentary review of its provisions and of the state of palliative care in Canada to commence at the start of the fifth year following the day on which it receives royal assent.

[Julia Beazley, Director, Public Policy, Evangelical Fellowship of Canada]

We are very concerned about the impact going down this road will have on suicide prevention efforts, on attitudes toward suicide, and on rates of suicide generally. In the long term, we believe this will impact the way Canadians understand suffering and the way they respond to it. We appreciate the statement in the preamble recognizing the lasting harm of suicide but feel the legislation needs to contain a stronger statement, acknowledging that suicide is a tragedy that hurts families and communities. We also ask that it be clearly stated in the preamble that the prevention of suicide remains a crucial public policy objective.

We would like to caution the committee against defining hastened death as health care. While this is not done explicitly in the bill, it is implied in the clauses in the preamble relating to the Canada Health Act and to the importance of a consistent national approach to health care. In nearly all public statements from the ministers it is clearly being framed as a form of health care or a medically essential service, as evidenced by the name “medical assistance in dying”.

First, we object to the notion that to deliberately hasten a person's death can be considered health care. Second, what the court allowed for and what the bill does is to create exemptions to Criminal Code prohibitions against culpable homicide and assisted suicide, which is solely federal jurisdiction and needs to remain there. To define this as health care is to relinquish that jurisdiction, and we urge caution on that point.

Further, if hastened death is defined as health care and accepted as such, it will become very difficult to deny access to anybody on any grounds. Such framing of the legislation sets it up for charter challenge.

We were relieved that Bill C-14 does not allow access to hastened death for individuals with mental illness or whose suffering is primarily psychological, but we note with concern that the preamble suggests that it is not so much a firm “no” as it is a “not yet”. We believe the risks to vulnerable Canadians are far too high to allow this. It should be an unequivocal “no”. To this end, in proposed paragraph 241.2(2)(c), we recommend that the words “or psychological” be deleted, so that the provision describes a condition that causes “enduring physical suffering that is intolerable” to the individual.

On the subject of reasonable foreseeability, we were advised by a lawyer that this concept comes from civil and criminal negligence laws. In the context of hastened death, a vague legal concept is not an appropriate criterion. Since under Bill C-14 it is doctors and nurse practitioners who will be the gatekeepers of eligibility, the criterion must be one that is medically understood and assessed. We suggest that “reasonably foreseeable” be replaced with either a specific time frame, such as six months, as in the state of Oregon, or “at the end of life”, as in Quebec. While there is still imprecision and guesswork in either of these concepts, they at least reflect the kind of assessment and judgment that medical professionals are accustomed to making, and therefore are much more appropriate.

We are very concerned that patients will be vulnerable to choosing hastened death if quality palliative care is not available to them as an option, so we affirm wholeheartedly the many calls you have heard for the importance of improved access. As Dr. Branigan said yesterday, we must make the right of access to palliative care as robust as the right of access to assisted death.

We recommend that proposed subsection 241.2(3) be amended to include a requirement that the medical or nurse practitioner ensure that the patient has had a palliative care or other professional consultation to ensure they have been fully informed about the range of available treatments and supports that could ease their suffering. We also affirm the recommendation of the Canadian Society of Palliative Care Physicians that the preamble include a commitment to the establishment of a national palliative care secretariat.

As an additional safeguard, Bill C-14 should require an independent prior review of all cases of hastened death. One way to do this, as you have heard, would be to extend the current requirement for judicial oversight as established by the court when the deadline was extended.

You have heard testimony about the efficiency of the consent and capacity boards in certain provinces. The key for us is this prior review of each case by more than just the two assessing physicians or nurse practitioners. Whether it is by extension of judicial oversight or some other mechanism, we strongly recommend that a straightforward, efficient system can and should be developed for independent prior review of all cases.

[Bruce Clemenger, President, Evangelical Fellowship of Canada]

We appreciate the opportunity to appear before you this evening.

The Evangelical Fellowship of Canada is a national association of evangelical Christians. We were intervenors in the Rodriguez and Carter cases and have appeared numerous times before parliamentary committees on related issues.

Our affiliates include over 40 denominations comprising 7,000 congregations. Pastors and church members regularly care for people in crisis and those who are nearing death. Some of our denominations have extended care facilities and hospices.

The issue before us is how we as a society respond to the suffering of others. We believe the appropriate response to suffering is care, comfort, and compassion, not the hastening of death. Our belief in and commitment to the sanctity of human life and our calling to care for vulnerable persons animate the care we provide.

It is on this basis that we oppose the decriminalization of assisted suicide and euthanasia, but as the government is proceeding with legislation, we are calling for protection of conscience and religious freedom, for the strictest possible safeguards in order to minimize harm and risk to vulnerable persons, to ensure that occurrences are rare, and to protect our society's commitment to the respect for life.

