Bill C-314

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

This enactment amends the Criminal Code to provide that a mental disorder is not a grievous and irremediable medical condition for which a person could receive medical assistance in dying.

Criminal Code

[Don Davies, NDP, Vancouver Kingsway, BC]

Mr. Speaker, in March 2023, legislation to extend by one year the temporary exclusion of eligibility for MAID where a person's sole medical condition is a mental illness received royal assent and immediately came into force. This means that persons suffering solely from a mental illness will be eligible for MAID as of March 17, 2024. Bill C-314, the bill before the House today, would remove this eligibility at least until we have satisfactory answers and guardrails to ensure that we can extend this profoundly permanent step with confidence. In my view, we do not have that necessary confidence today, and I think the majority of Canadians and health professionals, and the data, concur.

Data released in September 2023 from the Angus Reid Institute found that a majority of Canadians, 52%, worry that treating mental health will not be a priority when MAID eligibility is expanded to include individuals whose sole condition is mental illness. A vast majority of Canadians, 80%, are concerned with the mental health care resources available in this country, namely that they are not sufficient. Overall, one in five Canadians says they have looked for treatment from a professional for a mental health issue in the last 12 months, and in that group, two in five say they faced barriers to receiving the treatment they wanted. These obstacles appear to be more of an issue for women, among whom 45% of those who sought treatment say it was difficult to receive, and young Canadian adults aged 18 to 34.

A majority of Canadians support the previous rules governing MAID, first passed in 2016 and then updated in 2021, but there was more hesitation when it comes to this next step. Three in 10 say they support allowing those whose sole condition is mental illness to seek MAID, while half are opposed.

I will turn to some of what the professionals are telling us, starting with the Centre for Addiction and Mental Health. A survey recently of CAMH physicians found a lack of agreement on whether or not mental illness could be considered “grievous and irremediable” for the purposes of MAID and what criteria could be used to determine whether a person is suffering from an irremediable mental illness. The survey also found significant disagreement among physicians on whether or not a request for MAID can be differentiated from suicidal intent. These physicians also highlighted the concerns they had about access to mental health care in the context of expanded eligibility for MAID.

Canada's mental health care system has experienced chronic underfunding, leading to a significant shortage of community- and hospital-based mental health care across the country. Between one-third and one-half of Canadians with mental illness were not getting their mental health needs met before the COVID–19 pandemic exacerbated the mental health crisis and increased the burden on our mental health system and therefore on Canadians. The results of that survey replicate the findings from the Canadian Psychiatric Association's member consultations in 2020 and the conclusion of the Council of Canadian Academies' expert panel working group report in 2018.

Let me turn to the Canadian Mental Health Association, Canada's premier organization dealing with mental health:

CMHA's position, first articulated in a national policy paper in August 2017, and later, in testimony to the Senate in November of 2020, is that until the health care system adequately responds to the mental health needs of Canadians, assisted dying should not be an option....

First, it is not possible to determine whether any particular case of mental illness represents “an advanced state of decline in capabilities that cannot be reversed.”

Second, we know that cases of severe and persistent mental illness that are initially resistant to treatment can, in fact, show significant recovery over time. Mental illness is very often episodic. Death, on the other hand, is not reversible. In Dutch and Belgian studies, a high proportion of people who were seeking MAID for psychiatric reasons, but did not get it, later changed their minds.

Third is the issue of whether this distinction for mental illness vis-à-vis all other types of illness is inherently discriminatory. Denying access to MAID for mental health reasons alone does not [necessarily] mean that those with mental illness suffer less than people afflicted with critical physical ailments.

That is true. The statement continues, saying, “What is different about mental illness specifically, is the likelihood [or not] that symptoms of the illness will resolve over time.”

We do not have the benefit of appropriate guidance from the Supreme Court of Canada on this issue, and that is something we need to take into account.

It is also noteworthy that with only 7.2% of Canada's health budget dedicated to mental health care, Canada spends the lowest proportion of funds on mental health among all G7 countries. For example, in the U.K., the National Health Service spends 13% of its budget on mental health care. According to the OECD's recent analysis of spending on mental health worldwide, it concluded that even that is too low, given that mental illness represents as much as 23% of the disease burden. The historical underfunding of mental health has been most pronounced in community-based mental health services and I think that ought to be taken into account.

