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

[Pam Goldsmith-Jones, Liberal, Parliamentary Secretary to the Minister of Foreign Affairs]

Madam Speaker, I thank the hon. member for St. Albert—Edmonton for his service on the special joint committee.

I am very interested in the questions that we are going to ask ourselves as a Canadian society in the future. I am interested in his views on advance consent, consent for mature minors, and eligibility based solely on mental illness.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Madam Speaker, I believe that any legislative response needs to adhere to the parameters of Carter. What the Supreme Court said with respect to minors is “competent adult person”. If the Supreme Court contemplated minors, the Supreme Court would have said so, but it did not say that. It was very clear in saying “competent adult person”.

Similarly, with respect to advance directives, the Supreme Court said that persons who were suffering intolerably from a grievous and irremediable condition have a right to physician-assisted dying, not persons who anticipate that they will suffer from a grievous and irremediable condition.

I would also note that in the province of Quebec, which cast Bill 52, over the course of six years, three national assemblies, and three different governments, advance directives were initially in the first draft of Bill 52, but they were ultimately removed from the legislation when it was passed by the Quebec National Assembly, because legislators in Quebec were not satisfied that advance directives could be incorporated into the legislation without mitigating significant risks.

[Garnett Genuis, Conservative, Sherwood Park—Fort Saskatchewan, AB]

Madam Speaker, I thank the member for his remarks and the good work he did on the committee, and to some extent, the brave face he is putting on.

Of course, members worked hard on that committee, but were aware of the problems in the process as well. The fact is, we heard from three separate panels from the lobby group Dying With Dignity Canada, and we did not hear from any anti-euthanasia advocacy group.

I want to follow up on the question about conscience, because I think we had some misinformation from the other side.

The reality is that right now in Ontario, the policy of the College of Physicians and Surgeons is that there is a requirement not only to refer, but also to provide services that are within the standard of care in an emergency situation. Members from other provinces, and I am not from Ontario either, should know that this is presently the reality in Ontario.

Therefore, if we pass this legislation without conscience protection, presumably euthanasia and assisted suicide will enter the standard of care and then fit within that existing policy framework of the College of Physicians and Surgeons in Ontario. We might hope that they might change the policy or create special accommodation, but in the absence of that, that will be the reality right away.

I want to know what the member thinks about that, and maybe just underline why conscience is important because of the current reality in Ontario and the need for consistency across the country.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Madam Speaker, I do not support an effective referral regime. I believe that an effective referral regime would contravene section 2 of the charter. I would also note that there is no jurisdiction in the world that has an effective referral regime, not Belgium, not the Netherlands, not any of the states in the U.S. that have physician-assisted dying, and not the province of Quebec.

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

Madam Speaker, I would like to thank my hon. colleague across the way for his work on the special joint committee and certainly for his speech today.

I appreciate the discussion around conscience rights of medical practitioners and institutions. I wonder if my friend has any comments on the Canadian Medical Association's agreement with respect to the legislation and not advocating a worry with respect to conscience rights.

Also, I would like to know if my friend—

[The Assistant Deputy Speaker, NDP, Carol Hughes]

I am sorry, We only have time for a brief question, and we need an answer.

The hon. member for St. Albert—Edmonton.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

Madam Speaker, first of all, there is a large number of physicians who have raised this issue. I think Parliament owes it to them to address the issue.

I agree with the Minister of Justice and Attorney General of Canada that it is absolutely imperative, absolutely essential, that Parliament pass legislation before the declaration on the stay of constitutional invalidity expires on June 6.

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.

[Jane Philpott, Liberal, Minister of Health]

Mr. Speaker, I am honoured today to speak following on the comments made by my colleague, the Minister of Justice and Attorney General of Canada, when she introduced Bill C-14, an act to amend the Criminal Code for medical assistance in dying.

This is a historic debate on a matter of tremendous significance for Canada and for all Canadians. Advancing this issue and getting a legislative framework in place to allow medical assistance in dying is a solemn responsibility. This a deeply personal issue for every Canadian.

When a dying person approaches the end of life, many more people other than just that individual are affected, including the person's family, community, and employer, as well as the people working in our network of social and health care services, those who provide support during our difficult times.

For many people, death is a difficult topic. Conversations about death are difficult to have, whether it is with a family member or, in particular, with a health care provider. This topic is difficult on both sides of the conversation.

Our government has given this matter careful consideration.

Over the past 30 years, I have experienced the reality of talking frankly and openly with, perhaps, hundreds of patients as they were facing death. Through every stage of the process, my patients have taught me valuable lessons, lessons about caring and compassion, about fear and anxiety, about the importance of support when recovery is no longer probable.

