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

[Emmanuella Lambropoulos, Liberal, Saint-Laurent, QC]

Mr. Speaker, as we saw in a lot of the feedback received during consultations, many people did think that a lot of the safeguards were preventing many people from receiving the right to receive MAID in their final moments or in times when they did not see a recovery and they saw their condition getting worse with time. Not everybody has a family, not everybody has a lot of people in their close circle. Obviously, I believe in protecting Canadians, but at the same time in making sure that everybody has equal access to rights. This obviously gives more accessibility to more people.

[Jenny Kwan, NDP, Vancouver East, BC]

Mr. Speaker, Bill C-7 sets the assessment period at 90 days for those whose natural death is not reasonably foreseeable, but are facing intolerable suffering. Does the member agree with the 90-day assessment and does she know how the government came up with the 90-day period?

[Emmanuella Lambropoulos, Liberal, Saint-Laurent, QC]

Mr. Speaker, I personally do not know how that number came up, however, I know that if someone's mental capacity is at the risk of being lost in that 90-day period, it will not take 90 days. However, I would imagine that, for somebody who does have many more years ahead of them and does not have a reasonably foreseeable death, perhaps more reflection needs to be done before actually going through with this kind of thing. I do agree with the 90 days. I think that people need to have enough time to really think about this issue and whether this is the route they want to take and to really consider all other options available before finally going with this one.

[Dane Lloyd, Conservative, Sturgeon River—Parkland, AB]

Mr. Speaker, when the government is talking about things like intolerable pain or unbearable pain, I think we can all agree that for some people it is a very fluid, subjective statement. Therefore, if we are basing it on subjectivity, what can be intolerable pain for one person could be a case of depression for someone else. Is the government not really admitting that it is opening the door in the future for people to get an assisted death for any and every reason because the criteria it is setting are just so subjective for people?

[Emmanuella Lambropoulos, Liberal, Saint-Laurent, QC]

Mr. Speaker, the bill also proposes to ensure that mental illness is not a reason to go ahead with MAID and that people who suffer solely from a mental illness will not be eligible for MAID. That has been taken into account. I still agree that this is something that people should have the choice to decide for themselves.

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

Mr. Speaker, today I am pleased to speak to Bill C-7, an act to amend the Criminal Code with respect to medical assistance in dying, which I will refer to as MAID throughout the course of my speech.

This can be a difficult issue for many to address because it intersects several issues in society. First of all, there are taboos, and societal norms associated with those taboos, around discussing dying, religious beliefs, social supports, or the lack thereof, related to people who are in difficult or life-threatening situations, love and compassion for one another, and the agency that each of us has to direct our future.

I would like to explain what this bill would do, what I am hearing from my constituents on this issue, my approach to addressing this legislation and my decision on how I will be proceeding on their behalf.

As has been mentioned in many speeches, this bill builds on previous legislation that allowed for legal, medically assisted dying in Canada. This bill would amend legislation to remove the “natural death has become foreseeable” clause, meaning that reasonably foreseeable death would not be a criterion for accessing MAID. Of course, this comes after a decision in the Quebec Superior Court ruled that reasonably foreseeable provisions violated section 7 of Charter rights to life, liberty and security of the person. It eliminates MAID access to those who only have mental illness as an underlying condition. My understanding is that the Minister of Justice said this would be addressed in the parliamentary review of this legislation.

It would also create a second set of safeguards for people accessing MAID without a reasonably foreseeable death clause including that, for both those whose deaths are foreseeable and those whose are not, this bill would change the Criminal Code so that only one witness is needed to sign the MAID request, rather than the two currently needed. It would eliminate the 10-day waiting period for MAID and its administration for those with foreseeable deaths. For those without foreseeable deaths, Bill C-7 would create a 90-day waiting period request. There is a bit more technicality. It builds on legislation that has already been passed in this place.