According to the Canadian Psychiatric Association, perhaps Canada's foremost experts on mental health diagnosis and treatment, its members are profoundly split on this issue. The CPA's most recent member consultations in 2020 found that 41% of respondents agree that persons whose sole underlying medical condition is a mental disorder should be considered for eligibility for MAID, 39% disagree or strongly disagree, and 20% were undecided.

According to CPA president, Dr. Grainne Neilson:

Balancing the commitment of psychiatrists to provide treatment, care and hope for recovery with a person's lived experience of suffering and right to enact personal choice in health-care decisions, including MAiD, is a fundamental challenge, particularly where death is not naturally reasonably foreseeable.

Equitable access to clinical services for all patients is an essential safeguard to ensure that people do not request MAiD due to a lack of available treatments, supports or services. Poor access to care is particularly relevant for people of low-socioeconomic status, those in rural or remote areas, or members of racialized or marginalized communities.

The Canadian Psychological Association, another very important group in this matter, states the following:

Many mental disorders are managed, not cured. Medications for mental disorders are largely palliative. While it is possible that medications and psychotherapy may successfully treat an episode which then doesn’t recur, it is often the case that mental disorders require management across a lifetime.

In assessing whether a condition is incurable and irreversible, consideration must be given to equity of access to interventions. Wait lists for publicly funded services are long. Services, like psychotherapy offered in communities by psychologists, are not funded by Medicare. Needed services are not always available in rural or remote communities. To fully address whether a condition is resistant to intervention, that intervention must be accessible.

It is not.

The mental functions required to give consent to MAiD are the very ones sometimes impaired with a serious mental disorder, despite the grievous and irremediable suffering the disorder imposes. Consideration must be given to how to assess capacity despite the impairment in thinking that can accompany serious mental disorders.

I believe that we must act cautiously and prudently, and we must take a phased approach in this area. As has been noted by all parliamentarians, this is an intensely sensitive issue with grave moral and consequential concerns.

Adequate time, in my view, is needed to facilitate a comprehensive national conversation about acceptable safeguards and the availability of medically assisted dying for those suffering from psychological or mental health conditions alone, so that we minimize negative impacts on people living with mental health problems and illnesses when they are most vulnerable, and on their caregivers and health professionals.

I think holding that national conversation must involve people living with mental health problems and illnesses, and their experiences because they play a central role. We must get their input into what mechanisms must be there to minimize the risk of wrongful death.

It is going to be my position to support this bill and I think we must move very cautiously. I do not think that we can say that we can never move into this area, but I think we can say with confidence that now is not the prudent time.

[Len Webber, Conservative, Calgary Confederation, AB]

Mr. Speaker, today I rise to speak to Bill C-314, an act that would amend the Criminal Code in regard to medical assistance in dying.

This enactment would amend the Criminal Code to provide that a mental disorder is not a grievous and irremediable medical condition for which a person could receive medical assistance in dying.

This is not the first time I have risen in this House to speak on the issue of medical assistance in dying, MAID, and I thank the hon. member for Abbotsford for the opportunity to speak to his bill.

As we know, MAID is an extremely complex issue that has generated some strong opinions on both sides. In May 2016, when I rose here to speak in support of the MAID legislation, I stated that, “when it comes to something as personal and sensitive as death, it is better to have options available, even if we do not like them, even if we do not believe in them. It is better to have some legal framework [in place] than none at all.”

I quoted from many letters I received from constituents in my speech back then and read letters from Ken, Connie, Valerie, Debra Lee, Catherine, Tracey, Doug and David. They all shared their personal perspectives with me, and it was extremely helpful in my own personal deliberations.

In the years since MAID was legalized, I have come to have known a number of people who have found comfort, personally and for their families, in the MAID process. Their death was foreseeable, there was no chance of recovery and when the dying process appeared to be both prolonged and cruel, it was an option they took advantage of. Their death was dignified, it was planned and it was peaceful. It allowed them to say their goodbyes to their loved ones, to their friends, when they could.

However, that being said, I am a very big proponent of hospice and palliative care, which must always be a viable and an available option to someone contemplating MAID. In the strongest of terms, MAID cannot be seen as a substitute for good palliative care, and it should never be.

Through my family’s volunteer experience with Hospice Calgary, and later with my wife’s final days with breast cancer at the Agape Manor Hospice care facility, I saw first-hand how critical it is we have a proper, well-funded palliative care system here in Canada. I saw then how underfunded this specialized care is within our health care system, and it is still that way today.

Canadians should have access to the support and care they need while living through one of the toughest times in their lives. We need to do better and we can do better, but we certainly have a long way to go.