On the matter of freedom of conscience and religion, the minister, when she appeared on Monday, said that this legislation does not compel medical professionals to participate in MAID. While that is technically correct, the minister also said that MAID is now considered “medically necessary” treatment. This places conscientious-objecting persons and institutions at risk of coercion.

Actually, in looking at it today, someone pointed out to me that proposed subsection 227(4) creates an exemption to section 14, which appears to, at least, delete the caveat of “no person is entitled to”. That seems to create an entitlement “for”.

Our concern is that creating a right establishes a corresponding obligation. If you accept the premise that medical aid in dying is a right, you have an obligation to protect, we submit, the freedoms and rights of doctors and other medical professionals.

The College of Physicians and Surgeons of Ontario, as you've heard, has already decided that all doctors must make effective referrals regardless of conscientious objection. What will this government do to protect medical professionals from being coerced to participate in the killing of another? Even in times of war, conscientious objectors were exempted. Medical practitioners must have the right to refuse to participate in physician-hastened death, either directly or indirectly, for reasons of conscience or deeply held beliefs, including the right not to make a referral.

Also, there has been no commitment made to exempt objecting institutions, thus protecting their staff and the communities that provide care, which we feel is equally important. We recommend that protections be included by express statements in the preamble of the bill. We also strongly recommend that conscience protection be included in the legislation as a stand-alone provision in Bill C-14, or as an amendment to the Canada Health Act, or by creating a Criminal Code offence that prohibits coercion of patients, medical care providers, and institutions in relation to medically assisted dying.

Did you know that the Bank Act forbids a bank from coercing someone to obtain a product or service as a condition of receiving another service, or that it is an offence to coerce someone either to belong or to refuse to belong to an artistic group? We are talking about hastening the death of another in this context. How much more important is it to protect the conscience of medical professionals and institutions?

[Dr. Carolyn Pullen]

I will comment first on that. From the nursing association's standpoint, we are comfortable with Bill C-14 as it is currently drafted, with the recommendation that the trifecta of age, mental illness, and capacity assessment, or advance directive, be studied in an expedient manner and in a thorough manner in the coming days. As the legislation stands right now, we are satisfied with that content and the safeguards it includes.

[Prof. Dianne Pothier]

Thank you. I appreciate the opportunity to be here.

My expertise is in constitutional law, including charter law. So that's where I'm coming from. Given the limited time, I'm focusing on the constitutional validity of the definition of grievous and irremediable medical condition in proposed subsection 241.2(2).

I think it's important to get the point that in some ways it's as significant what the Supreme Court of Canada in Carter 2015 didn't say as much as what it did say. The Carter decision, in paragraph 95, refers to the protection of the rights of vulnerable peoples as the constitutional rights of vulnerable peoples, but they don't elaborate on that. That wasn't the nature of the claim before them. They acknowledged that there were constitutional rights of the vulnerable, which they didn't elaborate on in the decision, but that's part of the context of what you have to do in responding to the Carter decision.

In analyzing both section 7 and section 1 and acknowledging the protection of the vulnerable, the real challenge in this context is that the vulnerable are not going to self-identify when they appear in this process. The point of saying we're talking about the constitutional right of the vulnerable is that it's for people who are not well placed to identify and defend their own rights. They're going to present as people who want to die, and the issue is, is this a matter of being at a time of weakness and saying you want something, which, if you had the opportunity to reflect on, you would change your mind about, while if your current wish is acted upon you'll never have that opportunity because you're going to be dead.

The issue is complicated by rights that are in a sense competing, but they're competing in an unusual way, because we're talking about difficulties in identifying the people who need protection.

I want to focus particularly on the provisions of proposed paragraph 241.2(2)(b), which is the advanced decline section, and proposed paragraph 241.2(2)(d), the reasonable foreseeable death sections. The question is whether those two limitations are constitutionally valid.

Lots of folks, including those next to me at this table, have said that since those provisions weren't referred to by the Supreme Court of Canada and Carter, that means you can't do that. I'm afraid that's not a very strong analysis, because, again, it's what they didn't say in terms of comparing it to what they did say.

With regard to proposed subsection (241.2(2)(b) about advanced decline, before Justice Smith at trial, the Quebec legislation wasn't in force yet but the Quebec committee recommendation was before her and she picked up their language in terms of advanced decline and capability, and put it into her declaration of invalidity. The Supreme Court of Canada did not incorporate it. They didn't disagree with it; they didn't agree with it. They didn't even acknowledge that she said it.

So to say that by completely not commenting, not even acknowledging, this issue they somehow pronounced upon it is a very extreme interpretation of what the court is doing. It didn't comment at all and it's the language that's picked up in the Quebec legislation and it's picked up in Bill C-14. A reasonable interpretation of the Supreme Court of Canada not commenting is that they're handing it over to Parliament for Parliament to exercise its best judgment.

