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.

Criminal Code

[Judy Sgro, Liberal, Humber River—Black Creek, ON]

Madam Speaker, they might be in a pitiful state. However, that does not mean that one would end their lives because they are in a pitiful state. In our eyes, there are a lot of people who are in a pitiful state when we look at them. However, nobody says that they necessarily want to end their lives. We may not like to see them suffering and reduced to a pitiful state, as the member called it, but they do not necessarily see that. Therefore, what we are trying to do is find that balance.

I hate the idea that anyone would be in such pain that they would ask to have his or her life ended. I would like to make that person as comfortable as possible and help him or her in every way we humanly can. I do not want to see a whole lot of people saying that their lives are miserable and that they want to end them. There are a bunch of conditions in Bill C-14. They would have to get two opinions. There is a whole list of things. Therefore, it would not be done casually. However, it is all in the eye of the beholder.

I do not want to make this easy, and I do not think Bill C-14 does that. It is trying find a balance that is fair for people to be able to make a decision if they are in a horrific situation. My seatmate may be in that situation.

What would the member say if he was asked and the person fit the conditions? I am not sure.

[Cara Zwibel, Director, Fundamental Freedoms Program, Canadian Civil Liberties Association]

Thank you.

Mr. Chair, members of the committee, on behalf of the Canadian Civil Liberties Association I want to thank the committee for the invitation to make submissions on Bill C-14.

The CCLA fights for the civil liberties, human rights, and democratic freedoms of all people across Canada. Founded in 1964, we are an independent, national, non-governmental organization working in the courts, before legislative committees, in the classrooms, and in the streets, protecting the rights and freedoms cherished by Canadians and enshrined in our Constitution. CCLA's major objectives include the promotion and legal protection of individual freedom and dignity, and for the past 51 years we have worked to advance these goals.

Like many of the groups and individuals you may be hearing from, the CCLA was an intervenor in the Carter case. We argued in that case that the absolute prohibition on medically assisted death was a violation of section 7 of the charter that could not be upheld. The Supreme Court's decision clearly affirmed that this is the case and recognized that to deny assistance to individuals who were suffering from grievous and irremediable medical conditions violates their most basic rights.

The government's decision to table Bill C-14 recognizes the need for national legislation on this issue, and to a certain extent, some of the provisions in the bill are in our view in line with the court's decision.

We have concerns about some aspects of the bill, and in our view it suffers from at least one significant and fatal flaw. That is where I will begin to focus my submissions.

The bill defines who is eligible for medical assistance in dying by requiring a “grievous and irremediable medical condition”, and that language is in keeping with the court's language in Carter. But the bill goes on to define the criteria required for establishing that condition by stating that the individual's

natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.

In our view, this requirement is not in keeping with the language or spirit of the court's decision in Carter. The focus of the ruling was on suffering and quality of life, not quantity. The reasonable foreseeability requirement will cause confusion, is unnecessary, and in our view should be removed. It's a clear departure from the court's decision and one that needs to be acknowledged and addressed by this committee.

The language of reasonable foreseeability is vague in the context of life and death: the death of every human being is reasonably foreseeable. Presumably this requirement connotes some proximity to a natural death, yet it's very unclear how this will be interpreted or assessed.

Adding to the confusion, the government has released background documents and the minister has made speeches suggesting that this requirement should not be a barrier for individuals such as Kay Carter, who suffered from spinal stenosis and was one of the people at the centre of the Carter case. Those explanations and justifications in our view do not sit comfortably with the bill's actual language.

If the government doesn't intend to create a barrier here, Parliament should amend the legislation accordingly. We have included a specific recommendation on this point in our written brief.

In particular, we propose that proposed subsection 241.2 (2) of the Criminal Code be amended to delete its paragraph (d) so that its remaining paragraphs would form the exclusive criteria for establishing a grievous and irremediable medical condition. We've included some language that we think should be added for greater certainty.

The second point I want to briefly address is the bill's exclusion of mature minors and its failure to allow for advance requests.

While the government's introduction of the bill was accompanied by a commitment to engage in further study on these issues, we are concerned that this further study will mean delays and suffering for individuals.

As I think we all know, the assisted dying issue is a controversial one. Parliament has in the past been unwilling to address the issue without the impetus of a judicial ruling. The fact that the Supreme Court's decision in Carter does not squarely address mature minors or advance directives does not in our view diminish the government's or Parliament's obligations to respect charter rights or to guard against needless suffering.

In CCLA's view there is no principled reason to distinguish between mature minors and competent adults, since the definition of a mature minor is someone who has been assessed to be capable of making a particular treatment decision. Amendments, in our view, should be made to allow for advance requests for medical assistance in dying where an individual is otherwise eligible. We see no principle basis to exclude an advance request when such requests are already permitted to allow an individual to consent to termination of life-sustaining treatment.

The third point I want to address is a smaller one, and it relates to one of the safeguards that's included in the bill, which dictates that a person's request for medial assistance in dying is signed before two independent witnesses. The bill goes on to exclude certain individuals from acting as independent witnesses. To be clear, CCLA doesn't object to this kind of safeguard in principle, but looking at the language of the safeguard, and who is excluded from acting as an independent witness, we are concerned it may be difficult to find individuals to fulfill that function. I am not sure how Parliament can best address this issue. It might be included in terms of a regulation-making power for the Minister of Health to address the permission of witnesses. We appreciate there are division of power issues here, but I did want to bring that issue to the committee's attention. In our view, failing to address it could pose a practical barrier for the effective implementation of this legislation.