However, today we are here to address the concerns of Canadians when it comes to the implementation of MAID with mental illness as the sole eligibility. This is the gist of Bill C-314. Should there be a permanent exclusion from MAID for people whose sole underlying condition is a mental disorder?

Back in 2016, during the original MAID debate, I had a meeting with a constituent, a young man named Anton. He came to my office, and Anton is the reason I am rising to speak today. He was a 25-year-old or 26-year-old, fit, good looking, articulate, intelligent and healthy young guy. When I say “healthy”, though, I mean in the physical sense only.

Anton came to my office to discuss his desire to have access to medical assistance in dying. He literally wanted to die. He shared with me his mental struggles and he said he was tired of living and he just wanted to die. It was something I just could not comprehend. This young guy seemed to have everything going for him and he wanted to die.

Anton felt the requirement in MAID that one’s death be foreseeable was unfair, a barrier and should not be in the legislation. He felt if one wanted to die, one should be allowed to through MAID, no questions asked. It should be as easy as going to get a haircut, he said.

I did ask him if he ever thought of taking his own life and why he would need MAID. He said he did not want to put a bullet in his head, jump off a chair with a noose around his neck or cut his wrists. That seemed too fearful for him, too painful and unfair for whomever would find him. We talked for what seemed like hours in my office.

I found it odd that he never once mentioned anything about a doctor, any treatments he was receiving or any medication he was on, so I asked him if he had seen a doctor. He had not spoken to a single health professional about his desire to end his life. I encouraged him to, and I said he needs to talk to somebody because I was certainly not the guy to talk to about suicidal tendencies. When he was leaving the office, he said he would seek some help. I gave him a hug, and I have had many sleepless nights since wondering if there was anything else I could have done.

About three months later, Anton requested another meeting with me. He told me that he had sought help and went to see a doctor. Whether it was a psychiatrist or psychologist, I do not know, but he told me of his horrific episode. The very doctor who Anton went to seek help from called the police, saying that Anton was a danger to himself and needed to be protected. Anton was taken away by the police and locked in a padded room for 14 hours without any food or water. He told me he only got out because he finally convinced authorities that he was fine, that he was normal and that things were good. He basically had to lie his way out. He said it was the worst experience of his life. He asked for help and had gotten none.

That is the problem. Many Canadians are just not getting the mental health assistance they need. Clearly, we need to put better supports in mental health and people's access to that help. We should be careful in asking police to be mental health professionals. We need to make sure we have the right people in the right place at the right time. I am pleased to hear that some police forces are now using health professionals in the field, but we still have a long way to go.

We need to put vulnerable Canadians back in control of their lives. We want to see them get the help they need and provide them with the social and mental health supports they need. We must never give up on them and allow them to prematurely choose MAID over access to mental health care.

Since 2016, I have heard nothing from Anton. I have often wondered whether he is still alive or dead. Before this speech, I tried to seek him out, and I went to social media. I had some assistance and found some information on Anton. I discovered that he had found love abroad. He is working to bring his new wife or girlfriend to Canada and is excited to start a new business. I know that if MAID legislation in 2016 had permitted mental health as a sole reason, it is quite possible that Anton would have ended his life without exploring all of his options. He never would have found the love and support that he has today.

I am very grateful for the perspective that Anton has given me on this issue, as it has profoundly convinced me that those whose sole condition is a mental disorder should not have access to medical assistance in dying. That is why I support the hon. member for Abbotsford's private member's bill, Bill C-314.

[Gabriel Ste-Marie, Bloc, Joliette, QC]

Mr. Speaker, I would first like to pay my respects to my colleague, whose personal accounts were very moving. Our hearts go out to Anton's family.

As we know, Bill C-314 amends the Criminal Code to provide that a mental disorder is not a grievous and irremediable medical condition for which a person could receive medical assistance in dying. The Bloc Québécois supports access to medical assistance in dying when a mental disorder is the sole underlying medical condition. We agree with the expert panel that the safeguards currently in place in the Criminal Code are sufficient. We think the exclusion should be maintained for one more year in order to give health care professionals a chance to develop standards of practice for cases of medical assistance in dying related to mental illness and to become familiar with those standards.

I would remind the House that the Bloc Québécois's position on medical assistance in dying has always been to uphold the consensus in Quebec, which came about following five years of consultations, specifically that medical assistance in dying is a right. Everyone has the right to die with dignity, of their own free will and with as little suffering as possible.

