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

[Peter Kent, Conservative, Thornhill, ON]

Mr. Speaker, the reality is that the three parties to the Carter decision would not be assisted by Bill C-14. I listed the three conditions: spinal stenosis, ALS, and multiple sclerosis. All three of these particular afflictions would require additional legislative provision. I believe that is why the legislation will be back before the Supreme Court to order an extension of its provisions.

[John Brassard, Conservative, Barrie—Innisfil, ON]

Thank you, Mr. Chair.

By way of comment, I want to say that this issue has obviously been very difficult for many people to deal with. I think the government has put forward legislation that is somewhat reasonable at this point. I want to commend the members of the joint committee for the work they've done and commend this committee for the work that you are doing to get a better handle on the legislation.

I have only one question and it's for both ministers. You've mentioned that there have been ongoing discussions with the territories and the provinces with respect to Bill C-14.

Mr. Chair, through you, have any of the provinces or territories raised any concerns whatsoever about this bill and, if so, could the ministers please explain some of those concerns to the committee?

[Jody Wilson-Raybould, Liberal, Vancouver Granville, BC]

Thank you for the question.

There is nothing in Bill C-14, our proposed legislation, that would compel a medical practitioner to engage in medical assistance in dying. As you quite rightly point out, this is within the jurisdiction of the provinces and territories, and Minister Philpott will continue to work with her counterparts to assist in putting together the regulatory framework, to assist the provinces.

[Peter Kent, Conservative, Thornhill, ON]

Mr. Speaker, I will be splitting my time with the member for Durham.

I think it is important for Canadians to realize that the legislation before us is neither the alpha nor the omega in the continuing conversations Canadians are having about physician-assisted death. The Supreme Court forced this legislative moment on reluctant politicians with the Carter decision, but the conversation has been simmering, occasionally percolating, for decades in hospital intensive care wards, doctors' offices, around family dinner tables and at the bedsides of loved ones, from holy pulpits and at congressional retreats, medical schools and law schools, from theist philosophers and from the atheist sort. Most personally, the conversation has been conducted within ourselves, in our own minds, in both sickness and in health.

If the proposed legislation before us is neither the beginning nor the end of our ongoing conversation about physician-assisted death, what is it? Where exactly are we?

First of all, I think it is abundantly clear that we are definitely not where the Supreme Court told us to go. The legislation before us, which I believe will easily pass the House, and should as well the Senate, is only an interim step that will almost certainly very quickly lead us again to the Supreme Court.

The official opposition has set as its highest priority safeguards to protect the most vulnerable in society as well as the conscience rights of physicians and other health care professionals. We are pleased that the government accepted recommendations from the Conservative dissenting report from the special joint committee to exclude minors, to include stringent safeguards to protect those with underlying mental health challenges, and to recognize the risks involved with advance directives, which I will come back to in a moment. However, there are still concerns with the proposed legislation before us.

First, a point that has been and will be raised by colleagues many times, and I believe on both sides of the House, is the lack of specified conscience protection, an assurance that medical practitioners and institutions may decline participation in physician-assisted death. However, I do not believe that should be a problem, because I do not believe there will be a shortage of physicians willing to assist those patients who meet the criteria for assistance.

Also, there are the concerns, again raised by many of my colleagues, on the need for greater provisions for prior review, for consideration of underlying health issues, and for the effect of possible psychological disorders on patient decision-making. I believe those matters should be thoroughly reviewed again in committee.

As well, many of my colleagues have expressed concern with the extension of the Supreme Court's specific direction that physician-assisted death be performed by medical doctors to also include nurse practitioners. We know the government's logic in broadening the responsibility is to provide for remote areas where qualified nurse practitioners now carry out many of the services traditionally provided by MDs. Again, I believe the legislation needs more specificity in this area. I firmly believe that many nurse practitioners are qualified, capable, and willing, but perhaps the legislation should explicitly state that nurse practitioners be engaged only as physicians of last resort in circumstances where no medical doctor is available.

I also recognize the widespread concern and resistance to the vague nature of such phrases within Bill C-14 as “reasonably foreseeable”. I personally accept such imprecise conditions because I realize that as magnificent as modern medicine is today, prognoses regarding the time of a final breath or a final heartbeat are still often only educated guesses. This is certainly worthy of further examination at committee.

Finally, one of the most important shortcomings in convincing Canadians to accept Bill C-14 is in the government's unkept and—I will be perfectly frank—broken promise on palliative care.

The Liberals made a campaign commitment to invest $3 billion in long-term care, including palliative care. The importance of access to palliative care in end-of-life decision-making was one of the few unanimous points of agreement in the special joint committee's report.

We as parliamentarians can rush to meet the Supreme Court deadline of June 6, but at the same time, the government has a clear duty, a moral obligation, to put in extra effort to expedite fulfillment of that promise to expand the availability of accessible, affordable, acceptable palliative care for all of those who, for reason of conscience, faith, or choice decide not to avail themselves of physician-assisted death.

I firmly believe that choice must be extended, as I believe the Supreme Court clearly meant it to be in the Carter decision, to patients suffering from the specific diseases and conditions that formed the basis of the Carter decision: the brutally imprisoning final stages of spinal stenosis; the choking, smothering final stages of ALS; and the unrelieved pain of irreversible but interminably long final stages of progressive multiple sclerosis.