Similarly the issue of reasonable foreseeability of death is not referred to in Carter, but before Justice Smith, before the Supreme Court of Canada, they canvassed the North American history versus the European history. In some of the North American versions, they do have some sort of end-of-life limitation. European ones don't.

You might have thought they should say what is good and what is bad, and what are the pros and cons. They don't enter into that analysis. Therefore, it seems clear to me that they're saying they haven't preordained what should happen here, and they are sending it back to Parliament for you to decide whether an end-of-life stipulation of some sort is appropriate here. I think the first point is that the Supreme Court of Canada leaves this open.

If you need confirmation that this is what they're doing, they told us that in Carter 2016 at the time when they were granting the extension of the suspended declaration of invalidity. They made a point of saying that they expressed no opinion on the Quebec legislation. The Quebec legislation has both of the things in proposed subsections 241.2(2)(b) and (d). Proposed subsection 241.2(2)(d) is a slightly different version of it, but it's in the same ballpark in terms of being an end-of-life stipulation.

The court has handed it back to Parliament to decide, but the question still is, if you choose to put in proposed subsections 241.2(2)(b) and (d), is that consistent with section 7 of the charter? My analysis is that it is consistent for both of them. At trial, Canada argued before Justice Smith that if there's even one person who wrongfully ends up dead because of this, that's enough to warrant an absolute ban on physician-assisted death. Justice Smith said that's going way too far, both as a matter of the principles of fundamental justice and as a matter of the section 1 defence for the government. That's going way too far.

Neither Justice Smith nor the Supreme Court of Canada said that there's some magic number here, but they're clearly saying, on the assumption that with safeguards, the risk of error or abuse, of having people prematurely die who ultimately would have changed their minds if they'd had the opportunity.... But if the risk of that is low—

[Dr. Carolyn Pullen, Director, Policy, Advocacy and Strategy, Canadian Nurses Association]

Thank you for this opportunity to suggest amendments to the draft wording of Bill C-14 on behalf of the Canadian Nurses Association.

We are the national association for 139,000 registered nurses across Canada, including nurse practitioners. My name is Dr. Carolyn Pullen.

CNA welcomes the federal government's moderate approach to this challenging legislation, and we support the expeditious passing of this bill. CNA strongly endorses the stated intention to work with the provinces and territories on a pan-Canadian care pathway for end-of-life care, which has the potential to reconcile issues related to access and conscience. We are lending our support to harmonized implementation of MAID across jurisdictions by convening nursing stakeholders, including regulators and educators, to develop a national nursing framework to guide nurses in the implementation of MAID.

The CNA recommendations for amendments to Bill C-14 are based on our view that it will best serve patients and health care providers if the legislation can be clearly understood, is possible for professionals to demonstrate in practice, and is practical to implement in the best interests of the patient. In accordance with these principles, our written brief suggests three amendments to the language used in the draft bill.

Our suggested amendments would remove the criteria that refer to “incurable and reasonably foreseeable death”. We respectfully offer an expanded definition of “grievous and irremediable medical condition”, which we believe is in accordance with the Carter decision, which focused on intolerable suffering rather than on timelines for death. By making the amendments we suggest, section 241.2(2) could be deleted from the bill.

The current wording used in section 6(a) and (c) that address independence of practitioners is also problematic. As written, these clauses leave room for questions about business relationships between practitioners as well as factors that could affect the objectivity of practitioners. For instance, if practitioners have only referred patients to each other in the past, does that imply a business relationship? In small communities, does simply knowing each other imply a relationship that affects independent practice? Confusion about the meaning of these clauses, if left as is, could lead to delays in access to MAID, particularly in rural and remote settings, where the numbers of health care providers to draw on may be limited.

While fully supporting the need for these important safeguards, here the CNA suggests revising these clauses so that they can be more clearly understood, demonstrated in practice, and practical to implement in the best interests of the patient.

Thank you for the opportunity to deliver these prepared remarks and to contribute to this important process.

Second Reading

[Mel Arnold, Conservative, North Okanagan—Shuswap, BC]

Madam Speaker, I feel very fortunate to rise to speak to this issue today. Unfortunately, as you mentioned, I will not have the full time. I was hoping to speak fully on the issue, especially on behalf of the constituents who have continuously contacted me in my office with their concerns over the issue. I feel unfortunate for those members who have no ability to speak to the bill because of the closure that was forced upon us by the Liberal government.

An issue of this importance should not be forced through closure, as has been done today. This needs to be fully debated to the fullest extent. I am appalled at the other side for what it has done to us here. We need to fully consider all the implications of what is being presented in the bill. There are so many details missing in the definitions and in the possibilities down the road.

I want to relate a personal story here that expresses why I am so concerned about what is missing and why I want to ensure all the safeguards possible are put in place in the bill.

