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

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

Madam Speaker, I urge members of this House to understand the seriousness of the matter of a legal void, which might exist. I recognize that some have argued that this is not an important point, but I want members to understand that, if what is important to them is that Canadians have access to medical assistance in dying, the best way to do that is to support this legislation. Without it, health care providers require further clarification. They are being advised to seek legal counsel. There will be serious problems with accessing medical assistance in dying.

I am also concerned about the other end of the spectrum, where patients might access assistance in dying without adequate safeguards in place.

My colleague also raises the matter that the legislation makes it clear that this assistance in dying is available for Canadians who are otherwise supported by our universally funded public health insurance plan. There would be serious concerns about whether or not there would be access to assistance in dying for people who do not fall into those eligibility categories.

[Elizabeth May, Green, Saanich—Gulf Islands, BC]

Madam Speaker, for both the Minister of Health and the Minister of Justice, with real sincerity, I know how difficult this has been. I think all Canadians are grateful for the care in the approach. However, that does not change the result right now, today, as I do not feel I can vote for Bill C-14.

It grieves me to say so, but I do not believe Bill C-14 is compliant with the Carter decision. I see this as a strange conflict in a sense between two professions in Canada: the legal community and the doctors. I know what the doctors want from Parliament, and I know what the legal community is telling us. As a trained lawyer, I do not see how Bill C-14 is compliant with Carter.

Because future judges will read these debates for guidance, how on earth could Kay Carter access medically assisted dying under Bill C-14?

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

Madam Speaker, as a health care provider, it is my understanding and belief that people like Kay Carter would be able to access assistance in dying under this legislation.

Also, I would refer the member to the Minister of Justice and the documents she has presented in this House, which affirm the fact that this legislation meets the requirements of the Charter of Rights and Freedoms. I look forward to further conversations to support that.

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 third time and passed, and of the amendment.

[Randeep Sarai, Liberal, Surrey Centre, BC]

Mr. Speaker, I am pleased to participate in the third reading debate on Bill C-14, which would provide a federal framework on medically assisted dying. As acknowledged by many in the House in the last number of weeks, medical assistance in dying is a complex, challenging, and deeply personal issue for us all.

Since the Supreme Court of Canada rendered its unanimous decision in Carter last year, it has been discussed by many Canadians in different settings from coast to coast to coast. The issues continue to be debated and thoughtfully discussed worldwide, from the United States to Europe to Australia and New Zealand. Almost everywhere in the world, the act of ending one's life deliberately and the act of helping someone to end their life are serious crimes punishable by severe sentences.

Nevertheless, Canada is not alone in creating a legislative regime to permit medical assistance in dying. There are four American states, Oregon, Washington, Vermont, and California, the country of Colombia, and the three European countries of Belgium, the Netherlands, and Luxembourg that currently have legislative regimes that allow some form of medical assistance in dying.

These different international regimes share similarities, especially with regard to safeguards, oversight, and reporting, most of which are included in Bill C-14. These similarities are as follows: requests for medical assistance in dying must be in writing, made voluntarily by the patient, and in many cases witnessed by independent witnesses; a second opinion from an independent physician must be sought; and a delay or reflection period between the request and the actual provision of medical assistance in dying is required.

Colombia has a unique approval process for medical assistance in dying. It involves interdisciplinary committees within each hospital that assess requests and support patients and their families throughout the process.

In addition, almost all international regimes have mandatory oversight systems involving independent national or regional committees and government agencies or departments, which collect and process data in order to properly monitor medical assistance in dying. They make annual or biannual reports on medical assistance public in their respective jurisdictions. This evidence was critical to the Supreme Court of Canada's analysis in the Carter litigation.

Unlike the fairly consistent approaches, the safeguard and oversight that we see in other countries, the various laws take two different approaches with regard to both: one, the form of medical assistance in dying that is permitted; and, two, the medical circumstances under which it can legally be provided.

