Indigenous and Northern Affairs Committee on March 26th, 2026

[Voices]

Oh, oh!

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes, ON]

Oh, my goodness.

When we're talking about the liability piece, there has to be intent. There has to be intent that an action that has happened has caused an effect. Consent is defined in the Criminal Code. You have protections for emergency medical treatments. It's section 45 of the Criminal Code. All of those are protected. Somebody comes in, they're bleeding out and you make a snap decision. Unfortunately, they get sterilized as a result, but you saved their life. That's covered.

I think what we're trying to stop, and what we've heard in committee through testimony, is the fact that there are women—and, yes, men—who have been told one thing and something else happens. They wake up and find that they can't have children. That's what we're trying to stop.

There are protections in the Criminal Code in, as I said, the sterilization and ensuring intent. We're just trying to find a path forward that stops this from happening and affecting people who have full intent to have more children but from whom, unfortunately, that magic is taken.

[Liliane Brassard]

I, too, have to say that I'm not a lawyer, so this isn't my area of expertise. I'm much more comfortable in a delivery room or operating room.

What I can tell you, though, from my 14 years of experience, is that consent is quite a complex thing.

At the end of the day, the decision has to be made between the physician and the patient. The patient's options have to be clearly explained to her. That is understood. Even though I do my job diligently, I've seen many cases over my career where patients regretted their decisions. Sometimes, people come to regret certain choices they've made.

I'll give you a real example. I had a patient who asked me for a tubal sterilization, so I removed her fallopian tubes because she no longer wanted to have children. I had been her doctor for all three of her pregnancies. We took time to discuss it. It wasn't performed during delivery; it was done as a second procedure. However, what she had never told me was that her partner abused her and that the procedure was her way of making sure she didn't have any more children with him. She came back to see me a few years later, when she was in a new relationship, and told me that she actually wanted to have more children, but there was no way of going backwards.

We have all had cases like that in our careers, and we will continue to see those cases. Even though the patient fully consents to the procedure, she could end up regretting the decision.

Obviously, you start to wonder. Had the patient given her full consent, given that she was being abused by her partner? What tools do I have to make sure that the patient is fully consenting? That is what worries us about Bill S‑228 and why we are sounding the alarm, if you will.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes, ON]

Okay.

[The Chair, Liberal, Terry Sheehan]

Thank you very much. That's all the time we have.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes, ON]

Oh, all right.

[The Chair, Liberal, Terry Sheehan]

Next we have MP Hanley, please.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much to all the witnesses for being here.

This is certainly turning into a really interesting question about the intersection between consent and criminality.

Dr. Brassard, I'm going to ask you my questions in English, because we're discussing something very technical, and I want to be sure I use the right words.

You heard the witnesses, particularly Ms. Therrien on feminist law reform, proposing some amendments that could make this more, one could say, palatable or perhaps more consistent with existing consent and practice.

I wonder whether you've had time, whether you have any reflections on some of those proposed amendments and, ultimately, whether your recommendation is that this entire bill is unnecessary or whether, with appropriate amendments, you could see a path forward.

[Liliane Brassard]

Thank you. I'm going to answer in French, because it's easier for me.

Of course, it's a bit hard to give you an answer on the spot. Not being a lawyer, I wouldn't want to say the wrong thing. Nevertheless, one thing I can say for sure is that if the bill is passed, the AOGQ is fully prepared to contribute and examine the concept of consent.

That being said, we are extremely concerned about the current wording of the bill. Our position is still that the real problem, the existing problem, needs to be dealt with. The law is already there. Patients do have legal recourse. What we want to know is why these cases aren't being prosecuted effectively. That is the problem. If that isn't fixed, what difference will this bill ultimately make? Probably none. That is what I come back to.

[Brendan Hanley, Liberal, Yukon, YT]

You're in an interesting position because you are a practising obstetrician-gynecologist, as well as having an executive position. As we hear from witnesses, I'm reflecting that the more we hear that is closer to the front line, the more we have reservations because these are the practitioners who are actually involved in consent and procedures and often living the complexities of consent. I think you referred to hearing concerns from colleagues.

Is it your impression that you're hearing more concerns perhaps from the practising world than from the more political, academic world?

[Liliane Brassard]

That is absolutely the case. Many of our practising members have reached out to us to express their concerns about the bill.

I can tell you that, in the current context, it is very difficult for a young woman who does not want to have children to access voluntary sterilization. A 23- or 24-year-old woman who has decided not to have children and does not wish to use any form of contraception is going to have a heck of a time finding a gynecologist who agrees to provide that care. That is known and documented.