Finally, I'd like to address a question in terms of the process before this committee. Witnesses invited to submit briefs to this committee were given very little notice and advised to keep written submissions brief. I appreciate your sitting tonight for a marathon meeting, and that a number of the meetings over the next few days are quite lengthy, but the committee is only spending four consecutive days on this important issue. The limits that are placed on the scope of submissions being made and the truncated timeline for consideration of the bill is cause for concern. We appreciate there was significant work done by the federal external panel, and by the interprovincial advisory group, and the special joint committee of the issue of physician-assisted dying, but the reality is this committee is the first opportunity anyone has had to look at a piece of legislation, and consider it, and make submissions in relation to it. This is an issue on which every Canadian is a stakeholder, and a more robust process for considering the legislation is warranted. We say this because the CCLA believes that the fact the declaration of invalidity will take effect in early June creates a legal vacuum.

The Minister of Justice, in introducing this bill, has said the bill falls within the parameters of the Carter decision, but that if no federal legislation is in place on June 6, it's the parameters of that decision that will govern. While we do believe national legislation on the issue is important and beneficial for a number of reasons, this doesn't mean we should rush to enact a law that hasn't been sufficiently considered through a meaningful democratic process.

Thank you.

[Judy Sgro, Liberal, Humber River—Black Creek, ON]

Madam Speaker, I cannot say I am pleased to join this discussion, because I think it is an issue that is very difficult for all of us as parliamentarians, as Canadians, to deal with these very sensitive issues. However, I do want to begin by thanking the constituents of Humber River—Black Creek. Many took the time to call or to write my office on the issue, or come by to see me, many in tears, talking and relating to episodes within their own family and their worries about what Bill C-14 would actually mean. As always, I appreciate my constituents' thoughts and the fact that they have taken an active role in what happens here because they understand that the debate here is going to impact on many of their lives.

As might be expected, the issue of medical assistance in dying is one that is difficult for many. The question is deeply personal, emotional, and even spiritual, and I understand and appreciate the concerns and challenges many have with the subject matter before us.

I, too, have struggled with these decisions, as have others. For example, I was deeply concerned when I was first confronted with the report of the Special Joint Committee on Physician-Assisted Dying. In particular, one of the areas I was concerned about was the idea that minors might be able to obtain medical assistance in dying. I was also concerned with the notion that doctors who, for legitimate issues of faith or conscience, oppose medical assistance in dying might be forced to participate in this process contrary to their personal beliefs. Both of these things would have made the bill clearly unacceptable to me.

Fortunately, Bill C-14 attempts to address these issues by seeking to find a balance in this legislation, the best approach to ensure that dying patients who are suffering unbearable pain have the choice of a peaceful death and that the vulnerable are protected. I still question whether we have done the very best job we could do. I know the committee worked very hard at this and spent many hours listening to people. I guess I am still looking to see if we can make it better. However, I have to acknowledge the extremely tight timelines we are under, and the House must contend with those deadlines or we will have no protection for anyone.

The Supreme Court decision and the parliamentary timelines over the past year have combined to thrust us into this time crunch that none of us would have preferred to be in. This does not change the fact that we are here now. Nor does it change the fact that the defeat of Bill C-14 would mean the current prohibition on medical assistance in dying would end. The fact is that the Supreme Court unanimously decided that Canadians suffering intolerably have the right to request assistance to end their suffering.

The issue before us is not if, but how, we do this. This is not a political issue for me, and I do not believe it is a political issue for anyone in the House. Like my colleagues, I have looked at this matter as a person, a daughter, a mother, a grandmother, and someone who has watched many friends grapple with the complex, costly, and emotional challenges connected with terminal illness.

Palliative care, parental leave, family leave, and home care, while not directly contained in Bill C-14, must be part of the discussion, and they are. As I listen to the debate, it is clear that the matter is one that members are contemplating in a holistic way. I am pleased to hear again as part of the debate on this legislation that the government is committed to supporting quality end-of-life services and will continue to work with provinces and territories to improve palliative care for everyone. That means we will engage with the provinces and territories to support the development of a pan-Canadian monitoring system to collect and analyze data, monitor trends, and publicly report on medical assistance in dying. This helps to assure us that the government's approach is one of caution, one that is seeking a balance.

I also need to acknowledge the parliamentary secretary's verification that the government will work with the provinces and territories to explore mechanisms to coordinate end-of-life care for patients who want access to medical assistance in dying, while respecting the personal convictions of health care providers.

This is important because it would ensure that the concerns raised by many within the medical community would be addressed.

I mention this for a key reason. Canadians want religious freedoms to be protected for all Canadians, including doctors. Canadians also expect their government to respect and defend the Charter of Rights and Freedoms. Bill C-14 would attempt to do this while putting safeguards in place to protect the vulnerable as well.

Again, the Supreme Court of Canada unanimously decided that Canadians who are suffering have the right to medical assistance in dying. This means that the issue before us again is not if but how. After extensive consultation and extensive work by the committee, the government is proposing a framework that considers different interests, including personal autonomy toward the end of life, the protection of vulnerable persons, and the rights of conscience.