One could describe the different approaches with regard to eligibility and the form as being a spectrum. At one end of the spectrum stands the four American states that enacted the legislation, starting with Oregon in 1997, Washington in 2008, Vermont in 2013, and most recently California, just last year.

In these states, a mentally competent adult aged 18 years or older can obtain the assistance of a physician to die, only if their request is voluntary, and if they suffer from a terminal disease, which is defined as an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months.

In the U.S. states, the physician is only permitted to provide the patient with a prescription for a substance that the patient must self-administer at a time of their choosing. This is commonly known as physician-assisted suicide.

What is commonly called euthanasia, where the physician administers an injection to the patient, is expressly prohibited in these states. Advance requests are also not allowed.

While these legislative measures in the U.S. accommodate individuals suffering from diseases that cause a steady, rapid, and predictable decline toward death, such as some forms of cancer, they do not accommodate other conditions, including some degenerative diseases that are enduring and predictable, nor do they enable patients who are physically unable to self-administer a substance to access a medically assisted death.

The Colombian regime, which was developed in response to two rulings from its Constitutional Court, has eligibility criteria similar to that of the U.S. states. It limits eligibility to adults who have a terminal illness, defined as a progressive and irreversible serious condition or pathology that will cause death within a relatively short time frame. It does not require the person to have a prognosis of six months, but it does require that death is expected in the short term. Unlike the American states, Colombia only permits a physician to administer a substance that causes a person's death. However, Colombia's regime does permit a patient to prepare an advance request for medically assisted death, which is not permitted in the U.S.

At the other end of the spectrum, there is Belgium, the Netherlands, and Luxembourg, known as the “Benelux” countries. In these three northern European countries, patients are eligible for medical assistance in dying if they have “intolerable” or “unbearable” physical or psychological suffering resulting from a serious and incurable medical condition where there is no prospect for improvement. Eligible individuals do not need to be dying or suffering from life-threatening conditions. Both physician-assisted suicide and what is commonly called voluntary euthanasia are permitted in these countries.

While advance requests are permitted, there are some differences between the Benelux states. In Belgium and Luxembourg, advance requests can only be carried out where the patient is in a state of irreversible unconsciousness, while in the Netherlands, advance requests are also permitted where patients are unable to express their wishes but are conscious, such as for persons with dementia or Alzheimer's.

While medical assistance in dying is only available to adults in Luxembourg, children as young as 12 years of age can request medical assistance in dying with their parents' consent in the Netherlands. In Belgium, adults and emancipated minors can request medical assistance in dying for the same kinds of conditions. In 2014, Belgium extended eligibility to minors of any age, but only where they are likely to die in the short term and where their suffering is physical. Additional safeguards must also be met.

The experience and lessons from the Benelux countries have been closely examined. For example, in the Netherlands, while the legislation permits advance requests for patients who have lost their ability to express their wishes, Dutch research suggests that physicians are generally unwilling to provide medical assistance in dying, due to the inability of these patients to comprehend their medical condition and their inability to express informed consent.

The government has sought to learn from the experiences of other jurisdictions. The proposed legislation is broader than the U.S. state approach, which only permits those with a fatal disease to access assistance. Instead, Bill C-14 provides the option of a peaceful death to everyone who is in decline toward the natural end of their life, not just those who suffer from fatal diseases or terminal illnesses. At the same time, it avoids some of the risks that the Benelux-style regimes might present, although such broader questions, and the experience of other regimes around the world, will continue to be studied.

I urge all members to support this incredibly important bill to answer the call of our Supreme Court to legislate in this area.

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

Mr. Speaker, I very much respect my colleague from Surrey Centre's rather broad survey of some of the jurisdictions around the world that have brought in medical assistance in dying. I particularly appreciated his detailed analysis in terms of giving us a framework in which we could construct our particular legislation that is currently before the House.

My question to my friend is this. We have certainly heard comments coming from the government, particularly from the Prime Minister, that have suggested that this particular legislation is simply an initial step. Are there aspects in some of the research he has done with respect to the other jurisdictions that he thinks would be helpful in contributing to the dialogue moving forward?