While I am on this point, I remarked earlier on the need to recognize the risks involved in advance directives for diseases such as Alzheimer's, dementia, and the like. That said, I believe advance directives must eventually be allowed in physician-assisted death.

I consulted with many individuals and groups in my riding of Thornhill in recent months and beyond. I greatly respect—profoundly respect—the advice and interventions of various faith communities, social agencies, and medical institutions and their concern over the need for greater protection of the most vulnerable.

My personal decision, which will determine my vote on this legislation, is a product of three individuals and their experiences. In my previous life as a journalist, I followed closely the unsuccessful legal crusade of Sue Rodriguez as ALS steadily increased its deadly grip and her rhetorical question posed to Canadians: “If I cannot give consent to my own death, whose body is this? Who owns my life?”

In the previous couple of Parliaments I became close with another thoughtful, courageous Canadian, a fellow member of Parliament, the Hon. Steven Fletcher, Canada's first quadriplegic MP, re-elected three times and just last month elected to the Manitoba legislature, who did not give up after his life-changing accident 20 years ago. He met immense challenges and he overcame them.

However, in two private members' bills tabled two years ago, which I seconded, and in testimony before the parliamentary committee this January, Steven made a powerfully convincing argument for self-determination to one day make a final decision. He said such a law would be based on an individual's own morals and ethics while stressing that there should be no pressure on that person from society, family, friends, or the institution they may be in.

I was also powerfully informed and persuaded by the tragically tortuous passing of my brother-in-law, Rik Davidson, a brilliant academic, through Alzheimer's. Should such an ending be diagnosed for me, I assure the House that an advance directive would be composed, and either under law or not, it would be fulfilled.

Finally, as a cancer survivor, I have had many hours of reflection, during treatment and since, to ponder the issues involved in this debate on a personal level. I am fortunate that modern medicine, faith, and an incredibly supportive wife and family have left me—for now—clear and happily continuing my late-life adventure as a politician.

I am honoured that I can participate in this debate to argue for the passage of Bill C-14, eventual broadening of this legislation's provisions, and immediate government action to expand palliative care facilities and services, because I passionately believe that the issue before us ultimately comes down to choice: the free choice of a competent adult individual to choose between accessible, affordable palliative health care and the constitutional right to physician-assisted death.

[Matt DeCourcey, Liberal, Fredericton, NB]

Mr. Speaker, with the Supreme Court's decision in Carter, Canadians were given notice that medical assistance in dying would effectively become legal in Canada. It was, hence, the responsibility of the government to put forward clear rules around who is eligible to obtain medical assistance in dying, what safeguards must be followed to protect vulnerable individuals, and to create a monitoring regime to ensure accountability, transparency, and public trust in the system. Federal legislation was also important to ensure that a consistent approach to medical assistance in dying would be available across Canada.

Bill C-14 is the result of extensive consultation over the past year with individuals, groups, and experts at home and abroad. It takes into account a range of interests, including personal autonomy and safeguards to protect the vulnerable. It also recognizes the diverse and personal ways in which individual Canadians arrive at the question of medical assistance in dying. It balances individual rights and informed conscience, and respects the professional ethics and conscience of physicians and medical practitioners.

This legislation also addresses and proposes broad action on an aspect of end-of-life care where Canadians, regardless of their views of medical assistance in dying, have clearly indicated that they want action, chiefly, palliative and hospice care. I had the pleasure yesterday to take part in Hike for Hospice in sunny Fredericton and I am proud of the overwhelming support demonstrated by community members for such a worthy and important cause.

As we address an issue as delicate as medical assistance in dying, we cannot act without a full and intentional movement toward expanding all options of end-of-life care. The government has made clear that as part of a multi-year health accord, financial resources to improve home care, including palliative care, will be of primary importance. Also, as we launch Mental Health Week today in Canada, we must recommit our efforts to providing greater care and support for those suffering from mental illness and deliver on clinical and community-based approaches that will allow greater access to mental well-being for Canadians who suffer from mental afflictions.

On December 11, a Special Joint Committee on Physician-Assisted Dying was tasked with reviewing recent consultation activities. The committee also consulted with Canadians and stakeholders and made recommendations on the framework of a federal response to the Carter decision. The committee met 16 times, heard from 61 witnesses, received more than 100 briefs, and tabled its final report to Parliament on February 25.

I would like to extend my thanks for the work of the committee, as well as for the individual commitment demonstrated toward this issue from each and every committee member.

I, too, have heard from hundreds of people in the riding I represent, and have sought out wisdom and advice from leaders within the disability community who are calling for assurances that those with vulnerabilities will be safeguarded from outside influence in their personal decision-making; from the faith community, including trusted mentors and friends, who have encouraged me to reflect upon my own informed conscience in rendering a decision on this important matter; from the medical community, including leading voices, who have called for a sage and measured approach to the development of a framework around medical assistance in dying; and from those seeking a more liberalized approach, who may be dissatisfied with the framework that is proposed in front of us.

I have listened, I am listening, and I will continue to listen to people in the riding I represent. I have reflected, I am reflecting, and I will continue to reflect upon this important decision that will change the way Canadians consider end of life.

I approached this question like many others, with great humility, understanding that in a pluralistic society as rich and diverse as Canada's there will undoubtedly be those who feel that this legislation does not meet their world view. I wish to extend my empathy and understanding to them, and let them know that I, like all my colleagues, will continue to do my best for them.