A few years ago, I had the honour and the burden of being the authorized representative for my mother in the final years of her life. Her health was gradually degrading through dementia and diabetes, to the point where it was getting difficult to have just a regular conversation with her. In fact, in the final few months it got to the point where she knew what a telephone was, but she did not know to answer it when it rang, or how to dial it anymore. Having done that for decades, she could no longer associate what to do with the telephone.

After three or four months of that, just before Christmas she became quite ill with the flu. We were not sure if she was going to be able to pull through or not. Whatever that illness did to her in her state of dementia, we are not sure. However, we were fortunate enough to visit with her on Boxing Day. We went in to see her. She had fully fluent and cohesive conversations with us. Not only that, earlier in the day she had picked up the telephone and phoned every one of my five siblings, dialing their phone numbers from memory. That was something she had not been able to do for months.

Right now, many people will look at dementia and some of these degenerative diseases as being incurable, but that day, that very short period of time proved to me that it is not always the case.

Therefore, when we are considering Bill C-14, every last one of us as members of Parliament really need to consider this because we are making a decision that is going to impact not just us in the House but the physicians and caregivers out there dealing with these patients, and with possibly many lives down the road.

I am appalled that we have closure on this today. I certainly hope that what goes to committee and what comes back does not open the floodgates to all the dangerous slippery slopes we see down the road.

[Maureen Klenk, Past President, Canadian Association of Advanced Practice Nurses]

My name is Maureen Klenk and I represent the Canadian Association of Advanced Practice Nurses. I am proud to be a nurse practitioner. I believe I may be the only nurse practitioner who will be presenting to you.

I would like to forward three concerns.

First, although Bill C-14 uses legal language, its primary purpose is to provide Canadians and health care providers with protection and accessibility for medical-assisted dying. Counselling is an everyday activity within every patient exchange. There will be much counselling between the time when a patient requests medical-assisted dying and the provider actually writing the prescription. Therefore, we believe the exemption for medical assistance in dying must include both clauses (a) and (b).

Second, an age restriction and requirement is discriminatory. A 16-year-old with a brain tumour will suffer as much as a 36-year-old, and their prognosis is the same. Yet, we do accept as lawful a 16-year-old signing a surgical consent for his two-year-old daughter.

Third, the terms serious and incurable are not medical terminology and provide the practitioner with no descriptive value.

Also, what is a natural death for a 60-year-old who has ALS? He's not going to die from natural causes. His death is going to occur from the horrible complications of ALS. When would a health care professional know that this 60-year-old's death was reasonable and foreseeable? We believe this is not a measurable term in any context.

CAAPN recommends the removal of clauses (a) and (d) from 241.2(2).

Thank you for the opportunity to contribute to this important process.

[Ahmed Hussen, Liberal, York South—Weston, ON]

This is for the Canadian Medical Association, either one of the representatives.

I'd like to know if you have any concerns with respect to Bill C-14 and whether patients will have difficulty accessing medical assistance in dying as it moves forward.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Madam Speaker, I want to note that after two and a half days of debate, I will be one of the last few speakers of the one-quarter parliamentarians who were actually allotted the opportunity to speak at second reading of Bill C-14. However, I do not want to waste my time raging against that particular issue, because we have an important debate in front of us.

I have watched with envy when some of my colleagues have been able to articulate a really clear position on the legislation, both for and against. Truly, it is going to be with no ease that I will make my vote tonight. It is a very difficult decision for many.

I want to start with a quick reflection on some of the facts about this case and really the two cases that were with the Supreme Court of Canada which ultimately ended up in very different results.

I have heard again and again that the public sees Sue Rodriguez and Gloria Taylor as remarkably similar in terms of the struggle they were having with ALS, which of course is a horrific degenerating neurological disease. Notwithstanding those very similar fact patterns, the 2015 Carter decision did not follow the 1993 precedent and, indeed, was really a completely contradictory position which struck down a 21-year-old law which declared physician-assisted suicide as an indictable offence.

It is an age-old argument that the court should interpret laws and not make them. I actually do acknowledge that the Charter of Rights and Freedoms requires interpretation by our courts, but I would also like to argue that once an interpretation is given, the offering of consistent rulings makes sense to the general public.

As societal views change on any particular issue, it is the responsibility of the legislative branch to adapt to changing public values.

I do want to reject the statements that many have made that Parliament was not willing to consider the issue. In 2010, there was a vote. I remember that my colleague Steven Fletcher spoke very eloquently. He had a private member's bill. I have no doubt we would have dealt with this issue again in this Parliament.

I also want to note that Quebec and many countries took a long time, six years, 10 years, to craft a piece of legislation to talk to their communities.

The Supreme Court of Canada's decision affects every Canadian, and every member of Parliament, I believe, had a responsibility to talk to their constituents in detail.