In working with patients in the final months and years of their lives, I have learned that every person, every story, is unique. However, much is shared in common: the hope to die in peace; the desire to be respected; and to have personal autonomy and dignity honoured by family and health care providers alike.

My experiences have also reinforced my 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.

On February 6, 2015, the Supreme Court of Canada declared that the Criminal Code prohibitions on assisted dying were unconstitutional. The federal government was given one year to develop a federal framework to address this decision.

On January 15, the Supreme Court granted a four-month extension, to June 6 of this year, to give our government time to develop a legislative framework for Parliament to consider.

The Supreme Court's decision marked a watershed moment in an important and long-standing debate surrounding the right of Canadians to have the choice to a medically-assisted death. However, how it will be implemented, for whom and by whom, needs careful consideration.

As parliamentarians, we have heard from Canadians on this issue through so many conversations with our constituents and through the dedicated work of the joint parliamentary committee. Hundreds of experts and organizations, both in our country and abroad, have contributed volumes to our understanding of this very difficult subject. Many have spoken passionately about their work on the front lines of palliative care, hospice care, and end-of-life care. Others have talked about personal experiences with loved ones and about easing the physical and emotional pain that they experience.

Our government is grateful for the work of the federal external panel on Carter and for the work of the Special Joint Committee on Physician-Assisted Dying.

We have also benefited from the work undertaken in the provinces and territories on this issue, including the thoughtful recommendations of the expert advisory group on physician-assisted dying.

We are grateful to members of Parliament who have shared their own thoughtful, considered, and wide-ranging insights over the past few months and, indeed, years.

Our government has listened, and the legislation we are tabling is the product of their efforts and their collective wisdom and experience.

Today, we are taking decisive action. I think that it is good news for Canadians, including those who are facing this personal and very difficult choice, their families, and their care providers, who have all been carefully considering this legislation.

For people who wish to have the choice of seeking medical assistance in dying, Bill C-14 would allow that, in keeping with the Supreme Court of Canada's decision. This proposed bill is the product of careful consideration of several principles that guide our government, including the desire to support personal autonomy and access to health care services, while recognizing that it is imperative to protect vulnerable persons, individually and collectively, from coercion and disrespect.

With Bill C-14, certain health care providers would, under certain circumstances and conditions, be exempt from Criminal Code offences in order to allow them to provide or assist in providing medical assistance in dying.

The bill would clearly define the criteria that must be met for individuals to be eligible. We have set up safeguards to be followed to ensure that these criteria are met and that the request is truly voluntary. This is critically important to protect vulnerable populations and, frankly, to ensure that anyone who contemplates medical aid in dying has fully reflected on their choice.

We also create the foundation for a regime to monitor medical assistance in dying so we can see how it is working in Canada.

With this bill, we are demonstrating our government’s commitment to supporting the autonomy of patients who are approaching the end of their lives, while protecting the most vulnerable in our society.

There has been considerable focus on whether providers should be free to exercise their conscience rights. I want to underscore that this proposed legislation does not compel any health care practitioner to provide medical assistance in dying. Practitioners will have the right to choose as their conscience dictates.

However, we must also respect the rights of people seeking this procedure by ensuring that those providers who have expressed a preparedness to help patients can do so without fear of criminal prosecution. Under Bill C-14, certain health care providers, such as physicians and authorized nurse practitioners who administer medical assistance in dying would be exempt from criminal prosecution.

Since nurses and nurse practitioners have the authority to deliver many of the same medical services as family physicians, in that they can assess, diagnose, and treat patients, they, too, would be exempt from criminal prosecution.

This is critical, as nurse practitioners often work alone providing vital health care services in underserved areas, such as the most remote and rural parts of Canada. Other providers, such as pharmacists, registered nurses, and physicians who may provide assistance would also be exempt from criminal prosecution.

Therefore, rest assured that health care workers who provide and assist in providing medical assistance in dying will have no reason to fear criminal prosecution as long as they follow the appropriate safeguards.

In consultations leading up to this bill, there was strong consensus among Canadians that standardized data needs to be collected on the practice of medical assistance in dying.

In addition to Criminal Code amendments, this bill creates the power necessary for the Minister of Health to make regulations about the information to be collected, the use and protection of that information, and the processes for collecting and reporting that information.

We agree that a robust, transparent monitoring system on the practice of medical assistance in dying is essential, and analysis and trends need to be reported to the public on a regular basis. We, as the Government of Canada and Canadians, need to understand as much as possible about how the system is operating in practice so we can address any potential concerns.

To that end, this proposed bill commits the federal government to working with the provinces and territories to develop a pan-Canadian monitoring system. The system will allow us to collect and analyze data, monitor trends, and make recommendations for potential legislation and policy reforms.