I want to outline some of the things I have been hearing from my constituents on both sides of this issue. The response in my office has been pretty evenly split between people advocating for these changes and against them.

Those in support of this bill have been writing to my office on the need to exercise personal autonomy, which would be the agency issue that I mentioned. The constitutional right to make choices about end-of-life access to medicine and health care should be part of a health care option that is available to Canadians. There is a need to ensure that, in our country, we have the ability to die with dignity: to look at death as part of the life process, and to ensure that the continuum of care involves a death with dignity. Also, there is a need to normalize and end the stigma surrounding death, and to respect individuals' and families' desire to end unbearable suffering.

Those who have issues with this bill have mentioned consent by minors and those who have mental illnesses, and what the nature of consent is in those situations. There are concerns that it is not clearly defined. There are concerns about how this legislation would impact the nature of consent in jurisprudence, as well as religious concerns around life, and doctors' conscience rights. There are concerns around repealing the 10-day waiting period and also allowing medical professionals to shorten the 90-day waiting period if the capacity to consent would be lost. I have heard those concerns.

This is my approach to addressing this legislation. As a legislator, it is my duty to ensure that individuals have the ability to use their agency in their choice on medical decisions, regardless of my personal proclivities. I will be supporting this bill through to the committee stage. I understand that there may be amendments proposed.

At the same time, some of the concerns that constituents have raised in my community against this bill are valid. From my perspective, some concerns that I have are whether we have proper supports in place for people who might be considering MAID in a not-foreseeable-death situation. I am talking about social supports for those who are in situations of great disability: Do we have social supports for day-to-day living? What about poverty? Is it a determinant of mental health?

With respect to palliative care, I do not think our country has yet addressed that issue adequately. I would like to see complementary legislation on that issue so we can be assured as a society that, in proceeding with this legislation, people are in the position of exercising their agency: They are not making a decision based on desperation or on our failure as a society to provide them with adequate social supports.

Another question I would like to see the committee address is this. When a person has lost the capacity to give consent, who will decide what is intolerable suffering? We need to suss that out. There needs to be some path to that. Parliament needs to give some direction to that so it is not simply left to the courts in the future. I think Parliament has a role in this because, as I am bringing the concerns of my constituents, both for and against, this is the place to give direction to the courts on any future decisions, and I would like to see the committee address some of those issues.

Another concern is for those struggling with mental health issues, such as depression, when death is not reasonably foreseeable. How will this legislation impact them?

With respect to mature minors, determining their capacity to decide and voluntary choice, free from duress, are concerns that have been raised. I also have those concerns.

I want to re-emphasize that I do not feel many Canadians have appropriate access to palliative care across the country. This is not the fault of any medical association, but I feel as a society we often spend a lot of time focusing on getting to a diagnosis. We have spent a lot of time in this place talking about dying with dignity, but we do not talk about how to live with dignity, and the choice of a person to see their life through to its natural end. If we are talking about choice and agency, somebody who makes the choice to see their life through without medically assisted dying should have the right and capacity to make that choice knowing that we, as a society, are caring for them. We are not just offering this as an alternative: that the only way to end suffering is to provide this as an option.

I give this nuanced answer because my own views on this have changed over the course of my term as a legislator with two very personal experiences. One experience was with both of my grandmothers, whose lives ended naturally. They both suffered from severe dementia. I do not think either of them would have chosen to have medically assisted dying because of their religious beliefs, but that option was not available to them, so I take that into consideration.

I am also living a situation right now, and she allowed me to share this, where earlier this year my mother-in-law, Debbie Garner, was diagnosed with a severe form of aggressive breast cancer. She has been fighting so hard and I feel so robbed because I just met this incredible woman a few years ago. She is fighting and giving it her all, but she lives in a jurisdiction where she does not have this option available to her. As part of her fight, she does not have the ability to exercise her agency in the way we are talking about, so this is now adding stress on her. She is doing everything she can to try and beat this disease, but the reality is there is a 50% chance, and probably greater with the form of cancer she has, that this will spread to her brain and leave her in a state I know she does not want to be in as a person. As a family member, I want to ensure that people in the position of my grandmother, who I know would have chosen to see her life through her way, have their wishes respected as do people in my mother-in-law's situation, who is saying she does not have the ability to exercise that choice, so she could use that agency as appropriately as possible.