[Randeep Sarai, Liberal, Surrey Centre, BC]

Mr. Speaker, there are certain aspects. I think the balance is going to be how open we can make this process, or how narrow it can be. There is always a fear of making it too broad, and on the other hand making it very restrictive for people who need this right so they are able to access it.

The other process that will be very important is to see what gaps might be in the system. Certain diseases or conditions might not be addressed properly in the legislation now, but as we monitor California, Vermont, and the various U.S. states, along with the Benelux countries of Belgium, Luxembourg, and the Netherlands, we can see where the gaps have been addressed and where they have come up in the courts. I hope that this House, along with the Minister of Justice, can address those from time to time as they arise.

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

Mr. Speaker, last evening in the House, we saw the reluctance on the part of the majority of the Liberal Party to include effective conscience protection for medical professionals and institutions that provide health care to Canadians. We do know that two colleges have already indicated that they expect their doctors, even if they are opposed to physician-assisted suicide, to make an effective referral to have physician-assisted suicide carried out.

My question to my colleague is, why would he and his party not realize the importance of allowing a medical professional with years and years of professional training, who opposes the idea of helping someone to die early, to have conscience freedom? Why would he oppose the aspect of having conscience freedom for medical workers, and also for the institutions that are providing very effective health care for our Canadian population?

[Randeep Sarai, Liberal, Surrey Centre, BC]

Mr. Speaker, I thank the member for his question, and I am glad that both sides of the House take this issue very seriously.

My understanding is that the bill and the preamble were already amended at the committee stage. The individual is protected, except for the institutions. I think the matter was already addressed, and that is why many members did not support that amendment. The matter has already been addressed in the preamble as well as the bill itself.

[Anthony Housefather, Liberal, Mount Royal, QC]

Mr. Speaker, I very much appreciate the excellent speech by my friend from Surrey Centre, and I want to reiterate what he said. Both in the bill and in the preamble, there are conscience exceptions for individuals, which was agreed to by all members of the committee.

However, many members are concerned about advance directives. The committee said that studies would begin within six months. However, one of the things that is very important to note is that advance directives, even in the one country that allows it for people with dementia and other declining illnesses, is not really carried out. In the Netherlands, given the concerns about what someone's wishes actually are at the time of death if they have dementia, almost nothing happens.

I wonder if my colleague would confirm that he also agrees that this matter requires further study before we would ever implement it.

[Randeep Sarai, Liberal, Surrey Centre, BC]

Mr. Speaker, I agree with the member. An advance directive is an issue that we need to study, and even six months might be a short period of study. I think a longer period would be needed to address such concerns.

We need to see how it would be carried out. Only after that has been looked at should we think about advance directives. It is a subject that needs a lot of comprehension. I think it would be hard for a person to make that directive initially, without guidelines and safeguards around it.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Mr. Speaker, I will share my time with my colleague the member for Carlton Trail—Eagle Creek.

This is a very difficult time in my short political career, because it is a sensitive subject that should be free of partisanship. All opinions are right, and no one is wrong. We are all good Canadians of good conscience, and we are looking for the best solution on such a sensitive subject.

When it comes to this subject, we are not here to try to convince anyone; we are here to explain our point of view. According to the Supreme Court’s decision in the Carter case, it is not a matter of determining whether we are for or against medical assistance in dying, but of determining how we will apply it.

Here we are at the final reading of Bill C-14. At my leader’s invitation, I had the privilege of participating in the parliamentary committee that studied the matter and produced a main report and a dissenting report. My official opposition colleagues and I signed the dissenting report, while my Conservative colleagues in the Senate signed the main report. This shows that there was no partisanship in our approach.

In our dissenting report, we raised five major concerns. Most of them were noted by the government and are reflected in Bill C-14. We were against the medical assistance in dying bill applying to minors; the government listened to us. We were against the bill applying in the case of mental illness; the government listened to us. We wanted complete openness concerning conscience protections for physicians and institutions; the government listened to us in part. We also wanted a clear commitment from the government concerning palliative care; the government listened to us in part.