The Bloc Québécois is of the opinion that it is wrong to draw false analogies between the different problems in society and the specific issue of access to medical assistance in dying when a mental disorder is the sole underlying medical condition. We are of the opinion that it is possible to defend the right to self-determination, which is what medical assistance in dying is, while contributing to improving our health care systems, especially our mental health services. On that note, the Bloc Québécois would remind the House that the government has not substantially increased health transfers. That is affecting the system.

I would like remind the House that, in this debate, it is not a matter of offering people euthanasia as an answer to society's ills, contrary to what the Conservatives are saying. It is frankly irresponsible to suggest that the government's actions are causing people to become depressed and that the government's solution is to offer them medical assistance in dying.

It is also important to remember that the Conservative leader spread disinformation by failing to mention the context, when he stated in his communications that the government decriminalized dangerous drugs. The context is that Ottawa authorized a three-year pilot project in British Columbia to decriminalize the possession of small quantities of drugs. It is a pilot project based on practices used in Portugal with the explicit goal of curbing the overdose epidemic that is happening in British Columbia. The hope is that this pilot project will set a course to help Canadians and Quebeckers with addictions.

What is more, it is misleading to say that the governments will be providing medical assistance in dying in less than a year. That suggests that people will have their request for medical assistance in dying approved in less than a year, when that is not at all the case. As the experts on the Special Joint Committee on Medical Assistance in Dying pointed out, it will take at least a decade, maybe several decades, before a person can get medical assistance in dying for a mental disorder. It will have to be established that decades of therapy using multiple approaches have done nothing to treat the patient's mental health condition. In short, that is the complete opposite of what is being said by the Conservative leader, who is suggesting that a temporary depression is sufficient grounds to access medical assistance in dying.

In the Truchon and Gladu ruling, the courts had determined that the criteria were too restrictive, hence the evolution of this legislation. At the end of a press conference, a journalist asked the Conservative leader if he was prepared to use the notwithstanding clause to block access to medical assistance in dying. The Conservative leader skilfully dodged the question by mentioning that it is not currently before the courts. The Bloc Québécois is curious to hear what his colleagues think of this.

It should also be noted that the expert panel did not recommend deferring the exclusion measure. This is a request by professional associations. Although the expert report is entitled “Final Report of the Expert Panel on MAiD and Mental Illness”, the experts recommend changing the terminology to “mental disorder” because “mental illness” does not have a standardized definition. The panel finds that its recommendations on safeguards, protocols and directives should apply to all clinical situations in which several or all of these important concerns are present, namely incurability, irreversibility and capacity. The expert panel considers that the safeguards currently included in the Criminal Code are adequate for cases of medical assistance in dying when a mental disorder is the sole underlying medical condition.

As my colleague from Repentigny said earlier, the panel made 19 recommendations to proceed with requests for medical assistance in dying when a mental disorder is the sole underlying medical condition. They fall into five broad categories: the development of practice standards for medical assistance in dying; the interpretation of the term “grievous and irremediable medical condition”; vulnerabilities; the assessment process; and implementation.

Briefly, the panel recommends that practice standards be developed and shared with professional associations so they can adapt and adopt them. It should be noted that the government set up a task group to address this and that these practice standards were published in early 2023.

When it comes to interpreting the expression “grievous and irremediable medical condition”, the criteria of incurability, irreversibility and enduring and intolerable suffering, which are currently contained in the Criminal Code, must be duly established. They must be appropriately interpreted in applications for MAID when a mental disorder is the sole underlying medical condition. Although the expert panel acknowledges that it is impossible to establish fixed rules surrounding treatments, their duration, number and variations, they must nonetheless be part of the considerations for accessing medical assistance in dying. Simply put, for someone to have access to MAID when a mental disorder is the sole underlying medical condition, that person must have a significant history of treatments and therapies.

With regard to vulnerability, this involves ensuring that applicants have access to sufficient resources—housing, pain management, community support—so that their choice to access medical assistance in dying is not based on an adverse social circumstances. Again, the Bloc Québécois reiterates that increasing health transfers and funding the construction of social housing must be permanent priorities for the federal government.

As for the recommendations regarding the assessment process, the key recommendation is that the Criminal Code requirement, in this case consulting a specialist, involve a psychiatrist.

Finally, the recommendations for implementation can be broken down into three areas: consultation with stakeholders, training, and data collection for monitoring purposes.

As my hon. colleague and friend, the Bloc Québécois member for Repentigny, explained, this is a serious subject. We must set partisanship aside and work with the expert panels.