Access to medical assistance in dying, as envisioned under Bill C-14, would be available only to those who meet these conditions: mentally competent adults who are in an advanced state of irreversible decline in capability; who have a serious and incurable illness, disease, or disability and are experiencing enduring and intolerable suffering caused by their medical condition; and who have deaths that have become reasonably foreseeable, taking into account their condition.

For me, this is not just a discussion about the extension of life, nor should it be exclusively a decision about prolonging one's death. In instances where the end of life is near, the court has spoken and Parliament must now step up. If we fail to take action, we know the consequences, so doing nothing is not appropriate.

In order for me to support Bill C-14, I need to be assured of the government's firm and unwavering understanding that it will continue to support quality end-of-life services and will work with provinces and territories to improve palliative care. Again, end-of-life care is not just about medical assistance; it is about so many other things.

We have to remember Dr. Low in Toronto and his appeal by video to end his own life. We remember Sue Rodriguez. We remember all of those. Do I have a right to decide who dies and who lives, or that someone should endure the kind of pain that many are suffering? What would I do if my husband had ALS and begged me to end his life because he could not stand the pain? Do I have the right to say no? However, I also believe that it is God's right to call us all.

Bill C-14 is attempting to deal with a very difficult issue for all of us and for Canadians. Let us get it to committee. Let us see if we can make it stronger and make it better so that we are putting the emphasis on the palliative care and on the kinds of drugs that would eliminate the pain and make people more comfortable, so that none of us will have to make that decision.

[Derek Ross, Executive Director, Christian Legal Fellowship]

Good afternoon.

Thank you, Mr. Chair.

I am Derek Ross. I serve as executive director and legal counsel to the Christian Legal Fellowship. With me is Jon Sikkema, associate legal counsel at the CLF.

We wish to thank this committee for affording us the opportunity to make these submissions.

CLF is a registered charity and a national association of more than 600 legal professionals who share a commitment to the Christian faith. As an organization of lawyers, we seek to advance justice and the public good by drawing attention to fundamental principles of law.

One of those core principles is the sanctity of life, which the Supreme Court recognized as one of our most fundamental societal principles in Carter. That principle affirms that every person's life, no matter how old, disabled, or infirm the person may be, has inherent equal worth and value.

As the Supreme Court recognized in Rodriguez, the active participation by one individual in the death of another is intrinsically, morally, and legally wrong. That principle, expressed by Justice Sopinka, was not challenged or overturned in Carter, although Carter does now allow a legal exception to it in certain circumstances.

The challenge for us, and for you the committee and for Parliament, is the question: how can we best protect and preserve the equal value and inherent worth of all people in a post-Carter Canada?

We have framed our submissions in answering that question on the presumption that Parliament will legalize euthanasia and assisted suicide, which we'll refer to as MAID, in certain circumstances, although there are other and in our view more appropriate options available to Parliament, which we've explained elsewhere.

However, because the bill before this committee takes the path of legalization, we urge Parliament to be forward-thinking and to proactively guard against some of the negative impacts, perhaps unforeseen and unintended, that Bill C-14 might have—negative impacts that can be at least partially reduced with certain amendments that we and others recommend.

We urge Parliament to consider the following questions.

How will the legalization of MAID affect our societal attitudes towards suicide?

How might it contribute to normalizing suicide as a choice-worthy option, not just in the MAID context, but generally?

We know that the drafters of Bill C-14 are attuned to this issue, as the preamble acknowledges that suicide is a public health issue, not just a private one, and the Department of Justice's background paper also says that MAID is not being made available in wide circumstances, because that could undermine suicide prevention initiatives and normalize death as a solution to many forms of suffering.

The government is right to be concerned about those potential consequences and needs to be even more deliberate in guarding against them. We need to protect the efforts of physicians, health organizations, and charities to prevent suicide. We are concerned that such groups may avoid steering individuals away from suicidal ideations for fear that they will be seen as interfering with MAID or access to it.

This is evident in Quebec, where the college of physicians recently discovered that emergency room doctors were allowing suicide victims to die, when life-saving treatment was available. In media reports, the legalization of assisted death in that province was cited as creating ambiguity about the need to intervene. Parliament must eliminate any such ambiguity here and play a lead role in combatting the normalization of suicide.

What specifically can this committee do within the framework of this bill?

We say that Parliament should specifically affirm in the preamble to Bill C-14 that suicide prevention remains an important public policy goal. In addition, the preamble should state that sanctity of life remains one of Canada's most fundamental societal principles; that it is not contrary to the public interest to express the view that participating in causing a person's death is intrinsically, morally, and legally wrong; and that MAID should be considered only as a last resort, not as a measure to be presented to patients as just another treatment option among others.

This, in our view, is an important means of sending a clear signal, even if Parliament chooses to allow MAID, that MAID is not to be seen as a new normal medical response to suffering or even just as one option among and equal to others. This also means that Parliament should protect the charitable status of organizations devoted to preventing suicide as well as religious organizations and health care facilities that decline to provide MAID at their facilities, and should do so through clear amendments to the Income Tax Act, which we set out in our brief.

These amendments will serve to promote freedom of religion, conscience, and expression, but just as importantly, respect and preserve a medical and societal culture in which treatment is promoted as a solution to suffering, not suicide.