I believe the ministers charged with crafting this legislation and the government as a whole have also approached this question with great sensitivity. The approach being taken is emblematic of a government that has listened to citizens, and will continue to listen to the wide diversity of opinion on this personal and challenging decision.

With this in mind, I wish to express my general comfort with the legislation before us. I would like to take the time to explain in greater depth the elements of the legislation and what it means for Canadians.

First, to allow access to medical assistance in dying in Canada, the Criminal Code would need to be amended so that doctors, nurse practitioners, and those who assist them can help eligible patients die without the risk of being charged with assisting a suicide or committing a homicide. There will also be safeguards to ensure that those who receive medical assistance in dying are eligible for it, can give their informed consent, and voluntarily requested assistance in dying.

A voluntary and informed request must be submitted in writing by the person in the presence of two independent witnesses, and a second medical opinion is required. No one aside from the person wishing to receive medical assistance in dying can make that voluntary request. This approach holds that the right to choose medical assistance in dying belongs only to the competent adult who would receive it. This is also necessary to protect vulnerable people.

A person who wants to access medical assistance in dying would have to meet the following criteria. They would have to be a mentally competent adult of 18 years or older. They would have to have a serious and incurable illness, disease or disability, be in an advanced state of irreversible decline of capability, and experience enduring and intolerable suffering as a result of their medical condition. They would, in effect, have to be on a course toward end of life. Death would have to be reasonably foreseeable.

The proposed legislation holds that mature minors would not be eligible nor would people suffering solely from a mental illness. The government is, however, proposing an independent study of the legal, medical, and ethical issues related to medical assistance in dying for mature minors, for those suffering from a mental illness, and around advance directives.

Again, the bill includes protections to ensure that patients are eligible and have given their informed consent. There would be a mandatory waiting period of at least 15 days, and patients could withdraw their consent at any time.

Also, there is nothing in the proposed legislation that would compel a health care provider to provide medical assistance in dying or to refer a patient to another practitioner.

The proposed approach to this most difficult of questions does its best to recognize individual choice for adults who are suffering intolerably and for whom death is reasonably foreseeable. It seeks to affirm the inherent and equal value of every person's life. It has the goal of protecting vulnerable people and reaffirms society's goal with regard to preventing suicide. It is an approach that recognizes where we are as a society and as a people advancing in the world. It is respectful of the divergent voices of Canadians and it demonstrates flexibility in its ability to reassess and examine the issue of medical assistance in dying in the weeks, months, and years to come.

I wish to thank my constituents who have reached out to me on this important matter and the many more who, I know, have wrestled with this question internally.

Know that this Parliament and I will do our collective best to serve each one's interests and those of their neighbours on this and on all important matters.

[Chris Bittle, Liberal, St. Catharines, ON]

Minister Wilson-Raybould, I wanted to commend you and your department for releasing the legislative background behind Bill C-14. I appreciate the commitment to openness and transparency. I think we can all agree that it's contributed to a significant debate across Canada, and will contribute to an intense discussion around this table.

Could you highlight to the committee the importance of this review, and address any of the possible concerns raised in it?

[Murray Rankin, NDP, Victoria, BC]

Because the time is so limited, let me ask a question on another topic.

Today's Globe and Mail has an article by UBC professor of medicine Dr. Jesse Pewarchuk, who talks about the issue that I also wanted to raise, that of advance requests, or so-called advance directives, which, as you know, is something that was recommended by the Senate-House committee. Dr. Pewarchuk writes as follows:

Bill C-14’s biggest flaw is that it forces the hand of those who have a progressive disease that relentlessly and predictably results in lost mental capacity to consent. Alzheimer’s patients can expect, with virtual certainty, to lose the capacity to make medical decisions over time.

He claims that “the wording of the proposed law introduces...doubt as to whether an Alzheimer’s patient who has yet to lose capacity (yet is certain to) would even be eligible, since death can take years...”. He says that “foreseeable death” and “advanced state of decline in capability”, the phrases in the definition in the bill, “are loaded, ambiguous clauses that seem to eliminate the Charter rights of dementia patients to be eligible...”.

Would you consider advance directives to address that problem?

[Sean Casey, Liberal, Parliamentary Secretary to the Minister of Justice and Attorney General of Canada]

Mr. Speaker, it is my honour to stand to speak in support of Bill C-14, a significant piece of legislation that would allow for the first time in Canadian history the provision of medical assistance in dying across the country.

I believe Bill C-14 directly and thoughtfully responds to the Supreme Court of Canada decision in Carter. This legislation would strike a careful balance between the autonomy of competent adults whose deaths are reasonably foreseeable to seek medical assistance in dying and the protection of vulnerable people through careful tailoring of the eligibility criteria and robust safeguards that are essential to prevent error and abuse.

As recognized by the Canadian Medical Association before the Special Joint Committee on Physician-Assisted Dying, one cannot underscore enough the significance of this sea change in Canadian medical practice and Canadian society as a whole.

At present, there are eight jurisdictions in the world, in addition to Quebec, that have adopted precise legal rules on medical assistance in dying: four U.S. states, Colombia, and the European countries of Belgium, the Netherlands, and Luxembourg.

The international community is looking at Canada's leadership on this issue right now, and I commend all hon. members on both sides of this House for their invaluable contributions to this complex and sensitive debate.