On another note, I salute my colleague from Sarnia—Lambton, who introduced Bill C-277 in the House almost exactly 24 hours ago. The aim of this private member’s bill is to force the government to make a firm commitment to provide the necessary palliative care to as many Canadians as possible. As we know, only one-third of Canadians have access to that type of care. With Bill C-277, we want that to be enforced.

Those are the elements of Bill C-14 that we consider positive or semi-positive. Now here are the things that are of great concern to us.

First, there is the famous definition of reasonably foreseeable death. For us, this makes absolutely no sense. “Reasonably foreseeable” means both everything and nothing. I am going to die some day. That is reasonably foreseeable, of course, but it means absolutely nothing. From sage experience, Quebec used the expression “end of life”. That is at least clearer.

There is also the matter of nurse practitioners, who have the same decision-making powers as physicians under the bill. I have tremendous respect for nurses, and I know what I am talking about, since they are often the first people, and sometimes the only people, who see us when we are in hospital. However, when it is a matter of life or death, and that is literally the issue here, I would prefer that physicians have the ultimate responsibility rather than the wonderful nurses.

The points I have just mentioned are based on Quebec’s experience. I know what I am talking about, because I was a member of the National Assembly of Quebec. We worked on and gave serious consideration to the issues surrounding medical assistance in dying for six years, whereas here in the House we had only a few months to do the same work.

Later, I will talk about an unfortunate statement we heard during question period.

Based on Quebec’s experience, we built our case for the dissenting report. The current bill includes some elements in full, others to some extent, and still others not at all. It is a fairly even balance of the positive and negative elements.

Then there remains the famous issue of constitutionality. Every bill that is put forward can be challenged. In fact, whatever bill was introduced, it would have been challenged by one group or another. For weeks, some people have been saying that it is constitutional, and others have been saying that it is not. Most of the people we heard from said that it did not make sense and that it did not comply with the Constitution or the Carter decision. However, this morning, in La Presse, if I remember correctly, three constitutional experts from three different universities, namely Laval University, the University of Montreal, and UQAM, said it was constitutional.

If we table a bill, we will hear a bunch of lawyers say that it is good and a bunch of lawyers say it is not good. This is the point, and we have to live with that. It is democracy. This is how it works in our judiciary system.

I say this with great respect for legal eagles. I know that there are some here, some prestigious ones in fact, and I salute them, including the member for Mont-Royal.

The charter issue is another interesting point. Some people say it complies with the charter, while others say it does not.

Let us try not to be too partisan. If we cannot rely on the Liberal government to draft a bill that complies with the charter, whom can we rely on? Do I need to remind anyone that it was the Liberal Party, under the leadership of the Right Hon. Pierre Elliott Trudeau, father of the current Prime Minister, who enshrined the Canadian Charter of Rights and Freedoms in the 1982 Constitution, signed some 300 feet from here by Her Majesty the Queen on April 17, 1982? We all remember that. The sky was overcast, and at the very moment the signing took place, there was a rumble of thunder. Just a brief history lesson.

Seriously, I am not the greatest fan of the charter, much less of the Liberal Party, especially not the Liberal Party, but good Lord, if we cannot rely on the Liberal government to draft a bill that complies with the charter, I wonder whom we can rely on.

The events are balanced. This bill has good points and bad points. Over the past 24 hours, three events occurred that are worth thinking about. First, yesterday we voted on 10 possible amendments and they were all defeated by the Liberal majority. I commend the government members who voted against their party's position for their courage, honour, and dignity. Well done.

However, I believe that two of those amendments, both of them introduced by the member for St. Albert—Edmonton, were essential.

The first amendment protected the most vulnerable members of our society by proposing that people undergo a psychiatric assessment before giving their consent. We think that is extremely important because protecting the most vulnerable members of our society is essential. Nevertheless, the government voted against that amendment.