Similarly, we need to protect patients from being pressured to obtain MAID. Counselling or abetting a person to commit suicide will wisely remain illegal under this bill. This provision, section 241(a), addresses suicide only, and does not seem to address things like voluntary euthanasia, which is considered homicide and not suicide. This may be a drafting error, but either way it must be remedied. The reality is that patients will face external pressures to obtain and receive MAID. Bill C-14 acknowledges this. Under the legislation, as drafted, when this happens, the only consequence is that a patient may be considered ineligible for MAID, and only if the patient's doctor determines that the request was made because of, and a result of, that external pressure. Even if the physician determines that the patient was ineligible, the patient can still seek MAID from another physician, potentially under continued pressure from that same third party. The second, or tenth, or twentieth physician may fail to detect the external pressure on the patient. With respect, this is a significant oversight that leaves even the most malicious and prolonged forms of pressure and coercion seemingly free of prosecution. We recommend specific provisions to remove any ambiguity in this regard, and make it an offence to counsel, encourage, intimidate, or coerce a person to die by suicide or homicide, including euthanasia.

We also urge Parliament to explicitly protect the rights of those who object to participating in MAID, such as health care providers. I know others will be speaking to that matter this afternoon. In legalizing euthanasia, Bill C-14 places the most vulnerable members of society at risk. CLF endorses the recommendations contained in the Vulnerable Persons Standard. In addition, we recommend a number of amendments to Bill C-14, to protect the most vulnerable from abuse, which are set out in our brief. It is our submission that the court's ruling in Carter does not preclude Parliament from doing any of these things, and all of these provisions and amendments are necessary, not only to protect the vulnerable, but to preserve a culture that celebrates the equal and inherent value of every life.

Thank you.

[Robert Aubin, NDP, Trois-Rivières, QC]

Madam Speaker, I thank my colleague for his question.

Several aspects of Bill C-14 blur the line between federal and provincial health jurisdictions. As soon as we start talking about palliative care, we are talking about health care, which is a provincial jurisdiction.

Nevertheless, the federal government can still take a leadership role, especially with its health transfers, so that Canadians across the country have equal access to palliative care as part of the end-of-life care continuum. Naturally, this must be done in accordance with the provincial and territorial legislatures.

[Robert Aubin, NDP, Trois-Rivières, QC]

Madam Speaker, I cannot tell you how privileged I feel to take part in this discussion, and I mean “discussion”, because in the course of our work, which went on until midnight last night and will do the same tonight, it really has been a discussion, with the goal of coming up with the best possible solution, and not a partisan debate.

These kinds of subjects come up very rarely in history, and when the time comes for me to leave politics, I will look back on this as one of the most memorable topics of discussion in my time here.

In studying a bill, we must of course take a rational and intellectual approach, based on facts and science; however, with this kind of subject, we cannot ignore our personal experiences and, for many of us, the dimension of faith that goes along with life and quality of life.

Just a few decades ago, it would have been unthinkable for us to have a debate on the issue raised in Bill C-14. Today, this discussion is essential in order to address the concerns many Canadians have about quality of life.

Our society is constantly evolving, and for obvious and sometimes valid reasons, our democratic institutions will always be partly out of step with popular sentiment. However, the wishes of the majority should not be the only factor that guides us in our decision-making, because if our democratic institutions do not protect minorities, I wonder who will.

There are some historic issues that stand out in the life of a parliament, and as a result of the Carter ruling, we are now being called on to deal with such an issue. Although we are aware that there is little time left to deal with such a vast and also complex issue, we nevertheless have the good fortune of being able to refer to the Quebec experience, which quite surely can be a source of inspiration and can answer many of our questions.

Today, armed with the Quebec experience, our personal experiences, and input from many organizations and people in our respective ridings, we are being called on to make the best possible decision about how to provide medical assistance in dying. This is not about whether or not this assistance should be available.

The Supreme Court made that decision in Carter. As we all know, it was a unanimous ruling that sent a clear message on behalf of those who have spent years fighting for the right to die with dignity. It is up to us to legislate a framework for that assistance in a way that ensures respect for everyone's charter rights.

The bill is far from perfect, but at this point, I plan to vote in favour of it so that we can have the opportunity to perfect it by suggesting useful amendments during the committee's study.

I would like to share a very personal experience because I think that is the best entry point with this issue. Until recently, I was spared any major health problems, but not long ago, when I had a kidney stone that was relatively benign and easily treated, I had to cope with waiting six hours to get a drug that would alleviate my suffering.

When I shared my story with a few people I know, several of whom had had similar experiences, I saw how quickly people responded to suffering with sincere compassion.

Although this was a relatively minor health problem, for the first time, I felt, in my own body, the pain that may have been felt by my own parents, who both died of cancer. I spent as much time as possible with them when they had to move into a hospice. There is no doubt that their suffering was enduring and intolerable and that their health problems were grievous and irremediable. They met all of the criteria set out by the Supreme Court.

The workers in that hospice understood and still understand that no one should have to suffer while they are waiting to die when there are ways to relieve their pain, even though, in many cases, one of the side effects of the drugs is to precipitate death.

I have to say that when I remember the relief that I saw on my mother's and father's faces, I am inclined to support this bill and try to improve it.

This bill should be accompanied by a real national strategy on palliative care. In my opinion, some or all of the $3 billion that the Liberals promised for home care during the election campaign should have been included in the most recent budget. However, that is not the case.

Cancer can strike at any age and often there is no hope of recovery. Many other diseases produce similar effects of enduring and intolerable suffering without necessarily being life-threatening.