I did send a letter to every household in my riding right after the Supreme Court of Canada decision. This was consultation before the last election. Of the over 1,000 responses I received, approximately 70% recognized there were some cases where they believed that physician-assisted suicide might be important.

Then we had the actual legislation. I made a commitment and said that if anyone wanted to join me in a round table, I would give them every minute of the last constituency week.

As members can imagine, we had round table after round table, including round tables with physicians and seniors groups. They were powerful discussions. They were divisive discussions. People had very different perspectives, but I think there are three areas that they did agree upon.

Palliative care has to be improved. There is no question about that. I did some quick calculations. That $30 billion over four years, in terms of a home care budget in the health authority I represent, is actually a pittance in terms of their being able to change a palliative care system.

Again, everyone agreed that there is a slippery slope and that there is no confidence that we are not going to head down that slippery slope. As a result, two recommendations were made.

One recommendation was that two physicians may make a decision but a social worker and a psychologist should inform the physicians' decision, or alternatively, there should be a judicial review process. I think those were important considerations. They absolutely 100% believe that the protection of health conscience rights of our providers must be in federal legislation.

I will reflect on a few comments from those opposed and from those who were supportive, and then I will conclude.

People opposed to the legislation were not opposed to any technical pieces of the legislation but because they believed we were talking about murder, a profound diminishment of respect for life, and that vulnerable individuals would choose to end their life if they felt they were a burden.

I would like to quote a physician who sent me an email. He said, “I certainly have some concerns with the proposed legislation and would not feel comfortable in bringing about a patient's death. That is not why I went into medicine. I am actively involved in palliative care and believe this is a compassionate and crucial service to people near the end of their lives. Sometimes it's messy and life spills all over the floor. It seems to me that sometimes families want to avoid the challenge of lovingly caring for these individuals. Our society likes tidy, convenient outcomes. It seems to me that this is frequently the motive underlying assisted death. I would take great exception to legislation that would force me to refer someone on for assisted suicide against my conscience. I would certainly explain to the patient that there may be other physicians that would be willing to assist them and taking their life”.

That was from one of the very reputable physicians in the community that I represent. Again, in these round tables there were community members both in support and against the legislation.

We had an 80-year-old woman come to a session who wanted that option available to her. She did not have to worry about family and said that it was strictly something that she wanted for herself.

Another constituent, who joined us, talked about being with her stepdad and dad when they died. She talked about the very awful, tragic end that both of them had in spite of the best palliative care that was available. She expressed how awful it was.

I think she would have rejected the physician's characterization that she would choose that end because it was tidy or because she did not have the compassion. She was clearly willing to do whatever she needed to do to help her stepdad and dad, but felt that they needed better options.

Probably one of the most emotional conversations was when someone said, “I respect your opinion on this issue, and I know that you believe it is wrong, but can you please respect mine?” Again, that dialogue was happening where there was a request of respecting one's opinion.

The legislation needs some work and certainly the commitment around palliative care is very minimal. We must have protection for the conscience rights of our health providers in the legislation. As well, we really need to reflect on providing protection for the vulnerable who feel they are a burden.

I will support the legislation at second reading for three reasons. First, I believe that ultimately it will serve Canadians better than having a legal void. Second, indications are that a significant number, a majority, in my riding do support assisted suicide and euthanasia. Finally, everyone reflects personally, and if I ever had family members with ALS or another devastating disease who said that they wanted to lie on their bed, listen to their music, look at the mountains, rather than palliative sedation at the end of their time, and that's what they choose, how could I not support them in their request to escape intolerable pain and suffering?

[Dr. Jeff Blackmer]

I think it's important to recognize that although we are both medical organizations, we come at this bill with slightly different perspectives and slightly different filters in terms of the way we interpret some of this. I have had a chance to read Dr. Stern's comments.

What I would say is that there has been a lot of discussion around clause (d) and the issue of natural death becoming reasonably foreseeable. We see this as an immeasurable improvement over the alternative, which is to leave it at grievous and irremediable, which has no meaning to physicians whatsoever, and it would essentially leave anyone with any medical condition the ability to request assisted dying.

What the wording in Bill C-14 does is it allows us to understand how grievous this condition has to be. So we would say while it may not be perfect from a physician standpoint—and I've heard colleagues who have said it provides clear guidance, and I've heard colleagues who say I'm not quite sure how to interpret that—it's certainly much improved.

If the committee felt there was additional language that could be added to further improve that, to further clarify that for physicians, we would welcome that.

We also recognize, though, that in a piece of federal legislation you cannot capture all eventualities.

[Dr. Cindy Forbes]

I think that as long as there is a provision.... Our original document did suggest two weeks, but we also suggested that in the case where the prognosis was much graver, much shorter, there be some flexibility. I think Bill C-14 actually does provide that.