That is my approach to this legislation. I would like to see this go forward to committee. I would like to see our society ensure that people have agency in both situations: that they are fully supported through the choice to see their life to its natural end, or are fully supported in a choice to end it with dignity and in a way that recognizes their own beliefs, their own agency and their own right to determination in these matters.

I thank the House for its time and I am happy to answer questions.

[Arif Virani, Liberal, Parliamentary Secretary to the Minister of Justice and Attorney General of Canada]

Mr. Speaker, I thank the member for Calgary Nose Hill for her analysis and for her very pointed and personal remarks today.

I am going to put a question to her that has been raised by some of her Conservative colleagues and was, in fact, raised in her speech.

When the member canvassed some of the pros and cons and related what she was hearing from constituents, she mentioned conscience rights. I find that criticism a little confusing, and am trying to understand it, because conscience rights are protected in the preamble of the old Bill C-14, in the text of Bill C-14, in section 2 of the Canadian Charter and even in the Carter decision, which is what got us all here. The Carter decision states, in paragraph 132, that, “In our view, nothing in the declaration of invalidity which we propose to issue would compel physicians to provide assistance in dying.”

I am wondering if the member for Calgary Nose Hill could flesh out what she understands to be the conscience rights concerns, because I believe that they are fully protected in the jurisprudence and in the statute.

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

Mr. Speaker, the member is correct in acknowledging that I raised that concern as something that is coming up in my constituency. I would argue that, because this is a common concern coming up in constituency offices across the country, the government has probably not explained this well enough to Canadians. I think that could be done with the parliamentary review on the previous bill in the previous Parliament, which should be happening. I find it unfortunate that the review could not have happened before this particular bill came forward.

With regard to my personal opinion on the issue of conscience, I do not believe that any Canadian should be denied the right to care at any point in time based on gender, sexuality, gender identity or in choice of agency in this situation.

[Mario Simard, Bloc, Jonquière, QC]

Mr. Speaker, I thank my colleague for her nuanced speech. I would also like to say how sorry I am about her mother-in-law's painful situation.

My colleague gave two examples. She spoke about her grandmother and her mother-in-law, and she mentioned the choice to see life through. I feel that goes without saying. I would like some clarification from her, because medical assistance in dying only occurs upon request. If the request is not made, it is understood that the right to live prevails.

I would like some clarification about what she presented as the right to live.

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

Mr. Speaker, there are stakeholder groups that represent Canadians with disabilities who are concerned that this legislation could diminish the value of the lives of people who live with severe disabilities. I believe that, in certain situations, social supports should be available to people living in those situations so that there is never any question that somebody is making a choice to end their life because of a lack of resources to live with dignity.

We spend a lot of time here talking about dying with dignity, but we also have to talk about living with dignity in a complementary way. I am talking about access to affordable housing for those living in poverty, especially for those who have disabilities who may not have the same access to opportunities for employment or success, and access to home care. These are all things that I believe people need to have in place in order to be in a position of empowerment when making the choice of how to proceed with either end of life or living with a severe disability.

I also think that in this place, as we are debating this issue, we need to reaffirm over and over again that those who have disabilities in Canada are equal in every way, and that we have a dual responsibility to ensure that they are supported and—

[The Deputy Speaker, Bruce Stanton]

We have time for one more question.

The hon. member for Windsor West.

[Brian Masse, NDP, Windsor West, ON]

Mr. Speaker, I thank the member for Calgary Nose Hill for her intervention.

