Bill C-7 (Historical)

An Act to amend the Criminal Code (medical assistance in dying)

This enactment amends the Criminal Code to, among other things,
(a) repeal the provision that requires a person’s natural death be reasonably foreseeable in order for them to be eligible for medical assistance in dying;
(b) specify that persons whose sole underlying medical condition is a mental illness are not eligible for medical assistance in dying;
(c) create two sets of safeguards that must be respected before medical assistance in dying may be provided to a person, the application of which depends on whether the person’s natural death is reasonably foreseeable;
(d) permit medical assistance in dying to be provided to a person who has been found eligible to receive it, whose natural death is reasonably foreseeable and who has lost the capacity to consent before medical assistance in dying is provided, on the basis of a prior agreement they entered into with the medical practitioner or nurse practitioner; and
(e) permit medical assistance in dying to be provided to a person who has lost the capacity to consent to it as a result of the self-administration of a substance that was provided to them under the provisions governing medical assistance in dying in order to cause their own death.

Criminal Code

[Kevin Lamoureux, Liberal, Parliamentary Secretary to the President of the Queen’s Privy Council for Canada and to the Leader of the Government in the House of Commons]

Madam Speaker, I must say right at the beginning that numerous members of Parliament, at least on the Liberal benches, have talked about the importance of palliative care. It has been incorporated in many ways, whether in budget issues or the throne speech.

When we talk about this particular piece of legislation, the member is upset over two or three aspects of it. I can appreciate that. I suspect the bill will eventually get to committee and in a minority situation, the member will be afforded the opportunity to bring forward ideas and changes that he would like to see with the legislation.

Would the member not agree that having this discussion, and having it go to committee, is a good thing to do? In regard to input, at the beginning of the year over 300,000 Canadians provided input on this legislation.

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

Madam Speaker, I already spoke about the flaws in the government's consultation process. If this bill gets to committee, I certainly look forward to the opportunity to raise these amendments around removing the provisions dealing with same-day death, around removing the provisions that deal with death without contemporaneous consent, and around removing provisions that deal with death without independent witnesses. I hope government members and members of other parties will listen to those proposals, recognizing that those aspects of the bill have nothing to do with the court decision that this bill is supposedly responding to.

The member is right to say that Liberals often speak about palliative care during debates about expanding euthanasia. However, what I have failed to see is action. How about they bring forward legislation on palliative care? How about they bring forward legislation on improving access to assisted living, instead of paying lip service—

[The Assistant Deputy Speaker (Mrs. Alexandra Mendès), Liberal, Alexandra Mendes]

The hon. member for Jonquière.

[Mario Beaulieu, Bloc, La Pointe-de-l'Île, QC]

Madam Speaker, I listened carefully to my colleague's speech. He shared a number of concerns, but I have to wonder what is behind them.

All members know that this bill is based on principles, and I think principles are behind his concerns. My colleague should know that our own personal principles should not violate someone else's principles. This is even more important in the case of dying with dignity. We cannot force our religious beliefs on others who may not necessarily share those beliefs.

One part of my colleague's speech about choice stood out to me. He said that people should have autonomy to make choices. I would remind the member that the word “autonomy” derives from the two Greek words “auto” and “nomos”, meaning “to be ruled by one's own laws”. It is up to an individual to decide whether to end their own life. It seems to me that any attempt to impede that decision would be made under false pretences.

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

Madam Speaker, I would welcome the opportunity to speak with my colleague at great length, perhaps outside of the House, about our religious views and how all of our basic a priori assumptions about human dignity and human value may inform things we are talking about.

We might find ourselves agreeing on the importance of some application of autonomy. I do not think removing the requirement for contemporaneous consent is consistent with autonomy. I do not think that if a person, at a low moment, says they want to die today, removing any possibility of a reflection period is consistent with autonomy. The values of autonomy should engage people in expressing their considered judgment over time with all the information in a situation where they have alternatives.

If we tell someone their only choice is between living in a cockroach-infested facility and death, they are more likely to choose death than if they are given a real, humane, living with dignity alternative. Let us agree on the importance of autonomy, but let us recognize that the architecture of choice informs the choices that are and are not available to people. We can do better by giving them a context in which to make a life-affirming choice, if that is what they wish.

[Alexandre Boulerice, NDP, Rosemont—La Petite-Patrie, QC]

Madam Speaker, we are not leading the way with this bill. We are already lagging behind. Hundreds of people have been dying in needless pain for years. We have the opportunity to take a step forward and let people die with dignity. It is not about moving from a cockroach-infested room to a clean one. It is not the same thing. People are prisoners in their own bodies and suffering needlessly.

Why should they not be able to make that decision?