[Jenny Kwan, NDP, Vancouver East, BC]

Mr. Speaker, I am honoured to have the opportunity to speak to Bill C-14, An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying).

Let me first thank the members who were part of the Special Joint Committee on Physician-Assisted Dying for this bill and for their hard work. Their work showcased Parliament at its best, what it is capable of when parties put aside politics and the best interests of Canadians are at heart, and in particular when vulnerable Canadians are put at the forefront. I would also like to recognize the members of the Standing Committee on Justice and Human Rights, who are working diligently and endlessly on this issue.

Since the debate began, we have heard many moving and deeply personal stories. These are heartfelt sentiments, some that are so moving, as I listened to their stories it brought a lump to my throat. I thought about how wonderful it is that we have Canadian democracy in this very House, where every single member was supposed to have the opportunity to voice their opinion on this very important issue.

In my view, it is a shame that the government brought forward closure. I do think it is a shame. It was not necessary. I think we could have afforded every single member the opportunity to be heard and to offer their point of view on this important bill.

This bill before us today is one of great importance and significance to Canadians from all walks of life, from coast to coast to coast. Its subject is something that has touched countless Canadians, at least to a degree. Whether caring for an ill member of their family, providing support to a friend or colleague, caring for a loved one, or just contemplating their own wishes should they be in a situation where they are forced to deal with enduring and intolerable suffering, this is an issue that truly impacts all of us.

As this legislation is quite literally dealing with life and death, it is of the utmost importance that Parliament put the best legislation forward. The rights and self-determination of individuals must be supported while simultaneously ensuring that the most vulnerable people in society are protected from harm.

This balance must, and I believe can, be struck. There is no question that end-of-life decisions can be incredibly hard on families, whether the family member is dealing with a serious condition, or the surrounding families and loved ones are witnessing the pain and suffering of their loved one. For those doing the support work, it is deeply emotional and deeply personal.

Should a person ultimately determine that they would prefer to, as many call it, “die with dignity” on their own terms, the gravity of that decision itself is enough for a family and the individual to grapple with. Over the years, we have seen the struggles of families of individuals who are fighting for their right to die with dignity go through time-consuming and difficult court battles, from Sue Rodriguez to Ms. Kay Carter.

These individuals went through the court battle, not just for themselves, I believe, but for all Canadians who wish to have the right to choose to die with dignity. For that, I thank them and their families for their courage, and the courage they have shown to have their voices heard in perhaps the most trying and critical time in their lives.

While I have not been in a situation where one of my loved ones has had to endure this kind of pain, I have known people who have. At such a difficult time, one would think that the last thing these families would want to deal with is the additional stress and hardship imposed on them because Parliament did not have the courage to act.

Parliament has been given the task by the Supreme Court of Canada, based on the ruling known as the Carter decision. The court unanimously decided that Canadians who are suffering intolerably as a result of a “grievous and irremediable medical condition” have a charter-protected right to access medical assistance in dying. On June 6 of this year, a new law adhering to this decision needs to be in place or a legal vacuum will result.

The Special Joint Committee on Physician-Assisted Dying spent considerable time listening to expert testimony and brought forward 21 recommendations in a legislative response to the Carter decision.

The very first question that needs to be answered on Bill C-14 is this: Does this legislation comply with the Carter decision? The special joint committee heard from some advocates and experts who stated that the bill would fall short. This could result in more lengthy court challenges, and more importantly, individuals, families, and medical professionals left navigating incredibly difficult decisions while operating in a legal gray area. In my view, to allow this situation to occur would mean nothing less than a failure of Parliament.

Kay Carter, one of the two women involved in the Supreme Court of Canada case, suffered excruciating and debilitating pain which left her wheelchair-bound and unable to feed herself. Fully mentally and legally competent, and possessing a fierce independence, she sought the right to choose medical assistance in dying if her suffering became unbearable. However, her condition was not considered fatal, and because the final criteria in Bill C-14 for undergoing physician-assisted death is “natural death has become reasonably foreseeable”, many experts have noted that Kay Carter would have been denied access under Bill C-14.

Surely we must question how it could be if Bill C-14 was meant to address the Carter decision, that Kay Carter and others like her, who are legally competent and suffering from serious and incurable but non-fatal conditions, would not be granted that very right under this new law.

My question for the government is quite simple: What is behind the decision to use such different terminology than was used in the court ruling?

Bill C-14 is also silent on a practitioner's right to conscientious objection. Presumably this means the government is leaving it up to the provinces to work that out. Respectfully, the Supreme Court of Canada has tasked the federal government with crafting these laws. Leaving out something as important as practitioners having the right to conscientious objection and failing to meet the test of the Carter ruling, in my view, is a failure of Parliament to live up to its responsibility.