That is why I am also concerned about the fact that in this bill, the government did not use the wording in the conditions set out in the Supreme Court's decision. The Supreme Court basically said that Canadian adults who are able to consent and who have a grievous and irremediable medical condition that causes enduring suffering that is intolerable to them have the charter-protected right to physician-assisted death. That is the crux of the Carter decision, which gave rise to the bill that is before us today, Bill C-14.

What is the government trying to do today with this fourth criterion that it added, whereby the natural death has to be reasonably foreseeable? I have to admit to the House that in my mind at least, this is confusing. The terms are hard to define, the likely commendable goal being to seek the broadest consensus, even though that consensus already exists. If not, we would not be debating this bill. The Supreme Court likely would not have ruled the same way either if it had not sensed the evolution of this society.

We are about to undermine the process with such a vague and mandatory criterion because the legislation tells us that to have access to medical assistance in dying, the person absolutely must meet the four criteria set out in the legislation. The first three criteria are easy to understand, but the fourth is exceptionally vague.

I hope to see this fourth criterion disappear during our discussions in committee. With it, we are about to force those who are suffering to again demonstrate the unconstitutionality of the legislation, leading us right back to where we are today. We are here now, so let us see the work through and do it properly. Let us agree to ensure that this bill complies with the Constitution, that it will not be challenged later, and that those who wish to use it can finally do so.

Other questions remain practically unanswered, which is why the work coming up in committee after the bill passes second reading, I hope, is so important. As we point out in our supplementary opinion attached to the report, the government must adopt an approach to legislating medical assistance in dying based on the following principles: protecting vulnerable persons; taking into account the ethical concerns of all medical professionals; guaranteeing equal access to medical assistance in dying; protecting the conscientious objection of health care professionals; and respecting jurisdictions.

My time is running out, so I will conclude by saying that the NDP's job is to clarify the ambiguous provisions in the bill, strengthen the bill to avoid charter challenges, and demand stronger commitments with respect to palliative care and mental health care services to protect the most vulnerable Canadians. I can sense this in listening to my colleagues and all members of this House.

I am prepared to take questions from my esteemed colleagues.

[Nicola Di Iorio, Liberal, Saint-Léonard—Saint-Michel, QC]

Madam Speaker, before I participate in the debate at second reading on Bill C-14, concerning medical assistance in dying, I want to tell the people faced with making difficult end-of-life decisions and their loved ones that I am thinking of them.

Everyone knows that medical assistance in dying is a complex, delicate, and extremely personal issue. Since the Supreme Court ruled in the Carter case last year, Canadians have been taking part in this national debate. This issue continues to be debated and seriously considered around the world.

I would like to share with my colleagues what is happening elsewhere in the world. Almost everywhere, the deliberate taking of a life or aiding someone to end their life are serious crimes punished by lengthy sentences. As many people know, Canada is not alone in legislating to authorize medical assistance in dying.

Oregon, Washington, Vermont, and California are examples nearby. A little further away, Colombia, Belgium, the Netherlands, and Luxembourg have legislation authorizing one type or another of medical assistance in dying. The provisions on safeguards, controls, and reports, which are all found in Bill C-14, are similar.

Usually, requests for medical assistance in dying must be voluntarily submitted by the patient in writing. In many cases, this must also be done in the presence of independent witnesses. The patient must obtain a second opinion from an independent doctor and must wait a certain amount of time between the day the written request is submitted and the day that the medical assistance in dying is provided.

Colombia has a unique approval process for requests for medical assistance in dying. Every hospital has interdisciplinary committees to assess such requests and support the patients and their families throughout the process.

Nearly all of the regimes we have looked at include a mandatory monitoring system in which independent committees collect information to monitor the situation. That information is then used to publish periodic public reports on medical assistance in dying.

The safeguards and controls set out in various statutes are relatively consistent. However, there are differences in the types of medical assistance in dying that are authorized and the circumstances in which medical assistance in dying is authorized. The differences in terms of who is eligible for medical assistance in dying and the way that assistance can be provided fall along a continuum.

On the one hand, we have the four U.S. states, which I mentioned earlier and which have enacted laws: Oregon in 1997, Washington in 2008, Vermont in 2013, and, more recently, California in 2015. In these states, a mentally competent adult 18 years of age or older can receive the assistance of a physician to die, provided that their request is voluntary and this person is suffering from a terminal disease, defined as an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months.

In these U.S. states, just one doctor may prescribe a substance that the patient administers to put an end to their life at the time of their choosing. This is what we commonly refer to as physician-assisted suicide. Voluntary euthanasia, in which the physician administers a substance that causes the death of the patient, is expressly prohibited. Patients are also not able to submit an advance directive.

In Colombia, a ministerial resolution was drafted in response to two rulings by the country's constitutional court. The resolution contains eligibility criteria similar to those of the U.S. states.

It limits eligibility to adults who have an incurable disease, which is defined as a serious, progressive, and irreversible disease, or a pathology that will lead to death within a relatively short time frame. It requires a specific prognosis of six months, in other words, the assurance that death is expected relatively soon. Unlike the U.S. states, Colombia authorizes only euthanasia. A doctor must administer the substance that will cause the patient's death.

At the other end of the spectrum are Belgium, the Netherlands, and Luxembourg. In those three countries, patients can access medical assistance in dying if they are experiencing intolerable or unbearable physical or mental suffering caused by a serious incurable illness and if there is no possibility of improvement. Patients do not have to be dying or suffering from an illness that puts their life in danger in order to be eligible. In other words, physician-assisted suicide and voluntary euthanasia are authorized in those countries.