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

Madam Speaker, the member referred to court decisions. Again, the focus of my remarks was on aspects of this legislation that have nothing to do with court decisions. I want us to remove same-day death, to remove death without contemporaneous consent, and to remove death without independent witnesses. I think all three of those are reasonable changes, and none of them would interact with a court decision that was made.

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

Madam Speaker, it is my honour and privilege to join this debate today, though it is a sad one for me. I remember coming to this place. We passed Bill C-14 right off the get-go. It is where I cut my teeth in politics, I would say. At the time, we mentioned that this was a slippery slope. We had seen it in the Netherlands. Currently the government there is passing legislation to allow children under the age of 12 to be euthanized. They are working with what's called the Groningen protocol, where it is not the individual but a group of doctors making the decision as to who gets to live and who gets to die. Here, we saw that this erosion of protection began virtually as the ink was drying on the original bill. We have seen the government not uphold the wishes of this Parliament. We have seen a junior court strike down the law, calling it unconstitutional.

This is where I have some frustration. The ink was not even dry on the bill when it was being challenged in the courts. It had just passed through the House of Commons. It is incumbent upon the executive branch of government to defend the decisions of this place, whether the government agrees with a court or not, and this was a brand new law that had just been thoroughly discussed in this place. We had worked hard for the amendments. For the government to abandon all the work we had done and decide that a junior court decision stood and that it was not going to appeal it to a higher court, like the Supreme Court, was an abdication of the executive branch's responsibility, and I definitely want to acknowledge my frustration that the government did not appeal this court decision.

That said, this bill is much broader than the court decision, and I would argue that we continue down the slippery slope. When Bill C-14 was introduced, I remember talking about the slippery slope and being assured it was not a thing. Yet here we are, removing safeguards from the bill.

This bill definitely makes two classes of Canadians. Across the country, we see a big emphasis on suicide prevention. Every level of government in this country has suicide prevention strategies. We see community groups getting together to run hotlines. Facebook has a warning system to help folks who are considering suicide. Facebook will even identify them and notify people who are close to them that their friend is not feeling well. The American military has worked with Facebook as well, to identify veterans who are considering suicide. We see throughout Canadian society that there is very much a focus on preventing suicide.

Where does that comes into play in this bill? It would create two levels of Canadians. In one case, there are able-bodied, otherwise healthy people suffering from mental illness who are considering suicide. All of those suicide-prevention apparatuses come to their aid. We even have bridges in this country that have nets to catch people in case they jump. All of that stuff comes to the aid of those particular people. However, for sick people who have a grievous and irremediable condition, that stuff is optional and they can request death. They can go to their doctor and say they are not feeling well and are suffering, and that their grievous and irremediable condition has affected their mental health and they are having suicidal thoughts. Then suddenly they are eligible for assisted suicide.

This creates two classes of people. If they are otherwise healthy, suicide prevention is granted to them; if they have an underlying grievous and irremediable condition, they are eligible for, as the government likes to call it, medical assistance in dying or assisted suicide. That is what this bill would do.

Prior to this bill, there was a requirement that a person's death be reasonably foreseeable. I remember that when we were discussing this, we found it to be kind of nebulous. What did that mean? There was no timeline on it. I remember we said that for a death to be reasonably foreseeable, it would have to be in six months or within a year. Those were amendments we brought forward. The government did not go for them back then. Now we see the courts are taking that off and the government is not even defending it. That is definitely one of the concerns we have. We are creating two classes of citizens: one for which suicide prevention is available and one for which it is optional.

The other thing I want to talk about is an amendment we brought to the original bill, one that I think would be an improvement on this bill. It is the need for video verification. In the current rendition of the bill, the timelines have been reduced or eliminated altogether, from the time of the request to the time when MAID is administered. There is a concern that family members may not be convinced that their loved one requested MAID and that they were giving consent at the moment thereof. There has been a suggestion by some groups that there be a video recording of the administration of MAID. That is an amendment I would seek at committee. We would definitely like to see something like this.

Lastly, we would like to see the government work to enhance assistance in living. With COVID, many of our old folks in seniors care facilities are not able to see their loved ones because of restrictions on movements and not being able to travel. The military had to be called in to deal with some of the situations. We talk a lot in this place about dying with dignity, but maybe it is time that we started focusing on living with dignity, having a dignified life, taking care of our elders and being part of a family.

I have talked to folks who have been working in the old folks homes lately and it has been a rough job. They say the loneliness is a major issue in old folks homes these days. The loneliness leads to mental health issues, and if those mental health issues are not addressed, people will become suicidal and will request MAID for loneliness. Is that what we really want in this country? Assistance in living is something we have to be concerned about.