The special joint committee recommended that the government consider the topic of advance directives. While the court was silent on this as cognitive decline and therefore legal competence was not going to become an issue for the plaintiffs in the case, the Canadian public has been vocal about this. Experts appearing at committee stated that people dealing with these sorts of illnesses, such as Alzheimer's and other forms of dementia, will be left with no legal options.

My constituents of Vancouver East have brought this issue to my attention. A Vancouver East resident wrote, “Without the option to make advance requests for assisted dying, Canadians with dementia, or other degenerative illnesses that rob victims of their competence, will be effectively excluded from access.”

It is my belief that this completely goes against the spirit of the Supreme Court ruling on physician-assisted dying.

In going forward, I hope there will be changes to this legislation to bring it to the place where it is both Carter compliant and charter compliant.

I have no doubt that my colleague the member for Victoria will continue to work diligently and consult on this very matter with experts and people affected.

I would like to point out that while the bill in its preamble cites the importance of palliative care, I hope that the government will actually deliver on palliative care as well.

It should be all of our obligation to make sure that these choices are afforded to Canadians and that in their choices, they are supported with every effort to make that choice a reality.

[Dr. Catherine Ferrier, President, Physicians’ Alliance against Euthanasia]

Thank you very much.

I'm a physician and I have over 30 years' experience diagnosing, treating, and caring for frail older people, often suffering from Alzheimer's disease and other dementia. In addition to seeing patients in the clinic, I often visit their home as a geriatric consultant to a home care service.

My professional niche, as it were, includes capacity assessment, assessment in intervention for patients and families in crisis because of cognizant, psychiatric, and social problems. I regularly see abused and neglected patients, and I often testify in court for abused patients or for those whose families are fighting over powers of attorney or inheritance issues.

I'm also the President of the Physicians' Alliance Against Euthanasia, a group of doctors who see any law allowing doctors to intentionally end the life of their patients as contrary to the goals of medicine and the good of our patients, especially the most vulnerable and those who cannot speak for themselves. Founded in Quebec in 2012, the alliance now includes over 750 doctors, each of whom has signed our declaration and is supported by more than 14,000 citizens. We are, of course, aware that Bill C-14 will legalize medically assisted dying in some form, as is already the case in Quebec. While remaining completely opposed to these acts, we offer our suggestions for amendments to the bill in an attempt to protect patients' health care environment and the integrity of our profession.

We are somewhat relieved that there is a certain caution in the bill compared with the extreme recommendations of the special joint committee. We also note that the bill does not propose euthanasia and assisted suicide as medical acts or health care, as they are in Quebec. We agree that they are neither, so it cannot be required of our profession to perform them. The international medical community maintains to this day its opposition to these practices.

Since the vast majority of desires for death are caused by mental illness, which can and often does co-exist with the medical conditions that are considered to justify euthanasia or assisted suicide in the Carter decision and in this bill, we are called to exercise extreme caution. Such desires can also be caused by feelings of hopelessness, loneliness, fear, grief, shame, lack of access to support, insufficient palliative care, poverty, unemployment, violence, and abuse. These can also be addressed by health and social service professionals.

In this context my colleague, Mr. Racicot, talked about the fact that they are not charter rights. I argue that neither are they health care. We fail to understand the concerns about access to death that are being expressed in the public debate around this law. Elderly and chronically and terminally ill Canadians do not need access to death, they need access to care—medical treatment, home care, care by family members, residential care—all of which are seriously lacking.

You just heard some descriptions of sorely lacking care of elderly patients. I would argue that the alternative to that is not to kill them but to take better care of them, which we should be doing in Canada in 2016. To facilitate access to death while remaining unable to provide the care our citizens need is irresponsible, to say the least, and is unworthy of a progressive and prosperous country such as ours.

We appreciate the government's commitment to developing non-legislative measures that would support the improvement of a full range of options for end-of-life care, as is said in the preamble to this bill, but that would have to be implemented at truly high speed if we want the choice of life to be as available as death will be before long.

If you wish to show a true commitment to life for Canadians, this bill must contain protection for patients who are at risk of constraint to choose death. As it stands, it's certainly not as bad as it could have been if you had followed all of the committee recommendations, but the criteria are still ambiguous and open to subjective interpretation. This is inevitable to some extent, because it's impossible to define an eligibility criteria that would protect everybody, but we think you can do better.

The only way to ensure patient safety in a regime of legal euthanasia and assisted suicide is to require prior authorization of the death by a judge. In practice in medicine, we use courts all the time for committing patients who are dangerous to themselves or others to hospitals, to ordering that somebody be removed from their home if it's no longer safe.

It's something that's common. It can be done rapidly. It does not need to be a barrier, and the cases we've seen in recent months in other provinces have shown it happened relatively quickly. I think this should also be done after an evaluation of the patient and the patient's situation by health and social service professionals to explore the causes of suffering, as well as any inducements to choose death that could arise from non-medical conditions and circumstances, and that measures should be taken to address these sources of suffering before accepting a request for death.

