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.

The House resumed from February 26, 2020 consideration of the motion that Bill C-7, An Act to amend the Criminal Code (medical assistance in dying), be read the second time and referred to a committee.

Criminal Code

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

Mr. Speaker, we are debating a bill today that strips away safeguards from the existing regime for euthanasia and assisted suicide. Debate started yesterday, and I want to continue in the line I was talking about.

Yesterday, I spoke about some of the philosophical problems underlining the government's desire to remove safeguards. Those philosophical ideas are clearly best understood in the realities of life under legal euthanasia and assisted suicide, in the experience of people and families who have been affected by it and in the concerns of people who will be further impacted by the proposed expansion of the practice and removal of safeguards.

The fact is that the expectation at the time of the Carter decision was for a legal regime that would apply narrowly. However, we have seen the alarmingly rapid process of expansion at the level of policy and practice continuing with this legislation. Given that this bill comes ahead of a scheduled statutory review, it looks like the pace of expansion of removal of safeguards and enlarging eligibility will continue apace even after this. Rates of identified euthanasia and assisted suicide have gone up dramatically every year since legalization, from about a thousand in 2016 to over five times that in 2019. Those rate increases show no sign of abating.

More and more horror stories are coming out about how the current regime has already changed the dynamics of our health care system. My grandmother was a Holocaust survivor, so I know about the long-standing traumatic effects that stay with many survivors for the rest of their lives. One instance of euthanasia at the Louis Brier nursing home in Vancouver, a Jewish facility that has Holocaust survivors among its clientele, was particularly traumatic for residents and staff.

Doctor Ellen Wiebe met with Barry Hyman and his family in the spring of 2018 and determined that he met all the criteria. She later went to the nursing home and closed his door without informing or consulting with nursing home staff. Hyman was killed by Dr. Wiebe on the evening of June 29, without any consultation with his primary caregivers at the nursing home. Perhaps Dr. Wiebe had good intentions, but someone sneaking into a nursing home and then asking us to trust her own notes as evidence of consent raises serious concerns.

Dr. Keselman, CEO of the Louis Brier nursing home, agrees. He said:

Imagine the implications for our staff and our residents and their families. We have a lot of Holocaust survivors. To have a doctor sneak in and kill someone without telling anyone. They’re going to feel like they’re at risk when you learn someone was sneaking in and killing someone.

Clearly Dr. Wiebe, in this case, was pushing the envelope. I doubt most doctors would behave in such a fashion, but we do see from analyses that have taken place in other countries that a small number of activist, pro-euthanasia physicians are overrepresented in cases with problems. A majority of doctors are trying to do the right thing, but a lot of death can flow from the choices of a small number of envelope-pushers.

In a paper studying cases of euthanasia in Holland between 2012 and 2016, bioethicists David Miller and Scott Kim of the U.S. National Institutes of Health noted significant problems in the application of these laws for vulnerable people, if the screws were not tightened properly.

During that period, Miller and Kim found 33 cases in which doctors had broken at least one rule while killing someone, though apparently none of these justified prosecution. Miller and Kim specifically identified the overrepresentation of certain activist doctors in cases that raised red flags.

I spoke in the House in 2016 about another case in Canada, where a physician declared a depressed person eligible for euthanasia even before examining that person, because the patient “could easily get bed sores and then die of infection”. A person's death was, prior to examination, declared reasonably foreseeable because the person could theoretically die from an as-yet-uncontracted bedsore infection.

It is striking that we have these cases to look to at all in Canada, given the massive data collection gaps. There is no requirement for advance legal review to determine if criteria are being met. There are no national standards on tracking data. In fact, in many cases when a patient dies as a result of euthanasia, their death certificate will not even indicate that as the cause of death.

People who have had bad experiences cannot tell their stories in most cases. The data that the government refers to is severely constrained by these realities. We tried, during the debate on the last euthanasia bill, to push for mechanisms for better data collection and reporting to ensure evaluation and protection was possible, but at the time unfortunately the government did not listen.

Those who have had negative experiences and have lived are understandably reluctant to speak out. However, I want to share one story, with permission, of someone close to me who had a negative interaction with the system after this regime began. This is Taylor's story.