This also deals with palliative care. Palliative care is something the government pays lip service to. We have called for national strategies on this. We have called for money to be put into it. In the absence of palliative care, there is no real choice. There is no ability for somebody to say that this is what they are choosing. Palliative care is an acknowledgement that while there is, humanly speaking, nothing more we can do, we can make a person comfortable and allow them to be surrounded by friends and family as they leave this earth. We would very much like to see the government pursue a significant improvement in palliative care, rather than allowing the elderly members of our families to vanish into an old folks home, where we are not allowed to visit them at this point, to die of loneliness and be offered MAID as the first available option.

This bill has many concerns. It is the first evidence of the slippery slope that is happening in the euthanasia debate, and I definitely wanted to raise that concern. I am also concerned that this bill creates two classes of citizens, as I clearly outlined. I am looking forward to the government making some amendments to the bill and look forward to being able to participate in those discussions at committee.

[Nathaniel Erskine-Smith, Liberal, Beaches—East York, ON]

Madam Speaker, of course, no one is going to disagree with improving the lives of our seniors through better palliative care, but the soft paternalism that ran through those comments is completely fabricated, as though if we just focus on assisted living and just provide additional support, nobody in any position is going to want to end their life and exercise personal autonomy and individual rights. There are individuals who are suffering intolerably, people who are of sound capacity and mind to make decisions about their own lives. They are suffering from an effectively incurable illness and some members want to take those rights away.

My question is simple. Has the member read the Supreme Court's unanimous decision in Carter, and if he has, what about the criteria established for eligibility does he disagree with?

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

Madam Speaker, I was pointing out that with Bill C-14, we entered a slippery slope, as the safeguards had been removed. Bill C-14 is the law of the land. I am merely pointing out that we are now removing the reasonably foreseeable requirement. We are not improving the safeguards at all with the bill. In fact, we are removing safeguards. In the absence of palliative care, in the absence of a true choice, that leaves folks with no choice at all.

[Alexis Brunelle-Duceppe, Bloc, Lac-Saint-Jean, QC]

Madam Speaker, I believe that two of my hon. Conservative colleagues in a row have spoken to us about palliative care and care in long-term care facilities, such as CHSLDs in Quebec. It seems to me that they are trying to sidetrack the debate. We are talking here about medical assistance in dying. The two are not related. They seem to be saying that, if we had better palliative care services, then there would be no need for this bill. That does not make any sense.

However, if they want to go there, then I would tell my hon. colleague that his party was in office from 2006 to 2015 and the provinces were not granted the increased health transfers that the Quebec and other provincial premiers are calling for. In fact, the Conservatives made cuts to those transfers. It seems to me that this party, which is lecturing us on palliative care, had a role to play in the fact that the provinces do not have enough money to manage their jurisdictions.

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

Madam Speaker, I would say that is fake news. Under Stephen Harper, health transfers actually increased. Under Stephen Harper, the sovereignty of the provinces was improved. Under Stephen Harper, the separatist movements across this country were diminished, both in the member's province and in my province. Under the current government, divisions run deep across this country and separatist movements are growing not only in his province, but also in mine.

[Eric Melillo, Conservative, Kenora, ON]

Madam Speaker, as I mentioned earlier in this debate, unfortunately in a lot of the rural and remote communities and the many indigenous communities in my riding, and I imagine in the hon. member's riding as well, there is not an equitable access to health care services. That includes palliative care, unfortunately, in many circumstances.

I am wondering if the member could speak to how important palliative care and all these health services are for every single Canadian.

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

Madam Speaker, across Canada palliative care is inconsistent. We are looking for some guidelines from the federal government on what palliative care should look like, with standardization across the country. We want funding to be dedicated to it. We also want the conscience rights of folks and organizations working in health care to be protected. In the Delta Hospice Society case, for example, the provincial health authority is forcing its ideology upon a hospice that is quite convinced that MAID has no place whatsoever in hospice care.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Madam Speaker, I am delighted to speak today to Bill C-7, an act to amend the Criminal Code, medical assistance in dying. Its proposed Criminal Code amendments to the medical assistance in dying regime are a true reflection of the value we as Canadians ascribe to individual autonomy.

I wish today to address a specific aspect of Bill C-7, which is the exclusion from eligibility for medical assistance in dying, or MAID, of those whose sole underlying medical condition is a mental illness. This is an aspect of the bill that has already attracted some attention, and I am grateful for the opportunity to make these remarks to provide context around the government's choice to not extend medical assistance in dying in this area at this time.

The government has heard from various sources that there are unique risks and complexities associated with medical assistance in dying on the basis of mental illness alone. These include the report of the Council of Canadian Academies' expert panel on medical assistance in dying where a mental disorder is the sole underlying medical condition, as well as the experts the ministers consulted in recent round tables on medical assistance in dying.