This should not be seen as gatekeeping of access to death, but rather as promoting life wherever possible, which should be the goal of the law.

I have some brief comments on the criteria as currently written. The requirement that the request be made by a capable adult is essential, but most doctors lack the skills to assess decision-making capacity, and even experts disagree in complex cases. The terms “grievous and irremediable medical condition”, “advanced state of decline in capacity”, and “irreversible decline” are wide open to subjective interpretation and could be understood to include hundreds of thousands of Canadians with serious chronic illness who would be eligible for death under this criteria.

Enduring physical or psychological suffering that's intolerable, and that cannot be relieved under conditions the person considers acceptable, is entirely subjective and opens the door to anyone refusing effective treatment and demanding euthanasia instead. The requirement that natural death be reasonably foreseeable means nothing to us as physicians. Doctors are not able to accurately estimate life expectancy until the last days to maybe two weeks before death. Before that it's a guessing game. Call it “imminently dying”, and then we know what you're talking about.

To ensure a request for death is voluntary and without external pressure requires in-depth psychosocial and family assessment by a team of professionals well beyond medicine. Even then there may be no way of knowing that the patient is acting out of guilt or protecting an abuser. The written consent waiting time and requirement for a second doctor are not protections against abuse or coercion to request death. The first two can be waived, and patients or others can doctor-shop until they find two willing doctors.

There should be no opening even later to children or people with psychiatric illness. I wrote a separate brief in my own name, besides the brief of the physicians' alliance, that speaks to the dangers of euthanasia by advance directive that we can discuss in the question period if you choose.

My second point is about what is often called freedom of conscience, but is also about protecting health care services from becoming death-promoting environments and thereby protecting patients from those environments. I suggest you include in the law a prohibition against requiring any health professional to cause the death of a patient, or to refer a patient to another person to obtain their death—even through a third party, as is the case in Quebec—and against requiring any health care institution to euthanize patients under its care or to assist in a patient's suicide.

There's no justification for imposing any duty to implement this political decision, which is foreign to the medical profession, on medicine as a whole, or on any individual practitioner or institution. Attempts to do so are already being seen, both in Quebec and in Ontario, through requirements to refer. The federal law cannot just leave this question to the provinces. In Quebec, since December, doctors who are unwilling to euthanize patients must refer them to an administrative body that will ensure the death occurs. This does not protect the patient or the professional integrity of the physician. If I were a surgeon and a patient asked me for a procedure I thought was either not going to help them or would be too risky, I would refuse to do it, and I would also refuse to send the patient to someone else who would do it. They would, of course, be free to go and find a doctor of their choosing if they wanted to.

In palliative care in Quebec, one excellent palliative care physician has compared her daily life under this law to living in a war zone. You never know when a death request is going to land on you. You can't be giving hope to dying patients in one room and euthanizing them in the next.

Another doctor retired early the day the law came into effect for this reason. Highly skilled doctors and nurses who have given years and decades to the care of dying patients are suffering burnout, taking sick leave, and being driven from the field by confrontations over a supposed right to be killed, and by threats of losing funding if they insist on caring for people rather than killing them.

Patients are refusing treatment for their symptoms because of their fear of receiving the injection without having asked for it. Some patients who attempt suicide by overdose are not being resuscitated because the notion is being promoted that people who want to die should be helped to do so instead of being saved from their suicidal impulses. We need safe spaces for patients where inflicting death is not an option, and we need to respect the freedom of those health professionals for whom it is a violation of their fundamental principles and institutions whose basic philosophy rejects it.

Patients can be transferred to another professional or another institution, if necessary. This would not cause problems of so-called access, only inconvenience at times. If the professional or institution makes their position clear, the patient need not consult them. The protection of patients should always trump access to death.

In summary, at the very least we need prior authorization by a court after a careful evaluation of the situation, as I discussed. We need to create safe spaces for patients by respecting all individuals and institutions that refuse to collaborate with inflicting death.

Thank you.

[Ali Ehsassi, Liberal, Willowdale, ON]

Mr. Speaker, of course, the reason I said that is that I have had plenty of opportunities to speak to various constituents. What I can say is that after having spoken to many constituents, they understood the context within which the bill has been adopted. They appreciate full well that the Supreme Court considered this issue. They also understand full well that many consultations went on and that what resulted from those consultations was Bill C-14.

[Guy Lauzon, Conservative, Stormont—Dundas—South Glengarry, ON]

Mr. Speaker, the member mentioned that he was very confident that the majority of his constituents would support his position on Bill C-14. I actually sent a survey to every one of the 45,000 homes in my riding and got the opposite result. As a matter of fact, 65% of the respondents are opposed to Bill C-14 and 35% are in favour of it.

I wonder if he would be willing to do that in his riding just to confirm what he is stating in the House of Commons.