Although medical assistance in dying is provided only to adults in Luxembourg, minors as young as 12 can seek medical assistance in dying, with their parents' consent, in the Netherlands. In Belgium, adults and emancipated minors can seek medical assistance in dying in similar circumstances. In 2014, Belgium expanded its eligibility to include children of all ages, but only if their death is likely to occur in the short term and their suffering is physical.

The experiences and lessons learned by the Benelux countries were closely examined. For example, the law in the Netherlands authorizes requests for patients who no longer have the ability to express their wishes. However, research suggests that doctors are generally not prepared to euthanize such patients.

Consideration was also given to the Benelux countries' experience regarding patients who are suffering intolerably solely because of a mental illness. This is a very controversial issue. Evidence shows an upward trend in the percentage of people who seek euthanasia solely because of mental illness, and experts are starting to express their concerns about the fact that medical assistance in dying under such circumstances is becoming increasingly common. For example, in Belgium, people have been euthanized because of intolerable suffering resulting from depression, anorexia, blindness, fear of a disability or further suffering, and the pain caused by the lost of a loved one.

Many people fear that such broad access to medical assistance in dying can present real risks for people who are lonely or isolated and those who do not have any social, economic, or community support. It could also reinforce prejudice regarding the quality of life of seniors, people who are sick, and people with disabilities.

Our government sought to learn from the experience of other jurisdictions. The government is committed to continuing to examine the more general issues, and it will continue to observe what is being done elsewhere in the world in terms of medical assistance in dying.

I support Bill C-14, which was introduced by our government. Once this bill is passed, it will alleviate the suffering of those covered by its scope and will allow people to die with dignity.

[Arnold Chan, Liberal, Scarborough—Agincourt, ON]

Mr. Speaker, I am pleased to rise to speak to Bill C-14, the government's response to the Carter decision that we have recently dealt with by tabling this particular piece of legislation.

I wish to state at the outset that I will be supporting the bill, but with some reservations. I will explain why I believe the bill deserves support, but by the same token, I believe that somehow in a future Parliament the bill could go further.

I intend to engage in this discussion by going through three thematic components in the brief 10 minutes I have to make my contribution to this important debate. I know this has been at times an emotional issue for parliamentarians, but in the three thematic components, I wish to give my rationale for my support at this time.

The first of the three themes looks at the moral considerations that many members and much of the broader public have expressed. Second, I want to discuss perhaps more fulsomely our duty as parliamentarians to respond to issues of constitutionality, particularly when they are challenged in the courts. Third, in the short remaining time I will have, I wish to express some personal thoughts on this as it impacts me directly.

First, I want to thank many constituents in my riding of Scarborough—Agincourt for their interventions on this subject. This has been an emotional matter, and I would have to state on the record that the overwhelming majority of constituents who reached out to me are opposed to the government introducing Bill C-14. That has been primarily on moral grounds. They feel that allowing physician-assisted death is essentially tantamount to murder.

In the opportunities I have had to discuss this matter with my constituents, I made it clear that Parliament is under a positive obligation to respond to the decision in the Carter case. If Parliament does not present some form of legislation, the consequence of its failure to do so would mean that the provisions of section 14 and subsection 241(b) of the Criminal Code would no longer be operative as of June 6. We would essentially be left in the situation of a legislative vacuum. It is important to put a regulatory framework around physician-assisted death.

As I pivot from the issue of morality to the issue of our responsibility as parliamentarians, I want to raise the point that while morality is important, and this has been a theme discussed in the House, ultimately we as parliamentarians must first make sure that we put in laws that pass the constitutional test. Where the Supreme Court of Canada has rendered a decision indicating that something is not constitutional, that it is a breach of some form of the constitution, whether on jurisdictional grounds or on grounds under the charter, Parliament needs to respond. In my view, that is what the government is doing in Bill C-14, under a very difficult timeline. That is perhaps why there has been a decision to introduce Bill C-14 in a relatively controlled and restrictive manner. It is reflective of the fact that we are under a very tight time obligation.

Therefore, I understand why the Minister of Justice, the Minister of Health and others, who have done yeoman's work in this regard, have taken initial steps to make sure it meets the constitutional test set out by the Supreme Court of Canada. However, in my view, it does not necessarily go far enough.

I want to pay tribute to the ministers and to all the other many parties and Canadians who have contributed to the debate. I note that there was incredible work done by the Special Joint Committee on Physician-Assisted Dying, led by Senator Ogilvie and the member for Don Valley West. I want to pay tribute to all the members who participated in that committee.

I want to note the contributions of the federal external panel, the provincial-territorial expert panel, and the many stakeholders and Canadians who have contributed to this very difficult debate.

I would note, though, that not only have many of my constituents expressed concerns with respect to this particular bill, but in some specific instances they have asked us to consider invoking the section 33 notwithstanding clause found in the charter, which of course is the legislative override provision. I would view that as a more sophisticated way of saying they oppose it and that ultimately parliamentarians should please consider overriding the charter rights of certain individuals by invoking or using the notwithstanding clause.

I would say to those individuals who have expressed that particular feeling that this is something we have to do and tread upon very carefully, particularly where we are potentially treading on rights that have been protected under the Canadian Charter of Rights and Freedoms. I would submit respectfully that it is important we do so in a manner that follows the tests that are similarly found in section 1 that were ultimately articulated in the Oakes decision that deals with the judicial override clause that is found in the charter.