In this Canadian-made context, very specific concerns have been raised in relation to mental illness, those illnesses that affect how a person perceives themselves, their environment, their place within it and sometimes their future. The first main concern is that the trajectory of mental illnesses is harder to predict than that of other illnesses. Unlike some dementia and intellectual disabilities, the underlying causes of mental illness remain largely unknown. Mental illnesses can spontaneously remit or can be difficult to treat for years until one treatment or one social intervention works and improves quality of life, reducing that person's suffering.

For example, we learned from the Council of Canadian Academies' report that an important percentage of persons living with borderline personality disorder will see their symptoms go away as they age, and some people with problematic substance use disorders also spontaneously remit. Experts disagreed on whether a mental illness can ever truly be considered incurable. Indeed, the Canadian Mental Health Association has indicated, “CMHA does not believe that mental illnesses are irremediable, though they may be grievous or unbearable [and] there is always the hope of recovery.”

A second main area of concern is that the desire to die can be a symptom of some mental illnesses. Here I address specifically the concerns just raised by the member for Peace River—Westlock around suicide. I acknowledge and recognize his sincere concern. Having a mental illness is, indeed, a significant risk factor for suicide.

This underscores the difficulty of assessing the voluntariness of a MAID request from a person who may be experiencing a desire to die as a symptom of mental illness. Some practitioners also raised the concern that an expanded MAID regime could negatively impact suicide prevention efforts if MAID were a legal option in response to suffering caused by mental illness alone, both at the level of public messaging and at the individual clinical level.

The Council of Canadian Academies' expert panel also noted the particularly troubling situation of suicide rates in indigenous populations. This is an issue that concerns us all deeply. It was the expert panel's view that the potential impact of MAID where a mental illness is a sole underlying condition, if any, on suicide prevention efforts must be explored more deeply with indigenous people.

By contrast, there are other conditions affecting the brain that do not raise these same concerns. For example, the trajectory of cognitive impairments such as Alzheimer's, Huntington's Disease or other neurodegenerative diseases is more easily predicted, in large part because the underlying pathology is better understood.

Intellectual disabilities are a permanent state and there are no concerns with an unpredictable illness trajectory or a person's perception of their place in the world being affected. Indeed, many do not consider such conditions to be a mental illness or mental disorder. While they may raise other concerns, these are likely more properly addressed by assessments of decision-making capacity.

On the other hand, those who live with mental illness can experience unimaginable suffering and even physical pain. There is no question that the suffering that some with mental illness endure can be intolerable. Some who suffer from both physical and mental illness have said that, if they were able to choose, they would easily choose to endure the physical pain if the mental anguish could end. It is understandable that there is no consensus on this issue.

The group of experts the Council of Canadian Academies recruited could not agree on several fundamental questions, including whether it is possible to have a valid and reliable method of distinguishing between suicide and an autonomous decision for medical assistance in dying where a mental illness is the sole underlying medical condition.

A subset of the Council of Canadian Academies' expert panel, the Halifax group, recently recommended that the MAID regime should not exclude persons whose sole underlying medical condition is a mental illness. Instead, there should be a legislative requirement that the decision to die be well considered to ensure that a MAID request is well thought out and not impulsive. Others say that to exclude those with mental illness only perpetuates stigma and discrimination.

On the other hand, another subset of the Council of Canadian Academies' experts, the expert advisory group on MAID, recommended that the MAID regime acknowledge that, at this time, it is not possible to determine that a mental illness is irremediable or that a state of decline due to a mental illness is irreversible. Therefore, persons whose sole underlying medical condition is a mental illness could not fulfill the current MAID eligibility requirements.

Given these diametrically opposed points of view from experts, it would not be prudent to permit eligibility for medical assistance in dying where a mental illness is the sole underlying medical condition at this time without more study and deliberation.

We, as legislators, are not experts in mental illness. Let us, instead, take the time to listen closely to what experts have to say on such an important topic, where the consequences of a decision are irreversible.

The parliamentary review will provide an opportunity to hear from experts and others, and allow parliamentarians to carefully consider, without the time pressure of responding to the Truchon decision, whether and how medical assistance in dying could safely be extended to persons whose sole underlying medical condition is a mental illness.

The government understands very well that mental illnesses can and does cause intolerable suffering. By excluding persons whose sole underlying medical condition is a mental illness, we are not seeking to send a message that this suffering is lesser, that persons struggling with a mental illness cannot make decisions for themselves, or that their autonomy to choose when and how to die matters less.

Instead, we are taking a pause and acknowledging that this very complicated question needs more time, careful consideration and requires us to proceed prudently. The Province of Quebec is adopting a similar approach, though not through legislative amendments. I think this is wise, and we will be paying close attention to the consultations taking place in that province as well.