The second amendment had to do with conscience protections for institutions. I speak on behalf on my friends from Quebec when I say that, in Quebec, institutions such as hospitals are secular. However, outside Quebec, some institutions are religious and act according to the dictates of their conscience. We need to protect their conscience rights, but this bill does not do that. We proposed that amendment, but the government voted against it. That is unfortunate. The government refused to accept amendments.

Moreover, this morning, Quebec's health and social services minister, Gaétan Barrette, made a statement. I know the guy. He is honest, hard-working, conscientious, and a man of integrity. He is also a medical specialist who was once an administrator and is now a minister. Speaking on behalf of the government of Quebec, he said:

I myself am disinclined, for governmental and professional reasons, to support C-14 because of its worst feature: reasonably foreseeable natural death. That makes no sense. It cannot be enforced. I would be very hesitant to get on board C-14 as it stands...

He added that the bill is very off-putting, that this is a bad clause, and that it is [too much] of a minefield for him.

The third element applies to the Prime Minister's statements in question period today. He said he is working with the provinces on this, but that has no basis in fact. Worse still, he said, “we drew a great deal of inspiration from the reflections of the Quebec National Assembly”.

I can tell you one thing. I sat in the National Assembly. I was there for the six years that this was being studied. What we have seen here in the past six months does not resemble in the least what took place in the National Assembly.

I will not revisit the unfortunate events that took place two weeks ago when there was to be a vote to restrict our right to speak. I will look at the overall process. Unfortunately, the government did not follow the example set by the National Assembly in terms of either substance or form.

Consequently, bearing in mind the positive and negative elements of the bill and the three events that have taken place over the course of the past 24 hours, that is, the vote against the amendments, which were all rejected, the statement by the Quebec minister of health and social services, and the misleading statement by the Prime Minister of Canada, I will be voting against this bill.

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

Mr. Speaker, I am going to be honest. I agree with a significant part of what the member has said today. I was one of the members on the government side who actually voted with the opposition on some of the amendments that were brought forward, including the one that related to protections to ensure there was an appropriate medical opinion when there was a question with respect to capacity in the case of someone with a previous mental health condition.

I want to get to the other issue that was advanced, and that was the one with respect to dealing with institutions. I did not support that amendment and I want to say why on the record. I felt the provision should not appropriately fall within the Criminal Code and that, in fact, there was a more appropriate type of response through our regulatory colleges at the provincial level. I think this is why the government side overwhelmingly rejected that provision.

I want to get back to the question my friend talked about with respect to reasonable foreseeability. I share some concerns that have been raised by members on the other side with respect to reasonable foreseeability. What would the member suggest would make this provision clearer, particularly as it relates to setting a clear legal standard as guidance for physicians who would have to operate under this provision?

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Mr. Speaker, because as the minister of health in Quebec said, it is unpractical. We cannot deal with that. I will say this in French because it is very difficult for me to say in English. It is raisonnablement prévisible. It is everything, but nothing. This is why we have to be clear.

As in the Quebec experience, it was crystal clear, end of life. That is why we suggest this. By the way, this is why all of our amendments were based on the Quebec experience. In the Quebec experience, there were six full years of studious work, which is not the case here. This is why the government should have followed the lead of the National Assembly of Quebec, which is not the case. This is not what the Prime Minister said.

Let me be clear. The bill is not perfect, but we all recognize that on June 7 there will be no law because the Senate will not have had enough time to adopt the bill. Therefore, I think the Conservatives will vote against the bill.

[Linda Duncan, NDP, Edmonton Strathcona, AB]

Mr. Speaker, I wonder if the member could speak to the issue of nurse practitioners. I do not know if he has had the opportunities I have had in my life. For example, I worked in Yukon. One of my friends is a nurse practitioner in one of the small towns in Yukon. Over time nurses were given expanded powers to do various things, like stitch people, and so forth.

Who will have the responsibility for enabling a patient who is seeking medically assisted death to have access to a physician and who will pay for that patient to go to where there is a doctor, or for the doctor, or doctors, to go to where the patient is in isolated communities?