Taylor Hyatt is a twentysomething former member of my staff. She has cerebral palsy. She is vibrant, accomplished and full of life. She went to the hospital a couple of years ago with cold symptoms. She was told that she would probably need some oxygen and was asked if she wanted that. She replied, “Yes, of course”, but then the doctors pressed her on the point by asking if she was sure. Taylor was asked if she was sure she wanted oxygen. She just had pneumonia.

When we look at the government's proposal to further expand euthanasia and assisted suicide, and to expand eligibility criteria and remove the small number of safeguards that exist, we need to ask the same question: Is it sure?

As these cases illustrate, we have particular reason to be concerned about cases in which people receive euthanasia or assisted suicide immediately or alone. If multiple family members and health care staff can see, over a period of time, that a person is clear in the desire to have life end, then there is less risk of vulnerability or abuse.

Imagine a case, though, in which children visit their mother in hospital on a Monday. It seems like she is having a good day and she makes no mention of wanting to die. She is experiencing some pain, but the nurse says she has promising ideas about how to manage that pain. The nurse says she thinks she needs to adjust the levels of a few things that should settle the pain down, and she will work on that as soon as the doctor has a chance to see her. The children leave on Monday feeling reassured.

Then the children are informed on Wednesday that their mother is dead. They are told that when she met with the doctor, she was in extreme pain and expressed the desire to die, so she was killed right away. They did not get a chance to say goodbye and they do not know if the doctor got it right or wrong.

Perhaps their mother really wanted to die, but maybe she was just experiencing a temporary low point from which she would have recovered. Her children will never know the details or the situation. Because of the absence of witnesses and legal review, there is very little evidence left behind. If their mother really wanted to die, she could, but would it be so unreasonable for the doctor to have given it a few days for the children to have been able to talk to her about her wishes?

This particular case is exactly where we should focus our concerns as we look at this legislation. The current legal system requires at least two independent witnesses who are not paid personnel, and there is a 10-day reflection period. I would underline, as members have said and as the government has generally failed to acknowledge, that there is already a mechanism by which the 10-day reflection period can be waived.

However, the 10-day period sets out a rule of general practice that is open to variation. It establishes the general and important principle that people should not have their lives taken as a result of a fleeting sense of hopelessness or because their medication levels are off for a period of time.

It makes no sense, as the government is proposing to do, to reduce the number of witnesses and remove the reflection period when there are already provisions for waiving it and managing that effectively in different situations.

Other members may have had these same experiences. I can tell them I had a close friend dealing with depression a few years ago and his state of mind would fluctuate dramatically from day to day. On certain days, he could not imagine going on, while on other days he would feel, in his words, like himself again.

Recognizing the realities of fluctuations and the development of people's experiences, it is horrifying to me that someone could opt for, and receive, euthanasia or assisted suicide within a few hours without independent witnesses or any reflection period. Therefore, the government must remove the clauses of this bill that reduce witnesses and eliminate that reflection period.

The government has included a clause in this bill dealing with so-called advance consent. The mechanism is that I, as a patient meeting the criteria, might ask to die on June 1, even if I had lost capacity. My consent right now would suffice for the taking of my life on June 1. However, the legislation contains no requirement that I be asked how I feel on June 1.

Suppose that I am facing a loss of capacity and I am afraid of the implications of that loss of capacity, not knowing what it would be like to mentally regress in the way that doctors have predicted that I will. Suppose that, in light of this fear, I sign on to advance consent but then, on June 1, while I have indeed lost substantial capacity, I actually have a much higher quality of life than I expected to have.

Should the advance consent that I have provided, in ignorance of my future circumstances, overrule my feelings in that moment? This is not just idle speculation.

Let me read from an article in the The Washington Post about a Dutch case involving an advance directive. It states:

The patient, referred to in official documents only as “2016-85”, had made an advanced directive requesting euthanasia in case of dementia. But the directive was ambiguously worded, and she was no longer able to clarify her wishes by the time she was placed in a nursing home—though her husband did request euthanasia for her.

Despite the lack of a clear expression from the patient, a physician concluded her suffering was unbearable and incurable—though there was no terminal physical illness—and prepared a lethal injection.

To ensure the patient's compliance, the doctor gave her coffee spiked with a sedative, and, when the woman still recoiled from the needle, asked family members to hold her down. After 15 minutes were spent by the doctor trying to find a vein, the lethal infusion flowed.