In my practice, I perform sterilization on young patients after meeting with them a number of times, but it's extremely tough as it is to be sure that the patient has fully understood the long-term consequences of total sterility. It's also important not to take a paternalistic medical approach. Women have the right to access this option.

Currently, gynecologists are hesitant to provide this care, but access has improved significantly in recent years. It's clear that our members have a lot of concerns. Doctors are not lawyers or legal experts. Criminalizing a specific medical procedure creates a tremendous amount of fear. It has consequences, and we've seen cases in Quebec illustrating that.

I'll give you an example. There's a surgical technique to treat patients with incontinence that involves the insertion of a vaginal sling. A certain percentage of women developed chronic pain after having the procedure, and about 5% to 6% of patients needed to have the sling removed. The situation drew intense media and political scrutiny, and as a result, so many rules around consent were introduced that, today, just about every doctor who used to perform the procedure no longer does. Obstetricians and gynecologists are primarily the only ones who still provide the service, because they care about women's health. Currently, women who suffer from incontinence no longer have access to a highly effective surgical procedure. The situation had a perverse effect.

I'm not even talking about criminal prosecution. I'm talking about legal actions.

There's no question that gynecologists in Quebec are worried. I can speak on behalf of my population, but I think the same is true in the rest of Canada. We are extremely concerned about the negative impact this could have.

[The Chair, Liberal, Terry Sheehan]

Thank you.

We now go to Mrs. Gill for six minutes.

[Marilène Gill, Bloc, Côte-Nord—Kawawachikamach—Nitassinan, QC]

Thank you, Mr. Chair.

Thank you to all the witnesses who are with us today. Clearly, as committee members and elected representatives, we want to do our job with as much rigour as possible, which is why we also need to address….

Sorry, Mr. Chair, but there's a conversation going on next to me, and it's distracting. I'm trying to ask my questions. I would appreciate it if those speaking would finish their conversation another time.

I'll start over, Mr. Chair.

I just want to thank all the witnesses for being with us today, knowing how difficult it is to have these discussions when there is agreement on the underlying principle of the bill. A number of witnesses, including those we've heard from today, have raised some fairly complex issues, especially around consent. I know the Collège des médecins du Québec, the Federation of Medical Women of Canada and the Association of Obstetricians and Gynecologists of Quebec have all addressed the issue.

Ms. Brassard, I'd like to hear your comments on consent issues. As you said, the bill does not define consent. There is no process either. You also talked about the fact that making a free and informed choice means understanding what is happening. Personally, I've had three Caesarean sections, planned and not. While I can't remember all the details, I did see how complex the process was.

I realize it's hard to cover everything, but could you explain consent and all its nuances? Could you also tell us whether there are solutions we can put in place? Earlier, I talked about potential flaws in the bill. How can we shine a light on this, while protecting both patients and physicians?

[Liliane Brassard]

In medicine, the meaning of consent is quite broad. In order to give consent, a patient must be able, at the time of the visit, to hear what they are being told. In the delivery room, when the patient is in pain, may not be the right time to obtain her consent. However, it's clear that consent doesn't mean exactly the same thing in all medical disciplines.

In gynecology and obstetrics, emergencies happen in the delivery room. Sometimes we see extremely serious complications, and we have to make very difficult decisions. Consent in emergency care is vastly different from consent in non-urgent care, where a treatment plan is decided on in the doctor's office with the patient. It's always much easier when a patient is able to give their consent with a clear mind.

Language barriers also come into play, and we don't always have the tools we need for those situations. Of course, then, improvements can be made and doctors can be given tools to strengthen consent practices. It's not unusual for my office to schedule an appointment with a unilingual patient. We aren't able to understand one another, so the appointment has to be rescheduled. We try to use tools like Google Translate, but it's difficult. There are things that need to be improved.

University faculties are already putting classes in place to improve consent practices. It's clear that consent is taken very seriously by the new cohorts of doctors. It was always taken seriously, but it's gone to a whole new level.

I would like to think that we are moving towards something better, but consent remains a very thorny issue in need of clarification.

[Marilène Gill, Bloc, Côte-Nord—Kawawachikamach—Nitassinan, QC]

As was mentioned, that clarification is not in the bill. Do you think that we, as lawmakers, should make that one of our objectives? I know my colleague said there was already a definition of consent, but I don't know whether it applies to this specific situation. As you said, consent differs depending on the medical specialization. What solutions are there, if any, to better deal with consent? It seems to me that the concept could even be divided.