I am pleased that the member is supporting the bill to get to committee. Where does she think that could be an advantage to resolve some of these complex problems?

As a PSW, I can tell the member that a person's quality of care can often be affected by their income. What does the member think about that?

What should the Canada Health Act do regarding that? A person's income can affect how many service hours they get as an individual, which affects quality of life and the decisions they make beyond that.

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

Mr. Speaker, my colleague, as always, makes an excellent point. This is exactly what I am getting at.

As we are considering this bill, we should also be considering reviewing situations such as the member just raised: national legislation and a framework around palliative care, home care, etc. I believe that all these issues influence someone's decision on how to proceed. For people who are living in poverty, with no hope of employment, in isolation and without access to home care, their sense of suffering might be different than if those supports were in place.

The bottom line is that we have to act to give people agency to end their lives with dignity, but we also have to act to give people agency to live their lives with dignity. I hope the committee study, as well as the parliamentary review of the previous legislation, would aim to resolve that.

[Élisabeth Brière, Liberal, Parliamentary Secretary to the Minister of Economic Development and Official Languages (Economic Development Agency of Canada for the Regions of Quebec)]

Mr. Speaker, I am very happy to have an opportunity this evening to share my thoughts on Bill C-7, an act to amend the Criminal Code regarding medical assistance in dying.

This bill has generated a lot of debate. It is good to talk about this because it is extremely important. It is important because too many sick people are suffering, knowing they will never get well.

I worked with such people for a long time, and I can say that knowing them, learning about their struggles, and helping them through their ordeal fosters a much better understanding. It goes without saying that medical assistance in dying is a matter of societal choices, choices that must be carefully considered from all angles.

I strongly believe that the government did its homework before introducing Bill C-7, which is the outcome of a series of round tables with experts and stakeholders, as well as a number of public consultations. We had to go through this process after the Quebec Superior Court's decision in Truchon and Gladu, which found that limiting medical assistance in dying to persons whose death was reasonably foreseeable was unconstitutional.

Ms. Gladu and the late Mr. Truchon both suffered from incurable degenerative diseases but were not eligible for medical assistance in dying because their deaths were neither imminent nor reasonably foreseeable.

The government's Bill C-7 proposes significant changes. It broadens the eligibility criteria to include people whose natural death is not reasonably foreseeable, as was the case for Mr. Truchon and Ms. Gladu. It also adjusts certain safeguards, allowing patients to waive final consent, for example. These are significant changes.

Let us first consider the reasonably foreseeable death criterion. A number of MPs are concerned about removing this criterion because they believe it would make it too easy to access medical assistance in dying. There is also some concern that people with disabilities or mental illness will not be properly protected. Life is precious and has so much to offer. I believe in that, and the government believes in it, too.

Under the provisions of this bill, mental illness is not considered to be an illness, disease or disability. The bill also expressly excludes people seeking medical assistance in dying solely because of mental illness. The government knows that the best treatment for mental illness is effective therapy, so greater emphasis needs to be placed on enhancing preventive measures and support resources.

What exactly is a reasonably foreseeable death, anyway? It is an assessment of the amount of time between a person's current state of health and their death. It is not something that can be measured with a blood test or a thermometer. It requires a clinical judgment based on an exhaustive medical evaluation of the patient. The fact remains that it is a difficult and sometimes imprecise exercise, and that is why the amendment is necessary.

Expanding patients' right to request medical assistance in dying does not necessarily mean it will be administered. Requesting medical assistance in dying does not automatically mean it will be administered. Even if the legislation is changed by removing a criterion, the spirit in which it will be applied does not change.

Requests will be evaluated based on the other criteria in the legislation and the new safeguards that I will get to shortly.

The government's priority is to strike a balance between the autonomy of eligible persons, the protection of vulnerable persons from being induced to end their life, and the important public health issue of suicide.