We are not starting from scratch. Around the world in other places that have legalized medical assistance in dying, mandatory oversight systems are in place to carry out monitoring and public reporting each year.

We can look to these examples to help us decide what is right for Canada. We can also look closer to home, in Quebec, where a monitoring system was recently established.

Developing a robust pan-Canadian system with provinces, territories, and stakeholders will take time, and we know we need to be tracking this information as soon as possible.

From a health perspective, I feel strongly that it is important for us work toward consistency in the provision of health care services for all Canadians, regardless of where they live. Canadians and stakeholders are expecting and hoping for a pan-Canadian approach. They do not want a patchwork where they observe significant differences in quality and availability of services in their own community, province, or territory relative to other parts of the country.

A fundamental value in Canada is our commitment that Canadians across the country will have access to medically necessary health care services when they need them. This view reflects the underlying principles of universality, accessibility, and comprehensiveness so vital to our health care system.

Bill C-14 contains well-defined eligibility criteria and safeguards, which go a very long way to achieving our government's objective of a consistent framework for medical assistance in dying. While certain implementation details will be left to provinces, territories, and medical regulatory bodies, we will all operate under the same legal and access framework.

My health minister colleagues across the country have looked to us for leadership on a consistent approach for all Canadians. I am pleased that our proposed bill fulfills that expectation.

No aspect of what we do on the question of complementary measures should be done precipitously. There are several particularly challenging issues. On these, our proposed bill suggests a cautious approach that will seek further advice, as suggested by the special joint committee.

However, we also recognize that there is a difference between the decision to accept or forgo treatment and the decision to hasten one's own death. Accordingly, a higher standard of decision-making capacity should be required in the latter case.

As part of the eligibility criteria, the bill specifies that individuals must have reached the age of 18 to seek medical assistance in dying.

There is the equally if not more contentious matter of advanced directives. Advanced directives are used to indicate wishes for treatment if a person can no longer communicate.

The prospect of permitting requests for assistance in dying through advance directives is concerning to many Canadians. At the same time, others feel strongly that they should be able to convey their wishes for a medically-assisted death in advance of a future point time when, as in the case of a progressively debilitating condition such as dementia, they are no longer competent to make a request.

Advance directives are a difficult issue for many individuals, family members and health care providers. As difficult as it is to discuss the end of life ln the final days, it can be even more difficult to predict one's wishes and circumstances in the case where it is further off, especially in the distant future.

Many people are also troubled by the prospect of patients with a psychiatric disorder being eligible for assistance in dying on the basis of psychological suffering alone. There are strongly held views on both sides of this issue. That is why legislating medical assistance in dying has required a cautious approach, and that is why we have committed to independent studies to explore the challenging issues of mature minors, advanced directives, and mental illness further.

Following a period of study and further reflection, we will be better positioned to determine how these issues best fit into a Canadian framework for medical assistance in dying.

I believe that this is an approach that most Canadians would favour.

I said earlier in my remarks that this bill did not compel participation by health care providers to do anything which would run counter to their convictions. At the same time, we are also mindful that the exercise of conscience rights by providers may constitute a barrier to access for those who are seeking medical aid in dying. There is therefore a federal interest on behalf of Canadians in working with our provinces and territories to support access.

Collaborative work with provinces and territories could build on important international examples, such as the well-established networks we see in the Netherlands and Belgium. These provide insight as to how an end-of-life care coordination system could help facilitate access to a consulting physician or nurse practitioner. This is particularly important in rural and remote areas, or in situations where identifying a second provider to assess eligibility may be problematic.

One of the things I have heard is that better palliative care would assist in the end-of-life care options that have now been prescribed by the Supreme Court. I know first hand that there is a place and a need for both.

Palliative care focuses on relieving suffering and improving the quality of life for the living and dying. It provides relief to people dealing with a range of life-threatening conditions such as cancer, cardiovascular disease and amyotrophic lateral sclerosis, or ALS.

Today, Canadians are aware, and have a general understanding, of palliative care. However, some studies have found that the overwhelming majority, perhaps 70% or more of us, do not have access to it, particularly in rural and remote areas. Many providers are not well trained to provide palliative care services. Reinforcing this government's commitment to quality palliative care, this proposed bill signals our intent to support improvements to a range of end-of-life care services.

Like other health care services, the delivery of palliative care is mainly the responsibility of provinces and territories. However, the federal government can make significant contributions in this area. We are already supporting a number of initiatives aimed at improving capacity in our health care system to provide palliative care.

In partnership with the provinces and territories, health care providers, and non-governmental health organizations, the federal government has funded initiatives designed to advance palliative care awareness, education, national standards, and research. For real improvements to be made, we need to work closely with provinces and territories.