Under Oakes, there are essentially three tests that need to be met, and if any one of those tests fails, namely in dealing with the judicial override, then one would not be able to invoke section 1, and I would argue that one would have to use the same principles under section 33 in exercising the legislative override. Those three tests basically deal with rational connection, that the impairment is done in as minimal a way as possible, and that we look at the deleterious effects and salutary benefits of any limitation that is imposed under section 1.

Typically, in application of section 1 of the charter in most instances, the failure falls under the second test, that the impairment is not as minimal as possible. Certainly, that was the basis in which the section 1 test was applied in Carter and which the court found that the proposed absolute ban on physician-assisted death did not meet the minimal impairment test. The court had carefully gone through the trial judge's analysis and concurred with the trial judge's position with respect to the application of section 1.

In terms of whether we would consider invoking section 33, as I mentioned already, this Parliament, this House of Commons, has never exercised section 33 as a legislative override, and I would argue that we too should be extremely careful. That is the test that we need to apply as parliamentarians in terms of determining whether we feel it is appropriate to use the legislative override.

As I mentioned before, the bill seeks to meet in a very expedited fashion a court-imposed time challenge and to deal with the suspension of the declaration of invalidity under sections 14 and 241 of the Criminal Code of Canada. We must do so by June 6.

As I have indicated before, I will be providing my support for the bill, but I would argue that there are a couple of additional things that we as a Parliament need to consider in the future. These were articulated quite clearly in the report from the special joint committee of the Senate and the House of Commons.

My first issue is that the bill currently does not deal with the issue of advance directives. I am sympathetic to those Canadians, particularly those who are suffering from diseases like ALS and others, who may still be in quite good shape at the present time, but at some future point, when they are getting close to their end-of-life situation, will not be able to express their particular consent. In my view, the issue of a clearly articulated regulatory framework that allows for advance consent should be considered.

I am also—

The House resumed consideration of the motion that Bill C-14, An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying), be read the second time and referred to a committee, and of the motion that this question be now put.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Mr. Chair, I would respectfully disagree with my colleague. My colleagues who sit on the government committee here are solely using the point that this legislation does not require a five-year review because the committee is master of its own domain. By the same logic, the health committee should be able to look at the issue contained in Bill C-14, yet the government has stated that it is material enough to require a review in five years. I respect the fact that the government.... I'm not sure what they would have to hide, or why they would vote against a five-year review, especially in light of the Auditor General report that we saw today on instances of fraud being not detected within the Department of Citizenship and Immigration.

I find my colleague is perhaps grasping at straws to justify his logic.

[Arif Virani, Liberal, Parkdale—High Park, ON]

Mr. Chen has offered me some of his time.

In respect to this issue, it's critical to understand this committee is the master of its own process. Apropos of what Mr. Chen has indicated, the matters the committee wishes to study can be determined by the subcommittee on procedure here at this committee earlier than a five-year period or later than a five-year period.

In terms of the point made by Ms. Rempel, as to whether there's an inconsistency by not implementing a mandatory review in this legislation with what is transpiring with the Bill C-14 issue, there is absolutely no inconsistency. That undermines the notion that somehow what is applied for with one piece of legislation under a different minister, and under their mandate, must therefore be applied to every single piece of government legislation that is being enacted by the Government of Canada.

That is clearly not the way this government operates, nor is that the way that any government has operated. Decisions made with respect to whether mandatory reviews are required are made in consultation with ministerial or departmental officials relevant to that ministry, relevant to that minister's own decision-making, and also germane to the issues that are at issue within that specific legislative context.

The position being articulated by Mr. Chen is that in the context of this legislation it does not meet that threshold requiring a mandatory review, particularly when you have a standing committee populated by members of all three parties that can initiate such a review on their own volition.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Mr. Chair, by that logic my colleague opposite has negated the Minister of Health in saying that Bill C-14 requires a five-year review, which is part of the bill we're debating in the Commons today, so there's a bit of a dichotomy there, or a lapse in logic.

I would direct a question to the department officials, and perhaps if they can inform the committee of the commonality of five-year reviews in terms of legislation, as well elaborate on whether a parliamentary review would constitute a sunset clause of this particular piece of legislation.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Mr. Speaker, as I said in my speech, the government chose to leave people who are not at the end of their lives out of Bill C-14.

In some cases, individuals might want medical assistance in dying. One example that comes to mind is people on hemodialysis, an onerous and time-consuming treatment. After 10, 15, or 20 years of such demanding treatments, people might be worn out and might want to stop. All patients have the right to refuse treatment. A patient who refuses this treatment will die in the short term, but continuing to receive the treatment will not cause death. That means that the patient's end of life is not reasonably foreseeable, and he or she may therefore not be covered under this bill. People may want medical assistance in dying, but some of them are not covered under this bill as written. That must be fixed.

I think we should concentrate on palliative care first and foremost. Allowing medical assistance in dying makes no sense unless we have optimal palliative care in place.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Mr. Speaker, I think it is very important to rise to speak to Bill C-14, today and on other days of debate.

As my colleagues probably know, I am a health care professional. I still work at the hospital a few times a month, mainly in emergency and intensive care. This is important to me. End-of-life care is very important, which is why I supported a motion that my colleague from Timmins—James Bay moved during the previous Parliament. That motion dealt with a national palliative care strategy.