I heard a survivor talking about the fact that she hadn't consented to having her water broken. I'm not a doctor, so I wonder about the risk of sterilization in a case like that. Sterilization is an effect, not the intended purpose. An effect and an intention are not the same. Elective abortions come to mind. In extreme cases, they can cause sterility. I say “extreme”, but that may not be the right word.

Basically, I have all kinds of questions. At what point is a person capable of giving consent? As you said, language can be a barrier. Then, of course, understanding comes into play; the patient needs to grasp everything that's going on. In addition, some situations are emergencies, which you talked about. At certain points, patients may have to be on medication, so they aren't able to give consent. I'm speaking from personal experience. I knew at the time that I wasn't able to make those kinds of decisions.

I'd like you to talk about the process. I know we don't have much time, but if we run out, you can send us all the necessary information in writing, including any amendment suggestions and recommendations for the committee, of course.

[Liliane Brassard]

When it comes to the legislative framework for consent, I don't have enough knowledge to tell you where to set the parameters. If I were to comment on that, I'd be talking through my hat, frankly.

I think that's a job for medical schools. I think that groundwork has to be laid during students' training. Just as I was taught how to perform a Caesarean section, deliver a baby and make tough decisions in the delivery room, medical schools need to incorporate consent directly into students' training. It's also necessary to partner with groups that represent indigenous populations, vulnerable women, immigrant communities and so forth. That is the way to improve consent practices.

I don't think the way forward is necessarily through a legislative framework, but I will tell you one thing: I've been practising for 14 years, and when you look at today's doctors and the doctors of 30 years ago, you see just how much the practice has changed. Nowadays, the patient is really seen as a crucial partner in the decision-making process. For instance, when I prescribe a birth control method to a patient, I always tell her that the best decision is the one that will work best for her. I may very well think that a certain method is the right one for her, but I still explain the advantages and drawbacks of each option, and in the end, she is the one who decides on the type of care.

I think it's up to medical schools and training physicians to make sure that the new generation is well equipped to obtain patients' free and informed consent.

[The Chair, Liberal, Terry Sheehan]

Thank you very much.

MP Morin, you have five minutes, please.

[Billy Morin, Conservative, Edmonton Northwest, AB]

Thank you, Chair.

In reflecting on a very serious conversation, I have an observation. Often, when it comes to free, prior and informed consent, the oxygen in our political world in Ottawa is taken up by a political discussion of major projects. It's a notable dynamic that we're now talking about it at the individual level, which is, I would say, in a lot of ways more important than some of the stuff that takes up all the oxygen. I acknowledge that, in the dynamics of the conversation today, thanking frontline staff is something to consider in this very important conversation, with the job frontline staff do and the pressures they're under.

This is for some of our guests online. I'll go to Dr. Modape Tunde-Byass from the Federation of Medical Women of Canada. Can you highlight some of the proactive education measures, the current practices of doctors in the field, the gynecologists and those who practise in this area and feel these immense pressures? I hear a consistent message that it should be a focus—I think that's pretty obvious—but where could it be improved? Arguably, this bill has been on the floor for seven years. I hear everybody say that coerced and forced sterilization is wrong. We all agree with that, it seems, naturally. Can you talk about what has changed, maybe in the last seven years, in the field to address this, even proactively beyond this legislation passing?

[Dr. Modupe Tunde-Byass]

Thank you, Mr. Chair.

I've been practising for 39 years. I have seen the new generation being taught about how to get better consent. “Consent” is describing the procedure, looking at the risks and benefits, and ensuring there is consent for refusal to have a procedure done. It's also important to give alternatives. In my work now, when I see patients, I give alternatives. I encourage them to think about the reasons and, especially around sterilization, regrets, and say, “This is extremely important. Once it's done, there is, really, no coming back.” This statement is now taught to this generation, and I see how this has changed from when I started practising. Consent is no longer signing the paper.

In an emergency situation, it's a bit different, and we continue to learn. When patients are having a Caesarean section and they're asking for sterilization at that time, it's not the best time, unless they have had a prior discussion with their health care provider and it's already documented in the charts that this is what they want. You would also ask them, “Is this what you have discussed?” If there is ambiguity, you would not carry out the consent. The emergency situation is usually where the problem is because of this: What becomes reasonable consent?

Having said this, we can still do more with education, with awareness, through both the patient's lens and that of the health care provider. We have seen that incorporating patients in helping with safety and guidelines and with being part of the committee has helped. During my lifetime, there was a time when surgeons operated on the wrong side of the body. That has almost been totally effaced because there's a patient's voice involved in that kind of consent process.