The government has tried in this legislation to avoid this most extreme case by saying that advanced consent would only apply to a particular date and that the procedure should not proceed if the patient was clearly refusing euthanasia. Unfortunately, the space left for abuse is still massive.

In the case just given, suppose the patient was given stronger sedatives so she was completely unaware of what was happening, and therefore offered no resistance. That would be allowed under the framework established by this legislation. It does not require that patients be informed or consulted at the time of their death. If they have provided advanced consent, that is considered sufficient.

In virtually every case, the requirement for contemporaneous consent is important in our law and is a necessary part of autonomy. If I am to be truly free, then I must be free from the directives of my past self. My past self should not irrevocably be able to bind my future actions.

Even so, it may be possible to still allow advanced consent, but to have some mechanism through an amendment to ensure that a patient, even with limited capacity, is informed and consulted at the time when his or her life is to be taken. I would encourage the government to consider that.

The government should be open to considering these problems and these fixes, taking out sections of the bill that dangerously remove safeguards and strengthening the section on advanced consent to ensure a patient is informed and consulted contemporaneously.

Finally, on the point of safeguards, let us go back and reflect on what the purposes of safeguards are.

Some members will feel that meaningful safeguards are not necessary because we should trust medical professionals and patients to get it right. The parliamentary secretary has used general data about trends in this area to suggest that there are no problems with abuse.

Let us be very clear that the reason we have safeguards is not to deal with general cases, but is precisely to deal with exceptional cases. Even if there are not problems in the vast majority of cases, we try to introduce reasonable verification mechanisms, because those verification mechanisms will catch instances of abuse and cases where vulnerable people might be pushed toward a death they do not want.

The reason we need law enforcement is not because most people are lawbreakers, but because some people are lawbreakers. The reason we have fire departments and expansive rules and protocols around fire prevention is not because most houses are on fire, but it is because some houses could catch fire.

I hope we will see through this debate that the safeguards in the current legal region really are a minimum and that we can provide reasonable safeguards like a short reflection period that can be waived and a requirement for independent witnesses which, like sprinkler systems in this room and security guards watching over us, insulate us against the possibility of something going very wrong.

For the sake of the vulnerable, let us not fire the security and rip the sprinklers out of our system just to make an ideological point.

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

Mr. Speaker, I want to point out four matters and lower the tone a bit. We need to talk about facts as opposed to emotional arguments.

My first point is to clarify that depressed individuals are not subject to this regime. We have specifically included a carve out for mental illness as a sole condition.

My second point is that the data collection the member seeks is being beefed up by this very bill.

My third point is that hyperbole has entered into this debate about people being “killed right away”. The notion of having a written consent witnessed by an independent witness and then the eligibility being verified by two independent practitioners, and that occurring in a matter of minutes or hours, is categorically false. That is not the way the system currently operates.

My fourth point is that it is an absolute red herring to raise a case based in Holland, which as has advanced directives for ailments such as dementia. We do not have dementia within the penumbra of ailments subject to this regime. We are also not proposing advanced directives; we are proposing advanced consent.

The member has raised, in some instances, concerns about what he perceives to be patients who are suffering or doctors who are acting aggressively. Those are important cases. If the member has cases, he should have those cases brought to the attention of either disciplinary bodies, regulated physicians or to law enforcement, because those should be enforced.

In fact, what we have is evidence to the contrary, that doctors are not practising this overly aggressively. In fact, there is a small of pool of doctors that—

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

Mr. Speaker, the member should know that the last legislation included a good faith exception, that a doctor who did not follow all the rules, but still acted in “good faith” would escape prosecution. Cases have been referred to disciplinary bodies, but there is a limited capacity to actually prosecute people who are, in the case, described as going into a nursing home and taking someone's life, without any consultation with the surrounding staff. These cases raise significant concern.

The member says that we should lower the tone and avoid hyperbole and then criticizes me for bringing up specific cases in Canada and in other countries that have similar legal regimes. The government should look at these cases and consider them before moving forward.