Bill C-14 would establish the criminal law rules regarding medical assistance in dying that address issues including eligibility, procedural safeguards, and the framework for a pan-Canadian monitoring system. In addition to the comprehensive legislative response proposed in Bill C-14, the government would undertake independent studies into three key issues that the Supreme Court declined to address in Carter: eligibility for persons under 18, advance requests, and requests for medical assistance in dying solely on the basis of a mental illness.

Allow me today to provide all members with further clarifications on the eligibility criteria included in Bill C-14 and how they respond to the Carter ruling, a question that has been asked numerous times since the bill was introduced.

Under Bill C-14, medical assistance in dying would only be available to mentally competent adults: one, who have a serious and incurable illness, disease or disability; two, who are in an advanced state of irreversible decline in capability; three, who experience enduring and intolerable physical or psychological suffering as a result of their medical situation; and four, whose natural death has become reasonably foreseeable taking into account all of their medical circumstances and without requiring any specific prognosis as to the length of time that they have remaining.

I would emphasize that those are the exact words of the legislation, because there has been some incorrect reporting on what is actually required. It is also important to remember that the criteria must not be read in isolation. Each element mutually informs the meaning and scope of the others. They work together to create a clear picture.

Some people wonder what reasonable foreseeability of death means given that everyone's death is reasonably foreseeable in the sense that death, like taxes, is inevitable for all of us. Bill C-14 expressly states that the person's natural death has become reasonably foreseeable, which clearly indicates that a change in the patient's medical circumstances is required. The patient is now on a path toward death, but previously he or she was not. A healthy person's death is not reasonably foreseeable unless the person experiences a change in his or her medical circumstances.

Mr. Speaker, at the outset of my remarks, I neglected to inform you, but I do now, that I will be sharing my time with the esteemed member for Fredericton.

The concept of reasonable foreseeability is also well known in law, and assessment depends on the context. In the context of medical assistance in dying, it would require a real possibility of the patient's death within a period of time that is not too remote from circumstances that can be predicted within a range of reasonable possibilities. Again, the legislation expressly states that a specific prognosis as to the time the patient has remaining would not be required. Because everyone's trajectory toward the end of life would be unique, this criterion was carefully crafted to provide maximum flexibility to medical practitioners so that they may assess the overall medical circumstances of a patient on a case-by-case basis. The overall medical circumstances, as opposed to any particular type of condition, are what matters when the objective is to give Canadians the option of a peaceful medically assisted death instead of having to endure a prolonged or painful one.

As recognized by medical standards and guidelines on prognostic indicators, there are many factors that may contribute to a patient's being assessed as approaching the end of life, including the presence of an advanced, progressive, and incurable disease, but also completely different factors, such as age, the general frailty of the patient, and risks of death from complications of other conditions that may not be fatal on their own, but which can jeopardize the life of someone who is otherwise weakened.

As recently recognized by the Canadian Medical Association, the requirement that natural death has become reasonably foreseeable would provide clearer guidance than the court's use of “grievous and irremediable” in that it would indicate , and I quote the CMA representative, that the condition should be “towards the end of the spectrum”, but does not mean “terminal or that death is immediately on the horizon”.

If we consider the Carter ruling itself, the Supreme Court expressly stated that the scope of its declaration was intended to respond to the factual circumstances of the case, and that it made no pronouncement on other situations where physician-assisted dying may be sought. Bill C-14 would directly respond to the factual circumstances of both Kay Carter and Gloria Taylor, who were both in decline and suffering while on a trajectory toward the end of their lives without it being certain when exactly they would die.

The Supreme Court did not define the term “grievous and irremediable medical condition”. It rather acknowledged that it was Parliament's task to weigh and balance the perspective of those who might be at risk in a permissive regime against those who seek assistance in dying. This is exactly what Bill C-14 does. It defines eligibility in a manner that is consistent with the Carter ruling read in its entirety, and provides necessary clarity on the assessment of eligibility.

Some have expressed concern over the lack of express protection for conscience rights of health care providers. The legislative objectives of Bill C-14, which are clearly stated in its preamble, include respecting the personal convictions of health care providers while also recognizing the provinces' jurisdiction over various matters related to medical assistance in dying. Balancing the interests of medical practitioners and those of patients is such a matter. Importantly, nothing in Bill C-14 would compel health care providers to provide any assistance that may be contrary to their conscience rights. More important than legal protections in a statute book are the concrete and practical actions that are directly aimed at supporting conscience rights of practitioners. In this regard, the Minister of Health has offered to work in collaboration with the provinces and territories on the development of an end-of-life care coordination system to help respect the providers' conscience rights while facilitating patients' access to care including assistance in dying.

Some have expressed concern that the safeguards in the bill are not sufficient. The proposed safeguards are generally consistent with and perhaps even a little stronger than the safeguards found in other medical assistance in dying regimes around the world.

The trial judge in Carter considered voluminous evidence on the efficacy of these regimes, and the evidence persuaded her that the risks to vulnerable people could be adequately managed under such systems. We are equally confident that these safeguards would guard against abuse and error.

I believe the proposed legislation is the right way forward on medical assistance in dying for Canada at this time and is a principled response to the Carter decision. I would urge all members to support second reading of Bill C-14.

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

Quickly, under the framework established by Bill C-14, a provincial health care facility could choose not to provide medical assistance in dying. I'd like to know what your views are on that.

[Jane Philpott, Liberal, Markham—Stouffville, ON]

I will add to that, because I think it's helpful to understand how we came to the decision you see before you in Bill C-14.