I also trained in another country, the United Kingdom, where universal education is important. I know the health care system is provincial in Canada, but for this kind of situation, I think we need to have a nationwide universal consent process that speaks to everybody across the board. In the U.K., this alone has reduced occurrences of maternal death for women, especially marginalized women, because they have a uniform education. I want to see that kind of process happen in our country so that we do not have a situation whereby one province is doing this, another province is doing that. Education and awareness are key, as is patient partnership.

[The Chair, Liberal, Terry Sheehan]

Thank you very much.

We'll now go to MP Ramsay.

Welcome to the committee.

[Jacques Ramsay, Liberal, La Prairie—Atateken, QC]

Thank you, Mr. Chair.

First, I'd like to thank the witnesses.

It's a simple principle, but you helped shed light on the complexities.

First, I have a request for you, Dr. Brassard. Mr. Hanley's first question is very important. The advantage of Ms. Therrien's proposal is that it brings together all the areas where we need to exercise caution. You said it was hard for you to comment on the proposal on the spot, and I completely understand. If possible, I would like the Association of Obstetricians and Gynecologists of Quebec to send us its views on the proposal in writing.

You talked a lot about consent. You mentioned the fact that people have regrets. As a doctor, I know that regret and consent are two different things. We all know that a patient can give informed consent and still have regrets later.

You also talked about the patient as a partner. That's such an important concept. I'm an old doctor. I had bosses who were paternalistic. Then, we moved to a more corporatist approach. Dr. Gaudreault sees where I'm going with this. In other words, we did what the corporation or college asked us to do. What was right, what was allowed by the college was what we had to do. After that, a patient-centred approach emerged, but even then, we decided what was best for the patient together. Now, you spoke about the patient as a partner. That is fundamental. That is what we need to keep in mind.

Dr. Gaudreault, I commend you. You talked about the study in Abitibi. You talked about the working group that the college established. You even said that you led the group, which is surprising for someone who's the president of a physicians' college.

Nevertheless, you realize that this committee meeting is happening today because the colleges didn't do their job. Where were the colleges all those years? I'm talking about the Quebec college and those of the other provinces. Why are we here today? Did the colleges offer up any sort of mea culpa, and if so, to who?

[Mauril Gaudreault]

I'm not here to talk about past colleges and presidents.

However, as I said, we were completely shocked when Professor Suzy Basile's report was released. I believe all of this also stems from biases experienced by both patients and health care providers. I think that colleges, organizations and institutions—like the college I have the privilege of presiding over—have done their part in the past. One issue that the focus group I chaired highlighted was that patients, particularly indigenous women, did not trust our institutions, including the Collège des médecins du Québec. They didn't feel protected by it, didn't trust the various institutions representing their rights and didn't dare to file complaints. This was made very clear by Ms. Basile's study, as well as by the testimony we heard during the focus group's work.

We've also acknowledged this in territorial position statements regarding all indigenous communities: We haven't always done the work we should have done. That said, what we have codeveloped with indigenous communities and what I mentioned in my remarks is really a program designed to raise awareness among various stakeholders and health care providers about the biases we may all harbour regarding how we welcome women, particularly those from indigenous communities, and how we address them.

To answer the question, I would say yes, obviously, there is work to be done. We acknowledge, for our part, that we could have done things differently.

[The Chair, Liberal, Terry Sheehan]

Thank you, Mr. Gaudreault.

Thank you, Mr. Ramsay.

Mrs. Gill, you have the floor for two and a half minutes.

[Marilène Gill, Bloc, Côte-Nord—Kawawachikamach—Nitassinan, QC]

Thank you very much, Mr. Chair.

I'll ask Dr. Brassard another question, and I'd like all the witnesses, if possible, including the representatives of the Collège des médecins du Québec, to also answer my question on consent. I wanted my next question to focus on the definition, as both the Collège des médecins du Québec and the Association of Obstetricians and Gynecologists of Quebec have weighed in on the definition.

I'll turn the floor over to you, Ms. Brassard and Mr. Gaudreault. Anyway, I'll let you answer.

[Liliane Brassard]

To answer simply, I would say that at the AOGQ, we represent our members to ensure that patients have access to quality care, but we rely heavily on the Society of Obstetricians and Gynaecologists of Canada, which is our academic institution. There have been working committees on the definition of consent. By definition, consent, as was said earlier, is….

Actually, maybe you could clarify your question.