[The Deputy Speaker, Chris d'Entremont]

The hon. member for Abbotsford for his right of reply.

[Ed Fast, Conservative, Abbotsford, BC]

Mr. Speaker, medical assistance in dying will soon be expanded to include those with mental illness, including depression. My bill, Bill C-314, would reverse this terrible decision. My bill is very narrow and would not repeal the other provisions of Canada's medical assistance in dying laws.

There is no national consensus on expanding MAID to include mental disorders, none. The most recent Angus Reid poll found that a very small number of Canadians actually favour expanding assisted suicide to the mentally ill, somewhere around 28%.

The mental health community has raised significant concerns. A recent letter to government from the heads of seven Canadian psychiatry schools implored decision-makers to hold off on expanding assisted suicide to the mentally ill. Similarly, the Canadian Psychiatric Association does not support the expansion of MAID due to the many ethical and clinical concerns that have not been resolved. They argue that mental illness is often highly treatable and that patients should be provided with the treatment they need to manage their symptoms and lead fulfilling lives.

Stakeholders have deplored the lack of social and economic supports for persons with mental illness and how this can lead people to consider MAID. They have pointed to the fact that the federal government has not fulfilled its promise to deliver dedicated mental health and palliative care funding to the provinces, leaving Canadians without access to the support that would lead them to choose life rather than death.

Many others have joined the chorus. They note that the issues of suicidal ideation, irremediability and competency have not been resolved, ensuring that Canadians will needlessly die because we have rushed ahead with expanding MAID.

At greatest risk are those suffering from depression, veterans suffering from PTSD, the opioid addicted on our streets, our indigenous communities and those seeking to escape a life of poverty. The government has even signalled its openness to allowing children to access assisted suicide, presumably without their parents' consent.

Last year, in my home town of Abbotsford, Donna Duncan was swiftly approved for assisted suicide after failing to receive proper treatment for chronic mental health issues. Her assisted death happened so quickly and so totally blindsided her daughters, Alicia and Christie, that they referred the case to the RCMP. Is this the dystopian world we are leaving behind?

Has anyone consulted with our first nations? Meaghan Walker-Williams of the Cowichan Tribe recently wrote in the National Post:

As a Sixties Scoop survivor, my lifelong personal journey back to my community of Cowichan has also been marked by the painful consequences of policies that didn’t respect or understand Indigenous cultures. Another policy, blind to my culture, may soon join them: assisted suicide for mental illness.

She concludes by saying, “it's crucial that the narrative remains firmly rooted in upholding the sanctity of life—a cornerstone of Coast Salish teachings.”

I note that the government originally excluded the mentally ill from its MAID regime and went to great lengths to explain why that was necessary. It was only after the unelected Senate included the mentally ill in Bill C-7 that the government suddenly enthusiastically embraced the idea.

The question is this: Should Canadians be able to trust their government to act in a way that values the life of every Canadian, or do we give up on the most vulnerable among us? Someday, all of us will have to give an account.

A famous world leader by the name of Moses once challenged his own people with a choice and a promise: “I have set before you life and death, blessing and curse. Therefore choose life, that you and your offspring may live”. I want my descendants to live, to prosper, to thrive, and I want the same for our mentally ill, our Indigenous peoples and indeed all Canadians. It is time to end this experiment. With so much uncertainty, surely we should err on the side of life, not death.

I respectfully ask members to support Bill C-314.

[The Deputy Speaker, Chris d'Entremont]

The question is on the motion.

If a member participating in person wishes that the motion be carried or carried on division, or if a member of a recognized party participating in person wishes to request a recorded division, I would invite them to rise and indicate it to the Chair.

[Ed Fast, Conservative, Abbotsford, BC]

Mr. Speaker, I would ask for a recorded division.

[The Deputy Speaker, Chris d'Entremont]

Pursuant to Standing Order 93, the division stands deferred until Wednesday, October 18, at the expiry of the time provided for Oral Questions.

The House resumed from October 5 consideration of the motion that Bill C-314, An Act to amend the Criminal Code (medical assistance in dying), be read the second time and referred to a committee.

[The Deputy Speaker, Chris d'Entremont]

The House will now proceed to the taking of the deferred recorded division on the motion at second reading stage of Bill C-314 under Private Members' Business.

(The House divided on the motion, which was negatived on the following division:)

Vote #423

[The Deputy Speaker, Chris d'Entremont]

I declare the motion defeated.