The request for personal autonomy was heard loud and clear. We heard it from the folks who were involved in the Carter case, and we are obviously very sensitive to their desires and the desires of others like them who want to have that personal autonomy.

Where Minister Wilson-Raybould and I felt particularly burdened was how we could make sure that we provided for that personal autonomy, while very much feeling the weight of the life and death decisions that were also on our shoulders in terms of the protection of not simply individuals, but society as a whole. I think you'll see that reflected in the legislation.

We are fundamentally committed to making sure people can, in a sense, write their own stories and write the final chapter of their lives as much as possible, but we felt a real weight with the fact this would be the end of people's lives. We need to make sure that appropriate safeguards are in place so that nobody comes to the end of their life without adequate protection. We as a government, and we as parliamentarians, have a responsibility to uphold that solemn responsibility.

If we had more time, I'd love to tell you a bit more about that. We undertook this with a deep sense of obligation to protect not only individuals and their rights, but also society as a whole and the challenges there.

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

In your opinion, does Bill C-14 adequately balance the principles of autonomy and the protection of vulnerable individuals? Please explain why or why not, and describe any improvements that could be made to the bill in this respect.

[Wayne Stetski, NDP, Kootenay—Columbia, BC]

Mr. Speaker, I rise today to speak to Bill C-14, an act to amend the Criminal Code and to make related amendments to other acts related to medical assistance in dying.

I support the bill at second reading. However, it does need to be amended.

I will start today with a story. Some years ago, my wife Audrey and I adopted a beautiful sable sheltie dog by the name of Princess Diana of Cornwall. She was named at a time when we lived on Cornwall Drive in Port Coquitlam, and the world was abuzz with a royal wedding involving two people named Charles and Diana.

Princess was a great dog. Unfortunately, when she was about 11 years old, she developed cancer. We were already living in our current home city of Cranbrook, located in the Rocky Mountains area of British Columbia. As the cancer progressed, Princess was living with more pain and discomfort. We consulted our local vet regularly. One day he told us that she was terminal and in a lot of pain and he thought the best thing we could do for her was to end her suffering. He asked us to bring her back the next day. We took her home to say our goodbyes, and the next day I brought Princess back to the veterinarian. He asked me if I would like to leave her with him or whether I would like to stay. I said I would stay. I held her in my arms and watched the needle go into her paw. She lay down and died in my arms. As I stood there with tears in my eyes, I thought that if I were ever in intolerable pain from an incurable disease, this is how I would want to leave this world, with a needle in my paw, lying in the arms of someone I love. I personally became a believer in physician-assisted suicide right there 20 years ago.

I am not suggesting that the death of a pet and that of a human are equivalent, though they certainly can feel much the same, as many who have loved a beloved pet will know. We need to take even more care that we have it right when we are talking about euthanasia through a human lens.

As members know, in February 2015, a unanimous Supreme Court ruling established the charter-protected right of competent adult Canadians who are experiencing enduring and intolerable suffering as a result of a grievous and irremediable medical condition, including a disease, disability, or illness, to access medical assistance in dying. We in the NDP are committed to implementing the Supreme Court order decision with balance and sensitivity, respecting the autonomy of patients, the rights of health care practitioners and vulnerable individuals, and the fundamentally personal nature of this issue to every Canadian; in other words, we need to get this legislation right.

Last week, when I was back in my riding of Kootenay—Columbia, I met with Bendina Miller, the past president of the Canadian Association for Community Living. The CACL was one of the main supporters of the vulnerable persons standard, the purpose of which is to protect the vulnerable in Canada, as Bill C-14, medical assistance in dying, moves forward. While the CACL believes that the bill in its current form takes appropriate steps toward addressing the vulnerability of people living with a disability, it believes some improvements are required to meet the Supreme Court's intent that the legislation must provide fair access to assisted death and also protect vulnerable persons who may be influenced or induced to use the system to die.

The Canadian Association for Community Living recommends five areas of substantive amendment to this draft bill. I will summarize them here.

First, Bill C-14 should be amended to extend the current requirement for judicial oversight until such time as a study of the merits and implications of the bill allows them to be clearly understood.

Second, included in the bill should be an explicit legal requirement to identify, explore, and record the sources of a person's suffering, and an attempt to address the motivations of his or her request for death.

Third, Bill C-14 should be amended to meet the requirements of the Carter decision and should specify that a voluntary request for medical assistance in dying cannot be made as a result of external pressure or any form of inducement.

Fourth, Bill C-14 should be amended to specify that the minister “will” make, not “may” make, regulations regarding the mandatory reporting of information about requests and the provision of assisted dying.

Fifth, it should mandate a palliative care or other professional evaluation to ensure patients' rights to informed consent by having information about the full range of available treatments and supports that could ease their suffering.

The bill should not proceed without an enhanced national palliative care strategy, which is clearly missing in the Liberal government's 2016-17 budget.

Back in November, I had the pleasure of meeting new members of Parliament from all of the parties represented here in the House, except the Green Party. I was struck by how consistent the words were from all of my colleagues. They said they were here to work collaboratively to build a better Canada. It was very encouraging for me as a new MP, because that is also why I am here.

When I am back home in my riding sharing with my constituents what we are doing here in the House, I tell them that we are working on three bills in particular that would fundamentally change Canada, going forward: first of all, proportional representation voting; second, legalizing marijuana; and third, physician-assisted suicide.