It is right to bring up the Dutch case, and I acknowledge the differences in the proposed regime in Canada from the Dutch regime. However, I pointed out very specifically that there was no requirement in the existing legislation for the person to be asked in the moment. I would beg the government to introduce that additional requirement for some contemporaneous consultation with the patients. After all, what does it have to lose? There very much is the possibility of someone being killed right away under the proposed legislation.

If the parliamentary secretary is so opposed to that characterization of the legislation, then why not leave in some waiting period? If he says that because of all the administrative requirements, inevitably there would be some delay, then leave the waiting period to consider—

[The Deputy Speaker, Conservative, Bruce Stanton]

Order, please. Questions and comments, the hon. member for Thérèse-De Blainville.

[Louise Chabot, Bloc, Thérèse-De Blainville, QC]

Mr. Speaker, I listened carefully to the member's remarks.

I have some important questions for him. I felt like his remarks were unrelated to the bill before us.

In my former life, I was a nurse. As I listened to the member, I got the sense that his stories were designed to appeal to our emotions. They seemed to suggest that health professionals are malicious rather than benevolent, but that is not true. I heard the member talk about doctors sneaking into care facilities to kill people. That seems a bit far-fetched to me. If something that terrible really happened, I hope my colleagues brought it to the attention of the appropriate authorities.

That is not at all what this bill sets out to do. The bill was improved thanks to two people who went to court. We are looking at how we can broaden the scope of the bill to include people who are suffering but are not necessarily at the end of their lives.

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

Mr. Speaker, simply put, the record will show that the member's characterization of my remarks is not at all accurate.

Let me just re-emphasize a point that I made. The very purpose of safeguards is to deal with the exceptional case. I agree that the vast majority of health care practitioners are not only well-intentioned, but also are not trying to push the envelope in any way. However, the data I cited suggests that in other jurisdictions we have seen how a relatively large number of problematic cases can emerge from the actions of perhaps also well-intentioned but definitely envelope-pushing physicians, who go beyond the intention of the legislature with respect to this bill.

The parliamentary secretary had some points that I wanted to get back to very quickly.

It is true that the legislation excludes depression as a sole condition, but it does not exclude people who suffer from depression from accessing it. In a previous Parliament, the member for St. Albert—Edmonton tried to introduce an amendment, whereby if someone was suffering from depression as well as other conditions, there would at least be a psychiatric assessment—

[The Deputy Speaker, Conservative, Bruce Stanton]

Order, please. I prefer not to have to interrupt hon. members when they are in the midst of their speeches, but there are many members who wish to participate in this time for questions and comments. I am stopping the clock here right now, so we are not going to take any more time away from the member.

It would help if members would direct their attention to the Chair in the midst of questions and comments. It would give me a chance to signal where we are in timing. Although there is nothing codified with respect to the limit for the time members should take to pose their questions or to respond, we will usually gauge the time by the number of people who are rising. If members see a lot of people standing up in questions and comments, perhaps they could keep their comments a little shorter. We will do our best to regulate that so we can get more members participating.

Just as a final reminder, questions and comments are for that purpose. I appreciate that members are trying also to get time in debate, and we will try to honour that as best we can. However, it is not a time for speeches; it is more for posing a question or a reflection on what the member has just said in his or her speech.

Questions and comments, the hon. member for South Okanagan—West Kootenay.

[Richard Cannings, NDP, South Okanagan—West Kootenay, BC]

Mr. Speaker, I need some clarification from my colleague. He finished his speech by talking about final consent. The act currently requires final consent at the time people are assessed and then they have to give final consent when that order proceeds. This has forced patients to make a cruel choice.

Once patients are assessed as being eligible for medical assistance in dying, they have to decide if they should do it right away, while they have the competence and can give an answer, or if they set a date in the future to allow themselves and their families to do all the things they want to do, but then risk that they are not competent and cannot answer and the procedure would not go ahead. I have a friend having to make that cruel decision.

Therefore, could the member clarify his statement about fixing advance consent?

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

Mr. Speaker, I have two points in response.

In the context of advance consent, it is important to note that people do not know precisely what their experience will be. They may get a prognosis and think they will feel a certain way about things at that point in time. It is important to underline that the reason we generally do not have advanced consent is because people do not always know what their experience of that will be.