To begin, I would like to highlight two or three points from the Supreme Court decision that I think are particularly important to this discussion. The decision states:

...the prohibition [of medical assistance in dying] deprives some individuals of life, as it has the effect of forcing some individuals to take their own lives prematurely, for fear that they would be incapable of doing so when they reached the point where suffering was intolerable.

And by leaving them to endure intolerable suffering, it impinges on their security of the person.

It is important to mention that the Supreme Court decision underscores the government's responsibility to address the suffering that people experience. It is also important to understand the difference between suffering and pain. Pain is a physiological reaction to stress, such as an injury. Suffering has to do with an emotional experience.

Take, for example, a very painful event such as childbirth. That pain is associated with a positive emotional experience, the birth of a child. That event does not necessarily cause suffering, but it does cause significant pain.

A person might also have a minor injury that can cause extreme suffering because of the emotional experience associated with it. I think it is important to make that distinction.

These days, we have excellent therapeutic ways to alleviate pain. Opiates were long used, but now we also have patient-controlled analgesic pumps. We can even offer continuous palliative sedation, similar to what intensive care patients receive when they are intubated to ensure that they do not feel any pain. There are a number of extremely effective ways of alleviating pain, in addition to non-pharmacological methods. We have a good range of treatments to offer patients who are in pain.

It is possible to alleviate the suffering that comes with an emotional experience such as the end of life or an end-of-life diagnosis without resorting to medical assistance in dying. In that case, palliative care is an option. The bill applies to adults with a serious and incurable illness, disease, or disability who are in an advanced state of irreversible decline in capability and whose natural death has become reasonably foreseeable.

Obviously, we are talking here about people who are at the end of their lives, people who need palliative care. The purpose of palliative care is to ease the suffering of both the patient and the family. Palliative care helps ensure that people are cared for properly, and that they have the help they need to get through the grieving process and the hardship associated with illness.

We want to take away all the pain, but we also want to provide support for the family.

Optimal palliative care helps not only the patient but also the whole family, so that the patient's death can be as peaceful as possible for everyone involved. We are going about things the wrong way by providing medical assistance in dying when the palliative care offered in Canada is not yet optimal.

When palliative care facilities are underfunded and need to try to drum up donations every year, they are unable to offer optimal palliative care. Most of these facilities can only take patients who are expected to die in less than three months. However, people can often live much longer than that with a terminal illness and they need a lot more support.

Moreover, in many rural areas, palliative care beds are reserved through surgical units. That means that nurses who are taking care of palliative care patients also have to take care of seven or eight other patients. Nurses are therefore unable to respond quickly or spend as much time as they should with the families, and the patient's death does not go the way he or she would like.

For people who do not have the means or who do not want to die at home, unfortunately the hospital is often the only other option when palliative care beds are not available. This is not an easy experience, and it can create suffering because patients do not always have all the support they deserve.

There has been a lot of effort in recent years to remove some natural processes from hospitals. One example would be the birthing centres that have been set up. The thinking is that it would be better for mothers to go through pregnancy and childbirth a little more naturally in a setting other than a hospital, as long as there are no medical complications.

The same thing is being done with death, which is a natural process. It is being taken out of hospitals to make the experience much more positive, in a place other than the medical setting of a hospital.

Hospices try to remove all traces of hospitals. They have hospital beds, but they try to use the patients' own bedding, have large windows, and help patients forget that they are not at home.

Unfortunately, no matter how hard the palliative care facilities work, they are often underfunded. For example, the Maison du bouleau blanc, in my riding, has four beds, only two of which are subsidized. It therefore relies on donations to maintain its other two beds. It has a large room with big windows and a shower, but this is the only room that the facility has been able to convert to an ideal palliative care room.

These people cannot afford nurses. The people who work there are extremely dedicated practical nurses. However, they have some legal limits. For that reason, all the protocols regarding doctors working with palliative care facilities had to be updated, in order to ensure proper care for the patients.

We could address a number of shortcomings and avoid making the patients suffer. If someone who receives a terminal diagnosis knows that they will receive good palliative care as their condition worsens, they may not choose to take their own life prematurely. This would therefore help protect the right to life.

However, as long as do nothing on palliative care, we are working backwards. We cannot reverse the life-based medical model to allow for medical assistance in dying if our palliative care services are not as good as possible or accessible to all Canadians, regardless of where they live, even if they live in a remote region.

Since I am out of time, I would be happy to take questions from my colleagues.

[Kate Young, Liberal, London West, ON]

Mr. Speaker, the minister went on to say that her experiences as a family physician reinforced her sense that we must “uphold the principles of palliative care, as well as respecting the rights of patients to make their own decisions about their care as they approach the end of life”.

Earlier this year, the minister met with provincial and territorial health ministers in Vancouver to launch discussions on a new multi-year health accord. Through the health accord process, our government will be making significant investments totalling $3 billion dollars to help deliver more and better quality home care services for Canadians. We expect that support for palliative care in a variety of settings, where patients can receive the ongoing care they need and deserve at the end of life, will be one of the priorities going forward. I agree that there is no doubt that care at the end of life should be there when people need it. We want all Canadians to have access to the best care possible.

The issues in this area are complex. However, I strongly believe that Bill C-14 has struck the right balance between competing rights and policy objectives.

I call on members of this House to support it.