This is the first of those three bills to come to the House for debate and further study, and we need to work together collaboratively to build a better future for Canadians. The bill would do three things: maximize one's willingness to live through expanded palliative care, ensure that our vulnerable citizens are protected, and give our citizens the Supreme Court assured right to choose to die in the arms of someone who loves them, if they are experiencing enduring and intolerable suffering as a result of a grievous and irremediable medical condition.

Let us amend the bill collaboratively and give Canadians the best possible outcome on this very important and emotional issue.

[Jane Philpott, Liberal, Minister of Health]

Thank you, Mr. Chair.

I will be making a few comments in French as well, for those who need the earphones.

Mr. Chair and honourable committee members, thank you for the opportunity to appear before you this afternoon. I am very pleased to be here with my colleague to discuss this important subject of medical assistance in dying.

I think that each of us around this table would not deny the monumental nature of the piece of legislation with which we are involved. This speaks to the profound and solemn nature of our responsibility as representatives of the people of Canada to make wise decisions, and I thank you for sharing with us in this process and look forward to your comments and questions.

Conversations about the end of life can be incredibly challenging. I can say that from personal experience, and I know that all of you have had similar experiences and have your own personal stories about end-of-life conversations, yet it's a vital conversation that we need to participate in as individuals, as members of Parliament, and as a society.

They are difficult conversations for health care providers as well. Health care providers may not have had an education that has adequately prepared them for discussing this, let alone providing the supports that patients need at the end of life. As we strive to meet the needs of Canadians at the end of life, we also encounter a system that can often frustrate the attempts of people to live out their personal autonomy.

We all want a system where respect for personal autonomy is a cornerstone of all policies. We also want a system where the rights of the most vulnerable are respected and protected. This legislation is one important piece of the puzzle when it comes to ensuring that Canadians have access to not only a good life, but also a good death.

It's about empowering patients to take control of their own narrative and ensuring that Canadians can receive compassionate care as they approach the end of life.

As you well know, we listened to what Canadians and stakeholders had to say before we developed this legislation. We reviewed it closely to ensure consistency with the charter. We looked closely at the Carter decision to ensure that individuals in similar circumstances would have access to care that would alleviate suffering, including the option for medical assistance in dying.

In the course of this debate and since the introduction of this bill, we have heard from several parliamentarians and many stakeholders. Some have had concerns that the legislation goes too far, and we acknowledge that for many the new reality in the post-Carter era is an unfamiliar one and will heighten anxieties about how we protect the most vulnerable in society.

I want to assure those Canadians that we acknowledge their concerns, and we believe that the safeguards in place in this bill will ensure that we protect the rights of those most at risk.

We've also heard from others who feel that the proposed legislation does not go far enough and who would like to see expanded eligibility in certain areas, and we would also like to thank these Canadians for speaking up on behalf of those who are suffering.

Our commitment as a government was to respond to the Carter decision. This necessitates changes to the Criminal Code that will protect health care professionals as they support patients in their decision-making. At the same time, we are committed to taking time to address additional questions that are more complex and where more time and study are needed.

For instance, the proposed legislation sets the minimum eligible age for decision-making at 18—the age of majority in most provinces and territories. We believe this is appropriate, given the unique and irreversible nature of this decision. We know that the capacity to make health care decisions is not tied strictly to age and that depending on the province, children as young as 14 have had the right to refuse or consent to medical treatment.

Given the divergence of opinion on this issue among Canadians and stakeholders, the special joint committee, as you know, called for further study and broad-based consultations on the issue surrounding the concept of mature minors. Our proposed legislation reflects that guidance and the need to tread carefully; however, we acknowledge the difficult situations that mature minors and their families face at the end of life, and we commit to taking the necessary time to study this matter in the months to come.

We faced similar challenges in considering the issue of advance directives. The Supreme Court did not deal with this issue in Carter, and the views of Canadians and stakeholders, as you know, are divided. I understand the hardship for those Canadians who fear that after being diagnosed with a disease such as dementia they may experience a decline that could compromise their dignity. This has led to pleas to allow people to make requests for medical assistance in dying well in advance of the time when the person is no longer competent to make or reaffirm a desire to accelerate their own death.

I had the opportunity to meet with a group called Dying With Dignity recently to understand their perspective and the thoughtfulness with which they presented their case.

After 30 years of practising medicine, I am well aware of the concerns of Canadians who endure suffering at the end of life, and understand why some would contemplate using advance requests to seek medical assistance in dying. However, we must consider the complex policy and medical practice issues raised by advance requests.

By their very nature, advance requests are made before they're needed. Even if reviewed regularly, they would be an enacted only when a person has lost competence or is no longer able to communicate. This means that the final consent, a key requirement in most assisted-dying regimes around the world, could not be verified by a health care provider or anyone else.

Health care stakeholder groups have cautioned that advance directives for other forms of medical treatment can be very difficult to respect in practice, and the implications would be more significant in the case of assisted dying.

As June 6 approaches, we have limited time to better understand how advance directives would work in practice. Determining how they would be carried out would require extensive consultations with Canadians, stakeholders, medical professionals, regulatory bodies, provinces, and territories. In light of these circumstances, we are proposing to explore this issue with further study.

The proposed legislation also does not permit eligibility solely on the basis of suffering from mental illness. There's no denying that mental illness can cause profound suffering, but illnesses such as chronic depression, cognitive disorders, and schizophrenia raise particular concerns with respect to informed decision making.