Since my appointment as the Minister of Health, it has been my immediate priority to reach out to provinces and territories to discuss needed transformation in our health care system, including care at the end of life, particularly in the setting where Canadians say they most wish to die; that is usually in their own home and community.

In that spirit, early this year I 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 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 believe that by working together, we can bring real change to the health care system so that Canadians can continue to have access to high-quality, sustainable care.

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. We want them to have autonomy in making decisions as they approach the end of their lives.

We are facing a challenging time frame to put this legislation in place, with a June 6 deadline. However, I believe that with this proposed bill, we have found a balanced approach that reflects the best interests of Canadians. That is why I urge all members of this House to support Bill C-14.

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

Mr. Speaker, I have some serious questions, especially for this minister.

Just now, the minister said that doctors' conscience was protected. I was very surprised to hear that. I did not read that clause. I would like the minister to tell me exactly which clause says that doctors' conscience will be protected.

Each and every one of us understood that, going forward, the provinces would define protection for doctors, which means that there could be 10 different interpretations. That is not a good thing. This is a federal Parliament, and we must act on behalf of all Canadians.

I have a second point I would like to raise. If there is to be protection for doctors' conscience, which we want, why not follow the Quebec model, which allows a third party to transfer a patient to another doctor? In other words, if the attending physician who does not want to treat the patient informs a third party, such as hospital or CLSC officials, the third party can transfer the case to another doctor.

I have two questions: Can the minister tell me exactly which clause in the bill protects doctors' conscience? Why not follow the Quebec model?

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

Mr. Speaker, as my colleague knows, this is a bill to amend the Criminal Code. As such, the bill is prepared in that format.

As he well knows, the matter of the care and delivery of care falls into the realm of provinces and territories.

I have made the commitment to work with my colleagues, the ministers of health across the country, to ensure that they understand that no health care providers should be required to provide care, that they should respect their conscience rights, but at the same time to make sure that all Canadians will have access to all options of care. I am prepared to work with them.

We have made the commitment to develop a pan-Canadian approach to care coordination at the end of life to make sure that all Canadians will have access to care.

We have deemed, through the tabling of the bill, to demonstrate that this is a medically necessary option for care at the end of life. I will work with my colleagues across the country to make sure it is there for Canadians.

[Murray Rankin, NDP, Victoria, BC]

Mr. Speaker, I commend the minister, as well as her colleague, the Minister of Justice, for their leadership on this very sensitive issue.

Aside from the issue of advanced requests and the issue of the unfortunate drafting of the bill, the issue I hear most about is the failure in this initiative to specifically commit to palliative care.

The minister has given words on that subject again today, but we note that there was nothing in the budget, despite campaign promises to that end.

I would ask the minister this. Would she consider restoring the secretariat on palliative and end-of-life care, and the development of a fully funded pan-Canadian palliative and end-of-life care strategy, in collaboration with provinces, territories, and civil society?

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

Mr. Speaker, that is an important question from the hon. member. I have reiterated, as he said, our commitment to ensure that we improve access to palliative care. Indeed, it would be my desire to see that every Canadian should access high-quality palliative care at the end of their life to give them that opportunity.

I often quote Dr. Atul Gawande, who talks about the fact that people not only need to have a good death, they need to have access to a good life to the very end.

This is extremely important to me. I will be working with the provinces and territories. I have already been working with my department. We will be investing in home care, and we will determine that all the necessary investments are in place. I am exploring all opportunities for how we can ensure that commitment is upheld and that care is available to Canadians.

[Sean Casey, Liberal, Charlottetown, PE]

Mr. Speaker, I thank the minister for her thoughtful speech and for her leadership on this extremely sensitive issue at an historic time for Canadians.

Much of what falls within the health domain is within the jurisdiction of the provinces. There is no question that the provinces are looking to the federal government for leadership.

Given the very compressed time frame that we have, I wonder if the minister could comment on the importance of the June 6 date with respect to the matters within the provincial domain. There is no question that the June 6 date is critical with respect to the matters that fall under the criminal law, but what is the significance of that date? Is it as important for the matters that are within the minister's jurisdiction?

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

Mr. Speaker, the hon. member has raised an important matter, and that is the reality that we need to have a legislative framework in place.

The provinces and territories have spoken to me loudly and clearly about their desire to make sure we have a consistent approach across the country. That came up in my meeting with health ministers in January. Since the bill has been tabled, my colleagues have told me they are pleased that it provides that framework for them. They have already done a tremendous amount of work across the country in determining their next steps. They have been working with regulatory bodies, and those regulatory bodies have put in place a number of measures to make sure that Canadian health care providers are educated and prepared for the changes the bill will put in place.

The June 6 deadline, no doubt, is an important one. That is why I urge all members of the House to support the bill, so that we will have a legislative framework that will provide that access to consistent care across the country.