Nonetheless, I want to be very clear. What I would propose as a middle way between having no advanced consent and the advanced consent regime proposed in the legislation is to allow people to give advanced consent, but to still require, even at the point at which they may have lost capacity, some contemporaneous consultation with them, so even at a point of reduced capacity they are told what is happening and will be given the opportunity to assent or not. Even at the point at which they have lost capacity, it is still fair to them to give them some information about what is happening in order to give them the ability to express their objection, if they are able to in the context of limited capacity.

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

Mr. Speaker, it would appear to me that the very concept of medical assistance in dying is the concept to which my friend from Sherwood Park—Fort Saskatchewan objects. The courts have ruled that it is a violation of our charter rights as Canadians not to have access to medical assistance in dying. I know it is a very difficult and fraught topic.

I would ask the member this quite directly, not to a hypothetical. Thinking of Audrey Parker of Nova Scotia, who knew she was terminally ill and who choose to end her life earlier because she was denied an advanced directive, would he agree that these sets of amendments to the Criminal Code are fair and within the context of what the courts have directed us to do?

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

Mr. Speaker, there have been various court decisions dealing with this broader topic, but I am not aware of court decisions dealing specifically with the issue of advanced consent.

Clearly the case of Ms. Audrey Parker should evoke a thoughtful response from us. I am not aware of all the medical details of the case. Many people have opinions about the case who also may not be aware of all the details, or the context or the information she received. Therefore, I do not feel comfortable giving an answer in the House of Commons about what should or should not happen in a particular individual's case.

We can, as members of Parliament, try to work together to find consensus, or to have our cake and eat it too, to use the expression. If it is the will of the majority, we can have some mechanism of advanced consent, but still require contemporaneous consent at the point at which somebody's life will be taken. That is very important. We would not want a situation where some people have their lives taken while they are unaware they are being taken or do not want it to happen.

I will just tease the member a little by pointing out that there was a court of appeal decision in Alberta opposing the carbon tax, and I hope she shares my enthusiasm for court decisions in that case as well. Some dialogue with the courts is maybe reasonable.

[Patty Hajdu, Liberal, Minister of Health]

Mr. Speaker, I am very pleased to rise in the House today to address Bill C-7 and to speak to our proposed changes to Canada's medical assistance in dying legislation.

The proposed measures respond to the Superior Court of Quebec's Truchon decision, in which it ruled that it is unconstitutional to deny access to medical assistance in dying to individuals who meet all the other eligibility criteria but are not near the end of life.

In responding to this ruling, the Government of Canada has had the opportunity to consider some additional measures for which there is strong support. That is why we are proposing changes that will help clarify and add precision to Canada's medical assistance in dying legislation.

Over the past few months, I have had the honour of listening to many Canadians, and it was important for me as the Minister of Health to hear first-hand what they had to say. My colleagues and I hosted a series of round tables and heard from more than 125 experts, academics, ethicists, doctors, nurse practitioners, members of the disability community, indigenous groups and key stakeholders. I also engaged my provincial and territorial colleagues, and my officials worked closely with their counterparts across the country.

In January, I was in Calgary and spoke to Cynthia Clark, who saw her husband through the process of medically assisted death last summer. Her perspective, as well as those of so many others with first-hand experience were invaluable.

I also listened to practitioners who have been providing medical assistance in death in a very thoughtful, compassionate way over the last four years. They had a lot to say about what was working well but also about what was not working well.

We heard many personal stories like Cynthia's, and they helped shape the changes that we are proposing today. In addition, the feedback received from our online consultation was astounding. In two weeks we had more than 300,000 responses.

It is clear that certain aspects could be improved in order to facilitate access, protect the vulnerable and respect personal choice.

With this bill, I think we have achieved a balanced approach that reflects the best interests of all Canadians.

Protecting the safety of vulnerable people while respecting the autonomy of Canadians remains our central objective. That is why the bill proposes a two-track approach to safeguards, based on whether or not a person's death is reasonably foreseeable.

Reasonable foreseeability of natural death would no longer be a requirement for determining whether a person can access medical assistance in dying. It would, however, be used to guide practitioners in determining which safeguards to apply. This is consistent with what we heard at the round table meetings.

Providers involved in assessing the eligibility of applicants for a medically assisted death told us they have a good understanding of the concept and are comfortable applying it. Under the amended law, they would use reasonable foreseeability of natural death to determine not eligibility, but rather which safeguards would apply.