We've consulted with numerous stakeholders on this issue and have concluded that the nuances are not sufficiently understood at this time to allow safe and appropriate legislation to be crafted.

To that end, the government is making a commitment to mandate one or more independent studies on the questions of requests by mature minors, advance requests, or requests for mental illness as the sole underlying medical condition.

Bill C-14 also includes a clause that requires Parliament to conduct a review of the legislation five years after royal assent. This will allow for a parliamentary review of the complex issues, as well as the evolving experience of Canadians in implementing medical assistance in dying.

Finally, one cannot discuss this legislation without a reaffirmation of the importance of improving access to high-quality palliative care for all Canadians. Our government is firmly committed to investing in this area, and I look forward to working with provinces and territories to ensure equitable access to all options for care at the end of life.

In closing, we believe this proposed legislation values the personal autonomy of Canadians, in line with the Supreme Court's decision in Carter, while ensuring the protection of vulnerable Canadians and the conscience rights of providers.

I want to thank all of you and others who have engaged thoughtfully and respectfully on this challenging issue. I know this committee is going to hear a range of views and opinions in the coming days and weeks.

I thank you for your consideration. I look forward to your responses.

I welcome any questions you may have.

[Harold Albrecht, Conservative, Kitchener—Conestoga, ON]

Mr. Speaker, there is a couple of things I would like to clarify. The member and his colleague who spoke earlier said, pretty unequivocally, that no doctor would be required to participate in this regime. I do not see any protection in Bill C-14 that would assure doctors they would not be required to participate, other than a very vague comment in the preamble talking about that possibility. It certainly does not put ironclad protection in the bill.

The other issue I would like to raise with all my colleagues on the other side is palliative care. We continue to hear their commitment to palliative care. I applaud that. We need better palliative care. I have been working on that years. We can talk about it, but I do not see any evidence in the budget of the $3 billion that was promised to be immediately invested. I am very concerned. We need to get working on this. I want to see an actual firm commitment within the budget so we have something we can take to Canadians that says help is on the way.

Barring that, to offer physician-assisted death without—

[Jody Wilson-Raybould, Liberal, Minister of Justice and Attorney General of Canada]

Thank you, Mr. Chair.

I will present first, and then my colleague will present after me.

First of all, I want to acknowledge you, Mr. Chair, and the members of the committee. Thank you for providing us with this important opportunity to be here to speak about Bill C-14, which responds to last year's unanimous decision of the Supreme Court of Canada in Carter v. Canada and introduces a federal framework around medical assistance in dying.

Medical assistance in dying, as you said, Mr. Chair, is a complex and deeply personal issue. Every jurisdiction in the world that permits it or has debated it has carefully considered the wide range of interests at stake. In Canada, we work within a distinct legal and constitutional framework, which includes a division of powers between provincial, territorial, and federal governments, and the Charter of Rights and Freedoms, all of which inform the government's choices as reflected in this bill.

Bill C-14 would establish criminal law rules regarding medical assistance in dying that address eligibility, procedural safeguards, and the framework for a monitoring system. The proposed legislation would re-enact sections 14 and section 241, paragraph (b), of the Criminal Code, so that it would continue to be a crime to assist another person to die or to cause another person's death with their consent, except if either of these actions were done in accordance with the rules for medical assistance in dying as set out in this bill.

Bill C-14 would exempt physicians and authorized nurse practitioners from criminal liability if they provide medical assistance in dying to an eligible person in accordance with the procedural safeguards in the legislation. It would also exempt others who might be involved in this process, such as pharmacists who fill the prescription for medication.

Importantly, the bill includes a parliamentary review five years after coming into force. The government is also committed to further studying the complex issues of medical assistance in dying in the context of advance requests, mature minors, and where a mental illness is the sole underlying medical condition, none of which were before the court in Carter.

The government chose this approach after thoroughly considering the full range of potential options for a medical-assistance-in-dying regime. As noted in our legislative background paper, which I tabled at second reading, this included analyzing and comparing regimes in other jurisdictions, including Quebec's legislation, certain American states, several European countries, the country of Colombia, and others.

The government also relied on consultations conducted in this country, including the work of the special joint committee, the external panel, the provincial-territorial expert advisory group, and Quebec's multi-year study that informed the development of that province's own legislation. We also engaged and consulted with a wide array of stakeholders.

With the benefit of all this evidence and knowledge, which exceeds even the detailed record that was before the Supreme Court of Canada in the Carter case, the government has thoughtfully addressed this issue. Bill C-14 would allow for greater flexibility than the laws that exist in the United States, which are limited to terminally ill patients. At the same time, it does not go as far as some of the more permissive regimes in European countries. As the court noted in its Carter decision, “Complex regulatory regimes”—such as this—“are better created by Parliament than by the courts.”

Bill C-14 is fair and practical, and presents a balanced approach.

In terms of eligibility. I'm aware the requirement that a person's natural death be “reasonably foreseeable” has received some attention, including in terms of how it relates to the Carter decision. I would like to address these concerns.

The bill was deliberately drafted to respond to the circumstances that were the focus of the Carter case, where the court only heard evidence about people with late-stage incurable illnesses who were in physical decline and whose natural deaths were approaching. The court said the complete prohibition on assisted dying was a violation of charter rights for persons in these circumstances. In this way, the eligibility criteria in Bill C-14 comply with the Carter decision. They focus on the entirety of the person's medical circumstances and not on the specific list of approved conditions or illnesses.