We care about compassion and dignity for both the patients and the process. In fact, that is why, in the first version of the legislation, the government included safeguards that would support decision-making, reflect the finality of the act, provide robust procedural guarantees to prevent errors and abuse, and protect vulnerable people.

Nevertheless, experience has exposed some gaps, and that is why we are proposing that two of these measures be amended.

The first change is to eliminate the 10-day waiting period between the date the request is signed and the date on which medical assistance in dying is provided, for individuals whose death is reasonably foreseeable. This 10-day waiting period needlessly prolongs suffering. Patients who are worried about losing their cognitive abilities and no longer being able to provide final consent live in fear. They may even refuse to take their medication and sometimes choose to request medical assistance in dying earlier.

The patient's stress also extends to their loved ones, making those last moments more painful than they need to be. Being able to choose when to die allows patients to go with their head held high, bolstered by the presence of their loved ones. These patients show noticeable relief when they realize that no matter what happens, they will get medical assistance in dying, as requested.

Although reasonably foreseeable natural death is no longer an eligibility criterion, it will be used to help determine which safeguards will be applied to requests for medical assistance in dying.

For people whose death is not reasonably foreseeable, a period of at least 90 days will ensure that there is informed consent. The sources of suffering causing the patient to request medical assistance in dying must be verified. Furthermore, it must be verified that the decision is being made without any outside pressure or influence.

The assessment of the person's overall medical condition is even more rigorous. We may be withdrawing the criterion of reasonably foreseeable death, but that does not mean greater access to medical assistance in dying. The bill continues to ensure that there is proper protection for the process, our medical practitioners and, above all, our patients.

Having recently discussed the bill with palliative care specialists, I can confirm that the 10-day waiting period often negatively influences a patient's decision and that removing this provision will make their last moments more peaceful.

The second safeguard I want to discuss today is the waiver of final consent.

Under the current legislation, immediately before providing medical assistance in dying, the medical practitioner or nurse practitioner must ensure that the person gives express consent to receive medical assistance in dying and give the person an opportunity to withdraw their request. The government's amendment means that final consent can be waived if certain conditions are met, such as the loss of cognitive ability and the signature of a written agreement stating that medical assistance in dying will be administered on a specified date. This measure helps to ease patients' anxiety so they can take their medication, suffer less and set a later date.

It is important to note that this is not the same thing as an advance request, meaning a request for medical assistance in dying on an unspecified future date under particular circumstances. That type of request could be included in a notarized health care directive. Currently, a person can state in their health care directive whether they would want to undergo aggressive treatment and what that term means to them, but they cannot request medical assistance in dying in advance.

That is a more complex subject because, in such cases, a legal representative is being asked to make a decision on behalf of someone else. This issue will be examined by a parliamentary committee. The committee will also discuss other issues, such as medical assistance in dying for minors.

All these changes to the reasonably foreseeable death criterion and adjustments to the safeguards reflect the government's desire to keep doing better, to create a more dignified, freer and more progressive society. I therefore encourage all members to vote in favour of this bill.

I would like to conclude with a quote from the late Jean Truchon: “I ask you to try to understand me and not to judge me”.

[Colin Carrie, Conservative, Oshawa, ON]

Mr. Speaker, I would like to thank the parliamentary secretary for her speech.

She talks about proper choice, but also safeguards. I would suggest that having available palliative care as a safeguard does reflect a person's ability to make a choice.

During the original bill, I had the opportunity as well to consult with some of the top palliative care experts in Canada, some would say in the world. One is in my own riding. Her name is Dr. Gillian Gilchrist. She has been a palliative care expert since 1981. One of the things she mentioned to me was that, in all her years of practice, she had never had one patient ask for medical assistance in dying. She said that if people are given proper medication, especially with the newer medications today, they can be kept very comfortable until the very end of their lives.

We have heard a lot of arguments that we should be making this more available because of the pain involved. Does the member agree that proper palliative care being available is important for choice? With 70% of Canadians not having palliative care available, is it something the government should make a priority?