For those whose death is reasonably foreseeable, we would ease some of the pre-existing safeguards. Under the current system, there is a requirement for a 10-day reflection period. We are proposing to eliminate this reflection period. For those who are at the end of their life, the decision to request medical assistance in dying is well considered, and this additional period only serves to prolong suffering unnecessarily.

The current system also requires that two independent witnesses confirm that the person who has signed a request for medical assistance in dying is who they claim to be and that no fraud has occurred, such as the forging of someone's signature. During our consultations, we heard that this requirement was a significant barrier for many people at the end of their life.

We propose requiring only one witness and allowing this witness to be a paid personal or health care provider. These individuals naturally would be excluded from acting as a witness if they are a beneficiary of the person's will or if they would receive a financial or material benefit from the person's death. Anyone involved in assessing or providing medical assistance in dying would continue to be ineligible to serve as a witness.

For those whose death is not reasonably foreseeable, we would create a new, more robust set of safeguards. We think it is important, even while improving access, to ensure that people who are suffering but who are not dying are given full and careful consideration as they assess whether or not to pursue an assisted death.

Strengthened safeguards would also serve to protect vulnerable individuals. For example, the bill proposes a minimum period of 90 days for assessing a MAID request in the case of a non-imminent death. This period would allow for exploration, discussion and consideration of options to alleviate suffering by the person seeking medical assistance in dying and with the practitioner.

The bill would also require that the person requesting MAID be provided with information on available counselling, mental health supports, disability supports and palliative care as part of the informed consent process.

We know that the majority of practitioners are already ensuring that their patients are aware of all of the supports and options that are available to them. This provision underscores the importance of the doctor-patient relationship. It allows for a practitioner and a patient to decide whether medical assistance in dying is the right step and provides sufficient time for the patient to discuss and consider other treatment options, which is crucial for patients weighing this kind of decision. This provision supports fully informed decision-making and individual autonomy.

Under the current legislation, those who become incapacitated lose their eligibility for medical assistance in dying because the person must give their consent immediately before the procedure. This means that some individuals deemed eligible for medical assistance in dying have chosen to end their lives earlier than they wanted out of fear of losing the opportunity to receive this service.

That is why we are proposing to include a waiver of final consent for persons whose death is reasonably foreseeable and who have been assessed and approved to receive medical assistance in dying. Individuals at the end of their life who risk losing their decision-making capacity before their chosen date would have an avenue to receive MAID without worrying that loss of their decision-making capacity before their chosen date would disqualify them. Support for this amendment is strong among stakeholders, Canadians and health practitioners.

Canada has had four years to reflect on the current MAID legislation passed in June 2016, and there are many complex issues that require further study.

In December of 2016, the Government of Canada asked the Council of Canadian Academies to conduct independent reviews on three specific types of requests for medical assistance in dying that are currently outside of the scope of the law: requests by mature minors, advance requests and requests where a mental disorder is the sole underlying medical condition.

The Council of Canadian Academies convened a multidisciplinary panel of 43 experts to review an extensive body of evidence, including Canadian and international academic and policy research.

We tabled those reports in Parliament in December 2018. They provide us with a thorough, thoughtful examination of these very difficult subjects. I encourage all members to read those reports as we continue our deliberations on the proposed legislative amendments and the parliamentary review that will be conducted later this year.

There is agreement among experts that allowing advance requests for people with illnesses such as Alzheimer's disease well before they would otherwise be deemed eligible is very complex and will require careful consideration and consultation before it could be included in legislation.

During the round tables I heard directly from health care providers who expressed discomfort because they have seen patients who, as their position progressed, might not have the same desire for medical assistance in dying as when they were first diagnosed. The Council of Canadian Academies' expert panel report on advance requests came to the same conclusion.

At the same time, we know that many Canadians have expressed an interest in advance requests so that they could have the comfort of knowing that they could avoid extreme suffering at some future date.

For all these reasons, we believe this issue deserves deeper examination through parliamentary review. That will be our opportunity to tackle questions that are profound and difficult to answer, even for practitioners who have been providing this service over the past four years.

The proposed changes to the medical assistance in dying legislation would exclude persons if mental illness is the sole underlying medical condition.