By defining the term “grievous and irremediable medical condition”, the bill would ensure that all competent adults who are in an irreversible decline while on a path toward their death would be able to choose a peaceful, medically assisted death, whether or not they suffer from a fatal or terminal condition.

A person can be approaching a natural death based on medical circumstances that are not directly related to a serious, incurable illness, for example. As well, eligibility does not depend on a person's having a given amount of time remaining, such as a certain number of weeks or months to live, as in the United States. Reasonable foreseeability of death is ultimately a medical decision, and not a legal one, to be made by taking into account all of the person's medical circumstances, including the types and number of medical conditions, frailty, age, etc.

The vice-president of the Canadian Medical Association has confirmed that reasonable foreseeability of death is a standard that provides sufficient guidance to physicians and nurse practitioners by taking out a lot of the subjectivity that was left by the court's undefined concept of a grievous condition, while allowing those with the necessary medical knowledge and expertise to make the decisions based on the individual circumstances of each case.

There are other compelling reasons for there to be a requirement that the person's natural death be reasonably foreseeable. First, it provides a fair way to restrict eligibility without making assisted dying available to almost everyone. Second, restricting eligibility in this way is necessary to protect the vulnerable.

Other approaches to eligibility that were proposed and suggested would be arbitrary. For example, it would be arbitrary to permit people with degenerative but non-fatal conditions to have access to medical assistance in dying before their deaths have become reasonably foreseeable, while excluding individuals with mental illness alone, or those born with a physical disability, or those suffering physically or psychologically for any other reason. These are not viable options, in our opinion, as they discriminate on the basis of a person's medical condition from the outset rather than allowing the medical practitioner to consider all of the person's circumstances.

Others have suggested that the government should grant access liberally, based on the subjective experience of suffering of each individual and the right to choose when life ceases to have meaning, with little in the way of objective parameters related to their condition or safeguards. Our government firmly believes that medical assistance in dying should not be available for any and all types of suffering. If that were the case, the risk to vulnerable people would be greatly increased and, frankly, would be unacceptable. Such an approach could contribute to the stigmatization of persons with disabilities; it could undermine suicide prevention; and it could lead marginalized or lonely individuals to seek medical assistance to end their lives prematurely.

As the court noted in Carter, when crafting legislation, Parliament must balance and weigh the perspective of those who might be at risk in a permissive regime. Our government respects the Supreme Court of Canada, and believes that in legislating in this incredibly complex and personal area, we must be concerned with protecting the dignity of these Canadians' lives.

This is why the criteria in the bill address the full range of medical circumstances that can make a person's death reasonably foreseeable. In doing so, the law sends a clear message about the intended purpose of medical assistance in dying: to give competent adults who are in a path toward their natural death the choice of a peaceful passing. It also provides maximum flexibility for medical assessment to health care providers, both in terms of the circumstances that led a person to be on a trajectory toward death and in terms of the time during which they can seek medically assisted death.

I want to emphasize the importance of having a legislative response in place before June 6, 2016, when the court's declaration of invalidity expires. Without a new law, on June 6 the parameters of the Carter decision would come into effect.

The scope of the decision is uncertain in several respects and, as a result, there would be uncertainty as to how it would be applied in practice. Assuming for a moment that the Carter decision read down in section 14 and section 241, paragraph (b), of the Criminal Code so that except for medical assistance in dying these criminal laws would be in force, sufficient uncertainty would still remain.

First, given that in the medical community there is no common understanding of a “grievous and irremediable” condition, it would become difficult for a patient who would be eligible under Bill C-14 to gain access to medical assistance in dying. Without a clear law in place, some physicians who may otherwise be willing to provide it could refuse to do so because they are not clear on who properly qualifies.

As well, failing to define the Carter parameters with federal legislation could lead to a wide variation on how eligibility is applied, not only between provinces or regions, but within them. Access in remote and rural areas would be negatively affected, not only because physicians may be unwilling to provide medical assistance in dying in such an uncertain legal environment, but also because, under the Carter decision, nurse practitioners are not able to provide assistance.

Second, the current interim court approval process will end on June 6. Therefore, outside of Quebec, there would be no legally binding framework to govern medical assistance in dying in Canada. In other words, there would be no mandatory procedural safeguards to prevent abuses and protect vulnerable persons.

Guidelines published by medical regulators are not binding, nor are they uniform, which further risks creating a patchwork across Canada. This can pose very serious public safety risks. For instance, a patient could both request and receive medical assistance in dying on the same day. Without going through an exhaustive list of risks, needless to say, it would be irresponsible to let June 6 come and go without a federal law in place.

As the court made clear in paragraph 117 of Carter, “the risks associated with physician-assisted death can be limited through a carefully designed and monitored system of safeguards”. Bill C-14 provides a responsible and balanced framework that limits those risks and puts in place those safeguards.

I certainly welcome the opportunity to discuss this bill and contribute to your study of the proposed legislation. The approach in Bill C-14 responds to the Carter decision with what I believe is sensitivity in all of the issues that were before the court in this case and creates a responsible and fair legal framework to permit medical assistance in dying in Canada for the first time in our country's history.

Now, with your permission, Mr. Chair, I would like to turn it over to Minister Philpott.