This does not mean that people with mental illness are ineligible; it means that mental illness cannot be the sole underlying condition. This is another complex aspect that warrants a more thorough discussion.

Since the federal legislation came into force in 2016, Health Canada has released four federal interim reports that provide more information on how the legislation is being implemented across the country.

In November 2018, we implemented regulations that resulted in the creation of a permanent monitoring regime that sets out obligations for reporting on medical assistance in dying cases by doctors, nurse practitioners and pharmacists. The first monitoring report under these regulations is expected to be released in spring 2020 .

Since MAID legislation was enacted in 2016, more than 13,000 Canadians have chosen this option of a medically assisted death. This is not unexpected. We have seen a gradual increase in the numbers over the last three years. The number of MAID deaths in Canada, slightly under 2% of all deaths, is in line with international regimes. The increasing use of MAID is largely a result of enhanced awareness of it as a legal option and greater acceptance by Canadians.

The federal government recognizes that public reporting is critical to ensuring transparency and also to ensuring public trust in the legislation. That is why we are proposing changes to expand data collection to help provide a more complete picture of medical assistance in dying in Canada.

Under the current legislation, only practitioners who receive a written request for MAID and pharmacists who dispense a MAID substance are required to provide information, but it has become clear that capturing information based solely on written requests for MAID received by physicians and nurse practitioners has resulted in an incomplete picture on who is requesting MAID across the country, and why.

The amended legislation would authorize new regulations to be developed in partnership with provinces and territories to allow for the collection of data on all assessments for MAID, and this would include those undertaken by other health professionals on the care team. It also clearly aligns with the original intent of the legislation to collect information on all requests for, and cases of, MAID in Canada.

I think we can agree that Canadians with life-limiting illnesses deserve the best quality of life possible as they approach the end of their lives. Palliative care and end-of-life care provide patients with relief from the pain and distress associated with a life-threatening illness. Supporting home care and palliative care is a key priority in our ongoing efforts to improve our health care system.

Through budget 2017, we made historic new investments in health care to improve access to mental health and addiction services, as well as home and community care, including palliative care.

To further support access to palliative care across the country, the government worked closely with provinces, territories, and stakeholders to develop the framework on palliative care in Canada, which we tabled in Parliament in 2018. We have released an action plan to support each of the priority areas identified in the framework.

I want to assure the House that the proposed bill responds to concerns identified by practitioners and experts through the round table discussions.

I will continue to work closely with the provinces, territories and key partners to support the implementation of the proposed legislative amendments, if they pass in Parliament.

This includes working with provinces, territories, health system partners and regulatory bodies to support best practices and information sharing on clinical guidance and other aspects of implementation, which includes training and retrospective reviews.

I have a great deal of respect for the practitioners who have been providing this service over the last four years with immense diligence and a huge amount of compassion. Their experiences have helped us craft legislation that much better meets the needs of Canadians. This law is constructed in a way that supports autonomy, but it includes the flexibility to allow a practitioner and a patient to work more closely together.

Medical assistance in dying is a complex and deeply personal issue. In tabling these changes, our government has considered carefully the need for personal autonomy and the protection of vulnerable people.

There is strong public support for change, and I believe we have found an approach that reflects the best interests of all Canadians. I urge all members of the House to support the proposed changes.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

Mr. Speaker, the minister said Canadians who are deciding whether they wish to receive medical assistance in dying are often experiencing prolonged suffering. The problem is that their prolonged suffering is due to a lack of palliative care. We were promised $3 billion would go to palliative care. Our dear member Mark Warawa spent nine days in hospital before he even saw a palliative care doctor.

I am wondering how on God's green earth we think that loosening these guidelines is a better way to ensure the best quality of life for Canadians.

[Patty Hajdu, Liberal, Thunder Bay—Superior North, ON]

Mr. Speaker, as the member opposite knows, we have made historic investments through provinces and territories to improve a range of health care services, including palliative care.

As I mentioned in my speech, it has been an honour to be part of a government that understands that having a strong framework and having actions that we can take together to improve palliative care at the end of life are very important to all of us, especially since we have an aging population that will require more of those services.

It is also equally important to recognize that Canadians have very loudly said, and courts have agreed, that they deserve to have autonomy at the end of their lives, and that includes the choice to use medical assistance in dying.